Saturday, September 11, 2010

More on SHEA's Flu Vaccine Mandate for Healthcare Workers

Last week, Dan blogged about SHEA’s new position paper, which calls for annual influenza vaccination as a condition of initial and continued employment for healthcare workers (HCWs). Simply put, SHEA is recommending that HCWs without a contraindication to influenza vaccine be fired if they refuse to be vaccinated. That’s a strong stance coming from an organization that typically avoids strong stances. I’ve blogged before about why I think that mandating influenza vaccination is a bad idea, but in this posting I want to focus on the evidence behind the recommendation.

Of note, there are 3 Cochrane reviews on influenza vaccination published this year that are worth reading. If you’re not familiar with Cochrane Reviews, you can read more about them here. These reviews are generally thought of as the highest quality, most rigorous reviews of the medical literature, and the reviews are developed free of any commercial funding.

The first Cochrane review, Influenza Vaccination for Healthcare Workers Who Work with the Elderly, is most applicable to the SHEA position statement. SHEA’s position on the utility of vaccinating HCWs to prevent influenza transmission to patients is based on 4 studies in long-term care facilities (LTCFs). And of note, those 4 studies are part of the Cochrane review, which comes to the following conclusion: “We conclude there is no evidence that vaccinating HCWs prevents influenza in elderly residents in LTCFs.”

Another recent Cochrane review evaluated the utility of influenza vaccination of healthy adults, which presumably represents the majority of HCWs. The authors concluded: Influenza vaccines have a modest effect in reducing influenza symptoms and working days lost. There is no evidence that they affect complications, such as pneumonia, or transmission.”

The last Cochrane review is least applicable to our current discussion, but interesting nonetheless. In reviewing the effect of influenza vaccine for the elderly, the authors conclude “The available evidence is of poor quality and provides no guidance regarding the safety, efficacy or effectiveness of influenza vaccines for people aged 65 years or older.”

So given the lack of rigorous evidence supporting the utility of vaccinating HCWs to prevent transmission to patients, I find it astonishing that the Society for Healthcare Epidemiology would adopt such a position. I certainly would have no problem with a position statement that strongly encourages vaccination, but to recommend that HCWs be fired for noncompliance with vaccination is over the top and undermines SHEA’s credibility. The level of compliance with any intervention to improve the quality or safety of patient care must be correlated to the strength of the evidence, and in this case, the evidence for a mandate is lacking.

As I was looking at the Cochrane reviews, I wondered aloud how the SHEA guideline writers could have come to their conclusion. My good friend and colleague, Gonzalo Bearman, quickly responded, “they were blinded by dogma.” Amen, Gonzalo!

6 comments:

  1. I would like to know SHEA's connection to the flu vaccine; to it's manufacturers, the WHO, etc. I speculate that someone's pockets are being padded heavily here.

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  2. Great posting, Mike! It seems to me that SHEA has gone with the easier route of righteous indignation; of course HCW should get vaccinated. The harder task for SHEA would be to guide regulators/ payers/ administrators/ HCW/ patients through the complex science and base their recommendation in the context of the overall evidence and the impact on patient safety

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  3. Niti:
    Thanks for your comment. I find it curious that SHEA would pick this particular issue to recommend firing for noncompliance. They don't recommend firing HCWs who repeatedly fail to wash their hands or surgeons who don't give pre-op antibiotics on time. But you could see how this could be the first step towards the development of a punitive culture in hospitals that would make the jobs of people like you in quality and safety much more difficult.

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  4. This comment has been removed by a blog administrator.

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  5. I removed the prior comment since it included personal email addresses. I don't think spamming authors of papers sanctioned by medical societies is the way to improve this process. I would write a letter to the editor of the journal that published the Guideline or otherwise make your opinions known without emailing individuals. Thanks.

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  6. Here is my opinion WITHOUT the doc's e-mail address per your request.
    At the end of the SHEA Position Paper there were 9 authors- 5 have a conflict of interest $$$$$$$
    VERY INTERESTING!!

    Thomas R. Talbot, MD, MPH (T.R.T) reports that he is a consultant for Joint Commission Resources, has received honoraria from GlaxoSmithKline through support of the Joint Commission Resources Flu Challenge Program, and has received research support from Sanofi Pasteur for donated Tdap vaccine for a CDC-funded study (his spouse has received research support from Wyeth, Vaxxinate, and Sanofi Pasteur).

    David J. Weber, MD, MPH (D.J.W) reports that he is a consultant for GlaxoSmithKline and has received honoraria from Wyeth, Pfizer, Merck, and OrthoMcNeil.

    Edward J. Septimus, MD (E.J.S) reports that he is a consultant for BD Diagnostics and Rymed Technology and has received honoraria from Sage, Care Fusions, Merck, and Cubist.

    Gregory A. Poland, MD (G.A.P) reports that he is a consultant to Merck, Avianax, Theraclone Sciences [formally Spaltudaq Corporation], MedImmune, Liquidia Technologies, Novavax, EMD Serono, Novartis Vaccines and Therapeutics, PaxVax, CSL, Emergent BioSolutions, and Glaxo-SmithKline, and has received research support from Wyeth and Novavax.

    Michael L. Tapper, MD (M.L.T) reports that he is a consultant to Human Genome Sciences, Pfizer.

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