Influenza Vaccination for Pregnant Health Care Workers Essay

A certain pregnant nurse was fired because of refusing to get a flu shot in Pennsylvania in December, 2013 (Murphy, 2013). Getting a flu shot is the one of the biggest issues for health care professionals who are especially pregnant health care workers. However, vaccination still remains the most effective way for preventing severe influenza illness. According Center for Disease Control and Prevention (CDC) and American College of Obstetricians and Gynecologists (ACOG), seasonal flu vaccination is recommended for all pregnant women (Goldfarb, Panda, Wylie & Riley, 2011). But, why do they hesitate to get a flu shot?Influenza Vaccination for Pregnant Health Care Workers Essay

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Current vaccination rate

Flu vaccination rate for pregnant women is still low in the US. In 2005, the US achieved just 16% influenza vaccination coverage of pregnant women, and it is estimated that less than 10% of pregnant women who are at highest risk of influenza receive the vaccine (Broughton, Beigi, Switzer, Raker & Anderson, 2009). Even with increased morbidity during pregnancy from seasonal influenza, only 11% of pregnant women were vaccinated during the 2008 through 2009 flu season (Dlugacz, Fleischer, Carney, Copperman, Ahmed, Ross & Silverman, 2012). In addition, influenza vaccination rates have remained substantially below 50% for Health Care Personnel (HCP). Within the population of HCP, nurses have been shown to have lower influenza vaccination rates than physicians (Clark, Cowan & Wortley, 2009). Although the rate is getting increase little by little, it is still low compared to physicians’ vaccination rate.Influenza Vaccination for Pregnant Health Care Workers Essay

Barriers for vaccination

According to a certain survey, 58.3% of patients reported feeling scared about seasonal flu infection during their pregnancy (Goldfarb, et al., 2011). What are the main causes they are afraid of getting a flu shot? One of those reasons is that they have a fear uncertainly because they do not know specifically how safe flu vaccine is while they are pregnant. In addition, they do not know as well about how dangerous unvaccinated status is during pregnancy. Vaccinated nurses demonstrated greater knowledge about influenza and risk factors for influenza, while unvaccinated nurses believed they were not at risk (Clark, et al., 2009). These facts show that knowledge about safety of vaccine is one of the most important keys to decide whether they get a flu shot or not. Vaccine declination was associated with less knowledge about influenza, lower perceived susceptibility, and beliefs that the vaccine is not efficacious of safe (Eppes, Cameron, Gracia & Grobman, 2013). Furthermore, health care workers in the obstetric field also have limited knowledge about the epidemiology of influenza infection and most of them do not consider influenza as a potentially serious disease (Broughton, et al., 2009).Influenza Vaccination for Pregnant Health Care Workers Essay

Political, social and economic backgrounds

The state’s role is to reduce morbidity and mortality by nosocomial inflammation of influenza and maintenance of a reasonable health care workforce and to show that mandatory influenza vaccination is sensibly related to reducing the flu budget (Ottenberg, Poland, Jacobson, Koenig & Tilburt, 2011). It can be one of the political reasons for getting a flu shot for health care workers and government forces them to vaccinate.

In addition, we can concern about economic aspect. The commerce legislation can make the federal government regulate activity essentially that affects inter-state commerce, including parts of the health care industry which is related to the management infectious disease and prevention. With the public health service act, health and human services department in the US has organized the national vaccine plan, the national vaccine advisory committee, and the national vaccine injury compensation program (Ottenberg, et al., 2011). Through these mechanisms, the commerce legislation permitted the federal government to control, strengthen, or potentially obligate the vaccination of health care workers against influenza and ensure fair movement to arbitrate complaints related to vaccination (Ottenberg, et al., 2011). It shows that mandatory vaccination can lead saving budget for government because they do not have to pay for the treatment of the secondary infection for people due to influenza.Influenza Vaccination for Pregnant Health Care Workers Essay

Ethical concerns

There are also possible ethical arguments underlying mandatory vaccination. Hospitals are enforcing health care workers to vaccinate for two primary reasons. The one is for supporting of the professional duty of health care workers to benefit for patients individually and to ‘Do No Harm’ and another is for meeting the shared obligations of hospitals and health care workers to protect the public health with infectious disease which is preventable (Ottenberg, et al., 2011). In these situations, we can think about the important questions such as “What are the obligations of health care workers to their patients?” or “Is it proper for patients to expect health care workers to get a flu shot because of influenza?”Influenza Vaccination for Pregnant Health Care Workers Essay

Possible solutions

I suggest some solutions to promote vaccination for pregnant health care workers. First of all, the convenience of influenza vaccination is strongly needed such as using mobile vaccination carts. Instead of fixed date or time for vaccination, health care workers can have it depending on their schedules. Secondly, provision of free vaccination and peer vaccination is another good method for promoting vaccination. For example, some pregnant nurses who are already vaccinated could be a good model for other pregnant nurses who are not vaccinated yet. Thirdly, incentive programs also can be a great way for health care workers. If they can get extra pay, the rate of vaccination can be raised. Lastly, education about safety of vaccination for pregnant health care workers is the most effective method. Indeed, I had concerned about wearing a mask while they are working without vaccination, but this could be not a perfect prevention of pandemic influenza. Instead of this, it would be better to persuade them who refuse vaccination and to emphasize again about the safety of vaccination during pregnancy.Influenza Vaccination for Pregnant Health Care Workers Essay

Safety of vaccination during pregnancy

There are already several studies to prove safety of vaccination during pregnancy. According to CDC, studies of a lot of pregnant women in scientific view have checked the safety of vaccination during pregnancy. These studies did not show any evidence of danger to pregnant women, even to the unborn fetus and to newborns of vaccinated women (CDC, 2013). In addition, the Food and Drug Administration’s (FDA) and CDC’s periodic monitoring of side effects’ occurrence has not raised safety concerns (CDC, 2013). Rumors and fears should not be an obstacle to promoting patient safety and public health. The implementation of mandatory vaccination should solve the ambiguous concerns and misconceptions of vaccine safety as well. Rates of serious side effects’ occurrence following vaccination, such as Guillain-Barré syndrome, are vanishingly low as no higher than 1 in 1,000,000 (CDC, 2013).Influenza Vaccination for Pregnant Health Care Workers Essay

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Conclusion

Among several solutions as I mentioned above, I guess the best way to promote the flu-vaccination rate for pregnant health care providers is education. An effective educational strategy should focus on known misconceptions and knowledge gaps. Furthermore, the influence of health care workers on patient vaccination coverage should not be underestimated. It has been shown that health care workers’ recommendations have positive effects on the likelihood of patients to be vaccinated (Broughton, et al., 2009). According to an article, women whose maternity care provider has recommended the vaccine are much more likely to receive it than those whose providers did not (Broughton, et al., 2009). It shows that how critical education affect not only pregnant health care workers, but also pregnant patients.Influenza Vaccination for Pregnant Health Care Workers Essay

I insist that health care workers should be vaccinated because reducing the transmission of preventable diseases cannot prevent any harm in the clinical care area. Health care worker vaccination of influenza is consistent with a collective professional accountability to treat all patients moderately and to use appropriate precautions against preventable harms.

With mandatory health care worker vaccination, health care organizations should make sure that vaccination is an informed procedure. Health care workers should also get the information clearly about benefits and risks related to influenza vaccination and that vaccines are offered handily.Influenza Vaccination for Pregnant Health Care Workers Essay

Influenza prevention and mitigation are key strategic issues for public health. Along with HIV, tuberculosis and health care associated infections, influenza is considered a priority worldwide and its prevention requires thorough planning involving both public and private sector. In this paper we review the available evidence to assess the impact of influenza prevention for public health. We focus particularly on immunization strategies, as use of vaccines is the most effective intervention and including non-vaccine interventions would broaden the discussion extensively. The main focus of the paper is on European experiences.Influenza Vaccination for Pregnant Health Care Workers Essay

In Europe and other temperate countries, during annual influenza seasons, an estimated 5–20% of the general population are infected and many of these develop clinical influenza, but in specific populations and settings attack rates of 40–50% are not unusual.1 Much less is known about the influenza burden in developing and equatorial countries due to limitation of surveillance systems.Influenza Vaccination for Pregnant Health Care Workers Essay

In fact, assessing influenza impact is not an easy task, even in presence of good surveillance systems because of the difficulties of detecting mild and asymptomatic infections and the fact that many severe disease cases present non-specifically. The impact of influenza epidemics is a mix of direct and indirect effects both on public health and, in general, on the economics of a country.Influenza Vaccination for Pregnant Health Care Workers Essay

Disease burden is due to the very high number of people affected by a mild disease, together with a much lower—but still sizeable—number of severe cases that require hospitalization, and may even die.3 Influenza-related mortality is difficult to measure because testing for influenza is not performed routinely in clinical practice and because by the time a patient dies prematurely from the complications of initial influenza infecion the virus may not be detectable even if a clinician considers testing for it. Therefore, overall influenza mortality is often estimated by using statistical methods applied to vital statistic data. In Europe ‘excess’ all-cause premature mortality is roughly monitored through the EuroMOMO network for a number of countries; this is calculated as the total number of deaths that are recorded during influenza epidemics that seem to “exceed” the expected number of deaths in the same period in absence of influenza.1 More sophisticated estimates are derived for individual European countries which are able to also allow for the coincidantal impact of other respiratory infections, especially respiratory syncytial virus and periods of cold weather.Influenza Vaccination for Pregnant Health Care Workers Essay

While every non-immune person can be considered at risk of influenza, disease severity depends on age and specific risk conditions. Some population groups can be considerd at higher risk of developing severe influenza if they are infected: older people, young children, and persons of any age with underlying clinical conditions.5 Pregnant women have a higher risk for serious complications from influenza than non-pregnant women of reproductive age.6

Influenza burden is not only related to death and disability. The ability of influenza viruses to affect large numbers of people in a limited time, usually few weeks, can create strong pressures on health care systems and on public services as a whole. School and work absenteeism during influenza seasons have an adverse impact on productivity and—in the worst case scenario—can even disrupt essential public services.3

Last but not least, the pandemic potential of influenza viruses has to be considered when assessing the public health significance of preventing seasonal influenza. Having already in place a good system for severe influenza, vaccinating risk and target groups for season influenza, strengthening capacity for vaccine production, implementing monitoring systems for assessing influenza vaccine safety and effectiveness, represent a solid basis for any pandemic preparedness plan. In general the experience of the 2009 pandemic was that systems that were in place for seasonal influenza worked tolerably well, while systems that were established for the first time in 2009–2010 did not.Influenza Vaccination for Pregnant Health Care Workers Essay

Objectives and Targets of Influenza Vaccination Programs
The main objective of influenza prevention programs is to reduce the impact of the disease linked to the number of mild, moderate and severe cases. Elimination of infections or disease is not feasible. The difficulty of vaccinating entire populations on an annual basis imposes the need of a thorough prioritization exercise aimed at defining selected population groups. Reducing the number of severe cases provides the double advantage of avoiding people suffering but also decreasing the burden on the health care system due to hospitalization.Influenza Vaccination for Pregnant Health Care Workers Essay

Selective vaccination for protecting the most vulnerable people is the preferred approach in Europe as well as in the rest of the world.8 One notable exception to this approach has been the Japanese vaccination program conducted until 1987 that focused on children.9 More recently some experiences of attempting to provide universal vaccination to the entire population have been conducted in Canada1 and in the US, and an intended universal vaccination of children has been piloted in Finland.10

Excluding the above mentioned exceptions, older people (65 y or older), very young children (>6 mo of age, as vaccines are not registered for use in younger infants) and those with underlying clinical conditions represent the primary target of seasonal vaccination strategies. European wide surveys of policies and coverage conducted by the VENICE Project found that all reporting countries were recommending influenza vaccination to the elderly (usually 65 y and older) and to all people over six months of age with chronic medical conditions: cardiovascular, pulmonary, metabolic or renal diseases, or immunodeficiencies. However, few countries recommend vaccination of healthy children and around one third of the countries recommend vaccination of pregnant women.11 Even in these countries that do recommend vaccination in pregnancy, no data were provided on vaccination coverage for this population group so it is hard to draw conclusions whether these recommendations are implemented. Vaccinating pregnant women would protect the mothers themselves and infants below 6 mo of age both preventing mother-to-child disease spread and through transmission of maternal antibodies.Influenza Vaccination for Pregnant Health Care Workers Essay

In addition to the above mentioned risk groups (those that are vaccinated in order to reduce their own risk for severe disease and complications), influenza vaccination is often recommended to other population groups and the term ‘target groups’ is a common term for those groups. Those are selected categories that are meant to be vaccinated either for indirectly protecting at risk people that they may be in contact with, or for assuring services like health care, security, transportation, etc, during an influenza period. There is considerable evidence from randomized trials that immunising those in close contact with patients at higher risk of severe disease and where immunization is less likely to be effective works13. According to the a recent VENICE survey all countries in the EU recommend influenza vaccination for health care staff.14

Assessing the Impact of Seasonal Influenza Vaccination
Influenza epidemics are sustained by different virus strains that may circulate in different seasons. The virus strains to be included in the seasonal influenza vaccines, usually one A(H3N2), one A(H1N1), and one B are reviewed annually by WHO and possibly changed in order to fit as good as possible the antigenic properties of the viruses that will circulate during the epidemic season.Influenza Vaccination for Pregnant Health Care Workers Essay

After repeated infections—or repeated vaccinations—antibodies against influenza viruses rise more quickly and tend to persist for long time. Unfortunately, antibodies to one type or subtype of influenza virus do not provide protection to other types or subtypes and may be not fully effective against variants (drift) of the same type or subtype during subsequent seasons.15

Definitively, individual protection to influenza conferred by vaccination is the result of different factors, including past history of repeated infections and personal capacity of immunological response, in addition to the good fit of vaccine with circulating strains.

In addition, as for any other vaccine against highly communicable diseases, herd immunity may play a role in the spread of influenza infection. High immunity levels either in the general population or in selected subgroups where the infection spreads more rapidly (school age children) might reduce virus spreading and provide some indirect protection to high risk people that missed vaccination.Influenza Vaccination for Pregnant Health Care Workers Essay

Influenza surveillance is well established in most industrialized countries. In the EU, the ECDC issues a Weekly Influenza Surveillance Overview (WISO), a surveillance report based on the data collected by sentinel physicians and the data collected and processed by national co-ordination centers belonging to the European Influenza Surveillance Network (EISN). For each reporting country, clinical and virological data for the previous week of the season are presented.17

Since 2007, the ECDC is also collecting data on influenza vaccine coverage in the EU through the VENICE Project14. While vaccine coverage data among older people (65 y and over) are available in all member states, unfortunately less data are available on coverage levels among other target groups like people with chronic conditions or health care workers.11,14

A direct assessment of vaccine effectiveness is performed through the ECDC funded I-MOVE project.18 During the influenza season 2008–2009, six EU member states piloted a total of eight studies to measure seasonal influenza vaccine effectiveness. After that, the I-MOVE project started annual monitoring of vaccine effectiveness, including during the pandemic 2009–2010,19 and currently it involves more than 20 EU countries.

Notwithstanding those recent efforts and the wealth of data available from routine surveillance, large surveys, and epidemiological studies, assessing the impact of influenza prevention through vaccination is not easy. As noted above there are a number of elements that come together to define influenza severity at population level.20 Ecological observations for estimating vaccine impact may be misleading.Influenza Vaccination for Pregnant Health Care Workers Essay

On the other hand, assessing vaccine efficacy and effectiveness at individual level may provide robust evidence to policy makers and public health experts. In addition, vaccine safety monitoring is paramount in order to counter-balance reports of adverse events following immunization and work out adequate risk management.

Influenza Vaccine Efficacy and Effectiveness
Efficacy and effectiveness
Although influenza affects all age groups, persons with underlying medical conditions and older persons are at greater risk of severe illness and possibly death. The most effective way to prevent the disease or its severe outcomes is vaccination. Safe and effective vaccines have been available and used for more than 60 y.3 In Europe, only inactivated influenza vaccines are used although in 2011 a live attenuated vaccine has received a marketing authorization from EMA.Influenza Vaccination for Pregnant Health Care Workers Essay

There are several factors that can influence vaccine efficacy and effectiveness estimation (Table 1). First, in years when the vaccine viruses match well the predominant circulating strains, the vaccine benefit for that season is likely to be higher than in years with a poor match. Influenza Vaccination for Pregnant Health Care Workers Essay