I have previously discussed in my columns the ramifications of pandemic influenza and how nurses and other healthcare workers could help alleviate the spread of the flu virus through vaccination (Glasper, 2014; 2017). Why am I reiterating the facts of these previous publications? It appears that, despite previous campaigns and the latest flu plan initiative by the Department of Health and Social Care (DHSC), Public Health England (PHE), and NHS England, which is designed to increase flu vaccine uptake among frontline health professionals (Van-Tam et al, 2019), little has changed over the past 6 years.
Although the Nursing and Midwifery Council (2018)Code states that nurses have a responsibility to protect their patients, some 40% of frontline healthcare staff in England are not availing themselves of flu vaccination (PHE, 2019a; ITV News, 2019). Flu vaccination for healthcare workers helps to stop the transmission of the flu virus and is fully supported by professional bodies such as the Royal College of Nursing (RCN) (2020).
Background
In the UK, government advice on immunisation is given via the ‘Green Book’ (https://tinyurl.com/peqclpm), regularly updated following advice from the Joint Committee on Vaccination and Immunisation. Chapter 19 specifically concentrates on influenza (PHE, 2019b).
Many people see flu as being similar to the common cold—irritating, but not especially dangerous. However, this seriously underestimates the power of the flu viruses. Flu causes an acute viral infection of the respiratory system and is highly infectious. For many healthy people influenza is an unpleasant but self-limiting disease with recovery usually within a week or so, but it may be complicated by subsequent secondary bacterial pneumonia and, in children, otitis media. In some cases, flu can be complicated by the development of meningitis, encephalitis or meningoencephalitis, with the risk being highest among children under 6 months of age, elderly people and those with underlying long-term conditions such as respiratory or cardiac disease. In pregnant women flu can be associated with perinatal mortality, prematurity, or lower birthweight.
Although pneumonia caused by flu viruses is a rare complication, it can occur at any age and is associated with higher mortality rates, especially during pandemics, such as the ‘Spanish flu’ pandemic that followed in the wake of World War 1 in 1918 and caused the deaths of 50–100 million people (Billings, 1997).
It is not just the deaths caused by flu that is of concern, but the sheer numbers of people who become ill once infected, often for weeks before symptoms abate. During the swine flu epidemic of 2009, for example, a total of 540 000 people were infected with the virus. The virus is spread via droplet infection or from contact with contaminated objects such as door handles and then subsequently through touching the eyes, nose or mouth (Glasper, 2014). Its spread is exacerbated by infected people travelling on public transport. Undoubtedly the majority of cases of influenza in the UK tend to occur during an 8–10-week period during the winter, but the timing, extent and severity of this ‘seasonal’ influenza can vary.
Flu immunisation
In winter 2019/20 the following are eligible for flu vaccination (Van-Tam et al, 2019):
Only 61% of healthcare staff in England have received the flu jab this flu season (PHE, 2019a) and the Government is considering making the vaccination mandatory. The UK is experiencing a serious outbreak of the disease and the Secretary of State for Health and Social Care thinks it is unacceptable for the vaccination uptake among NHS staff to be so low. He has stated that it is unethical for any frontline NHS staff not to be vaccinated against flu without a good medical reason (Smyth, 2019) and believes that flu vaccination is an essential measure to ensure that both patients and staff are protected. He aspires to achieve universal flu immunisation uptake for NHS workers next winter. The DHSC is now understood to be considering making flu vaccination a requirement of NHS employment (Smyth, 2019).
However, Edmond (2019) believes that a more achievable strategy for reducing the transmission of respiratory viruses such as flu in care environments is to promote vaccination and reduce ‘presenteeism’. This is where people continue to work while suffering symptoms of illness. There are some nurses, for example, who come to work while ill because they do not want to let their colleagues down, mistakenly believing that in doing so it will alleviate pressures caused by staff illness, whereas it actually makes matters worse and endangers co-workers, as well as patients. Edmond (2019) hypothesised that reducing presenteeism may be more effective than mandatory vaccination. Furthermore, he has calculated that hospitals that achieve baseline vaccination compliance of 70%, and reduce presenteeism by 2% have the equivalent impact of mandatory vaccination without threatening a person's employment for noncompliance.
Reducing the spread of infection
As part of its ‘Help Us Help You—Stay Well This Winter’ campaign (https://tinyurl.com/w6vw2w7), PHE uses the ‘Catch It, Bin It, Kill It’ message, to help prevent the spread of this highly infectious disease. PHE is advising people to get vaccinated and to adopt good respiratory and hand hygiene as this is the best way to prevent the spread of the flu virus, which can survive on hands and surfaces for 24 hours.
The frontline healthcare worker flu vaccination campaign is now part of NHS England and PHE's winter campaign and is no longer led by NHS Employers, who since 2010 have supported NHS trusts in improving the flu vaccination uptake figures among frontline healthcare staff through the Flu Fighters campaigns. PHE's latest flu campaign was launched on 24 October 2019 and aims to support NHS partners in sharing the flu vaccination campaign messages. These also include raising awareness about flu vaccinations among members of the public because almost 7.5 million eligible people missed out on their free NHS vaccination last year (NHS England and NHS Improvement Midlands, 2019).
The case for mandatory flu jabs
The Virginia Mason Medical Centre in Washington state, USA, was the first in the world to introduce mandatory flu vaccination for all its employees (Talbot and Schaffner, 2010). Many professionals now believe that more hospitals should introduce staffing polices through which annual flu vaccination is a condition of both initial and continued employment (Perl and Talbot, 2019). Grey and Mayo (2015) reported that Canadian hospitals in provinces such as British Columbia and Saskatchewan have followed the example of Virginia Mason and have implemented mandatory influenza immunisation for their healthcare workers.
The Society for Healthcare Epidemiology of America (2020) recommends masks for all hospital workers who have not been immunised and endorses a policy in which annual flu vaccination is a condition of both initial and continued employment.
Such radical steps have been deemed necessary in the face of flu vaccination rates among health staff remaining unacceptably low. Crucially, Perl and Talbot, (2019) cited studies that show a correlation between increased influenza vaccination rates among frontline clinical staff and reduced hospital-acquired infection among patient groups.
Virginia Mason uses a variety of methods to highlight the benefits of flu vaccination for health professionals, and offers nurses and others different types of vaccine administration such as intranasal versions. Significantly, Virginia Mason lost very few staff because of their mandatory policy. However, the Washington State Nurses Association filed a grievance against the implementation of this mandatory flu immunisation policy, which resulted in nurses belonging to the union having the choice of whether or not to be vaccinated (Schnirring, 2010). Despite this ruling, Virginia Mason still achieved nearly a 96% success rate in persuading nurses to accept flu immunisation in 2018 (Perl and Talbot, 2019).
The remaining nurses who refused to be immunised were ordered to wear masks when dealing with patients and again the nurses’ union challenged this as being unfair. However, the judge upheld the policy as an infection control measure (Schnirring, 2010).
The RCN supports an incentivised rather than a punitive approach to flu immunisation for nursing staff (RCN, 2018).
Conclusion
Frontline clinical staff who do not have a flu jab are a danger to themselves, their colleagues and their patients. Nonetheless, relying on potentially litigious and controversial mandatory flu immunisation polices can be avoided by adopting more persuasive strategies that challenge some of the negative and misleading untruths and misconceptions about the vaccine. These include that flu vaccines actually cause flu. Such untruths arise because it takes 2 weeks for the flu vaccine to initiate the immune response and it is perfectly possible to catch flu during this 2-week period. Furthermore, the flu vaccine has been shown to only confer between 40% and 60% protection (Centers for Disease Control and Prevention, 2019). Better this than no protection!