JAMDA 15 (2014) 847e849
JAMDA journal homepage: www.jamda.com
Letters to the Editor
Healthcare Worker Influenza Vaccination in Nursing Homes To the Editor: The report on “Healthcare Worker Influenza Vaccination in Nursing Homes”1 is very interesting. Campbell et al1 reported that “Given that [nursing homes] generally have low employee influenza vaccination rates, it may be necessary to target lowperforming facilities to achieve substantial improvements.” In fact, the problem of prevention for influenza among paramedical personnel and students is an important issue that is usually forgotten.2,3 To increase influenza vaccination is the aim of present infection control. Winston et al4 proposed an effective method to increase influenza vaccination rate among health care workers: the “mandated H1N vaccination.” Winston et al4 noted that “the mandate helped to increase [health care worker] influenza vaccination rates dramatically.” Naleway et al5 also noted that health care workers “said they would have been vaccinated if required by their employer.” To increase the vaccination rate in nursing homes, the mandatory vaccination policy should be applied for all centers and targeting “low-performing facilities,” as suggested by Campbell et al,1 might not give much advantage. References 1. Campbell LJ, Li Q, Li Y. Healthcare worker influenza vaccination in Oregon nursing homes: Correlates of facility characteristics [published online ahead of print. J Am Med Dir Assoc July 20, 2014]. http://dx.doi.org/10.1016/j.jamda.2014.06.005. 2. Wiwanitkit V. Swine flu infection among medical students: an issue of concern. Am J Infect Control 2009;37:868. 3. Wiwanitkit V. Hospital maid: A worker at risk of contracting swine flu. Int J Occup Environ Med 2010;1:144e145. 4. Winston L, Wagner S, Chan S. Healthcare workers under a mandated H1N1 vaccination policy with employment termination penalty: A survey to assess employee perception. Vaccine 2014;32:4786e4790. 5. Naleway AL, Henkle EM, Ball S, et al. Barriers and facilitators to influenza vaccination and vaccine coverage in a cohort of health care personnel. Am J Infect Control 2014;42:371e375.
Sim Sai Tin, MD Medical Center Shantou, China Viroj Wiwanitkit, MD Visiting Professor Hainan Medical University Haikou, China http://dx.doi.org/10.1016/j.jamda.2014.07.017
Health Care Worker Influenza Vaccination in Oregon Nursing Homes: Correlates of Facility Characteristics In Reply: We appreciate the comments by Dr Sim and Dr Wiwanitkit on our article,1 where they raised some important issues regarding mandatory health care worker influenza vaccination programs. Although evidence suggests that mandatory vaccination policies increase health care worker vaccination rates in acute care settings,2e5 we note that there is a lack of evidence regarding the effectiveness of mandatory policies in long-term care settings and that there are legal and ethical challenges to mandatory vaccination. For example, opponents of mandatory vaccination as a condition of employment for health care workers have stated that it interferes with First, Fifth, and Fourteenth Amendment rights, regarding freedom of religion, freedom of contract between employer and employee, and the right to due process.6 In addition, court decisions in both the United States and Canada have found mandatory influenza vaccination for health care workers unwarranted.7e9 Therefore, although we agree with Drs Sim and Wiwanitkit on the benefits of mandatory influenza vaccination, we hesitate to recommend it as a strategy to combat low nursing home employee vaccination rates due to legal considerations and the lack of evidence on its effectiveness in this setting. In addition, mandatory vaccination programs may cause potential harms to care staff (eg, loss of autonomy and lack of trust in management).6 Although voluntary programs, which may include free vaccine, convenient access to vaccine, education programs, and public reporting, may not achieve as high of an employee vaccination rate as mandatory programs do, voluntary programs in nursing homes may, over time, achieve improvements without facing as many legal or ethical challenges as mandatory programs.2,7,10,11 Protecting vulnerable nursing home residents is a top priority, but it seems that many domains, not just medical and economic, but moral, legal, and ethical, should be considered, as well as both patient and provider perspectives, before a decision that is beneficial to all stakeholders can be reached. References 1. Campbell LJ, Li Q, Li Y. Health care worker influenza vaccination in Oregon nursing homes: Correlates of facility characteristics. J Am Med Dir Assoc; 2014
848
2.
3.
4.
5.
6. 7. 8. 9. 10.
11.
Letters to the Editor / JAMDA 15 (2014) 847e849 Jul 20. pii: S1525-8610(14)00346-6. http://dx.doi.org/10.1016/j.jamda.2014.06. 005. [Epub ahead of print]. Babcock HM, Gemeinhart N, Jones M, et al. Mandatory influenza vaccination of health care workers: Translating policy to practice. Clin Infect Dis 2010;50: 459e464. Rakita RM, Hagar BA, Crome P, Lammert JK. Mandatory influenza vaccination of healthcare workers: A 5-year study. Infect Control Hosp Epidemiol 2010;31: 881e888. Winston L, Wagner S, Chan S. Healthcare workers under a mandated H1N1 vaccination policy with employment termination penalty: A survey to assess employee perception. Vaccine 2014;32:4786e4790. Naleway AL, Henkle EM, Ball S, et al. Barriers and facilitators to influenza vaccination and vaccine coverage in a cohort of health care personnel. Am J Infect Control 2014;42:371e375. Stewart AM. Mandatory vaccination of health care workers. N Engl J Med 2009; 361:2015e2017. Anikeeva O, Braunack-Mayer A, Rogers W. Requiring influenza vaccination for health care workers. Am J Public Health 2009;99:24e29. Olsen DP. Should RNs be forced to get the flu vaccine? Some facilities are mandating it, in an effort to protect patients. AJN Am J Nurs 2006;106:76e79. Finch M. Point: Mandatory influenza vaccination for all heath care workers? Seven reasons to say “no.” Clin Infect Dis 2006;42:1141e1143. Kimura AC, Nguyen CN, Higa JI, et al. The effectiveness of vaccine day and educational interventions on influenza vaccine coverage among health care workers at long-term care facilities. Am J Public Health 2007;97:684e690. Ajenjo MC, Woeltje KF, Babcock HM, et al. Influenza vaccination among healthcare workers: Ten-year experience of a large healthcare organization. Infect Control Hosp Epidemiol 2010;31:233e240.
Lauren J. Campbell, MA Division of Health Policy and Outcomes Research Department of Public Health Sciences University of Rochester Medical Center Rochester, NY Qinghua Li, PhD RTI International Waltham, MA Yue Li, PhD Division of Health Policy and Outcomes Research Department of Public Health Sciences University of Rochester Medical Center Rochester, NY http://dx.doi.org/10.1016/j.jamda.2014.08.001
Refeeding Syndrome: Unrecognized in Geriatric Medicine To the Editor: Malnutrition is a well-established syndrome in geriatric medicine, affecting, in particular, fragile elderly individuals in the hospital and in long-term care facilities. Compensating for nutritional deficiencies is a constant and prevailing feature of medical management in geriatric care. Conversely, the potential dangers of refeeding are less well known in fragile, elderly individuals as compared with the context of intensive care. Over a 5-month observation period, 5 patients in our geriatric medicine ward (2% of all cases) presented refeeding syndrome (Table 1). We present here an illustrative clinical case, and the typical characteristics of refeeding syndrome, with a relevant review of the literature. Clinical Case A female patient aged 75 years, with a history of depression, histrionic personality, and chronic back pain in association with
balance and degenerative disorders, was hospitalized for viral gastroenteritis with diarrhea and vomiting that had started 8 days earlier. The patient was infused and rehydrated, and received potassium and vitamin K. On day 7 of her hospital stay, intravenous (IV) antibiotic therapy (ceftriaxone IV, followed by oral levofloxacin) was initiated for left basal bronchopneumonia caused by Haemophilus influenzae and Streptococcus agalactiae. After initiation of the antibiotics, the patient was transferred to our geriatrics unit, where her appetite returned, although she remained weak and slow. The patient presented no particular complaints, but suffered balance disorders with mobilization difficulties. The health care team described the patient as confused and somewhat “strange.” Additional tests revealed hypokalemia (3.3 mmol/L, normal values 3.5e5.1 mmol/L), hypomagnesemia at 0.53 mmol/L (normal range 0.7e1.1), hypophosphatemia at 0.77 mmol/L (normal range 0.87e1.45), and thiamine deficiency at 91 nmol/L (normal >116 nmol/L). In light of these findings, a diagnosis of refeeding syndrome was confirmed and the patient received phosphate, magnesium, potassium, and thiamine supplementation for 5 days, associated with a progressive increase in daily nutritional intake (from 800 to 1600 kcal per day). The patient’s mental and overall state quickly improved, and she was discharged to her home 2 weeks after initiation of nutritional supplementation. Refeeding Syndrome Refeeding syndrome is defined as the adverse effects that occur when nutrition is reintroduced in a malnourished patient, or in a patient who has been fasting for a prolonged period. The definition of the syndrome covers a wide spectrum of conditions, encompassing the biochemical and metabolic changes and clinical manifestations that may alter a patient’s general state after oral, enteral, or parenteral administration of carbohydrate-based nutrients.1e3 The shift to anabolic phase induces insulin secretion, and, subsequently, the introduction of glucose into the cell, creating an increased need within the cell for phosphate, potassium, magnesium, and thiamine (all contributors to numerous enzyme activities), with a corresponding reduction in the serum concentrations of these agents. Hyperglycemia and hyperinsulinemia can cause sodium retention with secondary fluid overload and possibly congestive heart failure. These symptoms usually occur within the first 5 days of refeeding, and may cause abdominal pain, nausea, vomiting, muscle weakness, tremors, and even delirium.1e6 Some diseases are known to incur a high risk of refeeding syndrome, such as anorexia nervosa, depression, cancer, chronic alcoholism, and digestive inflammatory disease, and patients in the postoperative phase or in intensive care are also especially vulnerable.4e6 Elderly patients, either in the hospital or in nursing homes, are often polymorbid with depleted physiological reserves, and thus should be considered at high risk of refeeding syndrome, particularly because the prevalence of malnutrition in this population can reach up to 50%.7,8 Refeeding syndrome is likely underdiagnosed in older hospitalized persons and those in long-term care facilities because of its unspecific clinical presentation in these patients (ie, patients who are undernourished, weak, confused, frail, with poor mobility). Indeed, it is quite uncommon for serum phosphate, magnesium, or thiamine to be tested in these patients. In one casecontrol study in a cohort of 2307 hospitalized patients older than 65 years followed for 2.7 years, Kagansky et al9 reported that 14.5% of patients presented hypophosphatemia compatible with the refeeding syndrome. The guidelines of the National Institute for Health and Clinical Excellence (NICE) are recognized as a useful tool
JAMDA journal homepage: www.jamda.com
Letters to the Editor
Healthcare Worker Influenza Vaccination in Nursing Homes To the Editor: The report on “Healthcare Worker Influenza Vaccination in Nursing Homes”1 is very interesting. Campbell et al1 reported that “Given that [nursing homes] generally have low employee influenza vaccination rates, it may be necessary to target lowperforming facilities to achieve substantial improvements.” In fact, the problem of prevention for influenza among paramedical personnel and students is an important issue that is usually forgotten.2,3 To increase influenza vaccination is the aim of present infection control. Winston et al4 proposed an effective method to increase influenza vaccination rate among health care workers: the “mandated H1N vaccination.” Winston et al4 noted that “the mandate helped to increase [health care worker] influenza vaccination rates dramatically.” Naleway et al5 also noted that health care workers “said they would have been vaccinated if required by their employer.” To increase the vaccination rate in nursing homes, the mandatory vaccination policy should be applied for all centers and targeting “low-performing facilities,” as suggested by Campbell et al,1 might not give much advantage. References 1. Campbell LJ, Li Q, Li Y. Healthcare worker influenza vaccination in Oregon nursing homes: Correlates of facility characteristics [published online ahead of print. J Am Med Dir Assoc July 20, 2014]. http://dx.doi.org/10.1016/j.jamda.2014.06.005. 2. Wiwanitkit V. Swine flu infection among medical students: an issue of concern. Am J Infect Control 2009;37:868. 3. Wiwanitkit V. Hospital maid: A worker at risk of contracting swine flu. Int J Occup Environ Med 2010;1:144e145. 4. Winston L, Wagner S, Chan S. Healthcare workers under a mandated H1N1 vaccination policy with employment termination penalty: A survey to assess employee perception. Vaccine 2014;32:4786e4790. 5. Naleway AL, Henkle EM, Ball S, et al. Barriers and facilitators to influenza vaccination and vaccine coverage in a cohort of health care personnel. Am J Infect Control 2014;42:371e375.
Sim Sai Tin, MD Medical Center Shantou, China Viroj Wiwanitkit, MD Visiting Professor Hainan Medical University Haikou, China http://dx.doi.org/10.1016/j.jamda.2014.07.017
Health Care Worker Influenza Vaccination in Oregon Nursing Homes: Correlates of Facility Characteristics In Reply: We appreciate the comments by Dr Sim and Dr Wiwanitkit on our article,1 where they raised some important issues regarding mandatory health care worker influenza vaccination programs. Although evidence suggests that mandatory vaccination policies increase health care worker vaccination rates in acute care settings,2e5 we note that there is a lack of evidence regarding the effectiveness of mandatory policies in long-term care settings and that there are legal and ethical challenges to mandatory vaccination. For example, opponents of mandatory vaccination as a condition of employment for health care workers have stated that it interferes with First, Fifth, and Fourteenth Amendment rights, regarding freedom of religion, freedom of contract between employer and employee, and the right to due process.6 In addition, court decisions in both the United States and Canada have found mandatory influenza vaccination for health care workers unwarranted.7e9 Therefore, although we agree with Drs Sim and Wiwanitkit on the benefits of mandatory influenza vaccination, we hesitate to recommend it as a strategy to combat low nursing home employee vaccination rates due to legal considerations and the lack of evidence on its effectiveness in this setting. In addition, mandatory vaccination programs may cause potential harms to care staff (eg, loss of autonomy and lack of trust in management).6 Although voluntary programs, which may include free vaccine, convenient access to vaccine, education programs, and public reporting, may not achieve as high of an employee vaccination rate as mandatory programs do, voluntary programs in nursing homes may, over time, achieve improvements without facing as many legal or ethical challenges as mandatory programs.2,7,10,11 Protecting vulnerable nursing home residents is a top priority, but it seems that many domains, not just medical and economic, but moral, legal, and ethical, should be considered, as well as both patient and provider perspectives, before a decision that is beneficial to all stakeholders can be reached. References 1. Campbell LJ, Li Q, Li Y. Health care worker influenza vaccination in Oregon nursing homes: Correlates of facility characteristics. J Am Med Dir Assoc; 2014
848
2.
3.
4.
5.
6. 7. 8. 9. 10.
11.
Letters to the Editor / JAMDA 15 (2014) 847e849 Jul 20. pii: S1525-8610(14)00346-6. http://dx.doi.org/10.1016/j.jamda.2014.06. 005. [Epub ahead of print]. Babcock HM, Gemeinhart N, Jones M, et al. Mandatory influenza vaccination of health care workers: Translating policy to practice. Clin Infect Dis 2010;50: 459e464. Rakita RM, Hagar BA, Crome P, Lammert JK. Mandatory influenza vaccination of healthcare workers: A 5-year study. Infect Control Hosp Epidemiol 2010;31: 881e888. Winston L, Wagner S, Chan S. Healthcare workers under a mandated H1N1 vaccination policy with employment termination penalty: A survey to assess employee perception. Vaccine 2014;32:4786e4790. Naleway AL, Henkle EM, Ball S, et al. Barriers and facilitators to influenza vaccination and vaccine coverage in a cohort of health care personnel. Am J Infect Control 2014;42:371e375. Stewart AM. Mandatory vaccination of health care workers. N Engl J Med 2009; 361:2015e2017. Anikeeva O, Braunack-Mayer A, Rogers W. Requiring influenza vaccination for health care workers. Am J Public Health 2009;99:24e29. Olsen DP. Should RNs be forced to get the flu vaccine? Some facilities are mandating it, in an effort to protect patients. AJN Am J Nurs 2006;106:76e79. Finch M. Point: Mandatory influenza vaccination for all heath care workers? Seven reasons to say “no.” Clin Infect Dis 2006;42:1141e1143. Kimura AC, Nguyen CN, Higa JI, et al. The effectiveness of vaccine day and educational interventions on influenza vaccine coverage among health care workers at long-term care facilities. Am J Public Health 2007;97:684e690. Ajenjo MC, Woeltje KF, Babcock HM, et al. Influenza vaccination among healthcare workers: Ten-year experience of a large healthcare organization. Infect Control Hosp Epidemiol 2010;31:233e240.
Lauren J. Campbell, MA Division of Health Policy and Outcomes Research Department of Public Health Sciences University of Rochester Medical Center Rochester, NY Qinghua Li, PhD RTI International Waltham, MA Yue Li, PhD Division of Health Policy and Outcomes Research Department of Public Health Sciences University of Rochester Medical Center Rochester, NY http://dx.doi.org/10.1016/j.jamda.2014.08.001
Refeeding Syndrome: Unrecognized in Geriatric Medicine To the Editor: Malnutrition is a well-established syndrome in geriatric medicine, affecting, in particular, fragile elderly individuals in the hospital and in long-term care facilities. Compensating for nutritional deficiencies is a constant and prevailing feature of medical management in geriatric care. Conversely, the potential dangers of refeeding are less well known in fragile, elderly individuals as compared with the context of intensive care. Over a 5-month observation period, 5 patients in our geriatric medicine ward (2% of all cases) presented refeeding syndrome (Table 1). We present here an illustrative clinical case, and the typical characteristics of refeeding syndrome, with a relevant review of the literature. Clinical Case A female patient aged 75 years, with a history of depression, histrionic personality, and chronic back pain in association with
balance and degenerative disorders, was hospitalized for viral gastroenteritis with diarrhea and vomiting that had started 8 days earlier. The patient was infused and rehydrated, and received potassium and vitamin K. On day 7 of her hospital stay, intravenous (IV) antibiotic therapy (ceftriaxone IV, followed by oral levofloxacin) was initiated for left basal bronchopneumonia caused by Haemophilus influenzae and Streptococcus agalactiae. After initiation of the antibiotics, the patient was transferred to our geriatrics unit, where her appetite returned, although she remained weak and slow. The patient presented no particular complaints, but suffered balance disorders with mobilization difficulties. The health care team described the patient as confused and somewhat “strange.” Additional tests revealed hypokalemia (3.3 mmol/L, normal values 3.5e5.1 mmol/L), hypomagnesemia at 0.53 mmol/L (normal range 0.7e1.1), hypophosphatemia at 0.77 mmol/L (normal range 0.87e1.45), and thiamine deficiency at 91 nmol/L (normal >116 nmol/L). In light of these findings, a diagnosis of refeeding syndrome was confirmed and the patient received phosphate, magnesium, potassium, and thiamine supplementation for 5 days, associated with a progressive increase in daily nutritional intake (from 800 to 1600 kcal per day). The patient’s mental and overall state quickly improved, and she was discharged to her home 2 weeks after initiation of nutritional supplementation. Refeeding Syndrome Refeeding syndrome is defined as the adverse effects that occur when nutrition is reintroduced in a malnourished patient, or in a patient who has been fasting for a prolonged period. The definition of the syndrome covers a wide spectrum of conditions, encompassing the biochemical and metabolic changes and clinical manifestations that may alter a patient’s general state after oral, enteral, or parenteral administration of carbohydrate-based nutrients.1e3 The shift to anabolic phase induces insulin secretion, and, subsequently, the introduction of glucose into the cell, creating an increased need within the cell for phosphate, potassium, magnesium, and thiamine (all contributors to numerous enzyme activities), with a corresponding reduction in the serum concentrations of these agents. Hyperglycemia and hyperinsulinemia can cause sodium retention with secondary fluid overload and possibly congestive heart failure. These symptoms usually occur within the first 5 days of refeeding, and may cause abdominal pain, nausea, vomiting, muscle weakness, tremors, and even delirium.1e6 Some diseases are known to incur a high risk of refeeding syndrome, such as anorexia nervosa, depression, cancer, chronic alcoholism, and digestive inflammatory disease, and patients in the postoperative phase or in intensive care are also especially vulnerable.4e6 Elderly patients, either in the hospital or in nursing homes, are often polymorbid with depleted physiological reserves, and thus should be considered at high risk of refeeding syndrome, particularly because the prevalence of malnutrition in this population can reach up to 50%.7,8 Refeeding syndrome is likely underdiagnosed in older hospitalized persons and those in long-term care facilities because of its unspecific clinical presentation in these patients (ie, patients who are undernourished, weak, confused, frail, with poor mobility). Indeed, it is quite uncommon for serum phosphate, magnesium, or thiamine to be tested in these patients. In one casecontrol study in a cohort of 2307 hospitalized patients older than 65 years followed for 2.7 years, Kagansky et al9 reported that 14.5% of patients presented hypophosphatemia compatible with the refeeding syndrome. The guidelines of the National Institute for Health and Clinical Excellence (NICE) are recognized as a useful tool
