Should the influenza vaccine be mandatory for frontline staff? Professor Alan Glasper from the University of Southampton discusses the latest flu plan initiative by the Department of Health, NHS England and Public Health England for the winter of 2014–15 designed to increase flu vaccine uptake among frontline health professionals
Background Every year PHE publishes a collection of information entitled the Green book which is designed to assist health professionals and immunisation practitioners in keeping up to date with developments in the field of infectious disease (PHE 2014). Chapter 19 of the Green Book gives significant detail pertinent to flu which is transmitted by droplet infection and primarily affects the respiratory
1044
tract. Flu is a much more serious illness than the common cold and, in susceptible people, there is a risk of developing illnesses that are life threatening.These include respiratory bacterial infections such as bronchitis and pneumonia, where hospital admission may be required. In certain situations, the disease and its variants may prove fatal, and Glasper (2011) cites the swine flu epidemic of 2009, which infected 540 000 people and caused many deaths in the UK. It is important to stress that it is not just the elderly who are at risk of being infected by the flu as it can often adversely affect very young children and people with underlying longterm medical conditions such as heart disease. Although often overlooked, it is nurses on the front line of care delivery who are particularly at risk of contracting flu and are therefore encouraged to have an annual flu vaccine to protect themselves and the patients they care for. Currently this stops short of mandatory immunisation. It is, however, important to stress that the Green Book recommends annual immunisation for health professionals directly involved in the care of patients. This strategy is designed to reduce the transmission of flu within healthcare institutions.
Increasing seasonal influenza vaccination Many argue that flu vaccination of frontline health professionals should be mandatory but in its absence, staff immunisation against flu must be pursued with vigilance. Clearly there are some groups of nurses who should be vaccinated, both for their own defence and to protect their patients. Isaacs and Leask (2008) have shown that vaccinating frontline health professionals who care for the elderly protects these vulnerable patients. Isaacs and Leask (2008) report that a 2004 North American Hospital initiative to introduce mandatory flu vaccination for health professionals resulted in over 600 staff complaints, which led to significant human resource management issues. However, immunisation uptake at this same hospital rose from 56% to 96%.
Although the feasibility of mandatory flu immunisation will continue to be debated, it is worthy of note that in 2012, a Royal College of Nursing (RCN) Congress resolution raised by the Suffolk branch, namely ‘That this meeting of RCN Congress asks Council to lobby for all nursing staff and students to be required to have an annual flu vaccination and for it to be provided free of charge’ was not passed, with over 90% of congress delegates not being in favour. (RCN, 2012)
Making the case for enhanced levels of staff immunisation Florence Nightingale first uttered the mantra of modern nursing: ‘It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.’ (Nightingale, 1863) In contemporary practice, it is the Nursing and Midwifery Council (NMC) who make it their primary mission: ‘To safeguard the health and wellbeing of the public by ensuring that nurses and midwives consistently deliver high quality healthcare.’ (NMC, 2010) Although it would be inconceivable for any nurse to intentionally infect a vulnerable patient, it should be noted that their very status as frontline carers makes them moresusceptible, because of their increased exposure, to contracting flu compared to members of the public. Undoubtedly, some nurses may unintentionally become both a harbinger and a vector of flu for patients, colleagues and family members. Additionally when nurses have to take sick leave because of flu, which is a very distressing and debilitating disease even in otherwise healthy victims, they can contribute to a staffing crisis within a healthcare institution, which further puts patients at risk.
© 2014 MA Healthcare Ltd
A
s autumn slowly fades and winter approaches, the first signs of seasonal illnesses begin to appear. Runny noses and sore throats herald the increased incidence of the common cold. But a much more malevolent virus is also prevalent in the same period; influenza! The media interest in the ongoing African pandemic that is Ebola haemorrhagic fever shows no sign of abating. Although the death rate from Ebola continues to rise and, at last count was over 4000 worldwide (World Health Organization 2014), over the ages, influenza has killed many more people. Spanish flu, which emerged at the close of World War One, affected more than one third of the world’s population, and was responsible for more than 50 million deaths compared to the 8.5 million soldiers who were killed in combat during the war (Prigg, 2014; historylearningsite.co.uk, 2011). It should be remembered that deaths from influenza in England and Wales were 21 497 for the 1999–2000 influenza season (Donaldson et al, 2010). Despite much publicity about the importance of influenza immunisation throughout 2013, nearly 50% of frontline health and social care workers failed to take up the offered vaccine putting themselves and their patients in danger of infection (NHS Employers, 2014). The 2014–15 Flu Plan is designed to address, among others, the failure of health professionals to immunise themselves against flu (Public Health England (PHE), Department of Health (DH), NHS England, 2014).
British Journal of Nursing, 2014, Vol 23, No 20
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 20, 2015. For personal use only. No other uses without permission. . All rights reserved.
HEALTHCARE POLICY Although the NHS is well accustomed to dealing with the winter pressures caused by seasonal illnesses, high levels of sick leave among key nursing groups can put a strain on the ability of individual institutions to cope. Although all types of flu can be potentially fatal for the infected person, it is the duration and burden of the illness that is often debilitating for the individual and for society as a whole, which has to carry on delivering services, often with a severely diminished workforce. When high levels of sickness among nursing staff occurs, this in turn puts further strain on those members of staff who remain uninfected and this compromises their abilities to maintain high standards of care. Crucially, were a seasonal flu outbreak to reach pandemic proportions among key nursing personnel, the ability of the NHS to provide a national service could well be jeopardised. Although compulsory flu immunisation may be very effective in preventing disease outbreaks, the benefits may be outweighed by the associated ethical problems. Furthermore, it is highly unlikely in the near future that the government will introduce compulsory immunisation against flu. However the 2014 seasonal influenza policy initiative (PHE et al, 2014) hopes that in raising the issues of noncompliance, higher levels of immunisation will be achieved through other approaches.
© 2014 MA Healthcare Ltd
The NHS Flu Fighters Campaign Flu fighter is an initiative by the NHS Employers organisation, which works closely with PHE and DH to improve levels of flu immunisation among NHS staff. It is important to stress that uptake of flu immunisation by NHS frontline staff has increased, from 35% in 2010–11, to 45% in 2011–12, to 46% in 2012–13 and 55% in 2013–14, but much more needs to be done to encourage further uptake (NHS Employers, 2014) The Flu Fighter campaign has developed a number of useful resources to support flu immunisation among health professionals, especially those working in the frontline. One of the initiatives has involved the creation of a series of informative letter templates, which can be personalised and sent to individual staff members. These letters can be embellished with clinical evidence which emphasises the safety of the vaccination and provides answers to commonly asked questions. Additionally, a series of seven case studies have been developed and are available via the campaign website. These case studies are designed to help NHS institutions plan: ■■ A flu immunisation communication strategy
British Journal of Nursing, 2014, Vol 23, No 20
KEY POINTS n Influenza is a disease which is highly contagious and can be life-threatening n Immunisation of nurses in the front line of care delivery is essential n Nurses, health care assistants and other frontline health professionals who are in direct contact with patients are highly vulnerable to contacting influenza n The flu vaccine is safe and effective and, despite myths, cannot cause flu ■■ A
campaign about the misconceptions held by staff about flu vaccination ■■ Accessible routes to take the vaccine to staff members e.g. the use of a ‘flu bus’ ■■ Staff rewards schemes to incentivise individual staff members ■■ Peer vaccination, which gives details on how institutions can appoint peer vaccinators, or create flu champions, to help lead the initiatives ■■ A corporate strategy, which has the support of all senior board level and managerial staff to ensure that everyone is involved ■■ A balanced flu team, which is representative of the whole organisation. (NHS Employers, 2014)
How can nurses help There are many misconceptions about the flu vaccine and nurses are well equipped to deride these. Nurses can help fight seasonal flu by promoting the following messages, which stem from this 2014–15 Flu Plan: ■■ It is the duty of health professionals to do everything in their power to protect patients against infection, including being immunised against flu ■■ Self-protection, patient protection and personal family protection can be enhanced by flu immunisation ■■ Everyone is vulnerable to seasonal flu, even when in good general health but frontline health and social care staff are particularly vulnerable, especially those whose job brings then into direct contact with sufferers ■■ Health professionals can be infected with flu, may show no symptoms but be contagious to others ■■ Good infection control measures are essential to mitigate the spread of flu, but this alone cannot prevent the disease spreading ■■ An attack of flu in vulnerable patients can be fatal and outbreaks of the virus can cause severe disruption ■■ The flu vaccine is safe and effective and, despite myths, cannot cause flu.When nurses are immunised, it encourages other nurses to follow suit. ■■ Immunised health professionals can act as
positive role models for elderly patients, especially those with long-term health conditions and pregnant women to access immunisation. (PHE, DH, NHS England, 2014)
Conclusion Flu is an acute viral infection of the respiratory tract with associated symptoms exemplified by an accompanying fever with headache, muscle and joint pain, and fatigue. In healthy patients, flu is a self-limiting illness, which usually lasts up to seven days. However, in vulnerable groups the disease can be fatal which is why the Flu Plan (PHE et al, 2014) mandates NHS organisations to have a duty to ensure that frontline health professionals are offered and are encouraged to have the flu immunisation. The other goal is to minimise the health impact of flu through effective monitoring, prevention and treatment. This can be achieved through targeting 100% of patients in clinical risk groups and achieving a 75% immunisation rate in people aged 65 years BJN and over. Donaldson LJ, Rutter PD, Ellis BM et al (2010) English mortality from A/H1N1. Comparisons with recent flu mortality. BMJ 340: c612 Glasper A (2011) Seasonal influenza: what every nurse needs to know. Br J Nurs 20(19): 1262–3 Isaacs D, Leask J (2008) Should influenza immunisation be mandatory for healthcare workers? No. BMJ 337: a2140 HistoryLearningSite.co.uk. (2011) First World War Casualties http://tinyurl.com/5frze (accessed 28 October 2014) Nightingale F (1863) Notes on Hospitals. Longman, Green, Longman, Roberts and Green. London NHS Employers (2014) Flu Fighter. http://tinyurl.com/ pa7pqja (accessed 28 October 2014) Nursing and Midwifery Council (2010) Our vision, mission and values. http://tinyurl.com/o53ga73 (accessed 28 October 2014) Prigg M (2014) Secret of what made 1918 Spanish flu epidemic that killed 50 MILLION the fastest in history Mailonline. 29 April 2014. http://tinyurl.com/npwv65w (accessed 28 October 2014) Public Health England (2014) Immunisation against infection diseases (The Green Book). http://tinyurl.com/ nqbpvr5 (accessed 28 October 2014) Public Health England, Department of Health, NHS England (2014) Flu Plan: winter 2014–2015. http:// tinyurl.com/ns97y7v (accessed 28 October 2014) Royal College of Nursing (2012) Flu jabs for all? http:// tinyurl.com/l3ondas (accessed 28 October 2014) Salmon DA, Teret SP, MacIntyre CR, Salisbury D, Burgess M A, Halsey NA (2006) Compulsory vaccination and conscientious or philosophical exemptions: past, present, and future. Lancet 367(9508): 436–42. doi: 10.1016/ S0140-6736(06)68144-0 World Health Organization (2014) Ebola Response Roadmap Situation Report Update 25 October 2014. http://tinyurl.com/pezgqe9 (accessed 28 October 2014)
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British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 20, 2015. For personal use only. No other uses without permission. . All rights reserved.
Background Every year PHE publishes a collection of information entitled the Green book which is designed to assist health professionals and immunisation practitioners in keeping up to date with developments in the field of infectious disease (PHE 2014). Chapter 19 of the Green Book gives significant detail pertinent to flu which is transmitted by droplet infection and primarily affects the respiratory
1044
tract. Flu is a much more serious illness than the common cold and, in susceptible people, there is a risk of developing illnesses that are life threatening.These include respiratory bacterial infections such as bronchitis and pneumonia, where hospital admission may be required. In certain situations, the disease and its variants may prove fatal, and Glasper (2011) cites the swine flu epidemic of 2009, which infected 540 000 people and caused many deaths in the UK. It is important to stress that it is not just the elderly who are at risk of being infected by the flu as it can often adversely affect very young children and people with underlying longterm medical conditions such as heart disease. Although often overlooked, it is nurses on the front line of care delivery who are particularly at risk of contracting flu and are therefore encouraged to have an annual flu vaccine to protect themselves and the patients they care for. Currently this stops short of mandatory immunisation. It is, however, important to stress that the Green Book recommends annual immunisation for health professionals directly involved in the care of patients. This strategy is designed to reduce the transmission of flu within healthcare institutions.
Increasing seasonal influenza vaccination Many argue that flu vaccination of frontline health professionals should be mandatory but in its absence, staff immunisation against flu must be pursued with vigilance. Clearly there are some groups of nurses who should be vaccinated, both for their own defence and to protect their patients. Isaacs and Leask (2008) have shown that vaccinating frontline health professionals who care for the elderly protects these vulnerable patients. Isaacs and Leask (2008) report that a 2004 North American Hospital initiative to introduce mandatory flu vaccination for health professionals resulted in over 600 staff complaints, which led to significant human resource management issues. However, immunisation uptake at this same hospital rose from 56% to 96%.
Although the feasibility of mandatory flu immunisation will continue to be debated, it is worthy of note that in 2012, a Royal College of Nursing (RCN) Congress resolution raised by the Suffolk branch, namely ‘That this meeting of RCN Congress asks Council to lobby for all nursing staff and students to be required to have an annual flu vaccination and for it to be provided free of charge’ was not passed, with over 90% of congress delegates not being in favour. (RCN, 2012)
Making the case for enhanced levels of staff immunisation Florence Nightingale first uttered the mantra of modern nursing: ‘It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.’ (Nightingale, 1863) In contemporary practice, it is the Nursing and Midwifery Council (NMC) who make it their primary mission: ‘To safeguard the health and wellbeing of the public by ensuring that nurses and midwives consistently deliver high quality healthcare.’ (NMC, 2010) Although it would be inconceivable for any nurse to intentionally infect a vulnerable patient, it should be noted that their very status as frontline carers makes them moresusceptible, because of their increased exposure, to contracting flu compared to members of the public. Undoubtedly, some nurses may unintentionally become both a harbinger and a vector of flu for patients, colleagues and family members. Additionally when nurses have to take sick leave because of flu, which is a very distressing and debilitating disease even in otherwise healthy victims, they can contribute to a staffing crisis within a healthcare institution, which further puts patients at risk.
© 2014 MA Healthcare Ltd
A
s autumn slowly fades and winter approaches, the first signs of seasonal illnesses begin to appear. Runny noses and sore throats herald the increased incidence of the common cold. But a much more malevolent virus is also prevalent in the same period; influenza! The media interest in the ongoing African pandemic that is Ebola haemorrhagic fever shows no sign of abating. Although the death rate from Ebola continues to rise and, at last count was over 4000 worldwide (World Health Organization 2014), over the ages, influenza has killed many more people. Spanish flu, which emerged at the close of World War One, affected more than one third of the world’s population, and was responsible for more than 50 million deaths compared to the 8.5 million soldiers who were killed in combat during the war (Prigg, 2014; historylearningsite.co.uk, 2011). It should be remembered that deaths from influenza in England and Wales were 21 497 for the 1999–2000 influenza season (Donaldson et al, 2010). Despite much publicity about the importance of influenza immunisation throughout 2013, nearly 50% of frontline health and social care workers failed to take up the offered vaccine putting themselves and their patients in danger of infection (NHS Employers, 2014). The 2014–15 Flu Plan is designed to address, among others, the failure of health professionals to immunise themselves against flu (Public Health England (PHE), Department of Health (DH), NHS England, 2014).
British Journal of Nursing, 2014, Vol 23, No 20
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 20, 2015. For personal use only. No other uses without permission. . All rights reserved.
HEALTHCARE POLICY Although the NHS is well accustomed to dealing with the winter pressures caused by seasonal illnesses, high levels of sick leave among key nursing groups can put a strain on the ability of individual institutions to cope. Although all types of flu can be potentially fatal for the infected person, it is the duration and burden of the illness that is often debilitating for the individual and for society as a whole, which has to carry on delivering services, often with a severely diminished workforce. When high levels of sickness among nursing staff occurs, this in turn puts further strain on those members of staff who remain uninfected and this compromises their abilities to maintain high standards of care. Crucially, were a seasonal flu outbreak to reach pandemic proportions among key nursing personnel, the ability of the NHS to provide a national service could well be jeopardised. Although compulsory flu immunisation may be very effective in preventing disease outbreaks, the benefits may be outweighed by the associated ethical problems. Furthermore, it is highly unlikely in the near future that the government will introduce compulsory immunisation against flu. However the 2014 seasonal influenza policy initiative (PHE et al, 2014) hopes that in raising the issues of noncompliance, higher levels of immunisation will be achieved through other approaches.
© 2014 MA Healthcare Ltd
The NHS Flu Fighters Campaign Flu fighter is an initiative by the NHS Employers organisation, which works closely with PHE and DH to improve levels of flu immunisation among NHS staff. It is important to stress that uptake of flu immunisation by NHS frontline staff has increased, from 35% in 2010–11, to 45% in 2011–12, to 46% in 2012–13 and 55% in 2013–14, but much more needs to be done to encourage further uptake (NHS Employers, 2014) The Flu Fighter campaign has developed a number of useful resources to support flu immunisation among health professionals, especially those working in the frontline. One of the initiatives has involved the creation of a series of informative letter templates, which can be personalised and sent to individual staff members. These letters can be embellished with clinical evidence which emphasises the safety of the vaccination and provides answers to commonly asked questions. Additionally, a series of seven case studies have been developed and are available via the campaign website. These case studies are designed to help NHS institutions plan: ■■ A flu immunisation communication strategy
British Journal of Nursing, 2014, Vol 23, No 20
KEY POINTS n Influenza is a disease which is highly contagious and can be life-threatening n Immunisation of nurses in the front line of care delivery is essential n Nurses, health care assistants and other frontline health professionals who are in direct contact with patients are highly vulnerable to contacting influenza n The flu vaccine is safe and effective and, despite myths, cannot cause flu ■■ A
campaign about the misconceptions held by staff about flu vaccination ■■ Accessible routes to take the vaccine to staff members e.g. the use of a ‘flu bus’ ■■ Staff rewards schemes to incentivise individual staff members ■■ Peer vaccination, which gives details on how institutions can appoint peer vaccinators, or create flu champions, to help lead the initiatives ■■ A corporate strategy, which has the support of all senior board level and managerial staff to ensure that everyone is involved ■■ A balanced flu team, which is representative of the whole organisation. (NHS Employers, 2014)
How can nurses help There are many misconceptions about the flu vaccine and nurses are well equipped to deride these. Nurses can help fight seasonal flu by promoting the following messages, which stem from this 2014–15 Flu Plan: ■■ It is the duty of health professionals to do everything in their power to protect patients against infection, including being immunised against flu ■■ Self-protection, patient protection and personal family protection can be enhanced by flu immunisation ■■ Everyone is vulnerable to seasonal flu, even when in good general health but frontline health and social care staff are particularly vulnerable, especially those whose job brings then into direct contact with sufferers ■■ Health professionals can be infected with flu, may show no symptoms but be contagious to others ■■ Good infection control measures are essential to mitigate the spread of flu, but this alone cannot prevent the disease spreading ■■ An attack of flu in vulnerable patients can be fatal and outbreaks of the virus can cause severe disruption ■■ The flu vaccine is safe and effective and, despite myths, cannot cause flu.When nurses are immunised, it encourages other nurses to follow suit. ■■ Immunised health professionals can act as
positive role models for elderly patients, especially those with long-term health conditions and pregnant women to access immunisation. (PHE, DH, NHS England, 2014)
Conclusion Flu is an acute viral infection of the respiratory tract with associated symptoms exemplified by an accompanying fever with headache, muscle and joint pain, and fatigue. In healthy patients, flu is a self-limiting illness, which usually lasts up to seven days. However, in vulnerable groups the disease can be fatal which is why the Flu Plan (PHE et al, 2014) mandates NHS organisations to have a duty to ensure that frontline health professionals are offered and are encouraged to have the flu immunisation. The other goal is to minimise the health impact of flu through effective monitoring, prevention and treatment. This can be achieved through targeting 100% of patients in clinical risk groups and achieving a 75% immunisation rate in people aged 65 years BJN and over. Donaldson LJ, Rutter PD, Ellis BM et al (2010) English mortality from A/H1N1. Comparisons with recent flu mortality. BMJ 340: c612 Glasper A (2011) Seasonal influenza: what every nurse needs to know. Br J Nurs 20(19): 1262–3 Isaacs D, Leask J (2008) Should influenza immunisation be mandatory for healthcare workers? No. BMJ 337: a2140 HistoryLearningSite.co.uk. (2011) First World War Casualties http://tinyurl.com/5frze (accessed 28 October 2014) Nightingale F (1863) Notes on Hospitals. Longman, Green, Longman, Roberts and Green. London NHS Employers (2014) Flu Fighter. http://tinyurl.com/ pa7pqja (accessed 28 October 2014) Nursing and Midwifery Council (2010) Our vision, mission and values. http://tinyurl.com/o53ga73 (accessed 28 October 2014) Prigg M (2014) Secret of what made 1918 Spanish flu epidemic that killed 50 MILLION the fastest in history Mailonline. 29 April 2014. http://tinyurl.com/npwv65w (accessed 28 October 2014) Public Health England (2014) Immunisation against infection diseases (The Green Book). http://tinyurl.com/ nqbpvr5 (accessed 28 October 2014) Public Health England, Department of Health, NHS England (2014) Flu Plan: winter 2014–2015. http:// tinyurl.com/ns97y7v (accessed 28 October 2014) Royal College of Nursing (2012) Flu jabs for all? http:// tinyurl.com/l3ondas (accessed 28 October 2014) Salmon DA, Teret SP, MacIntyre CR, Salisbury D, Burgess M A, Halsey NA (2006) Compulsory vaccination and conscientious or philosophical exemptions: past, present, and future. Lancet 367(9508): 436–42. doi: 10.1016/ S0140-6736(06)68144-0 World Health Organization (2014) Ebola Response Roadmap Situation Report Update 25 October 2014. http://tinyurl.com/pezgqe9 (accessed 28 October 2014)
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British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.194.020.173 on November 20, 2015. For personal use only. No other uses without permission. . All rights reserved.
