Flu season has invaded,” warns a current HSE radio advertisement. “It’s time to fight back. Our first mission is to protect people at risk.”
The ad urges over-65s and other vulnerable groups to get the flu vaccine. The HSE itself is not immunised, however. The latest statistics, up to the end of November, reveal that only 38% of almost 65,000 workers in 48 hospitals had received the vaccine. Among nursing staff, the rate was only 32%.
So why are healthcare workers not getting the vaccine? Are they putting patients at risk? And should Ireland follow the example of some US states, where flu vaccination for healthcare workers is now compulsory?
There is a strong variation in uptake of the flu vaccine in different healthcare jobs. Uptake rates are likely to have increased in recent weeks but, at the end of November, 56% of medical and dental staff in hospitals had received the vaccine, compared with 32% of nurses and 31% of general support staff.
The HSE did not collect data on why the remaining 44% of doctors and dentists and almost 70% of nurses and support staff were not vaccinated.
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International studies suggest a range of reasons. In 2007, the University of Pennsylvania Health System — Penn Medicine — surveyed those of its staff who were opting out of the vaccine. It had made a big effort to improve the accessibility of the vaccine to its 18,000 staff, making it available on wards, including for shift workers. Similar measures have been taken this year in Ireland. However, as in Ireland, the uptake rate within Penn Medicine facilities remained below 40%.
The survey found that unvaccinated staff underestimated the prevalence of flu, feared vaccination would cause illness, or believed that “clean living” would prevent transmission, according to a 2013 article by Penn Medicine director of occupational medicine Amy Behrman. In 2009, Penn Medicine made vaccination mandatory.
Paul Bell, healthcare divisional organiser at Siptu, the trade union representing thousands of healthcare workers, including support staff, said “there would be massive resistance to someone being instructed to take a vaccine for the flu virus” on a mandatory basis.
Bell believes some healthcare workers resist getting the flu vaccine “for the same reasons as other people in the community”, including a previous bad experience or a belief it doesn’t work. He noted this year’s vaccine did not match the predominant strain people were catching.
It is also possible that stressed staff in overcrowded hospitals do not like being nagged by employers. One nurse, who declined to be named, said mandatory vaccination would make her feel like “some kind of farm animal that needs to be ‘winter well’”, and would send the message, “you’re not allowed to be sick, so work harder”. It would also carry the “stigma of [nurses] being seen as a ‘threat’ to our patients”.
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She said: “This evening I left the ward at 9.30pm from an understaffed, unsafe shift after working 14 hours, with no break since 1pm. If I or my colleagues call in sick tomorrow, it won’t be the flu. If there was a vaccination for burnout and exhaustion, it needs to be looked into promptly if it is believed that the solution lies in a syringe.”
The Irish Nurses and Midwives Organisation (INMO), like Siptu, advises members to get the vaccination. Yet the INMO secretary general Phil Ní Sheaghdha does not believe patients are catching flu from staff. “The flu is a community-acquired infection. You get it before you come to hospital,” she said. “Healthcare workers are not giving people the flu. People have the flu and attend hospital for care.”
She claimed there is “a lot of scaremongering in the media about the healthcare-worker angle”.
Yet Anthony Staines, a professor of public health in Dublin City University, said there are strong reasons for healthcare workers to get vaccinated, including to protect patients. “There are cases in the [international] literature of outbreaks of flu in acute hospital settings, enough to cause concern,” he said. “Healthcare workers work with people who are vulnerable. If you work in a cancer centre, there are a lot of people around whose immune systems are weak.”
A systematic review of existing studies in 2016 did not find conclusive evidence that vaccinating workers protects against flu, its complications, or mortality in over-60s in care homes. However, Staines said the quality of evidence in that study was low and the data limited. It is difficult to prove that vaccinating workers protects patients as large-scale randomised controlled trials are not really possible: it would be deemed unethical to use an unvaccinated hospital as a control.
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Cillian de Gascun, director of the National Virus Reference Laboratory, said, while the flu vaccine is not one of the more effective jabs, “50%-60% effective is a hell of a lot better than 0%”.
“Some people will think, ‘I’m young and healthy, I’m never going to get it.’ People think of the impact on themselves and don’t focus on the fact that we’re vaccinating for the patients’ benefit, not theirs. Healthcare workers can be asymptomatic and have the flu,” said de Gascun.
Senior officials working on this year’s flu outbreak, in which 34 people have died so far, are frustrated by the low staff-vaccination rate. Both de Gascun and Kevin Kelleher, the HSE’s assistant national director for public health, favour mandatory vaccination.
Kelleher said that there is likely to be “massive resistance” to this, given current low uptake. However, rates have improved year on year, and Kelleher believes, if the HSE could get staff uptake to 55%-60% on a voluntary basis through improved access to the vaccine and education about it, a mandatory programme “would not be as hard to do”.
“One of the biggest problems we have is that, in nursing homes, invariably the uptake among residents is well over 90% and in staff it’s 30%. There is a poor knowledge among healthcare workers about how vaccines work. Our doctors’ rate is over 50% and that shows knowledge makes a difference.”
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De Gascun said the wider risk from low vaccination rates among healthcare workers is that it presents a “leadership issue” at a time when public faith in vaccines has been shaken by misinformation online, particularly in relation to HPV.
He said: “The bigger concern for me is that we in medicine and nursing are very strong advocates for vaccination for the public. It has to be a case of ‘do as we do’.”