Infectious Disease

Should We Be Vaccinating Our Patients Against Influenza?

ED vaccination strategies have been successful and reimbursable and are advocated by several major clinical practice advisory groups. So why aren't we offering flu vaccines routinely?

Influenza is among the top 10 causes of death in the United States,1 with more than 700,000 flu-related hospitalizations annually and 50,000+ flu-related deaths.2 The annual economic burden of influenza has been estimated to be $87 billion.3 Despite these statistics, influenza vaccination coverage has been shown to be poor, with only 37.1% coverage for the 2017-2018 influenza season. This is a 6% drop from the 2016-2017 season,4 raising alarm for improved efforts to address poor vaccination compliance.

Emergency department personnel are uniquely positioned to vaccinate a substantial number of patients who would not otherwise be vaccinated, including many high-risk populations. This represents a substantial missed opportunity as 2.8 million patients seen in the ED annually who are at high risk for complications from influenza leave without being vaccinated,5 despite such initiatives for emergency department-based vaccination programs being supported by national organizations. A 2015 ACEP Policy Statement supports the immunization of high-risk patients in the emergency department against influenza,6 and more broadly, ACEP has recommended influenza vaccination of hospitalized patients for more than 20 years.7,8

Only 36% of adults aged 65 and older receive the influenza vaccine annually, a population which is the fastest growing proportion of emergency department patients9 and a population particularly at risk for influenza related complications.10 Influenza vaccination of the elderly can have a profound impact, with studies showing upwards of a 75% reduction in death and up to a 39% reduction in hospitalization.11 For the institutionalized elderly there is a 50% reduction in hospitalization.12 The FLUVACS Trial, a prospective randomized study, demonstrated a 23% relative risk reduction for severe ischemia, nonfatal myocardial infarction and cardiovascular death among those immunized against influenza compared with unimmunized matched controls.13

Influenza outbreaks have been associated with a substantial increase in ED utilization for those 65 and older for influenza related infections and its complications. In fact, it has been shown that for every 10 new cases of influenza, there is a 1.5% increase in the proportion of elderly patients in the ED who presented with influenza-related infections and upper respiratory infections.14 Prevention of influenza can offset the surges seen in ED utilization during the 2009 H1N1 pandemic.15-20 During times in which the CDC declared “widespread influenza activity” there is a significant increase in department resource use,21 particularly among patients with underlying respiratory illness.22 Additionally, influenza outbreaks are associated with increased ambulance diversion.23 For every 100 cases of influenza per week, ambulance diversion increased by 2.5 hours per week. Taken together, these data suggest that influenza infections contribute to all the complications associated with ED overcrowding.

Differences in perspectives regarding vaccination are not uncommon among nurses and physicians.24-26 While survey data collected from ED nurses suggests a negative view of influenza vaccine programs in the department,27 it has been shown that such vaccination implementation programs can be effective, easily administered, and do not have a detrimental effect on quality indicators.28 Research shows higher vaccine rates among resident and attending physicians and lower rates among nursing staff,24,29 which may help explain these divergent findings. Similarly, clinicians who receive vaccinations are more likely to recommend them for patients.30-32 From a patient perspective, survey data suggests that most unvaccinated ED patients would be amenable to vaccination if it were offered.33,34

While concerns have been raised about the feasibility of ED-based vaccination programs - such as perceived disruption of department flow and lack of time29 - these programs are well-received by emergency physicians, nursing staff, and patients alike.28,35

Nearly half of U.S. medical care is now provided through the ED.36 and emergency physicians represent a safety net.37 This is not a new concept. The ED has a front-line role in combating vaccine-preventable illness. In fact, due to recent increases in the number of pertussis cases the CDC recommended TDAP in lieu of Td for those requiring tetanus vaccination as part of wound management,40 and this approach has been found to be beneficial and cost effective.41

ED vaccination strategies have been successful and reimbursable and are advocated by several major clinical practice advisory groups. This represents a cost-effective opportunity to address the wellbeing of an underserved population, without disrupting workflow.


References

  1. Murphy S, Xu, J, Kochanek, K, Arias, E. Mortality in the United States, 2017. National Center for Health Statistics. https://www.cdc.gov/nchs/products/databriefs/db328.htm. Published 2018. Accessed November 28, 2019.
  2. Prevention CfDCa. Vaccine-Preventable Adult Diseases. https://www.cdc.gov/vaccines/adults/vpd.html. Published 2016. Accessed November 28, 2019.
  3. Molinari NA, Ortega-Sanchez IR, Messonnier ML, et al. The annual impact of seasonal influenza in the US: measuring disease burden and costs. Vaccine. 2007;25(27):5086-5096.
  4. Prevention CfDCa. Estimates of Influenza Vaccination Coverage among Adults—United States, 2017–18 Flu Season. FluVaxView Web site. https://www.cdc.gov/flu/fluvaxview/coverage-1718estimates.htm. Accessed November 28, 2019.
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  6. ACEP. Immunization of Adults and Children in the Emergency Department. https://www.acep.org/patient-care/policy-statements/immunization-of-adults-and-children-in-the-emergency-department/. Published 2015. Accessed November 28, 2019.
  7. Bridges CB, Fukuda K, Cox NJ, Singleton JA, Advisory Committee on Immunization P. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2001;50(RR-4):1-44.
  8. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1997;46(RR-9):1-25.
  9. Fiore AE, Shay DK, Broder K, et al. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008. MMWR Recomm Rep. 2008;57(RR-7):1-60.
  10. Smetana J, Chlibek R, Shaw J, Splino M, Prymula R. Influenza vaccination in the elderly. Hum Vaccin Immunother. 2018;14(3):540-549.
  11. Nichol KL, Nordin JD, Nelson DB, Mullooly JP, Hak E. Effectiveness of influenza vaccine in the community-dwelling elderly. N Engl J Med. 2007;357(14):1373-1381.
  12. Nichol KL, Nordin J, Mullooly J, Lask R, Fillbrandt K, Iwane M. Influenza vaccination and reduction in hospitalizations for cardiac disease and stroke among the elderly. N Engl J Med. 2003;348(14):1322-1332.
  13. Gurfinkel EP, Leon de la Fuente R, Mendiz O, Mautner B. Flu vaccination in acute coronary syndromes and planned percutaneous coronary interventions (FLUVACS) Study. Eur Heart J. 2004;25(1):25-31.
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  16. Sills MR, Hall M, Fieldston ES, et al. Inpatient capacity at children's hospitals during pandemic (H1N1) 2009 outbreak, United States. Emerg Infect Dis. 2011;17(9):1685-1691.
  17. Graham J, Shirm S, Storm E, Lyle K, Linam WM, Romero J. Challenges and solutions: pandemic 2009 H1N1 influenza A in a pediatric emergency department. Am J Disaster Med. 2011;6(4):211-218.
  18. Sugerman D, Nadeau KH, Lafond K, et al. A survey of emergency department 2009 pandemic influenza A (H1N1) surge preparedness--Atlanta, Georgia, July-October 2009. Clin Infect Dis. 2011;52 Suppl 1:S177-182.
  19. Miroballi Y, Baird JS, Zackai S, et al. Novel influenza A(H1N1) in a pediatric health care facility in New York City during the first wave of the 2009 pandemic. Arch Pediatr Adolesc Med. 2010;164(1):24-30.
  20. Sills MR, Hall M, Simon HK, et al. Resource burden at children's hospitals experiencing surge volumes during the spring 2009 H1N1 influenza pandemic. Acad Emerg Med. 2011;18(2):158-166.
  21. Silka PA, Geiderman JM, Goldberg JB, Kim LP. Demand on ED resources during periods of widespread influenza activity. Am J Emerg Med. 2003;21(7):534-539.
  22. Menec VH, Black C, MacWilliam L, Aoki FY. The impact of influenza-associated respiratory illnesses on hospitalizations, physician visits, emergency room visits, and mortality. Can J Public Health. 2003;94(1):59-63.
  23. Schull MJ, Mamdani MM, Fang J. Community influenza outbreaks and emergency department ambulance diversion. Ann Emerg Med. 2004;44(1):61-67.
  24. Martinello RA, Jones L, Topal JE. Correlation between healthcare workers' knowledge of influenza vaccine and vaccine receipt. Infect Control Hosp Epidemiol. 2003;24(11):845-847.
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  26. McEwen M, Farren E. Actions and beliefs related to hepatitis B and influenza immunization among registered nurses in Texas. Public Health Nurs. 2005;22(3):230-239.
  27. Venkat A, Hunter R, Hegde GG, Chan-Tompkins NH, Chuirazzi DM, Szczesiul JM. Perceptions of participating emergency nurses regarding an ED seasonal influenza vaccination program. J Emerg Nurs. 2012;38(1):22-29.
  28. Casalino E, Ghazali A, Bouzid D, et al. Emergency Department influenza vaccination campaign allows increasing influenza vaccination coverage without disrupting time interval quality indicators. Intern Emerg Med. 2018;13(5):673-678.
  29. Fernandez WG, Oyama L, Mitchell P, et al. Attitudes and practices regarding influenza vaccination among emergency department personnel. J Emerg Med. 2009;36(2):201-206.
  30. LaVela SL, Smith B, Weaver FM, Legro MW, Goldstein B, Nichol K. Attitudes and practices regarding influenza vaccination among healthcare workers providing services to individuals with spinal cord injuries and disorders. Infect Control Hosp Epidemiol. 2004;25(11):933-940.
  31. Toy WC, Janosky JE, Laird SB. Influenza immunization of medical residents: knowledge, attitudes, and behaviors. Am J Infect Control. 2005;33(8):473-475.
  32. Yassi A, Murdzak C, Cheang M, Tran N, Aoki FY. Influenza immunization: knowledge, attitude and behaviour of health care workers. Can J Infect Control. 1994;9(4):103-108.
  33. Polis MA, Smith JP, Sainer D, Brenneman MN, Kaslow RA. Prospects for an emergency department-based adult immunization program. Arch Intern Med. 1987;147(11):1999-2001.
  34. Polis MA, Davey VJ, Collins ED, Smith JP, Rosenthal RE, Kaslow RA. The emergency department as part of a successful strategy for increasing adult immunization. Ann Emerg Med. 1988;17(10):1016-1018.
  35. Taylor A VE, Elizalde M, Li-Brubacher J. Influenza and Pneumococcal Disease Vaccinations: Is There a Role For Prevention In the Emergency Department. BCMJ. 2018;60(2):116-120.
  36. Marcozzi D, Carr B, Liferidge A, Baehr N, Browne B. Trends in the Contribution of Emergency Departments to the Provision of Hospital-Associated Health Care in the USA. Int J Health Serv. 2018;48(2):267-288.
  37. Rhodes KV, Gordon JA, Lowe RA. Preventive care in the emergency department, Part I: Clinical preventive services--are they relevant to emergency medicine? Society for Academic Emergency Medicine Public Health and Education Task Force Preventive Services Work Group. Acad Emerg Med. 2000;7(9):1036-1041.
  38. Pascual FB, McGinley EL, Zanardi LR, Cortese MM, Murphy TV. Tetanus surveillance--United States, 1998--2000. MMWR Surveill Summ. 2003;52(3):1-8.
  39. Pallin DJ, Muennig PA, Emond JA, Kim S, Camargo CA, Jr. Vaccination practices in U.S. emergency departments, 1992-2000. Vaccine. 2005;23(8):1048-1052.
  40. Prevention CfDCa. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine in adults aged 65 years and older—Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report Web site. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6125a4.htm. Published 2012. Accessed November 28, 2019.
  41. Talbird SE, Graham J, Mauskopf J, Masseria C, Krishnarajah G. Impact of tetanus, diphtheria, and acellular pertussis (Tdap) vaccine use in wound management on health care costs and pertussis cases. J Manag Care Spec Pharm. 2015;21(1):88-99, 99a-c.

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