key: cord-0852492-s1kkp1x5 authors: Grech, Victor; Borg, Michael; Gauci, Charmaine; Barbara, Christopher; Montalto, Simon Attard; Agius, Steve; Falzon, Celia title: Needed: less influenza vaccine hesitancy and less presenteeism among health care workers in the COVID-19 era date: 2020-10-01 journal: Early Hum Dev DOI: 10.1016/j.earlhumdev.2020.105215 sha: e1f05756f84a59031c0f94d02dc2aaeec4ad4d9f doc_id: 852492 cord_uid: s1kkp1x5 Seasonal influenza causes significant morbidity and mortality, and healthcare-associated disease is particularly problematic as it affects high-risk groups. For this reason, annual vaccination against influenza is generally recommended for all healthcare workers, thereby embracing the twin principles of beneficence and non-maleficence. The cost and burden of influenza vaccination is minimal, and it has been argued that employing institutions are under an obligation to ensure that employees are universally vaccinated. Presenteeism, i.e. reporting for work when unwell, is another significant cause of nosocomial infection and may easily occur as even in the hypothetical ideal situation of 100% vaccination coverage, the influenza vaccine is not 100% effective. This paper reviews the combined benefits of increased vaccination rates and reduced presenteeism rates in healthcare workers, particularly in the event of a winter surge in COVID-19 infections that will result in simultaneous infection with influenza and COVID-19, with potentially severe consequences. Influenza-like illness is caused by more than 200 different viruses and bacteria, of which only 10% of cases are due to the influenza virus. 1 The World Health Organization estimates that seasonal influenza annually infects 5% to 15% of the global population, with 3-5 million cases of severe illness and up to half a million deaths. 2 Hospital-acquired influenza is often spread by infected healthcare workers, 3 and has a particularly high mortality, with an estimated median of 16%, rising up to 60% in high risk groups such as transplant recipients and intensive care patients. 4, 5 This is unfortunate as a significant proportion of the burden of this disease is vaccine-preventable. 6 Hence, in the United States, the Centers for Disease Control have recommended annual influenza vaccination for all healthcare workers since 1981. 7 Nevertheless, vaccination rates in the general population and healthcare workers remain low, in the region of about 45% and 56.5%, respectively, in Malta. 8, 9 In the absence of an effective vaccine, next winter, the novel pandemic coronavirus COVID-19 is likely to circulate in conjunction with seasonal influenza. Symptoms of both viral infections are similar, and the combined effect of co-infection with these two viruses (and any future strains) is unknown. This paper reviews the benefits of increased influenza vaccination rates in healthcare workers, and the effect that presenteeism may have on exacerbating the evolving situation this coming winter. This initiative will need to be combined with improved vaccination rates in the general population, as well as high risk groups including children. Mandating vaccination? There is growing awareness amongst clinicians, but also ethicists and legislators, for mandating seasonal influenza vaccination for healthcare workers. In 2005, the Society for Healthcare Epidemiology (SHE) published a position paper stating "all healthcare workers should receive influenza vaccine annually unless they have a contraindication to the vaccine or actively decline vaccination." 10 With increasing evidence favouring vaccination, this posture hardened five years later with a revised position paper that recommended that annual influenza vaccination should be a condition of employment for healthcare workers, 11 a stance later endorsed almost universally by professional bodies. 12 Nicolas Cortes-Penfield has also argued that "given the mounting evidence for the efficacy of influenza vaccination in infection control […] the provision of health care by non-vaccinated health care workers is not merely suboptimal health care, but it is also at variance with generally accepted principles of health care ethics". 12 Routine influenza vaccination for healthcare workers embraces the twin ethical principles of beneficence and non-maleficence. The former promotes patients' well-being and the latter embodies 'do no harm' (primum non nocere). The influenza vaccination of healthcare workers will reduce flu transmission, especially in hospital settings, and is therefore beneficent. However, Cortes-Penfield has also cogently argued "that vaccination against influenza should be mandatory because practicing without vaccination is maleficent because it falls below the standard of medical care". 12 Efficacy in healthcare settings Several prospective trials have shown that the vaccination of healthcare workers reduces influenza morbidity and mortality in influenza-vulnerable populations. This is especially the case in the elderly and those in care homes. [13] [14] [15] [16] It is known that, with increasing age beyond 20 years, immune function declines by 2-3% per annum. 17 For this reason, influenza vaccination of the elderly has a high failure rate, making it especially important that their J o u r n a l P r e -p r o o f Journal Pre-proof carers are vaccinated. It has been estimated that effective vaccination in just 11 to 125 carers would prevent one healthcare-associated patient death from influenza. [13] [14] [15] [16] Burdens of vaccination The commonest reason for influenza vaccine hesitancy in healthcare workers is a lack of knowledge about the vaccine and its safety, even in this population. It has been shown that improved information about the vaccine correlates positively with voluntary vaccine uptake. 18 In 2010 in Malta only 56.5% of healthcare workers availed themselves of free flu vaccination, and uptake depended mainly on their place of employment within the Health Service, whether they believed that vaccination caused actual influenza and whether they believed that this vaccine was effective. 9 This is disappointing especially since Vaccine Adverse Event Reporting Systems have convincingly confirmed the safety of this vaccine. Moreover, medical contraindications are few, and despite popular perception, they do not include egg allergy, HIV seropositivity, pregnancy or a history of Guillain-Barré Syndrome. Indeed, the reverse is true and influenza itself increases the risk of Guillain-Barré. 19 Side effects occur <15%, 20 and are mild and typically resolve within two days (table 1) . 20 The rate of serious adverse effects (such as a severe allergic reaction) is estimated at 1 in 300,000 vaccinations, and is significantly lower than the risk of pneumonia and/or death following influenza infection. 20 In Malta, the vaccine is available at no cost for healthcare workers within their workplace, or at a nominal price of circa €7-11 if taken in the private sector. Some have argued that mandatory vaccination of healthcare workers imposes an undue infringement on personal autonomy. 12 This is only partially correct as the vaccine does carry a small risk of harm (as explained above). However, a small risk of personal harm is always present within a healthcare setting, and the personal and individual benefits of vaccination greatly outweigh any risks. Healthcare workers and their institutions accept professional responsibility for the care and well-being of their patients, 12 and this accountability is accompanied by the obligation to follow reasonable, evidence-based best practices. 21 Most institutions take pride in and even advertise high standards of care and, to this effect, many have concluded that "institutions are obligated to enforce universal vaccination of their health care workers against seasonal influenza." 12 Vaccine failure The influenza virus has a high mutation rate and annual vaccination usually confers protection for only a few years, with effectiveness annually estimated at just 25-60%. 22 For this reason, for each and every year, the World Health Organization attempts to predict which influenza strains are likeliest to circulate and directs pharmaceutical companies to produce targeted vaccines. 23 Since the vaccine does not include all active strains in any particular season, it is occasionally possible for new/overlooked strain/s to become prevalent/epidemic/pandemic. 23 Journal Pre-proof Presenteeism One possible risk of universal influenza vaccination is presenteeism, which is defined as reporting to work while ill. This is eminently possible as even in the ideal hypothetical scenario of universal (100%) vaccination coverage, the influenza vaccine is not 100% effective. 24 Hence, some healthcare workers thought to be protected by the vaccine will, nevertheless, remain influenza-naïve, and may still spread the virus in the event that they attend for work despite being unwell. While presenteeism is ubiquitous across most industries, it is particularly devastating in healthcare settings as infected workers may infect vulnerable patients, including the elderly, those with comorbidities and/or the immunosuppressed. Presenteeism has been reported in 41-92% of healthcare workers with influenza-like illness. 25, 26 Several drivers for this have been noted, including the incentive to work anyway while ill so as not to utilize time off, 27 and a misplaced sense of professionalism that compels attendance so as not to disappoint patients and colleagues (especially among the medical profession). 28 It has been calculated that in a hospital with a staff vaccination rate of 70%, reducing presenteeism for influenza-like illness by just 2% is equivalent to increasing staff vaccination to 100%. Population vaccination uptake Dr. William Schaffner, an expert in infectious diseases from Vanderbilt University Medical Center, USA stated: "We're in for a double-barrelled assault this fall and winter with flu and COVID. Flu is the one you can do something about". 30 All initiatives to reduce influenza should be strongly encouraged since any reduction in influenza-related admissions (and inevitable deaths) in winter will alleviate the strain on health services, especially if these are already under pressure if there is a simultaneous resurgence of COVID-19. Furthermore, for a given individual, especially one in a high risk category, co-infection with both these viruses, could exact an extremely heavy toll. 30 The twin principles of beneficence and nonmaleficence apply to the 'at risk group' as much as they do to healthcare workers. Children are known to be the population cohort most exposed to influenza and influenza-like infections, and are therefore a very important group in the spread of influenza virus in the population. 31 Furthermore, the generally low severity of COVID-19 infection in this population is associated with a high incidence of asymptomatic or only mildly symptomatic infection, making children efficient carriers of this condition too. Governments should strongly encourage/mandate influenza vaccination of children as well as for other high risk/vulnerable groups. In Malta, with regard to COVID-19, the Superintendent of Public Health has acknowledged: "We don't know what's going to happen with this virus, but we need to be prepared … for an eventuality where this virus reappears as winter restarts … around the same time that influenza returns … October, when it peaks in January and goes down again by May … With influenza, we do have a vaccine. Every year, we make an emphasis for this vaccine to be taken by the most vulnerable; the elderly, people with chronic illnesses, and children younger than five years. These are the people who should take it to help decrease seasonal influenza's impact. Once we arrive at a point where schools are reopened, measures will need to be taken. And at this point, we're also evaluating the impacts, benefits and added value of having mandatory flu shots for certain groups". 33 An emphasis was also made on prevention: "The advantage we have is that COVID has really taught us a lesson on how to enact proper prevention; washing your hands, not J o u r n a l P r e -p r o o f Journal Pre-proof sneezing in public, not going out next to other people if you're sick. These are all measures which can help stop not only the spread of COVID, but also that of influenza". 33 In anticipation of increased influenza vaccine demand next season, manufacturers are ramping up production. Indeed, a Reuters/Ipsos poll of 4,428 adults conducted between [13] [14] [15] [16] [17] [18] [19] May 2020 found that 60% of U.S. adults plan to take the vaccine, as opposed to the 'usual' <50% uptake in this country. 30 Yet another survey between January and May in the USA showed willingness to take the vaccine increased from 34 to 65% and an increasing likelihood to take the vaccine at a pharmacy rather than a medical clinic or a healthcare center. 30 Demand for the vaccine is expected to be so heavy that options being considered include vaccine administration in parks, community centres and even home visits for vulnerable patients. 30 Conclusions Healthcare worker influenza vaccination clearly benefits patients. The vaccination burden vis-à-vis safety, cost, pain, suffering and infringement of personal autonomy is minimal and ethically obligatory as non-maleficent care. 12 Institutions should seek employees 'buying in' with educational campaigns that target common misconceptions such as vaccine efficacy and safety and reinforce the message that said vaccination comprises part and parcel of ethical, beneficent, and professionally competent care. 12 An alternative to mandatory vaccination for non-compliers could include the mandatory use of a protective respiratory mask. 12 These strategies have been shown to yield >98% healthcare worker vaccination rates. [34] [35] Reducing/eliminating presenteeism is also effective and an equally important measure. Worker education campaigns may also help in this regard. Pushing/mandating vaccination of children, high risk/vulnerable groups are all possibilities. Indeed, "as we look at immunization this coming fall, it will play an enormous role in this battle against COVID-19" noted David Ross, vice president of commercial operations for North America at Seqirus. 30 All possible measures should be employed in order to mitigate the effects of annual seasonal influenza next winter in the setting of the potential parallel circulation of COVID-19. 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Mandatory Flu Shots For Next Winter Currently Being 'Evaluated', Charmaine Gauci Confirms The moral foundation of medical leadership: the professional virtues of the physician as fiduciary of the patient Championing patient safety through mandatory influenza vaccination for all healthcare personnel and affiliated physicians The authors have no conflict of interest to declare.