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Johns Hopkins Bloomberg School of Public Health


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Graduate students in JHSPH’s Vaccine Policy Issues class examine current national and international policy issues across the spectrum of vaccine work. As a part of the course, students selected topics for analysis. Selected entries will appear in a series on the IVAC blog. This is the second in the series.

Guest post by Jennifer Lam

Last fall, when the CDC announced that the flu season had officially started, they also reiterated the message we hear every winter: It’s not too late to get the flu shot. As a student getting a graduate degree in Public Health, and as someone who’s had the unpleasant experience of getting the flu, I’m an easy sell. Each year, I dutifully get my flu shot at the beginning of flu season. I also remind my family and friends to do the same. The person I would never think to remind is my doctor, and ironically, this is the person in my life who’s probably the least likely to have gotten a flu shot.

The author, Jennifer Lam

The author, Jennifer Lam.

Getting healthcare workers vaccinated against the flu has been one of the most frustrating challenges in public health in the U.S. Each year, the Centers for Disease Control (CDC) recommends that all healthcare workers get a flu shot. This includes not just doctors and nurses, but also administrative staff, hospital volunteers, emergency responders – basically, anyone who has contact with patients. Yet, during last year’s flu season only 63.5% of healthcare workers were vaccinated, a mere 2.5% improvement from the previous year despite attempts at federal and state levels to increase vaccination coverage.

To me, the benefit of getting healthcare workers vaccinated is a no-brainer. Healthcare workers are in contact with patients every day. The volume and frequency of contact they have with people who are sick, including patients at high risk for suffering severe consequences from the flu, like children with leukemia or transplant patients, makes it the responsible thing to do to get vaccinated. Not only are they protecting themselves, but they are lowering the chance of inadvertently passing the flu to patients. Plus, since they encourage us to get vaccinated, shouldn’t they follow their own advice and get vaccinated too?

The flu is easily transmitted like the common cold – sick people sneeze and cough and pass the virus onto healthy people – and each year, thousands of people get infected. Getting vaccinated is the best protection against the flu because people can be infectious before they start showing symptoms, so they can pass the flu onto you without even knowing it. When vaccination rates in the population are low, flu spreads easily and outbreaks can happen. This has been documented in hospital and nursing homes setting, especially when a majority of the healthcare workers are not appropriately vaccinated.

Some people argue that since we can’t get healthcare worker flu vaccination rates to an acceptable level, we should restrict the type of patients unvaccinated healthcare workers can have contact with. However, keeping unvaccinated workers away from high-risk patients is hard to enforce and can be a logistical nightmare to carry out in a hospital setting.

Some people suggest that healthcare workers should be required to get the flu shot, especially since it’s been shown that when employers require flu shots, 98.1% of healthcare workers get vaccinated. Flu vaccination mandates are not a new idea and have been met with staunch opposition for years. In 2009, the New York Health Department became the first state to require healthcare workers get a flu shot. New Jersey is currently considering a similar mandate. These mandates have generated an outcry from private citizens and organizations alike who feel that vaccination is a choice, and that requiring workers to get vaccinated is unethical and unconstitutional.

When hearing about this vaccine policy tug-of-war between public health officials and healthcare workers, I think it’s important to remember patient choice as well. For this reason, I suggest that States require hospitals and other medical providers to make their flu vaccination coverage rates public. The data are already being collected – all States have flu vaccine coverage surveillance systems and hospital infectionists are responsible for making sure healthcare workers are up-to-date on their shots. Why not make this information publicly available?

A parent should have the right to know whether the staff at the pediatrician’s office have been vaccinated before bringing a young infant for a check-up. Children finding a nursing home for their parents have a right to know which ones enforce flu vaccination for their employees and which ones don’t. Just as healthcare workers have a right to decide whether to get their flu shot, patients should be able to weigh the risks and benefits of seeking care at a hospital where most staff have not been vaccinated.

By posting flu vaccination coverage data publicly, hospitals and other medical providers have an incentive to encourage flu shots for their staff. We may find that resistance to vaccination drops quickly once hospitals and providers realize that not vaccinating can hurt their bottom line; patients can choose to go to a different medical provider.

Vaccination coverage data are often reported as aggregate percentages. I know that nearly 37% of healthcare workers do not get their flu shot. As a patient, this statistic is not helpful to me. What I’d like to know is whether my family doctor is in the ‘vaccinated’ or ‘unvaccinated’ group. Also, if I were running a hospital, low flu coverage percentages are unlikely to make me spring into action. However, if it’s public knowledge that my hospital ranks the lowest in vaccination coverage of all hospitals in my county, I might be more likely to take note and encourage my workers to get vaccinated.

Making flu vaccine coverage information available is beneficial for public health, and also gives both providers and patients a fair choice. The importance of getting healthcare workers vaccinated can no longer be overlooked and underestimated. We need to take action to make sure that the responsibility of getting vaccinated falls on everybody – patients as well as healthcare staff.

Jennifer Lam is a PhD student in the Global Disease Epidemiology and Control Program at the Johns Hopkins Bloomberg School of Public Health.

By Adam L. Cohen

The operator of a clean cookstove cooperative in Mulanje, Malawi.

The operator of a clean cookstove cooperative in Mulanje, Malawi. Photo by Matt Feldman / IVAC.

When I moved to South Africa a year and a half ago to work for the U.S. Centers for Disease Control and Prevention on surveillance for pneumonia and influenza, I didn’t realize how much pneumonia affects communities here. Most of the children in the hospital wards where I work are having trouble breathing, hospitalized with pneumonia. Pneumonia is the leading cause of death among children under five in South Africa and worldwide. Mothers want their children with pneumonia to get better, and public health policymakers want to do what they can to make their country as healthy as possible. But how can we help countries do this? There are multiple, proven interventions to prevent and treat pneumonia, but it can be difficult to get these interventions to the people who need them most. At the CDC, we set out to examine the opportunities presented by the delivery of preventive measures, such as childhood immunization, to explore practical approaches for integrating other interventions to treat and control pneumonia in children. Our complete findings are published in the Bulletin of the World Health Organization.

With so many existing methods of reducing the burden of childhood pneumonia, there are exciting opportunities to integrate multiple approaches to improving child health. But there are also many challenges. Most children have access to basic immunizations—could we use this to help protect the children of the world against pneumonia? Globally, many routine vaccination programs are strong, which means that huge strides could be made in pneumonia prevention and treatment by integrating interventions like pneumococcal and Hib vaccinations, zinc distribution, and caregiver education with routine immunizations.

Neither vaccination nor case management alone is enough to eliminate child pneumonia deaths, owing in part to the large number of bacteria and viruses that cause pneumonia. Other important interventions include caregiver education, referral to health care facilities during routine immunization visits, zinc supplements, HIV testing, and the promotion of health behaviors such as breastfeeding, proper nutrition, hand-washing with soap, and the reduction of indoor air pollution.

However, not all interventions are easily distributed, like cleaner burning but bulky cookstoves, and overburdening community heath workers could cause frail health systems to falter or break. There are few of us in the field of public health working to evaluate the integration of multiple interventions. Further, integration of service delivery would require coordination and cooperation across the entire range of donor organizations, NGOs, and governmental ministries.

To address these challenges, we must conduct small-scale studies that elucidate best practices and evaluate the impact of integration before scaling up to large national programs. This will help us empty the hospital wards in South Africa and worldwide.

Dr. Adam L. Cohen is the Influenza Program Director at Centers for Disease Control and Prevention in Pretoria, South Africa.