From the Massachusetts Nurse Newsletter
October 2010 Edition
By Mary Crotty, Joan Johnston and Chris Pontus
Associate Directors of Nursing/Health & Safety
The 2010-2011 influenza vaccine season is expected to get underway early this fall. The vaccine that will be in use was formulated to protect against A/H1N1 influenza, which was the new pandemic threat last year; influenza A/H3N2; and Influenza B.
The MNA encourages its members to avail themselves of influenza vaccine as a means of protecting themselves so they can care for their patients. “It is imperative that the health care workforce be vaccinated against the flu so that they can be on hand to deliver care at a time of intense need,” says Julie Pinkham, RN, executive director of MNA.
“But that decision must be an informed decision to ensure that those workers who may be medically susceptible to complications from the vaccine do not put themselves at risk.” The MNA opposes the mandatory vaccination of workers who, after receiving education about risks and benefits, choose to decline the vaccine. Also, requirements for workers to reveal medical reasons for declination violate individual privacy rights.
Legal requirements in Massachusetts
All licensed Massachusetts hospitals, clinics and long-term care facilities are now required to offer all personnel (not limited to just employees) influenza vaccine between August and March. Beginning this year, facilities will be required to report doses given by the facility (using number of employees as the metric), doses received by personnel elsewhere (to the best of their ability), and declinations. DPH confirms that facilities are required to report coverage rates, but not name individuals who decline. The new regulations were based on last year’s emergency 90-day regulations that called for health care workers to receive education about the vaccine’s benefits and risks as well as influenza vaccination unless they fell under an exemption to the requirement. Those regulations were modeled on existing long-term care influenza regulations, which also remain in effect.
Move toward vaccination mandates
There has been a growing movement to make vaccination mandatory for health care workers. MDPH has expressed disappointment that despite the first-time requirement last year for facilities to offer vaccinations, which was initiated via emergency public health regulations, the results were disappointing, yielding only a 10 percent increase from previous rates. They would like to improve the vaccination rate among health care workers. In a policy statement released in September, the American Academy of Pediatrics, the nation’s largest pediatricians’ group, strongly endorsed mandatory flu vaccinations for doctors, nurses and other health workers. The Society for Healthcare Epidemiology of America recommends that the annual seasonal flu vaccine be required for initial and continued employment of all health care employees, regardless of whether they have direct patient contact. They refer to the failure or refusal to be vaccinated as “unethical and unprofessional” and have collaborated on a proposal to make flu shots mandatory for those working in the health care field.
In October 2009, the American Nurses Association revealed that it had received two-year funding to promote influenza vaccination among health care workers from CDC (the U.S. Centers for Disease Control). Unfortunately, the conferring of financial rewards to organizations to promote influenza vaccination provides them with a profit motive, muddying the waters regarding the potential for unwarranted bias toward vaccination.
Vaccination remains controversial for various reasons. Some parties question the profit motive of pharmaceutical companies and organizations that receive grant funding to increase vaccination rates. Perhaps the biggest factor is identified by CDC itself. CDC recently released data showing that the “VE” (vaccine effectiveness) rate for the H1N1 vaccine last year was 62 percent, lending fuel to the concerns of those who question the effectiveness and/or safety of vaccines. Others are concerned that vaccination may be used as an “easy fix” when other worker and patient protections are needed as well.
Workplace protections
MNA strongly advocates for appropriate workplace protections (see sidebar below) for workers from the threat of influenza to decrease the likelihood that workers will be exposed while caring for patients and then become vectors for disease transmission. Last season, CDC called for N95 respiratory protection for health care workers, but in June 2010 they published updated draft guidance in which they suggest face masks can be used, referring to N95 respirators as an option. The public comment period for this guidance ended on July 22 and CDC stated it “intended to publish final guidance prior to the 2010-2011 influenza season.” However, flu season is here. Vaccine has been delivered to pharmacies. Vaccination of the public has begun—all without any posting of final CDC guidance on respiratory protection. MNA is following the waffling by CDC and will post updated information on the MNA Web site. We have asked CDC whether its previous guidance calling for N95 respirators is still in effect; as we go to print, it has not responded to our inquiry. CDC is undoubtedly under pressure by hospitals to lift the N95 respirator requirement and yet in their own guidance, CDC acknowledges that airborne transmission via small particle aerosols may occur, which would dictate use of N95 respirators to protect against inhaling airborne particles.
DPH regulatory requirements
The Massachusetts Department of Public Health has updated its regulations for vaccination of health care personnel in hospitals, clinics and long-term care facilities.
The complete text of the regulations can be found here.
The new regulations call for health care workers to receive education about the vaccine’s benefits and risks as well as influenza vaccination unless they fall under a specefic exception.
Given that the vaccine is not 100 percent effective and that not all health care personnel will get vaccinated for a variety of medical, religious, personal or other reasons—including potential supply problems, which happened last year—the last line of protection for the nurse and his/her patients is respiratory protection. To compromise patients and staff by providing only simple face masks is unacceptable.
MNA will be posting updates on the 2010-2011 flu season related activity on our Web site. Please contact Mary Crotty or Chris Pontus if you are asked to sign other than the MDPH and MNA recommended declension form or with other vaccination related questions. Other potentially useful Web sites are listed below.
A statement by MDPH on “Control of Influenza and Pneumococcal Disease in Long Term Care Facilities,” which contains several links to information such as CDC guidelines and the MDPH declination form (which MNA endorses), is on the MNA Web site.
MDPH has posted “Model Influenza Vaccine Standing Orders” for 2010-2011 on its Web site at www.mass.gov/flu for those nurses involved in administering vaccine.
An acceptable declination form for healthcare workers is this Web site here. A link to the form is also on the MDPH Long Term Care statement.
For more information about influenza vaccination, please contact Mary Crotty at mcrotty@mnarn.org 781.830.5743 or Chris Pontus at cpontus@mnarn.org at 781.830.5754.
Influenza protections required by health care workers
OSHA states that health care workers are at “very high exposure risk” and “high exposure risk” from influenza, depending on the jobs they do and the departments they work in…and that they should be provided with or afforded the following protections when exposed to patients known or suspected to have H1N1 influenza.
These are basic CDC infection control guidelines, CDC emergency preparedness guidelines and requirements of OSHA’s respiratory protection standard that hospitals should already have in place.
Personal protective equipment
- NIOSH-certified respirators that are N95 or higher are recommended by NIOSH and the AMA.
- CDC recommended N95 respirators last year, but changed its recommendation during the pandemic to allow surgical facemasks. As we go to press, CDC is in the process of evaluating this guidance and has issued proposed, but not final, guidance allowing for face masks and asking for public comment on its proposed change.
- CDC states that, “An employer may provide respirators at the request of employees or permit employees to use their own respirators, if the employer determines that such use will not in itself create a hazard.”
Surgical masks are NOT NIOSH-approved respiratory protection. Before an employee is required to use an N95 respirator, fit testing must be conducted according to the OSHA Respiratory Protection Standard 1910.134. Most hospitals have been fit testing employees for the past few years to meet this OSHA requirement. - Gloves and isolation gowns are recommended when caring for these patients.
- Eye and face protection are recommended depending on the likelihood of spray or splatter of infectious materials.
Engineering controls
- Use specialized negative pressure ventilation rooms for patient care and for aerosol-generating procedures in healthcare settings.
Work practices
- Provide training and education on all emergency planning and infection control policies and respiratory protection that are relevant to pandemic influenza (H1N1).
Administrative controls
- Post signs describing CDC Guidelines for Cough Etiquette requesting patients, visitors and others who are in the emergency room or other areas to follow and make surgical masks and tissues readily available for this to occur.
- Provide opportunities for nurses and other hospital employees to receive H1N1 influenza vaccine at no cost to the employee and with the right for refusal.
- Provide employees with paid sick leave and encourage employees who show symptoms of the influenza to stay at home according to Mass. Department of Public Health.
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