Protecting Staff and Resident Health Requires a Comprehensive Staff Immunization Program—During Flu Season and Beyond

December 17, 2019

ECRI Institute and Annals of Long-Term Care: Clinical Care and Aging (ALTC) have joined in collaboration to bring ALTC readers periodic articles on topics in risk management, quality assurance and performance improvement (QAPI), and safety for persons served throughout the aging services continuum. ECRI Institute is an independent, trusted authority on the medical practices and products that provide the safest, most cost-effective care.

Vaccines have helped to eliminate some very serious diseases in the United States and throughout the world. For illnesses that have not been fully eradicated, vaccines have helped to both lessen the effects of the illnesses and decrease the number of people affected. Various federal agencies and groups have recommended that personnel who work in aging services and home care be immunized against specific illnesses, such as hepatitis B virus (HBV) and influenza (flu), due to inherent risks from the job and resident or client susceptibility to some diseases.

Additionally, the risks associated with infectious outbreaks go beyond the direct impact of illness. Infectious outbreaks can have serious negative effects on the day-to-day care and service delivery environment—which then can act as root causes and contributing factors for other adverse events for both persons served and those delivering services. These outbreaks can simultaneously intensify resident and patient care workloads and affect continuity of staffing and scheduling. Comprehensive immunization programs can therefore be an important part of a provider organization’s risk, quality, and safety practices contributing to environments that help to inhibit adverse events. 

CDC-Recommended Immunizations

Some vaccine-preventable illnesses are of particular importance to people working in aging services because they are at higher risk of exposure and because residents may be more susceptible to some diseases. For example, many aging services workers are frequently exposed to body fluids, which can pose an HBV risk. Additionally, older adults may be more likely to experience serious complications if they contract certain diseases; certain subpopulations of residents (eg, those who are immunocompromised) may be at even greater risk.

The potential for severe complications of vaccine-preventable illnesses can be higher in older adults than in other age groups because of decreased immunity and sometimes because of the communal living environment, for those who live in such settings. Cognitive or physical limitations may also increase illness severity because disease symptoms may be harder to identify, potentially delaying treatment and causing the individual’s condition to worsen.1 For example, the risk of dehydration may be higher among older adults with cognitive impairment who have the flu, as they may be unaware of their water loss.2 Because some vaccines do not provide as much protection to older adults, vaccination of personnel who work for aging services providers can be even more imperative than in other settings (eg, hospitals).

Infection prevention and control programs are essential to all aging services and home care providers, and maintaining staff immunity is an important component of these programs. The Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) recommends that health care personnel (HCP) be vaccinated against or have evidence of immunity to measles, mumps, and rubella; tetanus, diphtheria, and pertussis; varicella; and seasonal flu.HBV vaccination is recommended for personnel who are at risk for exposure to blood or body fluids (in addition, the Occupational Safety and Health Administration [OSHA] requires employers to make HBV vaccine available to such employees). For certain other diseases (eg, meningococcal disease, typhoid fever, polio), ACIP recommends vaccination only for specific groups at high risk (eg, those who travel to countries where the disease is more common).3 In addition, ACIP annually updates its general recommendations on vaccination against seasonal flu, and these recommendations address immunization of HCP.4 CDC has also published guidance on evaluating staff members’ HBV immunoprotection after vaccination.5

ACIP emphasizes that the recommendations applicable to all HCP concern more than just those with responsibility for direct resident or patient care. In its recommendations on immunization of HCP, ACIP uses the following definition of HCP3:

HCP are defined as all paid and unpaid persons working in health-care settings who have the potential for exposure to patients and/or to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or contaminated air. HCP might include (but are not limited to) physicians, nurses, nursing assistants, therapists, technicians, emergency medical service personnel, dental personnel, pharmacists, laboratory personnel, autopsy personnel, students and trainees, contractual staff not employed by the health-care facility, and persons (e.g., clerical, dietary, housekeeping, laundry, security, maintenance, administrative, billing, and volunteers) not directly involved in patient care but potentially exposed to infectious agents that can be transmitted to and from HCP and patients.

Staff who are not directly involved in resident care may frequently enter resident areas. Also, many of these illnesses are highly contagious, so even staff who might not directly expose residents could expose a coworker who may have resident contact. In addition, staff may miss work or be less productive if they become sick or have to take care of sick family members.

ACIP specifically lists long-term care (eg, skilled nursing, assisted living) and home care as settings that its recommendations for immunization of HCP apply to. But it also states that the recommendations are not limited to those settings listed. Therefore, aging services providers should carefully consider which staff throughout the organization the recommendations apply to, instead of simply limiting their immunization programs to skilled nursing or “health care” settings. Accordingly, use of the term “health care personnel” in this article refers to all individuals included in ACIP’s broad definition.3 

The ACIP guidelines state that organizations should review the vaccination and immunity status of HCP upon hire and at least annually. Immunization records should be maintained for HCP; records should include documentation of the individual’s immunity status regarding recommended vaccine-preventable diseases (documented disease, vaccination history, or serology results), vaccinations administered, and postvaccination adverse events. In the event of an outbreak, up-to-date, well-organized records can help the organization identify susceptible personnel and take appropriate action. 3

Vaccination Programs and Promotion

Vaccination programs for staff are important to promoting vaccination. Aside from state or employer requirements for vaccination, the literature suggests that no one specific method or component will make a campaign successful; rather, a multifaceted approach to increasing vaccination rates is often suggested. Active promotion of the vaccines also seems particularly helpful in ensuring high acceptance rates among staff.6 Many organizations offer tools and other resources to promote vaccination, including a toolkit available for purchase from AMDA – The Society for Post-Acute and Long-Term Care Medicine.7

Organizations should determine whom to include in the vaccination campaign, remembering that most of ACIP’s recommendations regarding immunization of HCP apply to CDC’s broad definition of the term. Potential factors to consider include levels of care, services provided, staffing patterns and rotations, infection risks faced by staff who work at other organizations as well, and physical spaces, amenities, and staff shared by residents from different units or levels of care.