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

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