SGEM#20: Hit Me with your Best Shot (Flu Shot for Healthcare Workers)

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Date: January 20th, 2013

Case Scenario: You walk into the emergency department for your shift and find chairs completely full of patients with flu-like illnesses. The triage nurses look exhausted and are discussing the flu shots. The conversation appears quite animated with strong opinions being expressed. They turn to you as the doctor and ask…what do you think?

Current Flu Outbreak: It has been a bad flu season in North America. The CDC and Health Canada both have detailed websites tracking how bad the 2012-13 season has been.

Canadian Stats

USA Flu Stats

Question #1: Does the flu shot work in the general public?

Immunization has been on of the most significant advances in modern medicine. Some vaccines have been highly successful (Haemophilus Influenzae B, small pox, polio) while others have been not as successful (HIV). Some vaccines work well but are their effectiveness decreases with time (whooping cough).

The flu vaccine this year was estimated to be about 60% effective by the CDC at the start of the 2012-13 flu season. A recent report by BC Centre for Disease Control shows the vaccine is protecting about half of those people who were immunized. There are a number of reasons the flu vaccine is not as effective as other vaccines for a variety of reasons.

Question #2: Is the flu shot effective in preventing transmission from health care workers (HCW)?

There is a Cochrane review that attempts to answer this question. It showed that vaccinating HCW, in addition to other preventative interventions, might protect the elderly in long term care facilities.

“We conclude that there is no evidence that only vaccinating healthcare workers prevents laboratory-proven influenza, pneumonia, and death from pneumonia in elderly residents in long-term care facilities. Other interventions such as hand washing, masks, early detection of influenza with nasal swabs, anti-virals, quarantine, restricting visitors and asking healthcare workers with an influenza-like illness not to attend work might protect individuals over 60 in long-term care facilities and high quality randomised controlled trials testing combinations of these interventions are needed.”

The evidence contained in the Cochrane review was not great and had high risk of bias. However, if you are waiting for 100% proof medicine is not the job for you. Sometimes the BEST evidence is not great. Being a critical and skeptical thinker you need to consider the face validity or a priori whether something would work. We do not have 100% proof that seat belts guarantee you will not be hurt in a motor vehicle collision but it makes sense hedge your bet and buckle up.

Question #3: Are there other things that work besides the flu shot?

There is some evidence that hand washing and wearing a mask if used within 36hrs after onset of symptoms can decrease household transmission (EPmonthly). Specific “complimentary alternative medicine” (CAM) medicines have been tried (TCM and Homeopathy) and not shown to work. Neuroaminidase inhibitors have some weak evidence demonstrating modest effectiveness (BMJ 2009). The CDC has some recommendations on how these antivirals should be used.

Recent controversy has arisen about oseltamivir. A concern that the majority of phase III clinical trial data was not published. The manufacture, Roche, has not provided independent scientist full access to the studies. The BMJ has launched an initiative called Open Data Campaign. The Cochrane Collaboration has updated their review of these drugs and lodged a formal complained to the European Ombudsman about the issue.

Question #4: Top Five myths about the flu shot?

I’ll get the flu from the flu shot – MYTH
The flu shot is worse than the flu – MYTH
It doesn’t work, so there’s no point – MYTH
I can’t get the flu shot –MYTH
I never the get flu. – We never know

Question #5: What about the growing trend of mandatory flu shots for health care workers?

The Canadian Medical Association Journal (CMAJ) advocated in a editorial October 2012 or all HCW to be vaccinated. This was in part because the immunization rates of physicians was historically poor. Failing to protect patients from a contagious disease also violated the principle of primum non nocere (first, do no harm).

However, there have been some concerns from HCW about forcing them to be immunized. Balancing the personal rights of the HCW vs. the rights of the patients is a complicated issue. In my opinion the right of the patient not to get a contagious disease from their HCW takes should be the #1 right. For those who can not be immunized due to contra-indications listed by the CDC can wear a mask with direct patient contact. This solution has been criticized for labelling the HCW as “dirty”.

HCW have to be vaccinated against a number of other diseases to prevent them from contracting the illness and transmitting it to patients. Other jobs have mandatory immunization policies such as members of the US Military. Some things are just part of the job. I would argue taking reasonable measures to prevent infecting our patients should be a basic expectation. The evidence of effectiveness of the flu shot may be weak but the risk to the HCW is low while the risk to the sick patient is deadly.

South Huron Hospital, the Little Hospital that Does, made flu shots part of our medical staff privileges this year. This was part of our Choose Wisely initiative. We also made a YouTube video for the community discussing the flu shot myths.

For a sarcastic podcast about HCWs not getting the flu shot listen to Dr. Mark Crislips Budget of Dumb Asses. For a Canadian perspective on the flu shot watch Rick Mercer’s YouTube video.

Case Scenario Conclusion: You answer all the difficult EBM questions by saying…“It depends”. Then validate the nurses concerns on both sides of the issue. Suggest that EM journal club done in a social setting over a few hours rather than a debate at the triage desk. Or set up a unique grand rounds. Put the flu shot on trial and have prosecutor and defender. Pick a judge to oversee the trail and supply them with a white wig, black robe and reflex hammer as a gavel. Invite different staff (RN, doc, admin staff) to form the jury of peers.

You then head back into the department and get ready to say over and over again, its the flu, antibiotics are not indicated, here are the symptomatic measures you can take, make shared decision about tamiflu, advise them of measures to prevent household transmission and remind them they can always come back if their symptoms get worse, they develop new ones or are concerned.

Keener Kontest: Last weeks winner was James Yan who is studying medicine in London, Ontario. He correctly defined the difference between a greenstick and buckle fracture. “A greenstick fracture is a fracture on young, softer bone, that bends/warps before cracking/breaking on one side (like a young, supple branch – hence the name, immature bone is less rigid). A buckle or torus fracture is one in which part of the bone bends in and compresses in on itself (buckles) without breaking..”

Listen to the podcast to hear this weeks Keener Kontest question. Email your answer to TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize.

It is NOT too late to cut your KT window less than one year. Get in contact with Teresa ASAP and sign up for SkiBEEM 2013 Feb 4-6 at SilverStar BC. You will have a jump start on the content for up coming TheSGEM podcasts.