Unvaccinated adults increasing risk of disease for all of us and at work. Occupational medicine should investigate !

Unvaccinated adults increasing risk of disease for all of us and at work. Occupationel medicine schould investigate!

29 Mar

Vaccines are in the spotlight again.

Public attention has recently focused on improving vaccination 

rates in Australian infants and children. But actually the largest 

unvaccinated group of people recommended for immunisation are 

adults.

 

Of 4.1 million unvaccinated Australians, 92% (3.8 million) are 

adults, and only a small fraction are children.

Improving adult vaccination rates will reduce their risk of illness 

and death, and lower transmission of infection in the community.

Fewer adults than children are vaccinated

The government provides free adult vaccines for influenza (flu), 

pneumococcal pneumonia and shingles for people over the aged of 

65 years, and selected vaccines for those with underlying medical 

conditions, Indigenous people older than 15 years and pregnant 

women.

However, our latest research shows that only 51% of older 

Australian adults receive all government-funded vaccinations each 

year, compared to 93% of Australian children, and 73% of 

Australian adolescents. Coverage in eligible high-risk groups is 

even lower: around 40% of people with medical or occupational 

risk factors receive their annual influenza vaccine, and only 

13% of indigenous young adults with medical risk factors receive 

their pneumococcal vaccine. Migrants, refugees and travellers are 

also often at risk and under-vaccinated.

Non-immunised children form a very small proportion of under-

vaccinated Australians, yet public health efforts focus on coercive 

measures and financial penalties to improve immunisation rates in 

infants. Unvaccinated adults have been ignored.

Adults suffer from and spread diseases

Adults contribute substantially to ongoing epidemics of vaccine-

preventable diseases. Most cases of whooping cough, for 

example, occur in adults. About half of all cases of measles that 

occur in Australia are in those aged 19 years or over.

In addition to poor adult vaccination rates contributing to the high 

cost of managing preventable infections, adults are often the 

starting point for epidemics because they have the highest rate of

 infections and so transmit infection more. Better vaccination rates 

in adults will reduce both cost and risk.

Health workers can be a vector for infection and trigger outbreaks 

among vulnerable patients. The highest risk institutions are 

hospitals, childcare centres and aged care facilities.

Health care and other institutions facilitate intense infection 

transmission and explosive outbreaks, where vulnerable patients, 

elderly residents or children may become ill and even die. The 

purpose of staff vaccination in these settings is not only individual 

protection, but protection of patients or children.

Staff have an ethical duty of care to reduce their own risk of 

infection and the risk they may pose to vulnerable others. Workers 

themselves may be at increasing risk, since hospitals and aged care 

facilities have an ageing workforce with associated underlying 

chronic health conditions.

The case for mandatory flu vaccination

Uptake rates of staff influenza vaccination continue to be low. 

Rates of vaccination in day care centre workers are less than 50%,

 and variably low in aged care workers and health workers.

When hospitals in the USA introduced mandatory influenza 

vaccination for health care staff, the response was variable, with 

legal challenges in New York.

There have been some great success stories lately from Melbourne,

 where hospitals have been able to get rates up to 80%. However, 

these hospitals have committed resources and personnel to 

implement intensive campaigns. Such vaccination campaigns based 

on voluntary or educational interventions will increase vaccination 

rates to 70-80%, but campaigns must be sustained and don’t 

achieve rates higher than this.

The groundwork for the introduction of mandatory influenza 

vaccination has been laid by many states and territories in 

Australia. For example, NSW introduced legislation in 2007 that 

required health care workers to demonstrate evidence of protection 

against a range of vaccine preventable diseases. The policy change 

was surprisingly well received and accepted by hospital staff.

Other states have similar recommendations for health care workers,

 but vary in the vaccines included and/or staff targeted. However, in 

all instances to date the influenza vaccine continues to be highly 

recommended but not required.

Mandatory vaccination still remains a controversial strategy that 

pits staff autonomy against patient safety. Coercive measures do 

work, but raise ethical issues. Further, some argue that the 

evidence of patient benefit for influenza is overstated.

Poor uptake of adult vaccination is due to many factors, including 

difficulty of access, lack of vaccination records, low perceived 

level of risk from vaccine-preventable diseases, lack of faith in 

vaccines for adults and value judgements about older people.

A range of strategies can improve vaccination rates, including 

a whole of life immunisation register, which helps doctors keep 

track of their patient’s vaccine history, eliminating financial 

barriers to vaccination, recording indigenous status and medical 

risk factors of patients, recommending vaccination to patients and 

providing reminders.

To improve immunisation in any occupational setting, it is 

important to commit resources, design health promotion programs, 

and provide culturally sensitive education on the risk of influenza 

and the overall benefits of vaccination.

It is also important to remove barriers and use regulation. For 

example, hospitals have patient infection outcomes linked to 

accreditation, but not staff vaccination. There are no such 

requirements for child care or aged care facilities. We could 

consider linking vaccination rates of staff to regulation of these 

institutions. We also need to ensure there are no other barriers to 

getting staff vaccinated.

C Raina MacIntyre, Professor of Infectious Diseases Epidemiology, Head of the School of Public Health and Community Medicine, UNSW; Holly Seale, Senior Lecturer, UNSW, and Rob Menzies, Senior Lecturer, UNSW