Influenza Vaccination of Healthcare Workers: Critical Analysis of the Evidence for Patient Benefit Underpinning Policies of Enforcement
Identifieur interne : 004227 ( Ncbi/Checkpoint ); précédent : 004226; suivant : 004228Influenza Vaccination of Healthcare Workers: Critical Analysis of the Evidence for Patient Benefit Underpinning Policies of Enforcement
Auteurs : Gaston De Serres [Canada] ; Danuta M. Skowronski [Canada] ; Brian J. Ward [Canada] ; Michael Gardam [Canada] ; Camille Lemieux [Canada] ; Annalee Yassi [Canada] ; David M. Patrick [Canada] ; Mel Krajden [Canada] ; Mark Loeb [Canada] ; Peter Collignon [Australie] ; Fabrice Carrat [France]Source :
- PLoS ONE [ 1932-6203 ] ; 2017.
Descripteurs français
- KwdFr :
- Essais contrôlés randomisés comme sujet, Grippe humaine (), Grippe humaine (virologie), Grippe humaine (épidémiologie), Humains, Infection croisée (), Infection croisée (virologie), Infection croisée (épidémiologie), Mortalité, Orthomyxoviridae (pathogénicité), Pandémies, Personnel de santé, Soins de longue durée, Vaccination (), Vaccins antigrippaux (usage thérapeutique).
- MESH :
- pathogénicité : Orthomyxoviridae.
- usage thérapeutique : Vaccins antigrippaux.
- virologie : Grippe humaine, Infection croisée.
- épidémiologie : Grippe humaine, Infection croisée.
- Essais contrôlés randomisés comme sujet, Grippe humaine, Humains, Infection croisée, Mortalité, Pandémies, Personnel de santé, Soins de longue durée, Vaccination.
English descriptors
- KwdEn :
- Cross Infection (epidemiology), Cross Infection (prevention & control), Cross Infection (virology), Health Personnel, Humans, Influenza Vaccines (therapeutic use), Influenza, Human (epidemiology), Influenza, Human (prevention & control), Influenza, Human (virology), Long-Term Care, Mortality, Orthomyxoviridae (pathogenicity), Pandemics, Randomized Controlled Trials as Topic, Vaccination (methods).
- MESH :
- chemical , therapeutic use : Influenza Vaccines.
- epidemiology : Cross Infection, Influenza, Human.
- methods : Vaccination.
- pathogenicity : Orthomyxoviridae.
- prevention & control : Cross Infection, Influenza, Human.
- virology : Cross Infection, Influenza, Human.
- Health Personnel, Humans, Long-Term Care, Mortality, Pandemics, Randomized Controlled Trials as Topic.
Abstract
Four cluster randomized controlled trials (cRCTs) conducted in long-term care facilities (LTCFs) have reported reductions in patient risk through increased healthcare worker (HCW) influenza vaccination. This evidence has led to expansive policies of enforcement that include all staff of acute care hospitals and other healthcare settings beyond LTCFs. We critique and quantify the cRCT evidence for indirect patient benefit underpinning policies of mandatory HCW influenza vaccination.
Plausibility of the four cRCT findings attributing indirect patient benefits to HCW influenza vaccination was assessed by comparing percentage reductions in patient risk reported by the cRCTs to predicted values. Plausibly predicted values were derived according to the basic mathematical principle of dilution, taking into account HCW influenza vaccine coverage and the specificity of patient outcomes for influenza. Accordingly, predicted values were calculated as a function of relevant compound probabilities including vaccine efficacy (ranging 40–60% in HCWs and favourably assuming the same indirect protection conferred through them to patients) × change in proportionate HCW influenza vaccine coverage (as reported by each cRCT) × percentage of a given patient outcome (e.g. influenza-like illness (ILI) or all-cause mortality) plausibly due to influenza virus. The number needed to vaccinate (NNV) for HCWs to indirectly prevent patient death was recalibrated based on real patient data of hospital-acquired influenza, with adjustment for potential under-detection (5.2-fold), and using favourable assumptions of HCW-attributable risk (ranging 60–80%).
In attributing patient benefit to increased HCW influenza vaccine coverage, each cRCT was found to violate the basic mathematical principle of dilution by reporting greater percentage reductions with less influenza-specific patient outcomes (i.e., all-cause mortality > ILI > laboratory-confirmed influenza) and/or patient mortality reductions exceeding even favourably-derived predicted values by at least 6- to 15-fold. If extrapolated to all LTCF and hospital staff in the United States, the prior cRCT-claimed NNV of 8 would implausibly mean >200,000 and >675,000 patient deaths, respectively, could be prevented annually by HCW influenza vaccination, inconceivably exceeding total US population mortality estimates due to seasonal influenza each year, or during the 1918 pandemic, respectively. More realistic recalibration based on actual patient data instead shows that at least 6000 to 32,000 hospital workers would need to be vaccinated before a single patient death could potentially be averted.
The four cRCTs underpinning policies of enforced HCW influenza vaccination attribute implausibly large reductions in patient risk to HCW vaccination, casting serious doubts on their validity. The impression that unvaccinated HCWs place their patients at great influenza peril is exaggerated. Instead, the HCW-attributable risk and vaccine-preventable fraction both remain unknown and the NNV to achieve patient benefit still requires better understanding. Although current scientific data are inadequate to support the ethical implementation of enforced HCW influenza vaccination, they do not refute approaches to support voluntary vaccination or other more broadly protective practices, such as staying home or masking when acutely ill.
Url:
DOI: 10.1371/journal.pone.0163586
PubMed: 28129360
PubMed Central: 5271324
Affiliations:
- Australie, Canada, France
- Ontario, Île-de-France
- Hamilton (Ontario), Paris, Toronto
- Université McMaster, Université de Toronto
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PMC:5271324Le document en format XML
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<settlement type="city">Paris</settlement>
</placeName>
</affiliation>
<affiliation wicri:level="3"><nlm:aff id="aff012"><addr-line>Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Unité de Santé Publique, Paris, France</addr-line>
</nlm:aff>
<country xml:lang="fr">France</country>
<wicri:regionArea>Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Unité de Santé Publique, Paris</wicri:regionArea>
<placeName><region type="region">Île-de-France</region>
<region type="old region">Île-de-France</region>
<settlement type="city">Paris</settlement>
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</author>
</analytic>
<series><title level="j">PLoS ONE</title>
<idno type="eISSN">1932-6203</idno>
<imprint><date when="2017">2017</date>
</imprint>
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<profileDesc><textClass><keywords scheme="KwdEn" xml:lang="en"><term>Cross Infection (epidemiology)</term>
<term>Cross Infection (prevention & control)</term>
<term>Cross Infection (virology)</term>
<term>Health Personnel</term>
<term>Humans</term>
<term>Influenza Vaccines (therapeutic use)</term>
<term>Influenza, Human (epidemiology)</term>
<term>Influenza, Human (prevention & control)</term>
<term>Influenza, Human (virology)</term>
<term>Long-Term Care</term>
<term>Mortality</term>
<term>Orthomyxoviridae (pathogenicity)</term>
<term>Pandemics</term>
<term>Randomized Controlled Trials as Topic</term>
<term>Vaccination (methods)</term>
</keywords>
<keywords scheme="KwdFr" xml:lang="fr"><term>Essais contrôlés randomisés comme sujet</term>
<term>Grippe humaine ()</term>
<term>Grippe humaine (virologie)</term>
<term>Grippe humaine (épidémiologie)</term>
<term>Humains</term>
<term>Infection croisée ()</term>
<term>Infection croisée (virologie)</term>
<term>Infection croisée (épidémiologie)</term>
<term>Mortalité</term>
<term>Orthomyxoviridae (pathogénicité)</term>
<term>Pandémies</term>
<term>Personnel de santé</term>
<term>Soins de longue durée</term>
<term>Vaccination ()</term>
<term>Vaccins antigrippaux (usage thérapeutique)</term>
</keywords>
<keywords scheme="MESH" type="chemical" qualifier="therapeutic use" xml:lang="en"><term>Influenza Vaccines</term>
</keywords>
<keywords scheme="MESH" qualifier="epidemiology" xml:lang="en"><term>Cross Infection</term>
<term>Influenza, Human</term>
</keywords>
<keywords scheme="MESH" qualifier="methods" xml:lang="en"><term>Vaccination</term>
</keywords>
<keywords scheme="MESH" qualifier="pathogenicity" xml:lang="en"><term>Orthomyxoviridae</term>
</keywords>
<keywords scheme="MESH" qualifier="pathogénicité" xml:lang="fr"><term>Orthomyxoviridae</term>
</keywords>
<keywords scheme="MESH" qualifier="prevention & control" xml:lang="en"><term>Cross Infection</term>
<term>Influenza, Human</term>
</keywords>
<keywords scheme="MESH" qualifier="usage thérapeutique" xml:lang="fr"><term>Vaccins antigrippaux</term>
</keywords>
<keywords scheme="MESH" qualifier="virologie" xml:lang="fr"><term>Grippe humaine</term>
<term>Infection croisée</term>
</keywords>
<keywords scheme="MESH" qualifier="virology" xml:lang="en"><term>Cross Infection</term>
<term>Influenza, Human</term>
</keywords>
<keywords scheme="MESH" qualifier="épidémiologie" xml:lang="fr"><term>Grippe humaine</term>
<term>Infection croisée</term>
</keywords>
<keywords scheme="MESH" xml:lang="en"><term>Health Personnel</term>
<term>Humans</term>
<term>Long-Term Care</term>
<term>Mortality</term>
<term>Pandemics</term>
<term>Randomized Controlled Trials as Topic</term>
</keywords>
<keywords scheme="MESH" xml:lang="fr"><term>Essais contrôlés randomisés comme sujet</term>
<term>Grippe humaine</term>
<term>Humains</term>
<term>Infection croisée</term>
<term>Mortalité</term>
<term>Pandémies</term>
<term>Personnel de santé</term>
<term>Soins de longue durée</term>
<term>Vaccination</term>
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<front><div type="abstract" xml:lang="en"><sec id="sec001"><title>Background</title>
<p>Four cluster randomized controlled trials (cRCTs) conducted in long-term care facilities (LTCFs) have reported reductions in patient risk through increased healthcare worker (HCW) influenza vaccination. This evidence has led to expansive policies of enforcement that include all staff of acute care hospitals and other healthcare settings beyond LTCFs. We critique and quantify the cRCT evidence for indirect patient benefit underpinning policies of mandatory HCW influenza vaccination.</p>
</sec>
<sec id="sec002"><title>Methods</title>
<p>Plausibility of the four cRCT findings attributing indirect patient benefits to HCW influenza vaccination was assessed by comparing percentage reductions in patient risk reported by the cRCTs to predicted values. Plausibly predicted values were derived according to the basic mathematical principle of dilution, taking into account HCW influenza vaccine coverage and the specificity of patient outcomes for influenza. Accordingly, predicted values were calculated as a function of relevant compound probabilities including vaccine efficacy (ranging 40–60% in HCWs and favourably assuming the same indirect protection conferred through them to patients) × change in proportionate HCW influenza vaccine coverage (as reported by each cRCT) × percentage of a given patient outcome (e.g. influenza-like illness (ILI) or all-cause mortality) plausibly due to influenza virus. The number needed to vaccinate (NNV) for HCWs to indirectly prevent patient death was recalibrated based on real patient data of hospital-acquired influenza, with adjustment for potential under-detection (5.2-fold), and using favourable assumptions of HCW-attributable risk (ranging 60–80%).</p>
</sec>
<sec id="sec003"><title>Results</title>
<p>In attributing patient benefit to increased HCW influenza vaccine coverage, each cRCT was found to violate the basic mathematical principle of dilution by reporting greater percentage reductions with less influenza-specific patient outcomes (i.e., all-cause mortality > ILI > laboratory-confirmed influenza) and/or patient mortality reductions exceeding even favourably-derived predicted values by at least 6- to 15-fold. If extrapolated to all LTCF and hospital staff in the United States, the prior cRCT-claimed NNV of 8 would implausibly mean >200,000 and >675,000 patient deaths, respectively, could be prevented annually by HCW influenza vaccination, inconceivably exceeding total US population mortality estimates due to seasonal influenza each year, or during the 1918 pandemic, respectively. More realistic recalibration based on actual patient data instead shows that at least 6000 to 32,000 hospital workers would need to be vaccinated before a single patient death could potentially be averted.</p>
</sec>
<sec id="sec004"><title>Conclusions</title>
<p>The four cRCTs underpinning policies of enforced HCW influenza vaccination attribute implausibly large reductions in patient risk to HCW vaccination, casting serious doubts on their validity. The impression that unvaccinated HCWs place their patients at great influenza peril is exaggerated. Instead, the HCW-attributable risk and vaccine-preventable fraction both remain unknown and the NNV to achieve patient benefit still requires better understanding. Although current scientific data are inadequate to support the ethical implementation of enforced HCW influenza vaccination, they do not refute approaches to support voluntary vaccination or other more broadly protective practices, such as staying home or masking when acutely ill.</p>
</sec>
</div>
</front>
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<name sortKey="Collignon, Peter" sort="Collignon, Peter" uniqKey="Collignon P" first="Peter" last="Collignon">Peter Collignon</name>
</country>
<country name="France"><region name="Île-de-France"><name sortKey="Carrat, Fabrice" sort="Carrat, Fabrice" uniqKey="Carrat F" first="Fabrice" last="Carrat">Fabrice Carrat</name>
</region>
<name sortKey="Carrat, Fabrice" sort="Carrat, Fabrice" uniqKey="Carrat F" first="Fabrice" last="Carrat">Fabrice Carrat</name>
<name sortKey="Carrat, Fabrice" sort="Carrat, Fabrice" uniqKey="Carrat F" first="Fabrice" last="Carrat">Fabrice Carrat</name>
</country>
</tree>
</affiliations>
</record>
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