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If you have scarce supplies of influenza vaccine, which health care workers (HCWs) would you immunize? Not an easy question, and the answers will certainly vary by institution.

From mandate to shortage: How do you prioritize?

From mandate to shortage: How do you prioritize?

Vaccinate HCWs treating high-risk patients

If you have scarce supplies of influenza vaccine, which health care workers (HCWs) would you immunize? Not an easy question, and the answers will certainly vary by institution.

To assist in the process, the Society for Healthcare Epidemiology of America (SHEA) has issued guidelines that address the difficult ethical issue of allotting flu vaccine during the kind of shortage that occurred last season.

The guidelines were developed in discussions with health care epidemiologists that wrestled with shortage issues during the supply problems of the 2004-05 flu season.

"We really tried to walk through what a lot of us went through in our institutions last year," says Thomas R. Talbot, MD, MPH, assistant professor of preventive medicine at Vanderbilt University Medical Center Nashville, TN, and lead author of the SHEA paper. "The tiers that we recommend are broad. You could end up with not enough vaccine to even do the first tier, so we tried to emphasize to the facilities, look at what you have, what your needs are, where your high-risk areas are, and really try to target the individual that would be at most risk to transmit if they were not vaccinated."

SHEA’s tiered approach

The SHEA tiered approach to influenza vaccine allocation includes the following key points:

The highest priority should be given to HCWs with the greatest risk of exposure to the patients at highest risk for influenza complications.

During a vaccine shortage, HCWs who have close (within 3 ft.), prolonged (several minutes), and repeated contact with the highest-risk patients comprise the first tier (tier 1A). For example, a specific facility may elect to vaccinate intensive care unit nurses and respiratory therapists before other staff who have less degree of close patient contact in order to maximize the benefits from a limited vaccine supply.

As vaccine supplies increase, other HCWs working with high-risk patients, essential HCWs, and HCWs in areas of high patient traffic should be vaccinated (tiers 1B & 1C). With larger supplies, all HCWs with patient care responsibilities should receive the vaccine (tier 2). For HCWs who are not vaccinated, as well as those who are, other strategies to reduce transmission also should be actively promoted and utilized to protect HCWs and their patients.

It must be acknowledged that in times of severe vaccine shortage, available supplies may not be sufficient to cover every HCW in the highest priority group.

Facility leaders, together with a multidisciplinary advisory panel, must base their decisions for vaccine allotment on the principles outlined above with clear communication of the rationale to all HCWs in the organization.

This process must be applied uniformly and must be transparent with the rationale for allocation decisions readily apparent.

Finally, this tiered system should only be applied in the event of a vaccine shortage; during non-shortage periods, facilities should follow the Centers for Disease Control and Prevention recommendations and offer influenza vaccine to all HCWs.

Summary of SHEA recommendations

  1. Vaccine allocation strategies must focus primarily upon the protection of patients at highest risk for complications from influenza.
  2. Allocation strategies must utilize data on influenza transmission risk to identify those HCWs at greatest risk of transmitting influenza to high-risk patients.
  3. During times of limited or attenuated supply, follow the tiered strategy.
  4. LAIV (live activated influenza vaccine) should be used in eligible HCWs in order to conserve regular vaccine supplies.
  5. As during times when vaccine supplies are ample, continue to emphasize non-vaccine measures (infection control precautions, respiratory hygiene/cough etiquette, chemoprophylaxis) for prevention of transmission of influenza as well as other respiratory viruses among HCWs and patients in health care settings.

Reference

  1. Talbot TR, Bradley SF, Cosgrove SE, et al. SHEA Position Paper: Influenza Vaccination of Healthcare Workers and Vaccine Allocation for Healthcare Workers During Vaccine Shortages. Infect Control Hosp Epidemiol 2005; 26:882-890.