Higher Flu Vaccination Rates for Home Health Care Workers Improves Patient Outcomes

Home health care (HHC) service staff visit patients millions of times a year. A recent study has shown quantitatively that a health care worker’s influenza vaccination status has a direct impact on the level of flu-related illnesses and hospitalizations among patients. Infection Control Today® (ICT®) spoke with lead author JingJing Shang, PhD, RN, FAAN, OCN, to talk about the new American Journal of Infection Control study, “Influenza vaccination of home health care staff and the impact on patient hospitalizations,” which focuses on this topic. The study is one of the first to focus on HHC staff influenza vaccinations in the United States at a national level, and it could have a potential impact on COVID-19 vaccinations for health care workers as well.

ICT®: What was the impetus for this study?

JS: So, we conducted this national survey, [which] was primarily looking at the home health care agencies [and] infection prevention and control related to policy and procedures. The survey was conducted right before the pandemic hit, so from the end of [2018] until December [2019]. And in this survey, we also asked the agency to describe the influenza vaccination [statuses] of their staff members. So, we just pulled out these few items to analyze these [data] because we know this previously, some [other] study described the influenza vaccination among the home health care staff was not that good. So we want to know how this policy will impact the home health care patients’ outcomes. So that is the purpose for conducting this analysis.

ICT®: Can you briefly summarize the key findings of your study?

JS: As I said, previously, like other researcher[s] have found, the staff vaccinations, like influenza vaccination rates, are sub-optimal. In home health care, we find a similar finding. We found that actually the home health care staff’s flu vaccination rate [is] strongly associated with the home health care patients—their respiratory infection related to hospitalization. So for those agencies that do not have the staff flu vaccination requirement, patients are more likely to get hospitalized because of respiratory infection. So that kind of emphasizes the significance, the importance of the agency’s requirement for the staff vaccination for the influenza.

ICT®: What are the potential ramifications for other health care workers, not just the home health care?

JS: Yes, certainly, I think this should apply to all health care settings. The reason why we want to focus on the home health care is because we all know the majority of our home health care patients, they’re elderly patients, they have multiple chronic conditions. The latest statistics show about 80% of the home health care patients have more than 3 types of chronic conditions and nearly 40% have more than 5 chronic conditions. So these patients, they're most vulnerable for flu-related complications. Also, we all know that elderly patients’ immune systems are not as strong as the general public. So that highlights the significance of the flu vaccination among the staff workers.

ICT®: Talking about the flu for sure, but what are the possible implications for other vaccines like COVID-19, pneumonia, or even future pandemics?

JS: Yeah, I think that is the other significant message we are trying to send out from this paper because it's so timely. Right now, we are still in the COVID pandemic, and we still see a lot of vaccination resistance and hesitancy among health care workers. So I think our study shows the significant association between the health care workers’ vaccination rates and the patients’ outcome. So this implies [that] is very important, [that] we have the main mandate for the vaccination for the COVID vaccination in order to protect our vulnerable, elderly population.

ICT®: The findings seem to lend support to the push in the United States to require vaccinations for health care workers.

JS: Yeah, that's correct. And another thing I forgot to mention is, I think, the innovative way we have done in this study is we put these [facts] into numbers. So, we created [an] ideal scenario, if all the agency’s [staff members] have the flu vaccination requirement…respiratory infection-associated hospitalizations can be avoided. So, we made the calculation [that] about more than 6500 hospitalizations caused by respiratory infections can be avoided if all the agencies implement the flu vaccination requirement.

ICT®: And how many of those 6500 will not die? Because of those infections?

JS: Exactly. Although, we do not have the data to give the direct number of the avoided deaths, but certainly, we know…more than half of deaths [in home health care patients are] associated with the influenza-related complication. So, definitely that is the significant implication the study trying to emphasize.

ICT®: Shifting a bit, what is the practical application for these key findings for infection preventionists specifically?

JS: The key message is still again, how the importance of this vaccination mandate for the agencies is important. And another thing is how to implement it, how to increase the vaccination rate among the health care workers. This is not from our study; we did not look at that, but in [a] previous study, in another qualitative study, researchers have find there's multiple reasons related to the vaccination hesitance and all the resistance, but one of the main reasons is some people, some health care workers, they just don't think they will get sick, or they think they are pretty healthy, then they're not going to get sick, and also they some have the misconception they don’t think the vaccination will protect them, will work, and some even have distrust of a pharmaceutical company. So all this information kind of reflects the public, [the information] is among health care, but also it kind of reflects what [the] public thinks about the vaccination. So I think it is very important too for our policymaker or the health care industry, they're trying to get their message out there, maybe in the more like lay language to give a more education about the importance of the vaccination. So I hope from our study, people we can [help] the health care worker see is not just protect you [the health care worker but] is going to protect our vulnerable patients…because we are all health care workers, what are we trying to [do. What is] the reason we are in this field? We try to help others. So how much you can further help your patients if you get a vaccine?

ICT®: Yeah. How do we overcome that hesitancy, especially with health care workers, you would think that they would know, that they would trust the medicine that they've studied? How do we overcome that? That hesitancy, that fear?

JS: Exactly, and again, this is from other [studies]. The other literature shows…the previous study showed the inpatient setting has a much higher staff vaccination rates, then the long term care setting, for example, nursing home, and home health care usually has the lowest flu vaccination rates. Some believe that is because [there are] a lot of home health aides; they are the primary reason why they don't get the high vaccination rates for the home health care agencies. But another reason could contribute to this is because they are hourly-based workers. So they really need to take time off to go get the vaccine. So another message is to the health care, or nursing home health care, like administrator, just give the [health care workers] a couple of hours paid time for them to get a vaccination. Okay, offer the vaccination in the worksite. So just give some, benefit for them to get to the vaccination.

ICT®: Yeah, that's a good idea. That's a very good idea, simply because people don't want to take the time off. You know, they're only open from 8 AM to 5 PM. Well, if you only if you work from 8 AM till 5 PM, it's hard to get there. And that's, you know, that's something that I myself have run into. I've talked to many people who've had that issue.

With thinking about your study, what results surprised you of what you learned?

JS: Some surprising part is what let's see. I would not say is totally surprising, but we are kind of disappointed to see the vaccination rate is not as what we would hope to see. So we only see so we have the only like a little bit over 70% of agencies have more than 75% [vaccinated]. Even though we know the home health care will be low, but too, we did not think that would be that slow…I think another surprising and then also disappointed [aspect], we saw the only like 26% of agencies had that flu vaccination requirement for their staff members. So that is that that is kind of disappointing finding we had.

ICT®: You might assume that it would be much higher.

JS: Because it is not like flu vaccination, which has been around for multiple years…the COVID-19 vaccine is relatively new, and people still have doubts about the vaccine, but flu vaccination is very established…and so [we were] just surprised [that] most agencies still don't have that requirement.

ICT®: It makes you want to find out what a facility’s mandates are for their health care workers to decide whether you're going to use that facility or not.

JS: Yes. I think that maybe CMS [Centers for Medicare and Medicaid Services] should include that one metric in there like home health care [to] compare data. That's something that probably can be [added].

ICT®: Do you have any future research with this topic that you're planning?

JS: Yes, I'm glad that you're asking this. Actually, we are. Our team is very lucky to get like another finding to study how the COVID-19 impact home health care and nursing home. So we have an ongoing study. And in this study, we are going to specifically look at the COVID-19 vaccination policy in the agency, and we are going to look at a lot of other like infection control related policies, but COVID-19 and full vaccination policy [was] one of the center items where we started. So we hope to see after the pandemic, to see how the agency has changed, how evolved in terms of the vaccination policy. So that is something we are still [going to] conduct, collecting qualitative data, and we assume we launched the national data of home health agency and nursing home. So, I hope your reader will keep an eye on our future. If your reader [has] any, like home health care and nursing home administrator, just keep eye on out for a future national survey. Recruitment coming out. Yeah, ICT® will cover that for sure. We'll keep an eye out for it. I'm interested in reading it when it's finished. Do you have any idea when it will be done?

JS: So we are conducting a qualitative survey right now. So we plan to launch the national survey. Now is March maybe in the October or the end of this year. So definitely the national survey will be coming out soon.

ICT®: Awesome. That's great. I look forward to reading it.

JS: Thank you.

ICT®: So do you have anything else that you would like to add for our viewers?

JS: Oh, the things I just want to give the credit to my team. We have a wonderful team. And we have my collaborator from Columbia and Rand Corporation. Also, the Thomas Jefferson University and also my project director and all the RAs [research assistants], they have been tireless do lead to help with the data collection and recruitment. Also, all these agencies [that] participate in our national study. We thank them very much.

ICT®: Thank you. Thank you for coming today and speaking with me.

JS: Thank you.

Transcript has been edited for clarity and length.