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Review
. 2016 Jun 2;2016(6):CD005187.
doi: 10.1002/14651858.CD005187.pub5.

Influenza vaccination for healthcare workers who care for people aged 60 or older living in long-term care institutions

Roger E Thomas  1 , Tom Jefferson, Toby J Lasserson
Affiliations
Review

Influenza vaccination for healthcare workers who care for people aged 60 or older living in long-term care institutions

Roger E Thomas et al. Cochrane Database Syst Rev. .

Abstract

Background: A systematic review found that 3% of working adults who had received influenza vaccine and 5% of those who were unvaccinated had laboratory-proven influenza per season; in healthcare workers (HCWs) these percentages were 5% and 8% respectively. Healthcare workers may transmit influenza to patients.

Objectives: To identify all randomised controlled trials (RCTs) and non-RCTs assessing the effects of vaccinating healthcare workers on the incidence of laboratory-proven influenza, pneumonia, death from pneumonia and admission to hospital for respiratory illness in those aged 60 years or older resident in long-term care institutions (LTCIs).

Search methods: We searched CENTRAL (2015, Issue 9), MEDLINE (1966 to October week 3, 2015), EMBASE (1974 to October 2015) and Web of Science (2006 to October 2015), but Biological Abstracts only from 1969 to March 2013 and Science Citation Index-Expanded from 1974 to March 2013 due to lack of institutional access in 2015.

Selection criteria: Randomised controlled trials (RCTs) and non-RCTs of influenza vaccination of healthcare workers caring for individuals aged 60 years or older in LTCIs and the incidence of laboratory-proven influenza and its complications (lower respiratory tract infection, or hospitalisation or death due to lower respiratory tract infection) in individuals aged 60 years or older in LTCIs.

Data collection and analysis: Two authors independently extracted data and assessed risk of bias. Effects on dichotomous outcomes were measured as risk differences (RDs) with 95% confidence intervals (CIs). We assessed the quality of evidence with GRADE.

Main results: We identified four cluster-RCTs and one cohort study (n = 12,742) of influenza vaccination for HCWs caring for individuals ≥ 60 years in LTCIs. Four cluster RCTs (5896 residents) provided outcome data that addressed the objectives of our review. The studies were comparable in their study populations, intervention and outcome measures. The studies did not report adverse events. The principal sources of bias in the studies related to attrition, lack of blinding, contamination in the control groups and low rates of vaccination coverage in the intervention arms, leading us to downgrade the quality of evidence for all outcomes due to serious risk of bias.Offering influenza vaccination to HCWs based in long term care homes may have little or no effect on the number of residents who develop laboratory-proven influenza compared with those living in care homes where no vaccination is offered (RD 0 (95% CI -0.03 to 0.03), two studies with samples taken from 752 participants; low quality evidence). HCW vaccination probably leads to a reduction in lower respiratory tract infection in residents from 6% to 4% (RD -0.02 (95% CI -0.04 to 0.01), one study of 3400 people; moderate quality evidence). HCW vaccination programmes may have little or no effect on the number of residents admitted to hospital for respiratory illness (RD 0 (95% CI -0.02 to 0.02, one study of 1059 people; low quality evidence). We decided not to combine data on deaths from lower respiratory tract infection (two studies of 4459 people) or all cause deaths (four studies of 8468 people). The direction and size of difference in risk varied between the studies. We are uncertain as to the effect of vaccination on these outcomes due to the very low quality of evidence. Adjusted analyses, which took into account the cluster design, did not differ substantively from the pooled analysis with unadjusted data.

Authors' conclusions: Our review findings have not identified conclusive evidence of benefit of HCW vaccination programmes on specific outcomes of laboratory-proven influenza, its complications (lower respiratory tract infection, hospitalisation or death due to lower respiratory tract illness), or all cause mortality in people over the age of 60 who live in care institutions. This review did not find information on co-interventions with healthcare worker vaccination: hand-washing, face masks, early detection of laboratory-proven influenza, quarantine, avoiding admissions, antivirals and asking healthcare workers with influenza or influenza-like illness (ILI) not to work. This review does not provide reasonable evidence to support the vaccination of healthcare workers to prevent influenza in those aged 60 years or older resident in LTCIs. High quality RCTs are required to avoid the risks of bias in methodology and conduct identified by this review and to test further these interventions in combination.

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Conflict of interest statement

Dr. Roger Thomas: no declarations of interest. Toby Lasserson is an employee of Cochrane and is an editor for the Cochrane Airways Group. He is an associate editor of the journal of 'Research Integrity and Peer Review'. Dr. Jefferson (TJ) was a recipient of a UK National Institute for Health Research grant for a Cochrane review of neuraminidase inhibitors for preventing and treating influenza. In addition TJ receives royalties from his books published by Il Pensiero Scientifico Editore, Rome and Blackwells. TJ is occasionally interviewed by market research companies about phase I or II pharmaceutical products. In 2011‐13, TJ acted as an expert witness in a litigation case related to the antiviral oseltamivir, in two litigitation cases on potential vaccine‐related damage and in a labour case on influenza vaccines in healthcare workers in Canada. He has acted as a consultant for Roche (1997‐99), GSK (2001‐2), Sanofi‐Synthelabo (2003), and IMS Health (2013) and in 2014 was retained as a scientific adviser to a legal team acting on oseltamivir. In 2014‐16 TJ was a member of three advisory boards for Boerhinger Ingelheim and is holder of a Cochrane Methods Innovations Fund grant to develop guidance on the use of regulatory data in Cochrane reviews. TJ is a member of an independent data monitoring committee for a Sanofi Pasteur clinical trial on an influenza vaccine.

Figures

1
1
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
2
2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
1.1
1.1. Analysis
Comparison 1 HCWs offered vaccination versus HCWs offered no vaccination: experimental design; data for periods of high influenza activity (three C‐RCTs; Carman 2000 and Potter 1997 152 days; Lemaitre 2009 118 days), Outcome 1 Influenza.
1.2
1.2. Analysis
Comparison 1 HCWs offered vaccination versus HCWs offered no vaccination: experimental design; data for periods of high influenza activity (three C‐RCTs; Carman 2000 and Potter 1997 152 days; Lemaitre 2009 118 days), Outcome 2 Lower respiratory tract infection.
1.3
1.3. Analysis
Comparison 1 HCWs offered vaccination versus HCWs offered no vaccination: experimental design; data for periods of high influenza activity (three C‐RCTs; Carman 2000 and Potter 1997 152 days; Lemaitre 2009 118 days), Outcome 3 Admission to hospital for respiratory illness.
1.4
1.4. Analysis
Comparison 1 HCWs offered vaccination versus HCWs offered no vaccination: experimental design; data for periods of high influenza activity (three C‐RCTs; Carman 2000 and Potter 1997 152 days; Lemaitre 2009 118 days), Outcome 4 Deaths from influenza or its complications.
1.5
1.5. Analysis
Comparison 1 HCWs offered vaccination versus HCWs offered no vaccination: experimental design; data for periods of high influenza activity (three C‐RCTs; Carman 2000 and Potter 1997 152 days; Lemaitre 2009 118 days), Outcome 5 Death from any cause.
2.1
2.1. Analysis
Comparison 2 HCWs offered vaccination versus HCWs offered no vaccination; three C‐RCTs (Carman 2000, Potter 1997, Lemaitre 2009) (adjusted analyses), Outcome 1 Influenza.
2.2
2.2. Analysis
Comparison 2 HCWs offered vaccination versus HCWs offered no vaccination; three C‐RCTs (Carman 2000, Potter 1997, Lemaitre 2009) (adjusted analyses), Outcome 2 Pneumonia.
2.3
2.3. Analysis
Comparison 2 HCWs offered vaccination versus HCWs offered no vaccination; three C‐RCTs (Carman 2000, Potter 1997, Lemaitre 2009) (adjusted analyses), Outcome 3 Admission to hospital for respiratory illness.
2.4
2.4. Analysis
Comparison 2 HCWs offered vaccination versus HCWs offered no vaccination; three C‐RCTs (Carman 2000, Potter 1997, Lemaitre 2009) (adjusted analyses), Outcome 4 Deaths from influenza or its complications.
2.5
2.5. Analysis
Comparison 2 HCWs offered vaccination versus HCWs offered no vaccination; three C‐RCTs (Carman 2000, Potter 1997, Lemaitre 2009) (adjusted analyses), Outcome 5 Death from any cause.
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