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Student Nurse Perspective: The Flu Vaccine.

Nurses attending to soldiersIngvar Árni Ingvarsson, a student nurse in the UK, wrote an excellent perspective on vaccines from his nursing eyeballs, which he graciously allowed me to re-post here.  

Little intro might be handy for this. This post has been on my mind for a long time now and finally I decided to pull my finger out and actually write it. What is to follow will be a mixture of factual, scientific and anecdotal writings. Because that is the way I roll. I have been itching to write something, anything about vaccinations for a little bit now, but so far decided not to because there are so many out there who do it and do a better job of it then I would dream of, so I’ll list some. Skeptical Raptor, Respectful Insolence, Red Wine & Apple Sauce, Just The Vax and many many more. 

Prior to starting my nursing course I was very much into my slightly alternative medicine. I was on the fence regarding vaccines, not just the flu vaccine but all vaccines. Now that I think back on it I’m not really sure why. It was never really something that I thought about properly until I started my university course. What was probably a turning point for me was the amount of patients over 70 I came across who had to use callipers and wheelchairs because they contracted polio when they were kids. I have never come across a patient under 70 who has had polio. Never. This sort of got me thinking about the importance of vaccination, and if there is one thing that I have learned since starting uni is that evidence is the key.

During my time in healthcare as both a support worker and a student nurse I have heard some rather odd statements from people who profess to work in an evidence-based profession.  The information that some of them believe regarding the flu vaccine has been especially astounding and the other factor has been that there is a group set up on Facebook, dedicated entirely to nurses who refuse the vaccine. This group is mainly US based where some states mandate for every healthcare worker should get the seasonal flu vaccine, or else risk losing their jobs or have to wear a mask during the flu season. Quite frankly I would be in favour of seeing a similar thing in the UK. Because the evidence, the real evidence, the researched evidence shows that it is safe.

Just to make it clear, the following blurb are based on what I have heard people say. There is an awful lot of misinformation I have read online, but that deserves to be tackled in a blog entry of its own.

As a future nurse in the UK I will have to abide (well, actually that is not the whole truth, even as a student nurse I have to abide by them) by the NMC Code of Conduct. It is clearly stated in the introduction:

The people in your care must be able to trust you with their health and well-being:

To justify that trust, you must

  • make the care of people your first concern, treating them as individuals and respecting their dignity
  • work with others to protect and promote the health and wellbeing of those in your care, their families and carers, and the wider community
  • provide a high standard of practice and care at all times
  • be open and honest, act with integrity and uphold the reputation of your profession

And in another section regarding providing high standard of care it says:

35. You must deliver care based on the best available evidence or best practice.”

What I have found astounding is that there are so many misinformed (that is me being polite) nurses working with patients. Especially when you consider the clientèle they work with. Health care workers take care of people at their most vulnerable, whether physically or mentally. They work with people who have suppressed immune system, like cancer patients, patients who have had organ transplants, who have immunity disorders like HIV/AIDS, who suffer from COPD, asthmatic, malnourished, children, the elderly, people who have just had surgery and on and on an on. Patients with COPD for example are encouraged to have their flu vaccine for the simple reason that the flu would exacerbate their condition and make them worse. Now the problem here is that the flu vaccine is unfortunately not as effective as most other vaccines. But it does reduce the risk of influence by 60% in the general population but up to 70-90% in healthy adults, and that is a lot more than 0% protection. With people in nursing/care homes it is up 50-60% effective in preventing hospitalization for example. And that last bit is important because we as nurses (okay a future nurse in my case) quite frankly want to make sure that no one comes to hospital who does not need to be there, especially if it is something that can be prevented in the first place. And this is where Herd Immunity comes in or community immunity as some people like to call it. The current vaccine we have are the best we have got at our disposal, not as good as we would like it to be but still generally better than most people give it credit for.

During my course I have heard some really rather dodgy and odd claims about the flu vaccine. These high stories can be boiled down to three claims. The first one is a variation of “I got the vaccine then I got the flu”. Which quite is impossible, this sort of reasoning is called Post Hoc Ergo Propter Hoc. The main reason being that it is impossible is because the influenza vaccine contains an inactivated virus, effectively a dead virus. It cannot come back to life in some sort of magical zombie way. Some people, even nurses, seem to not know the difference between a cold and a flu. Some people seem to think that the influenza is just a stronger version of the common cold. Which is just wrong, oh so very very wrong. The common cold is generally caused by Rhinovirus, whereas the flu is caused by a family of virus called Influenza Virus.  If you get the flu, you know about it. I do remember having it once some years back, completely and utterly destroyed Christmas for me that year, and I do not remember feeling nearly as lousy. Ever. There is a small chance that you could be symptomatic if you get the flu mist, which contains an attenuated virus. But the flumist has been found to be more effective for children whereas the injection works better on adults.

The second claim I have heard is a variation of “well I’m fit and health I don’t need to worry about the flu,” sometimes followed with “besides it mainly only kills children and elderly.” Anyone who works in healthcare that says the former sentence and adds the latter to it should not be working in health care. At best they should work as  chimney sweeps. Or maybe as car crash dolls. In fact anyone who thinks this way should be disqualified from the human race for shoving. During the Spanish Flu epidemic the biggest number of deaths was in young adults. The flu can be deadly to healthy people. A recent statistical report from the CDC shows, for example, that:

Between October 1, 2013 and January 4, 2014, 2,622 laboratory-confirmed influenza-associated hospitalizations were reported. This is a rate of 9.7 per 100,000 population. The most affected age groups are those 0-4 and ≥65 years; however, those aged 18-64 years account for 61% of reported hospitalized cases.

And the Public Health England website had this to say:

Indicators of influenza activity remain at low levels of intensity with evidence of sporadic detections of influenza. However, increasing influenza positivity and influenza-confirmed hospitalisations in young adults (15-44 year olds) has been reported, with A(H1N1)pdm09 predominating.

And the ECDC in their report added:

In the majority of countries, the most affected age group as reported from primary care services has been 0–4 year-olds, even though in Belgium, Iceland, Ireland, Malta and Norway, rates of influenza-like illness and acute respiratory infection (ILI/ARI) have been higher among 15–64 year-olds.

Or to quote Orac

I don’t care how healthy you are. The flu can kill.

The third claim I have heard and has so far gone down as one of the most stupid claims I have ever heard. “I refuse to have the flu vaccine because many years ago a lot of patients I took care of re-stroked.” I am not sure where to begin with this really rather dubious claim. The fact that no one else actually remembers this particular re-stroke season did not really help to support that statement. This goes against all the accrued evidence where it has been shown that people over 65 who got the flu vaccine had a marked risk reduction in major cardiovascular incidents and strokes, which a meta-analysis done by The Journal of the American Medical Association in 2013 rather emphatically showed. This was especially evident in patients who had active coronary disease. There was also a study done by the American Heart Association done in 2003, where it was mentioned of course that further studies were needed in order to establish why the influenza vaccine would have that kind of effect, but as is mentioned in the AHA article:

Influenza activity has been suggested as an explanation for the winter peak of MI.5,30,31 Glezen and colleagues,32 in a study in Houston from 1975 to 1977, found the incidence rates of death due to ischemic heart disease, hypertension, and cerebrovascular disease were similar to that of death attributed to influenza and pneumonia, with peaks and troughs that lagged influenza activity by ≈2 weeks.

But generally, even in healthy older adults(over 65’s) who received the influenza vaccine and/or pneumococcal there was up to 57% reduction in total mortality. So regardless of whether they are healthy or not, it is beneficial for everyone. Bit like having an ace up your sleeve in the battle against the flu.

Contracting the flu on the other hand can lead to further strokes and heart attacks:

A total of 20,486 persons with a first myocardial infarction and 19,063 persons with a first stroke who received influenza vaccine were included in the analysis. There was no increase in the risk of myocardial infarction or stroke in the period after influenza, tetanus, or pneumococcal vaccination. However, the risks of both events were substantially higher after a diagnosis of systemic respiratory tract infection.

Which sort of leads us again to the idea of Herd Immunity. I have already talked about this a little bit earlier in the post, but I suppose it needs to be said again. We as healthcare workers work with people who are at their most vulnerable. Which makes it even more important that nurses take every step to protect them, and that includes getting the annual influenza vaccine. By getting the flu vaccine a healthcare worker will reduce incidents of influenza transmission, reduce the risk of hospital-acquired influenza infection, along with other respiratory tract illnesses, hospital admissions from care home to hospital,  reduce staff sickness and it saves hospital trusts money. After all the flu does not just kill it also maims. It can lead to pneumonia, bronchitis, endocarditis, myositis and other lifelimiting complications.

We as nurses are there to take care of the patient. That might be pointing out the obvious, but sometimes it seems that people often forget the obvious. If taking care of our patient and making sure that they are safe from harm and to prevent harm from happening. And if that means to suffer a slight discomfort around the injection area. Then so be it. As professionals then we should not believe the misinformation and use anecdotes to back them up. We should be working with the evidence. And the evidence for flu vaccines for healthcare workers is clear. It is worth it for us and for our patients. Even until a better vaccine is developed every one who is involved in the care of patients should be vaccinated with the vaccine that is currently in use. 60% protection is better than 0% protection.

I will finish this with a small section from the American Nurses Association Code of Ethics which puts this rather neatly and to the point:

The nursing profession is committed to promoting the health, welfare, and safety of all people.


Michael Simpson

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