Week in Review
Are un-immunised hospital workers putting us at risk?
If you need to go to hospital, it mightn't occur to you that the workers there may not be vaccinated. Newsroom science editor Eloise Gibson tried to find out what proportion of workers in every DHB in New Zealand were vaccinated from measles and other illnesses. The answer? Nobody knows.
Here's what she found:
- Only two of New Zealand’s 20 DHBs know what proportion of staff are immune to measles, whooping cough or other infectious diseases.
- The Ministry of Health says health workers should be vaccinated to lower their risk of spreading serious illnesses, but DHBs don't make it compulsory.
- At least two DHBs make vaccination a condition of employment for new staff, but not existing staff. It is possible to work in a patient contact role in a newborn intensive care unit or maternity ward without being vaccinated.
- At last count, almost half of staff at one DHB had not had a whooping cough vaccine. Up to 11 percent were not immunised against measles.
- A measles-infected staff member worked at a Christchurch hospital while contagious last month and other hospital workers have also had measles this outbreak.
- In some regions, only a third of hospital midwives are accepting the recommended free flu vaccinations.
For the first two days, measles may have no symptoms.
This helps explain how, last month, a Christchurch woman went to the gym, ate at a Vietnamese restaurant and bought her groceries at New World without realising she was infectious with measles.
Crucially, she also went to work - at a hospital.
As of last week, the woman hadn't infected anyone, but things could have gone differently. The woman's employer is Burwood Hospital, which caters mainly to elderly patients likely immune by virtue of childhood exposure. Many of its staff are also over 50, and likely to be protected.
While healthy people who are fully immunised can occasionally catch a devastating dose of measles, the chances are much smaller than for the unvaccinated. Around seven percent of the 1906 people to catch measles during this outbreak so far were fully vaccinated.
The most vulnerable are babies too young to have been immunised, unvaccinated pregnant women (who can’t be safely vaccinated until they’ve had the baby), children, and people with low immunity (for whom the vaccines don’t work), all of whom you'll find in a hospital.
Of the roughly 600 people hospitalised by this outbreak, more than a hundred were babies. Some of the infants almost died, and two pregnant women lost their unborn babies. Children with low immunity, such as those having chemotherapy, have a 50 percent risk of death if they get measles.
Hospital staff are on the front lines of any measles outbreak, fighting to save the sickest people from death or permanent brain damage. Yet they can also catch measles. The risk of an unvaccinated person contracting the virus if they encounter it is as high as 90 percent. Measles is so contagious that when an infected person sneezes, the air in the sneeze zone can stay infectious for up to two hours. Simply being inside the same supermarket is considered a health risk for unvaccinated or otherwise vulnerable people.
While the Ministry of Health strongly recommends healthcare workers are vaccinated against measles, as well as Hepatitis B, influenza, mumps, chicken pox and whooping cough (if they work with babies and children), vaccination is not a condition of employment at most New Zealand hospitals.
Yet the woman at Burwood “was not the only healthcare worker in the country to have had measles this year," says Canterbury’s Medical Officer of Health, Cheryl Brunton. Brunton is responsible for containing measles in Canterbury and the weekend she learned of the woman's case, there were five other suspected infections in her area. She does not know how many other health workers around the country have been infected during the outbreak. The Ministry of Health does not know, either. It doesn't track how many hospital workers have caught measles, or whether they've infected patients. It leaves preventing outbreaks in hospitals to DHBs.
DHBs don’t have to publicise measles cases -- the public usually only hears about an individual case if the person has been somewhere so public that it is hard to trace their contacts without help from the media.
We know about the Burwood case not because the woman works in a hospital, but because she went to New World.
It's difficult to say what your chances are of encountering an unimmunised health worker in your area. The Ministry of Health does not track healthcare workers’ immunisation rates. Nor do most DHBs.
The only vaccination DHBs report on to the Ministry is seasonal 'flu. Those numbers show large disparities in vaccine coverage between DHBs, especially for hospital midwives. At some DHBs, only around a third of hospital midwives are accepting the free vaccine.
Flu shots have to be given each year, so the rates tend to be lower than for once-or-twice in a lifetime vaccines such as measles and chicken pox.
Waitemata, the DHB that runs Waitakere and North Shore hospitals, was the only one of New Zealand’s 20 DHBs that could say what percentage of its staff had had the measles, whooping cough and other vaccinations recommended for health workers by the ministry. At last count, in 2017, 89 percent were vaccinated against measles and chicken pox, 72 percent against rubella, 66 percent against seasonal ‘flu and 52 percent against whooping cough.
In other words, 11 percent of the workforce was potentially susceptible to measles and 48 percent may not have had an up-to-date whooping cough vaccine -- a health measure recommended by the ministry to reduce the risk of spreading the virus around the community, especially to babies.
Waitemata's vaccination rates may be better now: the DHB says it has targeted measles and whooping cough vaccinations among its staff recently. Whooping cough boosters are usually targeted at people working with babies and children, so the children's areas of the hospitals may have higher rates.
The reason Waitemata doesn’t have up-to-date figures is the same reason that other DHBs gave Newsroom when they explained why they had no data at all on immunity rates for staff inside their hospitals (seasonal flu excepted).
Immunity and vaccination records are kept on people’s individual files, which, while useful for sending out reminder letters when someone is overdue for a booster shot, does not easily allow DHBs to collate staff vaccination rates.
Waitemata is moving to a new system next year that will allow quick retrieval, but others still keep the information individually, sometimes on paper files.
Counties Manukau, which runs Middlemore Hospital, said extracting its rates would take too long – and staff were already busy battling Auckland’s major measles outbreak. Some DHBs, such as Tauranga's Bay of Plenty DHB, said they had only this year started collecting information on whether existing staff were vaccinated.
The Ministry of Health says it's up to DHBs not to roster unvaccinated staff to work with the most vulnerable or at-risk patients.
Yet even at Auckland DHB -- one of the most proactive in the country when it comes to measuring and increasing worker vaccination -- there is a sprinkling of staff who are not confirmed to be vaccinated from measles working in patient contact roles across newborn intensive care, paediatric intensive care, accident and emergency and the maternity ward.
The DHB has up-to-date numbers on these wards because in March 2019, it embarked on a measles vaccination audit of all patient contact staff in the highest-risk hospital areas: newborn intensive care, paediatric intensive care, cancer care, the emergency department and the maternity ward.
It found 97 percent of these staff were already immunised against measles and managed to raise the rate to 99 percent. Nine staff remain either un-immunised, or the hospital hasn't been able to find out their status. That small group is sprinkled across newborn intensive care, paediatric intensive care, accident and emergency room, orderlies and the maternity ward. All staff in cancer care are measles-vaccinated.
At Newsroom's request, Auckland DHB extracted its whooping cough vaccination rates, though, because of the work involved, it only supplied rates for the Starship children’s emergency department. This is the largest area of the hospital caring for children and babies. 86 percent of the 111 nurses, doctors and other patient contact staff were recorded as being up to date with their whooping cough vaccines. This included 77 percent of doctors and 86 percent of nurses.
The DHB says those numbers are probably a slight underestimate, since they are missing some records for junior doctors as well as some one-off booster shots that were given to staff recently. On the other hand, other areas of the hospital would have lower whooping cough vaccination rates than children's ED, the hospital said.
That leaves 14 percent of staff who are possibly unvaccinated from whooping cough, in children's ED in a hospital that measures its rates proactively.
The Ministry of Health and the Immunisation Advisory Centre recommend all health staff working with babies and children should have a whooping cough vaccine every decade, because immunity to the illness wears off after around 5 or 10 years.
Adults can be contagious without realising what they have, because they may not get the tell-tale "whoop" sounding cough that plagues young babies. During New Zealand's regular whooping cough outbreaks, expectant parents, grandparents and any other adults who’ll be close to a newborn are often advised to get booster shots to try to “cocoon” the baby until its vaccinations begin, at six weeks' old.
In the 13 years to 2014, the highly contagious illness hospitalised more than a thousand New Zealand babies and killed six newborns before they could be vaccinated. In the United States, there are well-studied cases of babies catching the illness in hospital: in 2004, six Texan infants born during the same week caught whooping cough from the same infected health worker.
Bernadette Heaphy, a Regional Immunisation Advisor for the Immunisation Advisory Centre, says the centre would like a targeted programme giving whooping cough vaccines to all healthcare staff working with babies and young children.
New Zealand has offered the whooping cough vaccine free to pregnant women for several years, though uptake is variable. But while Heaphy says the biggest gains will come from getting pregnant women and babies vaccinated on time, getting health workers immunised provides an "added layer" of protection. "It is certainly beneficial to make sure staff who are working in neonatal unit, and paediatric units are vaccinated to help reduce the risk of spread," she says.
Several New Zealand DHBs have each given staff thousands of free whooping cough boosters over the past decade. Yet despite their efforts, it is not always clear whether the vaccines are reaching all of those who need them. Palmerston North’s MidCentral DHB started a whooping cough vaccine catch-up programme five years ago, focusing on high risk hospital areas such as the emergency department, paediatric services and the cancer ward. The DHB told Newsroom it had put “significant energy” into making it easy for staff to get all recommended vaccines. Yet: “While access has improved, staff uptake has had mixed results,” it says. It couldn't say what percentage of staff were immunised against whooping cough at the start, or the end, of the whooping cough programme
Measles and whooping cough aren't the only vaccine-preventable illnesses that are most risky to babies and pregnant women, among other vulnerable groups. Influenza, for example, poses the biggest risk to pregnant women, young children and over-65s.
Last year, the Ministry of Health set a target of 80 percent of healthcare workers having the seasonal influenza vaccine. “Health care workers, by virtue of their occupation, are at increased risk of contracting influenza and may transmit the infection to susceptible contacts, with the potential for serious outcomes," the Ministry says in its flu tracking report.
The Ministry requires all DHBs to track what proportion of doctors, nurses and midwives get the annual flu vaccine -- an easier proposition than tracking measles immunisation rates, because workers need to have the vaccine every year.
Just two DHBs -- Tairawhiti and Northland – achieved 80 percent flu vaccine coverage last year. The average rate was 68 percent, and that was the highest since the tally started being recorded in 2010.
While nurses and doctors ranged from the high 50s to high 90s, depending on the district, hospital midwives were accepting free flu vaccination at rates as low as 26 percent.
Four regions -- Canterbury, Auckland, Wairarapa and Whanganui – had high, 70 percent-plus rates for their midwives,
But Taranaki was at 26 percent. Lakes DHB’s rate for midwives was 33 percent. Bay of Plenty’s was 35 percent. Waitemata, Waikato, Nelson, Midcentral and Southern DHBs each had less than 50 percent coverage.
The figures look a little better after adding staff who've had their 'flu shots elsewhere, such as at their personal doctors. Some DHBs add these to their totals to get a more complete picture, though they don't report the offsite vaccinations to the ministry. Wairarapa’s midwives, for example, went up by four percentage points once outside vaccines were added, to 75 percent. However adding these outside vaccines doesn't radically change the picture, possibly because health workers usually have to pay for any flu shots they receive outside the workplace.
But there is a bigger gap in the flu vaccine numbers than people getting them at their GPs. The DHBs' statistics only cover midwives who work directly for DHBs. They do not cover community midwives, known as a lead maternity carers, who check on women during pregnancy, meet women at the hospital to deliver their babies, and carry out home visits to mums and newborns. Pregnant women commonly have most of their contact with these community midwives. There are no vaccination statistics for them.
The midwives’ professional body, the College of Midwives, says it recommends its members are immunised but is “not in a position to mandate or require this of its members.” That’s because community midwives “largely work in a self-employed capacity under a Ministry of Health contract,” it says.
Newsroom asked the ministry a short list of questions about midwives’ immunity rates. In response, it referred to this advisory issued by the midwives’ college, recommending midwives make sure they're vaccinated against measles.
Asked about the lack of data for non-DHB midwives, one DHB, Tairawhiti, suggested pregnant women should do their own due diligence. “It is appropriate for women to ask their lead maternity carer if they have been immunised against pertussis (whooping cough) and influenza.”
'What is the real data?'
DHBs listed several ways in which they’ve tried to raise staff’s vaccine coverage. They screen for immunity on employment, write reminder letters, and offer free catch-up vaccinations. Some even bribe people to have the ‘flu vaccine with coffee vouchers.
Many trainee health workers are prodded to check their immunity to measles and other illnesses during training, says Heaphy. “A lot of the health schools are very proactive and insist on vaccination records when students enrol,” she says. “And some of the DHBs are now saying that if students aren’t vaccinated, they’ll have limited choice around clinical placement.”
At least two DHBs – Waikato and Rotorua’s Lakes – say they will no longer hire unvaccinated staff, unless the person has a medical reason for not vaccinating. Lakes DHB says it used to accept a written waiver declining to be vaccinated, but this is no longer good enough.
The no-jab-no-hire rule doesn't apply to people who are already employed by hospitals, even at those DHBs that have the policy for new hires.
While it's common for DHBs to ask new staff for proof of immunity from the ministry's list of diseases, they will still hire new staff who decline vaccination. “If vaccination is declined, then the Line Manager is informed, so that they can consider and manage that risk,” says Counties Manukau. “While vaccinations are not compulsory, staff are strongly advised of the risks of not being vaccinated and this is clearly communicated with staff,” says Hutt Valley.
DHB's policies for managing these staff vary, but they include saying managers can keep unvaccinated people off the highest-risk wards, or send people home if they have symptoms of something serious. Or, they can move people to lower-risk hospital areas during disease outbreaks. The system tends to rely on managers keeping tabs on individuals.
Yet it can be hard to know when a disease outbreak is coming, or when a health worker may be infectious. Measles often arrives from overseas during times when New Zealand appears free of it. (Transmission goes both ways, sadly. Last week, New Zealand learned that it had exported its measles outbreak to Tonga, via a travelling school rugby team.)
Heaphy believes DHBs are improving. “I think we’ve done substantially better over the last few years,” she says. Tracking the flu jab had helped raise awareness, she says, and “measles has brought everything to the fore, as well.”
On the other hand, she says, not being able to see vaccination rates to know how well a push is working must be “frustrating” for DHBs.
“I think there are two issues here,” she says. “One is the ability to say, what is the real data? What is the situation in terms of immunity for health professionals against these key diseases?.”
“The other aspect is to improve access to vaccines,” says Heaphy. “If you look at the flu numbers, areas where DHBs have made vaccine easier to access seem to have much better rates. Finding a way to make sure you vaccinate night staff as well as day staff, for example.
“One of the things that’s worked at several DHBs is having peer vaccinators on the ward, so people can see their colleagues getting vaccinated and follow their lead, and so you’re not taking people off a busy ward.”
Risk of backlash
Heaphy says just because someone works in a hospital, it doesn't mean they're vaccination experts. Just like anyone, staff may be doubtful or misinformed about the benefits, and they may need education.
Compulsion is one option, although it's not used widely internationally. Some countries make whooping cough vaccinations mandatory for certain health workers. Finland makes measles vaccination compulsory. In the United States, it is common for seasonal flu vaccines to be mandatory for hospital staff. Several US states made it a condition of employment, after voluntary measures failed and unvaccinated workers were found to have contributed to patient complications and deaths. Uptake of the flu jab is now 78 percent among US health workers overall and above 90 percent for doctors and nurses. Some US states also require full measles vaccination before a hospital worker can begin work.
When New Zealand tried its own experiment with compulsory flu vaccines, things did not go smoothly. The edict happened under the troubled reign of former Waikato DHB chief executive Nigel Murray. During the 2015 flu outbreak, staff who hadn’t had the ‘flu shot were told they had to wear face masks, spurring fierce opposition from the New Zealand Nurses' Organisation and other medical unions. One nurse was fired for refusing to comply and others were threatened with disciplinary action.
The impact on flu vaccination rates was strong, but it didn’t last. Waikato DHB's flu vaccination rates jumped from 53 percent to over 80 percent, then they fell to 66 percent. Last year, Waikato DHB was the only one in the country to record a significant drop in its flu coverage.
Newsroom asked the New Zealand Nurses' Organisation what went wrong, and what it thought of the policy now. The organisation’s regional representative, Hilary Graham-Smith, said the policy was imposed in a draconian way, without consultation, and the way face masks were being imposed on people felt punitive.
Although Graham-Smith says the policy was abandoned, Waikato DHB denies this. “We have not dropped the face mask (policy). If we have an influenza outbreak then employees not vaccinated would be required to wear a mask,” said the hospital's chief nursing officer.
Despite the friction over flu and face masks, Graham-Smith says nurses would probably have no problem with measles and whooping cough being made compulsory. “Requiring vaccination for Hepatitis B or proof of immunity is pretty standard, and with the outbreaks of pertussis (whooping cough) and measles in recent times it is reasonable that they will require those as well. I don’t think we would have a problem with that,” she says.
Newsroom asked the Health Ministry for its view. “It's not about making vaccination compulsory. It's about ensuring that staff who choose not to or are unable to be vaccinated are not rostered on to work with high risk or very vulnerable patients,” was its answer.
Cheryl Brunton didn’t want to hazard an estimate of what it might cost to stop measles spreading from a hospital worker. When anyone in Christchurch gets measles, her team springs into action and asks anyone unvaccinated whose entered the person's orbit to stay home until the incubation period passes. This time, it seems to have worked. An infection control team inside Burwood worked in parallel with Brunton's team, containing the disease from spreading in or from the hospital.
Heaphy says there is a significant workload for hospitals whenever they have a worker infectious with any vaccine-preventable illness, not just measles “Even if you had a susceptible health care worker who came into contact with a child with chicken pox, there’s lots of work that goes on in the background,” she says.
Overseas, there've been attempts at counting the cost. One report from the United States estimated giving a single Cleveland hospital worker a US$30 whooping cough vaccine could have saved the hospital US$12,000 in time and treatment. By the time he was diagnosed, the employee exposed 92 staff and more than 50 babies and children, including child cancer patients, to whooping cough. The hospital had offered staff free vaccination, but half the employees who’d been exposed to the sick worker hadn’t had the jab. The estimate cost of a measles outbreak in a hospital has been put much higher than whooping cough.
Newsroom asked Brunton and Heaphy whether, given how vulnerable some patients are, immunisation should be a condition of employment, at least for staff working in the highest-risk areas of a hospital.
Brunton says it is not the kind of call that one DHB would make alone. “That’s the kind of decision that might be made on a more collective basis by DHBs,” she says. “One of the issues is the very large number of people employed by DHBs. Here in Canterbury alone, it is several thousand. There would be resourcing implications,” she says. "But then again, there are resourcing implications from managing these (infection) cases.”
Heaphy makes a careful distinction between her own views, and those of the advisory centre.
“That is an avenue some DHBs are looking at," she says. "As the Immunisation Advisory Centre we don’t have a particular policy around the mandatory aspect,” she says. “We do know that with good communication and education, we can bring people along with us, and that there can sometimes be backlash around making things compulsory,” she says.
"But I can’t say that on a personal level I disagree with the idea that, if you’re going to go and work in an area with high risk patients, you wouldn’t be vaccinated. It makes logical sense.”