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A two-pronged approach to protecting SNF residents from influenza

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William Schaffner, M.D., President, National Foundation for Infectious Diseases
William Schaffner, M.D., President, National Foundation for Infectious Diseases

Good news: More skilled nursing facility staff are getting their annual influenza vaccine than ever before. Last season, nearly 70% were vaccinated, up from 64% a year earlier. Bad news: SNF staff still have the lowest influenza vaccination coverage rates of healthcare professionals by work location — 10% below national HCP vaccination rates and more than 20% below the vaccination rates of their colleagues working in hospitals.

Achieving and maintaining high yearly rates of influenza vaccination in SNF staff is particularly important because they care for some of the most vulnerable patients. SNF staff have regular contact with older adults, individuals with disabilities, and those with chronic health conditions. All of these patients are at increased risk of serious flu outcomes. High HCP influenza vaccine coverage rates translate into better, more consistent care from individuals who are less likely to spread influenza.

A 2005 Call to Action, Influenza Immunization among Healthcare Workers, issued by the National Foundation for Infectious Diseases, reported on several influenza outbreaks linked to virus transmission between HCPs and high-risk patients. In one long-term care facility where just one in 10 workers was immunized, the influenza outbreak included 65 residents. More than half of the 65 residents developed pneumonia, 19 were hospitalized and two died. Today's HCP vaccination coverage rate of 70% should help ensure these types of outbreaks do not continue to occur.

Preventing influenza, especially in older adults age 65 years and older, is about more than just preventing respiratory illnesses. In older adults, influenza increases the risk of heart attack by three to five times and the risk of a stroke by two to three times in the first two weeks of the infection. Moreover, these risks remain elevated for up to three months.

Critical Step #1: Annual Influenza Vaccination of SNF Staff

It is the duty of every HCP to get vaccinated and to encourage his or her colleagues and co-workers to do the same. Unvaccinated HCPs are at increased risk of carrying and passing the influenza virus on to patients in their care. They also increase their odds of getting sick and missing work during the winter respiratory season—a time when patients and colleagues count on HCPs most. As important as their presence is, it is also very important to note that it is also their duty to stay home when sick.

Critical Step 2: Influenza Vaccination for all SNF Residents

It is also critical to make sure as many SNF residents as possible are vaccinated, regardless of whether they are planning a short or long stay. Close living quarters facilitate the spread of respiratory viruses such as influenza and others. Fortunately, in the case of influenza, there is a vaccine available – a tested and proven way to lower the risk of infection and the worst outcomes of influenza including hospitalization and death.  

There are many reasons patients, families, and HCPs alike mention for not getting an influenza vaccine. Only one is valid—a true contraindication to the vaccine itself—an anaphylactic reaction after a previous dose of vaccine or to a vaccine component. The other reasons are baseless — the vaccine cannot cause the flu, it is safe — it has been given to hundreds of millions of people for more than 50 years, even young and healthy can get the flu and die from it, and so on.

Some patients may refuse influenza vaccine on the grounds it is not effective enough. Although we would all welcome a vaccine that is 100% effective, none exist. Even childhood vaccines that seemingly wiped out diseases like polio and smallpox are not 100% effective; part of their success is directly linked to the very high vaccination rates in US children.

But it is not just lower vaccination rates that are a challenge for influenza. The influenza virus is tricky—making regular changes to its structure to evade vaccines and the human immune system. These changes lead to variable vaccine efficacy from one year to the next, but vaccines virtually always provide some protection, with minimal risk.

While not every SNF resident is age 65 years or older, most are, so it should be welcome news that two influenza vaccines, high-dose and adjuvanted, have been approved specifically for the 65+ population. These influenza vaccines are designed to provide a better immune response. Immune systems decline as adults age, and while 70 may be the new 60, the immune system needs all the help it can get from recommended vaccines.


Ideally, all SNF visitors will have gotten their flu vaccines early in the season to protect themselves. While it is likely impossible to limit visitors based on immunization status, every effort should be made to encourage them to be vaccinated for the protection of their loved ones and other SNF residents. Facilities can do this by communicating their commitment—starting with visible vaccination programs for staff and residents. A simple way to do this is with a button or sticker worn by staff to show their vaccination status. Vaccine commitment can also be highlighted in admission documents, on posters displayed prominently throughout the facility, and by staff in their conversations with visitors. NFID provides free resources

Improving influenza prevention: An added benefit

For SNF staffers, understanding and educating themselves as well as patients and their families about the potential impact of influenza and the value of annual vaccination may also help lay the groundwork for the future prevention of respiratory syncytial virus. In the US, RSV kills approximately 14,000 adults age 65 years and older each year and hospitalizes 177,000. Because there is no specific treatment or prevention method currently available, RSV often goes undiagnosed. But there are a number of RSV vaccines currently in various stages of development and the better we are at preventing influenza, the better equipped we will be to prevent RSV when a vaccine does become available.

If flu vaccination rates are lagging in your facility, here is more good news: there's still time to get vaccinated this season. Influenza vaccine takes about two weeks to become effective and the season can last into late winter or early spring. Vaccination in January or even later is of value, but because the flu season can also start in the fall, in general, vaccination is recommended earlier in the season.

We have the power to greatly reduce the negative outcomes of influenza on SNF residents by vaccinating staff and residents, and encouraging vaccination of all others who enter the facilities.

For more information about influenza in older adults, read NFID's Call to Action, Reinvigorating Influenza Prevention in US Adults Age 65 Years and Older available at

For more information about RSV in older adults, read NFID's report Respiratory Syncytial Virus in Older Adults: A Hidden Annual Epidemic available at

William Schaffner, M.D., is medical director of the National Foundation for Infectious Diseases. He is also Professor of Preventive Medicine in the Department of Health Policy and Professor of Medicine in the Division of Infectious Diseases at Vanderbilt University School of Medicine in Nashville, TN. He is a hospital epidemiologist at Vanderbilt University Hospital. Schaffner is a member of numerous professional societies, including the Infectious Diseases Society of America, Society of Healthcare Epidemiology of America, and the American Public Health Association.



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