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Influenza vaccine is effective at preventing influenza in healthy young adults.[1] The strategy to encourage influenza vaccination for health care workers is partly based on the simple notion that this can reduce the risk of staff acquiring and transmitting influenza to vulnerable patients and thereby reduce associated morbidity and mortality. A number of investigators have attempted to demonstrate the impact of influenza vaccine in healthcare workers on patient outcomes.[2–5] They have used the most robust methodology available to them for assessing group interventions, namely the cluster randomized controlled trial. These trials have focused on long-term care facilities (LTCF) for the elderly. Such facilities house frail elderly patients for months or years in congregate settings. Outbreaks of respiratory tract infections in LTCF are extremely common. For example a surveillance study in Toronto identified 46 outbreaks across 5 homes in 3 years (more than three outbreaks per home per year with an average case fatality rate of 8%).[6] Despite high levels of resident vaccination, low vaccine efficacy in the elderly means that they remain vulnerable to influenza and its complications. Residents have very high rates of mortality and hospitalization especially during periods of influenza circulation. Even when residents have regular visitors, their main contact with the outside world is via healthcare staff. Long-term care facilities, therefore, provide an opportunity to demonstrate proof of the principle that healthcare worker influenza vaccination can prevent influenza and associated morbidity and mortality in their patients. Cluster randomized trials of staff vaccination in these settings have consistently shown benefit to residents (2–5) and this evidence has been used to support influenza vaccination of healthcare workers more generally. Since part of the rationale for vaccinating healthcare workers is patient protection some employers have chosen to make staff vaccination a condition of employment, which has led to legal challenge. De Serres and his co-authors present a number of arguments based on their assessment of the evidence as to why they think mandatory vaccination is not warranted.[7] In our study [4] we aimed to test the hypothesis that a campaign promoting influenza vaccination of staff would reduce influenza-related morbidity and mortality in elderly residents of long-term care facilities. The study was based in a national chain of LTCF providing 24 hour nursing care (i.e. the subset of LTCF catering for the most frail elderly). We hypothesized that the effect of the vaccine would be confined to periods when influenza was circulating and undertook the study over two years to minimize the risk of being unable to demonstrate an effect in a year with low levels of influenza circulation. The study took place over two winter seasons, the first of which had considerably higher levels of community influenza activity and influenza related deaths than the second. Although the first year has been reported as a vaccine

Influenza Vaccination of Healthcare Workers Is an Important Approach for Reducing Transmission of Influenza from Staff to Vulnerable Patients