Medical Director, Infection Prevention, El Camino Hospital, Palo Alto Medical Foundation
SOURCE: Tenforde MW, Weber ZA, DeSilva MB, et al. Vaccine effectiveness against influenza-associated urgent care, emergency department, and hospital encounters during the 2021-2022 season, VISION Network. J Infect Dis 2023;228:185-195.
Influenza vaccine efficacy (VE) was investigated among adults presenting to emergency departments/urgent care (ED/UC) or requiring hospitalization with one or more acute respiratory illnesses (ARI) during the 2021-2022 respiratory season. Data were captured through VISION, which is the Centers for Disease Control and Prevention-sponsored multistate network for patients with ARI with confirmed respiratory virus, including COVID-19 and influenza A/B.
Relative to the previous year, the 2021-2022 respiratory season saw an increase in influenza illness, which was dominated both in Europe and in the United States by influenza A (H3N2) 3C.2a1b subclade 2A.2 viruses. This clade is genetically similar but antigenically different from the 2021-2022 season A(H3N2) vaccine strain.
During the 2021-2022 season, 102,593 adults ≥ 18 years of age presented to ED/UC with ARI and had an influenza molecular test, which was positive in 9% of cases. For these outpatients, 31% of positive cases were vaccinated against influenza vs. 42% of controls. For patients 65 years of age and older, 63% were vaccinated compared with 64% of controls. The calculated VE for those presenting to ED/UC was 29% for adults ages 18-64 years and 7% among adults older than 65 years of age. VE was similar at 14-119 days post-vaccination compared with ≥ 120 days post-vaccination (27% vs. 24%). However, for those with immunocompromising conditions, VE was only 4%, compared to 25% for those without immunosuppression.
Among 21,805 adults ≥ 18 years of age with ARI who were hospitalized and had testing for respiratory/influenza infection, 4% were positive for influenza. Of these, 46% were vaccinated compared with 57% of controls. VE for those with ARI-associated hospitalization was 25%, including 17% among adults ages 18-64 years and 29% among adults older than 65 years of age. There was a trend toward diminished VE comparing 14-119 days post-vaccination vs. ≥ 120 days post-vaccination (44% vs. 22%), although the confidence intervals overlapped. VE was only 16% for those with immunocompromising conditions.
COVID-19 was diagnosed in 14% of influenza-negative controls presenting to the ED/UC and 23% of influenza-negative controls requiring hospitalization. Inclusion of COVID-19-positive controls in this analysis further diminished the calculated influenza VE, most likely because those with COVID-19 were more likely to lack COVID-19 vaccination, and therefore also more likely to lack influenza vaccine — and these individuals are more likely to present for testing and care.
This study confirms the surprisingly poor efficacy of the 2021-2022 influenza vaccine against a genetically similar but antigenically different strain of influenza A (H3N2). Excluding persons with COVID-19, VE for adults ≥ 65 years of age presenting to ED/UC with respiratory illness was only 7% and for those requiring hospitalization was about 29%. VE for those with immunocompromising conditions was especially poor (ranging from 4% to 16%). These data were confirmed by another similar study of adults presenting for outpatient care that observed that influenza VE during the 2021-2022 respiratory season also varied by age, ranging from 32% among adults 18-49 years of age to only 10% for those ≥ 50 years of age.1
These data highlight the need for better influenza vaccines, especially in those who most need it — older persons and those with immunocompromise. The authors suggested that studies of influenza VE should exclude patients with acute COVID-19 from the analysis, as this negatively biases the results for influenza vaccination.
Reference
- Price AM, Flannery B, Talbot HK, et al. Influenza vaccine effectiveness against influenza A(H3N2)-related illness in the United States during the 2021-2022 influenza season. Clin Infect Dis 2023;76:1358-1363.
SOURCE: Swartz TH, Aberg JA. Preserving the future of infectious diseases: Why we must address the decline in compensation for clinicians and researchers. Clin Infect Dis 2023;77:1387-1394.
Much has been said this year about the drop in applicants for both adult and pediatric infectious disease (ID) fellowships. In 2023, only 67% of adult ID fellowship positions were filled, a decrease of 7.1% compared to the previous year. In contrast, the Pediatric Infectious Diseases Society was heartened to see an improvement in 2023 with 20 (37%) programs filling all of their open positions, and 37/77 (48%) positions filled — hardly data to cheer. These dismal results for ID occurred despite this being the largest match in the 70-year history of the National Residents Matching Program. How has this been allowed to happen on the heels of not one but two recent international pandemics (COVID and mpox)? During COVID, suddenly every facility needed an ID physician. And yet, according to the 2023 Medscape Physician Compensation Report, ID physicians are among the lowest paid subspecialties in medicine. The Association for American Medical Colleges 2022 report found that ID-trained physician mean salaries were $40,000 to $80,000 less than other medical specialties.
The direct downstream result will be insufficient ID specialists in the coming years. I believe this effect already is being felt: Our large multispecialty medical group, located in northern California, was actively searching for one ID physician in 2022-2023. It took 15 months to fill the position. At one point during the search, there were 21 open ID-related positions in Northern California, including three competing Kaiser positions, several open Sutter positions, as well as numerous public health jobs (on the heels of an exodus from public health COVID burnout).
ID physicians have overwhelmingly demonstrated their value in so many areas:
- reducing hospital mortality and days of hospitalization;
- improving antimicrobial stewardship (AS), with direct impact on use of antimicrobials, with its attendant benefits and cost savings;
- reducing hospital-acquired infections and improved infection prevention (IP) strategies;
- developing and implementing policies and procedures in response to outbreaks and pandemics;
- enabling the surgical subspecialties, improving their outcomes, and reducing their liability;
- overseeing outpatient parenteral intravenous (IV) therapies (OPAT);
- implementing ID preventive strategies;
- performing activities integral to public health.
This list could go on. So why are these multifaceted and useful (and at times indispensable) pro-fessionals so undervalued and underpaid? It’s a confluence of the traditional under-valuation for the “thought-based” specialties, exacerbated by the misalignment of relying on relative value units (RVU) to define compensation vs. the actual intensity and breadth of the job; the lack of a systemic approach to defining ID physician staff ratios for acute care; the disproportionate amount of call required to provide hospital ID coverage; and undefined pay valuations for ancillary services, including IP, AS, OPAT, etc.
Beyond the existing fee-for-clinical care, a ready change in ID remuneration could be structured as follows:
- Nationally defined staffing targets for IP medical directors for every acute care facility. There are now nationally defined IP staffing levels for healthcare ( ~1 IP per 70 acute care beds). These recommendations should extend to IP/ID physician involvement.
- Nationally defined staffing targets and salary for AS medical directors for acute care facilities, with added bonuses for meeting goals.
- Payments for ID call coverage for urgent care and emergency services — availability has a price. Such payments often are provided to surgical subspecialties to guarantee sufficient emergency coverage, but ID physicians provide this service gratis. Similar contractual agreements at a fraction of the pay offered to the surgeons could be created for ID (e.g., $350 per night), which could go a long way to improving their income. Consider this: at our facility, 30 orthopedic surgeons are paid to share emergency department (ED) call coverage about one day per month to maintain their staff privileges. In contrast, each ID physician covers the ED 10-12 days/nights per month. While ID has not historically been paid for ED/urgent care call coverage, this service has a value to the clinics and hospitals they serve. And it cannot just be $10 a phone call or $0.50 an email (seriously) — availability has a price.
- Nationally defined billing structure for overseeing OPAT programs and their components.
- Bonuses for quality projects, i.e., establishing a virtual prevention program for pre-exposure prophylaxis (PrEP).
The federal government has set the bar high for national patient safety goals, and ID is integral to meeting those goals on several key levels. Medicare reimbursement to hospitals should reflect those goals — and help to fund the very individuals trained to help meet them. Rather than Medicare penalties for hospitals failing to meet healthcare-associated infection and quality goals, how about nationally defined incentives to those institutions that achieve optimal results?
