Menu Close

Author: WorkCompAcademy

WCRI Studies Chiropractic Care for Workers with Low Back Pain

The Workers Compensation Research Institute (WCRI) announced the release of a new study on chiropractic care for low back pain. The study reveals substantial variation in the use of chiropractic care across 28 states and offers insights into the patterns and outcomes of chiropractic care.

“Chiropractors often participate in the delivery of physical medicine services for low back pain, but few workers received chiropractic care in states where employers or insurers control the selection of providers,” said John Ruser, WCRI’s president and CEO. “This study will be helpful for policymakers and stakeholders who are interested in re-evaluating the role of chiropractors, especially those who have been adopting evidence-based practices and contributing to cost-effective care.”

This study, Chiropractic Care for Workers with Low Back Pain, describes the prevalence of chiropractic care and provider patterns of physical medicine treatment for workers with low back pain. It provides some evidence as to how different provider patterns of physical medicine treatment are associated with variations in overall medical and indemnity costs, and the duration of temporary disability. The study also looks at the utilization of medical services, including magnetic imaging studies, opioid prescriptions, and pain management injections.

The following is a sample of the study’s key findings:

– – The prevalence of chiropractic care varied substantially across the 28 study states. States that give employers control of selecting medical providers were among the states with the lowest prevalence of chiropractic care.
– – When chiropractors are involved in care, they alone may provide physical medicine care or deliver physical medicine care in conjunction with other non-chiropractic physical medicine providers.
– – Based on the experience of 16 states with prevalent chiropractic care, 12 percent of workers with low back pain received physical medicine care exclusively from chiropractors, and 17 percent received physical medicine treatment from chiropractors and other non-chiropractic providers, concurrently or sequentially.
– – Claims with care provided exclusively by chiropractors were associated with lower costs and shorter duration of temporary disability than a set of claims with similar characteristics where care was exclusively provided by non-chiropractic providers.

The data used for this study are from the WCRI Detailed Benchmark/Evaluation database, which includes more than 2 million open and closed claims from 28 states, with injuries from October 1, 2015, through September 30, 2017, and detailed medical transactions up through March 31, 2019.

The 28 states are Arkansas, California, Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nevada, New Jersey, New Mexico, New York, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, and Wisconsin.

To learn more about this study or to download a copy, visit WCRI’s website. Dongchun Wang, Kathryn L. Mueller, Donald R. Murphy, and Randall D. Lea authored the study.

Three Face Charges for $128K State Fund Premium Fraud

Three Sacramento Area residents face charges of worker’s compensation premium fraud by allegedly manipulating their companies payroll resulting in a loss of nearly $128 thousand in State Compensation Insurance Fund premium.

Troy Williams, 49, of Angels Camp, Nanci Morman, 68, of Somerset, and John Allison, 63, of Rocklin, were arraigned on multiple felony counts of insurance fraud after a joint investigation with the California Department of Insurance and the El Dorado County District Attorney’s Office revealed the defendants allegedly conspired together to illegally lower their company’s workers’ compensation insurance premiums and defraud the State Compensation Insurance Fund.

Williams has owned and operated a framing business called Archer Building Company since 2001, which reported carpentry payroll between 2013 and 2016; however, in 2016 the company’s work-related claims costs increased, which would increase its worker’s compensation insurance rates.

The joint investigation found that Allison, an Archer Building Company employee, created Allison Development. Between 2016 and 2020, Archer Building Company diverted its carpentry payroll to Allison Development in order to avoid paying accurate workers’ compensation insurance premiums.

In 2020, Allison Development’s workers’ compensation policy was cancelled and the employees transferred back to Archer Building Company.

The investigation found Archer Building Company and Allison Development attempted to defraud State Fund of $127,795 by not paying the correct amount of premium. Also, it was revealed that Morman was the bookkeeper and point of contact for insurance audits for both companies.

On March 10, 2022, Williams and Morman self-surrendered to the El Dorado County Jail. Allison self-surrendered on March 14, 2022.

They are scheduled to return to court on May 26, 2022. The El Dorado County District Attorney’s Office is prosecuting this case.

California is Losing Legal Battles Over Corporate Director Diversity Laws

S.B. 826 requires that, by December 31, 2021, publicly held corporations in California have at least 1 female director if the number of directors is 4 or fewer, at least 2 female directors if the number of directors is 5, and at least 3 female directors if the number of directors is 6 or more.

Assembly Judiciary Committee analysis describes S.B. 826 as “essentially a quota system for private corporate boards. Should this bill be challenged, the State would confront a difficult challenge in showing a compelling government interest in requiring a gender-based quota system for a private corporation.” And their expectation of having “difficult” challenges seems to be the case.

In the most recent case, plaintiffs allege that S.B. 826 violates Equal Protection under Article I, Section 7 (aka Equal Protection Clause) and violates Equal Protection under Article I, Section 31 (the prohibition on discrimination based on sex in public employment, education or contracting) of the California Constitution.

Los Angeles County-based California Superior Court Judge Maureen Duffy-Lewis just found in her May 13, 2022 ruling, that S.B. 826 is unconstitutional under the Article I, Section 7, and thus the Court “need not make any determination as to plaintiffs’ second count under Article I, Section 31 in the case of Crest v Padilla, 19STCV27561 (May 13, 2022).

The first prerequisite to a meritorious claim under the equal protection clause is a showing that the state has adopted a classification that affects two or more “similarly situated” groups in an unequal manner. When a statute makes express use of a suspect classification, a plaintiff challenging the statute meets their initial and ultimate burden simply by pointing out the classification. The statute is presumed to be unconstitutional, and the government bears the burden of demonstrating otherwise.

The Court found that the Plaintiffs carried their burden to prove that men and women are similarly situated for purposes of S.B. 826’s gender-based quota.” As Plaintiffs have demonstrated that S.B. 826 is presumptively unconstitutional, thus the burden shifted to the defendant to prove that S.B. 826 satisfies strict scrutiny.

To meet the strict scrutiny test, the defendant must show (1) a compelling state interest, (2) that S.B. 826 is necessary and (3) that S.B. 826 is narrowly tailored. The strict scrutiny standard applies even if a law is claimed to be remedial.

Defendant claimed three compelling state interests: (1) S.B. 826 was passed to eliminate and remedy discrimination in the director selection process for publicly held corporate boards in California. (2) S.B. 826 was passed to increase gender diversity on the boards of publicly held corporations to benefit the public and the state economy. (3) S.B. 826 was passed to increase gender diversity on publicly held corporations headquartered in California to benefit and protect California taxpayers, public employees and retirees.

However in her Opinion, Judge Duffy-Lewis said “Generalized assertions of discrimination in a particular region or industry are insufficient to give rise to a compelling governmental interest, as are mere statistical anomalies, and the discrimination must be identified with specificity.”

She went on to say that “S.B. 826’s goal was to achieve gender equity or parity; its goal was not to boost California’s economy, not to improve opportunities for women in the workplace nor not to protect California’s taxpayers, public employees, pensions and retirees.”

The Court considered all evidence but concluded “a Compelling State Interest is lacking.”

Tom Fitton, president of good-government group Judicial Watch, which represented the plaintiffs in court, welcomed the decision by Duffy-Lewis. Fitton noted that this was the second recent California court decision finding that quotas for corporate boards are unconstitutional.

On September 30, 2020, California Governor Gavin Newsom signed AB 979 (Corporations Code§ 301.4) into law on the heels of SB 826. It had similar provisions for the protection of members of “underrepresented” communities rather than women. On the same day that AB 979 was passed in September 2020, three California taxpayers filed a lawsuit against the Secretary of State in Los Angeles County Superior Court. .

In that case, also cited as Crest v. Padilla – 20 STCV 37513 (April 1, 2022), Los Angeles County-based California Superior Court Judge Terry A. Green ruled on April 1 that the law “violates the Equal Protection Clause of the California Constitution on its face.”

Sacramento-based Pacific Legal Foundation (PLF), a public interest law firm, is also pursuing similar litigation in federal court in California. Its lawsuit was filed on Nov. 22, 2021, in the U.S. District Court for the Eastern District of California. That case was dismissed by the trial judge who found that a shareholder has no standing to challenge the law.

But, in a unanimous published opinion, the Ninth Circuit Court of Appeals reversed, and held that a shareholder of a California company has standing to sue in the case of Meland v Weber 2 F.4th 838 (2021)

O.C. Physician Assistant Sentenced for Selling Blank Opiod Prescriptions

A former physician assistant at a Fountain Valley medical clinic was sentenced to 46 months in federal prison for conspiring to issue and sell prescriptions for oxycodone, a highly addictive opioid painkiller, without a medical purpose, to drug dealers, knowing the drugs would be sold on the street.

56 year old Raif Wadie Iskander, formerly of Ladera Ranch, but who now resides in Ennis, Montana, was sentenced by United States District Judge James V. Selna. He was a graduate of Stanford University, and became a licensed physicians assistant in 2011.

Iskander pleaded guilty in November 2020 to one count of conspiracy to distribute oxycodone.

From 2018 to April 2019, Iskander, who was a licensed physician assistant in California, wrote prescriptions for purported “patients” he had never met or examined. Iskander provided to drug dealers multiple paper prescriptions that he had signed, but with the patient names left blank, to be filled in by drug dealers later.

Iskander wrote fraudulent oxycodone prescriptions for two co-defendants – Adam Anton Roggero, 36, of Costa Mesa and Johnny Gilbert Alvarez, 42, a.k.a. “M.J.,” of Santa Ana, who sold the prescribed drugs on the street as well as to an undercover officer.

Iskander knew that the oxycodone filled from the prescriptions would be sold to drug customers who were not using the oxycodone for legitimate medical purposes and whom he had never met or examined.

Alvarez pleaded guilty in November 2021 to one count of distribution of methamphetamine and is scheduled to be sentenced on June 13.

The Drug Enforcement Administration, the Costa Mesa Police Department, and the California Department of Health Care Services investigated this matter.

Assistant United States Attorney Rosalind Wang of the Santa Ana Branch Office prosecuted this case.

Probation ends Nurse’s Controversial Conviction for Medication Error

After a three-day trial that gripped nurses across the country, former nurse, 38 year old RaDonda Vaught, was convicted in Tennessee of two felonies, gross neglect of an impaired adult and negligent homicide, and is facing eight years in prison for a fatal medication mistake. She was scheduled to be sentenced on May 13.

She was arrested in 2019 in connection with the killing of Charlene Murphey, who died at Vanderbilt University Medical Center in late December 2017. Murphey was prescribed a sedative, Versed, to calm her before being scanned in a large, MRI-like machine. Vaught was tasked to retrieve Versed from a computerized medication cabinet but instead grabbed a powerful paralyzer, vecuronium.

Vaught overlooked several warning signs as she withdrew the wrong drug – including that Versed is a liquid but vecuronium is a powder – and then injected Murphey and left her to be scanned. By the time the error was discovered, Murphey was brain-dead.

Court House News reports that she was sentenced to three years of probation Friday as hundreds of health care workers rallied outside the courthouse, warning that criminalizing such mistakes will lead to more deaths in hospitals.

A state judge imposed the sentence on RaDonda Vaught after she apologized to relatives of the victim, Charlene Murphey, and said she’ll be forever haunted by her mistake. Vaught was found guilty in March of criminally negligent homicide and gross neglect of an impaired adult after she accidentally administered the wrong medication.

Nashville Criminal Court Judge Jennifer Smith said Vaught would receive judicial diversion, a way for first-time offenders to have their charges dropped and their records expunged after successfully completing probation. Prosecutors had argued against diversion, although they were not opposed to probation.

The crowd of nurses outside protesting cheered, cried and hugged after hearing the sentence. The relief came after the health care workers spent hours in the sun and clung to every word of the judge’s lengthy sentencing explanation, some linked in a chain with hands locked.

The fact that Vaught, 38, faced any criminal penalties at all has become a rallying point for many nurses who were already fed up with poor working conditions exacerbated by the pandemic. The crowd outside listened to the hearing through loudspeakers and cheered when some of the victim’s relatives said they wouldn’t want jail time for Vaught.

In weighing whether to grant Vaught judicial diversion, Judge Smith cited Vaught’s remorse as well as her honesty about the medication error.

After Vaught was found guilty in March, health care workers began posting to social media that there were leaving bedside nursing for administrative positions, or even quitting the profession altogether. They said the risk of going to prison for a mistake has made nursing intolerable.

On Friday, Vaught’s supporters wore purple T-shirts reading “#IAmRaDonda” and “Seeking Justice for Nurses and Patients in a BROKEN system,” as they listened to speeches from other nurses and supporters. They also held a moment of silence to remember Charlene Murphey.

Vaught reported her error as soon as she realized what she had done wrong – injected the paralyzing drug vecuronium instead of the sedative Versed into 75-year-old Charlene Murphey on Dec. 26, 2017.

Vaught admitted making several errors that led to the fatal injection, but her defense attorney argued that systemic problems at Vanderbilt University Medical Center were at least partly to blame.

Multiple Carriers to Share $2.4M Restitution Order After Fraud Conviction

The San Bernardino District Attorney’s office reported last week that the proprietor of a San Bernardino-area janitorial business found guilty of fraud last year was ordered to pay over $2.4 million in restitution this March while serving two years of felony probation.

45 year old Almirante Perez of Highland  was ordered to pay $2,407,573.14 in restitution for committing workers’ compensation and tax fraud. Perez was the owner of Capital Janitorial Services, Cal Best Service Group Inc., Southern Pacific Janitorial Group and United Pacific Contractors Inc., from March 2013 to November 2018

Over multiple years, Mr. Perez committed workers’ compensation and tax fraud by failing to fully insure his employees for workers’ compensation and underreporting his employee payroll. He  was arraigned on multiple felony counts of insurance fraud and tax evasion. .

An investigation by the Department of Insurance revealed Perez failed to report employees and wages to his workers’ compensation insurance carrier and to the Employment Development Department (EDD). The investigation discovered $1,982,597 in underreported premium fraud and $609,430 in payroll taxes owed to the EDD.

It is further alleged, as to some of the counts, that the offenses alleged are related felonies, a material element of which is fraud and embezzlement, which involved a pattern of related felony conduct, and the pattern of related felony conduct involved the taking of, and resulted in the loss by Republic Underwriters Insurance Company, NorGuard Insurance Company, dba Atlas General Insurance Company, and Ohio Security Insurance Company of more than five hundred thousand dollars ($500,000).
.
He pleaded no contest to one count of felony workers’ compensation fraud with a criminal enhancements for aggravated white collar crime. He admitted he had failed to pay for workers’ compensation insurance and was underreporting payroll for multiple years, district attorney’s officials said. He was placed on felony probation for the maximum period of two years last May.

The $2,407,573.14 in restitution will be paid to multiple victims, including the Employment Development Department, Republic Underwriters, Berkshire Hathaway and Liberty Mutual.

QME Rules Allow Claimant to Select QME He Previously Struck

Gus Kowal claimed two injuries while employed as a roofer by the County of Los Angeles. But, on August 5, 2019, the employer sent to applicant a Notice of Denial of Claim for Workers’ Compensation Benefit citing “02/28/2012” as the “DOI.”

In response, on October 11, 2019, Kowal requested and obtained a QME panel in orthopedic surgery for the 2012 cumulative trauma claim. On October 16, 2019, the employer sent Kowal a letter objecting to the CT panel, and also striking Dr. Robert Kolesnik from the panel as a precaution.

On October 29, 2019, Kowal sent a fax to defendant with his strike of Dr. Hananni from the panel. About one year later, Kowal sent a letter on October 8, 2020 to the employer advising that an appointment had been scheduled for December 8, 2020 with the same doctor he struck from the panel, Dr. Hananni, to conduct the QME evaluation.

The employer then sent him a letter objecting to the evaluation with Dr. Hananni since he had previously struck this physician from the panel.

The matter proceeded to trial on the issue: “Can applicant set a panel exam with a doctor they untimely struck when, after defendants timely struck, the remaining doctor was not able to see applicant within the statutory time period?” The WCJ concluded that Kowal could not.  Reconsideration was granted, and the WCAB panel allowed him to proceed with the QME evaluation in the case of Kowal v County of Los Angeles, ADJ12372302 (May 2022).

The QME panel in the CT case issued on October 11, 2019. The employer made a timely strike from the panel on October 16, 2019. However, Kowal sent a letter striking Dr. Hannani from the panel on October 29, 2019. Even accounting for additional time for mailing, applicant’s strike from the panel was untimely and invalid. Thus, both remaining doctors on the panel remained viable choices as the QME.

Rule 31.3 provides the procedures for parties to schedule an appointment with the QME. A represented worker has the right to schedule the appointment for the first 10 days. After that, either party may schedule an appointment with the QME.

In an en banc decision, the Appeals Board noted in a footnote that if the employee fails to schedule an appointment with the QME within ten business days, “the clock stops running and either party has an indefinite time to schedule the appointment.” (Cervantes v. El Aguila Food Products, Inc. (2009) 74 Cal.Comp.Cases 1336, 1348, fn. 11.

Therefore, after that initial 10-day period, the employee may still schedule the appointment, or the appointment may be scheduled by the claims administrator or the claims administrator’s attorney pursuant to AD Rule 31.3(d).

The WCAB noted that “this is a unique set of facts since applicant scheduled an appointment with the physician he attempted to strike from the panel. His strike was untimely per the discussion above. Both parties had the right to schedule an appointment with the two remaining physicians on the panel and applicant chose to exercise that right by accepting an appointment with Dr. Hannani within 90 days of his appointment request.”

Therefore, the WCAB panel rescinded the F&O and issued a new decision finding that Kowal was permitted to schedule an examination with the doctor that he untimely struck. The parties were ordered to proceed with using the existing panel.

Hospitals Face Nationwide Shortage of Contrast Media for CT Imaging

The Food and Drug Administration is reporting shortages of GE Healthcare’s iohexol and iodixanol intraveneous contrast media products for computed tomography imaging.

In an April 19 letter to customers, GE Healthcare said it was rationing orders for its iohexol products after a COVID-19 lockdown temporarily shut down its production facility for iodinated contrast media in Shanghai, China.

GE Healthcare, through a spokesperson, said on Wednesday that the weeks-long outage at the company’s Shanghai production plant due to the city’s COVID-19 lockdown is not only affecting U.S. hospitals but also other world regions it did not specify, though to a less extent.

According to a report by Reuters, some of the largest U.S. hospitals said on Tuesday they are facing critical shortages of iodinated contrast media products.

The Cleveland Clinic in Ohio; Kaiser Permanente in Oakland, California, Rochester, Minnesota-based Mayo Clinic, and Providence in Renton, Washington all said in statements they were taking steps to secure as much supply as possible and conserve use.

A Providence spokesperson told Reuters that GE’s production in Ireland would only cover about 20% of normal supply to all customers through the end of June, adding that most of the U.S. supply comes from Shanghai.

The Greater New York Hospital Association (GNYHA) warned on May 4 of temporary supply shortages of GE Healthcare’s iodinated contrast media – specifically its Omnipaque products made in Shanghai.

“We are working around the clock to expand capacity of our iodinated contrast media products,” a GE spokesperson said after the company had to close its Shanghai facility for several weeks due to local COVID policies. It has now reopened, but is not yet fully up to speed. “We are working to return to full capacity as soon as local authorities allow,” the spokesperson said.

In addition to increasing output at its Cork, Ireland facility to help resolve U.S. shortages, GE has flown product from Cork and Shanghai to the United States, rather than ship by sea to accelerate delivery, the company said. It did not give details on the increase in capacity or what extra costs it had incurred due to the measures.

GNYHA said an 80% cut in supplies was expected to last for the next 6 to 8 weeks and advised healthcare providers to ration stocks.

Providence said it is prioritizing existing supply for critical cases such as stroke, trauma, acute aortic syndrome, new cancer diagnosis (staging), pulmonary embolism and acute coronary syndrome.

Shanghai authorities have tightened a city-wide lockdown imposed more than a month ago on the commercial hub with a population of 25 million, a move that could extend curbs on movement through the month.

GE Healthcare has four contrast media manufacturing facilities, including the one in Shanghai.

A spokesperson for Bayer, which competes with GE Healthcare in contrast media, said it is not facing a similar situation. Bayer was taking “several measures to help manage the market situation with incremental volumes to support customers and minimise patient impact,” the spokesperson said, without elaborating further.

Nancy Foster, American Hospital Association’s vice president for quality and patient safety policy, said, “We are aware of this global shortage of IV contrast fluid due to production shutdowns in China and have raised this issue with the Administration.

Anti-Inflammatory Medications May Increase Long Term Disability Risk

A new study, published Wednesday in the journal Science Translational Medicine claims that the treatments often used to soothe pain in the lower back might cause it to last longer.

According to the study authors, chronic pain inflicts huge societal costs, in terms of management, loss of work productivity, and effects on quality of life. And chronic low back pain (LBP) is the most frequently reported chronic pain condition. LBP ranks the highest of all chronic conditions in terms of years lived with disability, with its prevalence and burden increasing with age.

Current treatments for LBP often target the immune system and include nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and corticosteroids, although all of these drug classes are minimally effective at best.

The transition from acute to chronic pain is critically important but not well understood. Despite advances in the understanding of social, psychological, and genetic factors, as well as brain processes associated with chronic LBP, scientists understand very little of the molecular mechanisms underlying the acute-to-chronic pain transition that might lead to more efficacious analgesic strategies.

Therefore the researchers investigated the pathophysiological mechanisms underlying the transition from acute to chronic low back pain (LBP) and performed transcriptome-wide analysis in peripheral immune cells of 98 participants with acute LBP, followed for 3 months.

Transcriptomic changes were compared between patients whose LBP was resolved at 3 months with those whose LBP persisted.

Clinical data showed that the use of anti-inflammatory drugs was associated with increased risk of persistent pain, suggesting that anti-inflammatory treatments might have negative effects on pain duration. Analysis of pain trajectories of human subjects reporting acute back pain in the UK Biobank identified elevated risk of pain persistence for subjects taking NSAIDs.

Thus, despite analgesic efficacy at early time points, the management of acute inflammation may be counterproductive for long-term outcomes of LBP sufferers.

Researchers then replicated their findings using a prospective cohort of similar design. The replication cohort comprised subjects with another musculoskeletal pain condition, temporomandibular disorders (TMD). Although the pathophysiology of TMD is likely not identical to LBP, they hypothesized that the active contribution of the immune system in the transition to chronic pain could be shared.

The authors say that these conclusions may have a substantial impact on medical treatment of the most common presenting complaints to health care professionals. Specifically, the data suggest that the long-term effects of anti-inflammatory drugs should be further investigated in the treatment of acute LBP and likely other pain conditions.

Flu Vaccine May Also Provide Some COVID-19 Protection

The influenza vaccine is protective against the influenza virus, reducing the number of cases and deaths that occur with this seasonal pathogen. Flu shots are a high priority for older adults and healthcare workers (HCWs) at a greater risk of infection and complications.

Earlier research suggests a link between SARS-CoV-2 infection/adverse COVID-19 outcomes and prior influenza vaccination. There was a need to make sure that this was not because flu shots are more likely to be taken by the health-conscious, who are also more compliant with protective health behaviors against COVID-19. This is called the healthy user effect and is a potential source of bias in such studies.

The current study, which appears on the medRxiv* preprint server, was conducted among health care workers at Hamad Medical Corporation, the principal provider of public healthcare services in Qatar and the nationally designated entity for COVID-19-related healthcare needs.

It included over 30,000 healthcare workers vaccinated against influenza during the period between September 17, 2020, and December 31, 2020, when the annual flu shots are usually given. Significantly, this was before the rollout of COVID-19 vaccines.

The vaccinated participants had a median age of 36 years, while a control group had a slightly lower median age of 35. All participants received the quadrivalent Influvac Tetra vaccine (Abbott). Cases and controls were in a ratio of 1:5.

The results showed that the flu shots reduced the risk of SARS-CoV-2 over the next two weeks by 30%. Conversely, they reduced the risk of severe or fatal COVID-19 by 90%. Of nearly 130 individuals who tested positive for SARS-CoV-2 by PCR after taking the flu shot, one developed severe COVID-19 (requiring hospitalization), and none progressed to critical or fatal disease.

In contrast, among nearly 400 unvaccinated patients who tested positive, there were 17 severe and 2 critical cases, though no deaths occurred.

It must be noted however, that the study included small numbers of severe cases. Nonetheless, the evidence supports the reported effectiveness of the influenza vaccine against both infection with and COVID-19 disease as a result of SARS-CoV-2.

The protection mechanism is as yet unexplained. More importantly, the study is not generalizable because it includes mostly young, healthy HCWs. However, this negates the healthy user bias. Overall, therefore, “The findings support benefits for influenza vaccination that extend beyond protection against influenza infection and severe disease.”