Mandatory Vaccines? It’s About Time

If you were to ask pretty much any layman if they thought that it was required that hospital personnel get flu shots, I dare say that most would answer yes. After all, it makes sense. Our nurses and doctors should be protected from getting the flu from patients and patients should be expected not to get the flu from the doctors and staff.

Rick’s Reviews

Thanks to two recent reports, there are no more excuses for not mandating vaccinations for healthcare workers.

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If you were to ask pretty much any layman if they thought that it was required that hospital personnel get flu shots, I dare say that most would answer yes. After all, it makes sense. Our nurses and doctors should be protected from getting the flu from patients and patients should be expected not to get the flu from the doctors and staff.

But we know that just because there is compelling logic behind something does not mean it gets done – especially in the hospital setting. I know that at my hospital, although employees are encouraged to get the shot, there is no major incentive to do so – and the same applies to the medical staff who can get free shots from the employee health nurse. If I were to bet, I would speculate that, in fact, the percentage of medical staff members who get the shot is less than that for the hospital employees. I may be wrong, but the point is that immunization is by no means universal.

You would think that the organized medical staff would be the driver of getting its members and the hospital staff immunized. After all, isn’t it the responsibility of the medical staff to make sure that the quality of care provided in the hospital is as good as it can be? But I don’t see this happening.

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Hospital administration and the medical staff have seemed to adopt a laissez faire approach. Concern over union objection, fear of lawsuits for untoward reactions and the potential push back by the customers of the hospital (the medical staff) have all combine to result in mediocre, at best, immunization rates.

In fact, a 2009 publication by the CDCP noted national healthcare worker flu immunization rates of approximately 44%. Miserable. Probably as a result of the pandemic scare last year, one report noted an immunization rate for healthcare workers of 62%. Less miserable, but it is unlikely to be sustained and go back to baseline given the pandemic never materialized.

Clearly, just because people are healthcare workers does not in any way suggest that they behave knowledgeably regarding healthcare – have you seen respiratory therapists who smoke? I have.
So what about making getting the flu shot mandatory? Certainly there are precedents that would support this. Can your kids go to school without proving they have received their childhood immunizations? Can there be a law that says you have to wear seat belts and motorcycle helmets? Absolutely. And, even more on point, can a person work in the OB department of your hospital who has not demonstrated immunity to rubella (and has gotten immunized if initial testing reveals no antibodies to it)?

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So why don’t we do the right thing? There are reasons, as noted above, from the fear of the unions to potential lawsuits resulting from adverse events to simply pissing off the employees and medical staff. Several years ago, when we had the “nursing shortage,” hospitals were very reluctant to do anything to upset the nurses and mandating flu shots may have qualified as an irritant. In any case, the time has come to mandate flu shots for hospital employees and medical staff members. Are there some success stories in this regard? You bet. The abstract above details the success achieved at the Virginia Mason system in Seattle. With about 4,700 employees (including about 400 doctors), they have achieve vaccination rates ranging from 97.6% to 98.9% between 2005 and 2009 (and their program mandates vaccination for all employees – independent of whether they have patient contact or not). To put this into perspective, their baseline rate prior to the start of their comprehensive program was 29% in 2004, 54% in 2003 and 38% in 2002.

These authors note that they are not alone in achieving success. They cite that BJC Healthcare in St. Louis (11 acute care and 3 extended care facilities – 26,000 employees) has achieved a 98.4% rate (and only eight employees were terminated in the process) and they also note that the New York State Health Department adopted a regulation in August of 2009 requiring flu shots for all healthcare workers with direct patient contact (although it was later rescinded). A commentary in the same issue of Infection Control and Hospital Epidemiology by Talbot and Schaffer notes that the Hospital Corporation of America with over 140,000 employees at 160 healthcare facilities achieve a 96.4% immunization rate last year and that MedStar Health system (9 facilities) achieved a 98% success rate with its 26,000 employees (and 95% with its affiliated physicians).

Just how Virginia Mason’s program works and how it handled objections by the nursing union are detailed in the article and anyone interested in moving into the 21st century with regard to improving immunizations in your hospital is advised to get this landmark paper.

W. Richard Bukata, MD, is the editor of Emergency Medical Abstracts (CCME.org) and professor of clinical emergency medicine at the University of Southern California in Los Angeles.

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Rakita, R.M., et al, Infect Control Hosp Epidem 31(9):881, September 2010

BACKGROUND: The annual mortality rate for influenza in the USA (36,000) is similar to that of breast cancer. Vaccination has been recommended for healthcare workers to prevent the spread of influenza, but immunization rates in healthcare personnel are typically only about 40-50%.

METHODS: The authors report on the implementation of a mandatory influenza immunization program for employees of Virginia Mason Medical Center in Seattle and vaccination rates achieved in 2005-2010. The program was developed by a multidisciplinary group with strong support from administration, and included a variety of methods to engage employee participation. Multiple vaccine options were offered, and requests for accommodation based on medical or religious grounds were reviewed. Employees who were granted exceptions were required to wear surgical masks while at work during the influenza season.

RESULTS: During the 2003-2004 flu season (pre-program), only 54% of employees were vaccinated. After implementation of the program, vaccination rates of 98-99% were achieved in 2005-2010. Only about 30 employees were granted exceptions each year, and only two of seven workers reporting a history of allergy or vaccine reaction in the past tested positive for such allergy. Although a grievance against the program by unionized nurses was upheld in the courts, the requirement for use of masks by nonvaccinated nurses while at work was also upheld and about 90-95% of unionized nurses have agreed to be vaccinated. Fewer than 0.5% of workers left or were terminated for refusal to comply.

CONCLUSIONS: A well-designed program of mandatory influenza vaccination for healthcare workers is feasible and capable of sustaining high rates of immunization. 67 references
(Joyce.Lammert@vmmc.org for reprints) (20653445 [PMID])
Copyright 2011 by Emergency Medical Abstracts – All Rights Reserved 1/11 – #20

LATE BREAKING NEWS: The American Academy of Pediatrics in the October, 2010, issue of Pediatrics published its recommendation for a mandatory influenza immunization policy noting that,
“Mandatory influenza immunization for all health care personnel is ethically justified, necessary, and long overdue to ensure patient safety.”