Mandatory flu shots boost health care worker immunization rate at Virginia Mason

The CDC recommended universal influenza vaccination for health care workers that suggested signed declination.

The Virginia Mason Medical Center in Seattle achieved a 96% influenza immunization rate at its hospital by implementing a new hospital policy this season: Get the shot, or find somewhere else to work.

Joyce Lammert, MD, deputy chief of medicine at the center, said that 96% of the medical center’s nearly 5,000 employees accepted vaccination, with less than 1% allowed exemption due to medical or religious reasons.

“We really feel that we’re setting a national benchmark by doing this,” Lammert said. “We think it’s really important. Influenza vaccination saves lives and we feel very proud of what we’ve done. We also feel that it protects our patients, it protects our staff and it protects our community.”

Weeks after Virginia Mason announced its success, the CDC published stronger recommendations for universal influenza vaccination for health care workers (HCWs). The CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC) drafted the guidelines.

Since 1984, the CDC has recommended that all HCWs receive influenza vaccine. The updated guidelines appeared in the Morbidity and Mortality Weekly Report last month.

The 96% rate achieved at Virginia Mason Medical Center is more than double the national average – 38% of HCWs received the vaccine last influenza season.

“They’ve clearly set a new standard and I think that’s great,” Theodore C. Eickhoff, MD, professor of medicine at the University of Colorado Health Sciences Center in Denver, said of Virginia Mason.

However, Eickhoff noted the issue that seems to be at the center of the debate: How far should experts go in getting HCWs to comply with influenza vaccination? “You can’t force it down people’s throats, obviously,” he said.

Those with medical contraindications and religious beliefs should be exempt, he said, but as far as financial consequences, that’s something his own hospital must iron out before implementing a plan.

“There should be some kind of downstream consequence,” said Eickhoff, who is also chief medical editor of Infectious Disease News.

The CDC recommends that:

• Facilities offer influenza vaccine annually to all eligible personnel, including students;
• The workplace offers vaccine during all shifts and at no cost to employees;
• Hospitals use strategies proven to improve vaccination coverage, including education, use of reminders to staff and having leadership set an example by getting vaccinated; and
• Facilities obtain a signed form from staff who decline vaccination for reasons other than a medical contraindication.

The CDC said the last recommendation is designed to help facilities better monitor who is offered vaccine, employee concerns and barriers to vaccination, so that appropriate strategies can be designed to improve vaccination coverage.

Further recommendations ask health institutions to monitor influenza vaccine coverage at regular intervals during the season and provide feedback of ward-, unit- and specialty-specific coverage to staff and administration.

The recommendations reiterate an earlier recommendation to use that influenza vaccination coverage of health care personnel as a health-care quality measure in states that mandate public reporting of health care–associated infections.

The National Foundation for Infectious Diseases (NFID) released a statement lauding the CDC and HICPAC.

“A key part of the recommendations are for health care facilities to develop systems to track immunization rates among health care workers and provide feedback during the influenza vaccination campaign, which will allow institutions to better manage information and, in turn, increase immunization rates and improve patient safety,” William Schaffner, MD, NFID board member and chair of the department of preventive medicine at Vanderbilt University School of Medicine in Nashville, Tenn., said in a release.

The Virginia Mason program

Lammert said the hospital’s new policy evolved from a 2004 workshop aimed at improving influenza immunization rates of HCWs. Program steps included free and on-site staff immunization, education about influenza vaccination, an awareness campaign and opportunities to request accommodations for special circumstances. The hospital gave staff members blue bracelets adorned with the campaign slogan, “Save Lives – Immunize.”

An internal Web site for employees provided information and forums to discuss the policy. The hospital even held a tailgate party with the Seattle Seahawks football team.

Hospital officials did not allow signing of declination, which requires employees to sign an opt-out form that states they are educated about the influenza vaccine and the effects of influenza but still decide to forego the vaccine.

“We did not allow signing of declination because we really felt that people needed to get flu immunizations,” Lammert said.

Hospital officials met with and educated all individuals who did not wish to receive the vaccine and did not have medical or religious exemptions, she stressed, but in the end let go.

She said that to date no one let go under the new policy has contested his or her termination. There are no data yet on how the immunization program affected infection rates at the hospital. Down the road, the hospital’s influenza group plans to publish the data and details about the plan, she said.

Schaffner promotes better HCW influenza immunization rates for the NFID and is curious to learn the intricate details of Virginia Mason’s program. “It’s very important to see exactly the details of the Virginia Mason program,” Schaffner said.

He would like to know if officials emphasized the ICU more than the clinic, for example.

“I’ve certainly been a staunch advocate of the notion that it is a health care worker’s obligation to [his] patients as well as to [his] colleagues to be immunized,” Schaffner said. “We need to try everything and see what works best. I’m quite sure, personally, that a number of different models will work. NFID is open to that.”

Mandatory vs. signed declination

Not everyone agrees with a mandatory program.

Jane D. Siegel, MD, professor of pediatrics at the University of Texas Southwestern Medical Center and former HICPAC liaison to the Advisory Committee on Immunization Practices, has worked in the past on developing statements about HCW immunization and supports signed declination.

“I think it’s important to distinguish between signed declination and mandatory,” Siegel said. “When you say ‘mandatory,’ [it’s] the concept [that] if one does not take the vaccine, there will be an adverse consequence such as reassignment of position or loss of job or that sort of thing.”

She said she supports signed declination over mandatory programs.

“I think that mandatory is beyond what we need to do at this time,” she told Infectious Disease News in an interview.

The American College of Occupational and Environmental Medicine (ACOEM) released a position statement in September 2005 that said mandatory influenza vaccination for health care workers is not justified.

“Vaccination is only one prong in a multifaceted approach to infection control,” William Buchta, MD, MPH, chair of the ACOEM’s Medical Center Occupational Health Section, said in a press release. “Health care workers must also appropriately use hand washing and personal protective equipment, and they should consider self-removal from work when experiencing symptoms of a communicable illness.”

Buchta also noted that reliance on employee vaccinations alone for prevention and control of influenza offers a false sense of security and ignores some of the more practical means of minimizing nosocomial infections. Instead of mandatory influenza vaccinations, the ACOEM endorses a multifaceted influenza control program and encourages health care organizations to facilitate participation by providing influenza vaccine and/or prophylactic medication at no expense to the employee.

“Making people sign a statement that they have declined to receive a flu shot not only impacts the employer-employee relationship in a negative way, but diverts resources from activities known to increase compliance and devotes them to enforcement of a policy with no proven benefit,” Buchta said. “Influenza control can be successful with creative programs that employ the ‘carrot’ rather than the ‘stick’ while still respecting the rights of both patients and employees.”

There are groups that do support signed declination. The Infectious Diseases Society of America (IDSA) recommends universal immunization of HCWs, with signed declination in “Principles for Actions Needed to Prepare the U.S. for Interpandemic/Pandemic Influenza,” a report.

The Society for Healthcare Epidemiology of America (SHEA) supports the NFID’s position and recommends health care workers “sign a declination each year if they refuse influenza vaccination after participating in an educational program or if they have medical contraindications to the vaccine,” according to a position paper from SHEA.

“Health care workers have frequent contact with patients at high risk for infection and can serve as the vehicle for spread of the flu and cause outbreaks, disease and morbidity. Absenteeism can place a profound stress on the health system in times of community epidemics,” said Tom Talbot, MD, MPH, at a SHEA influenza teleconference last month.

As of 2003, only 40% of HCWs were vaccinated against influenza, which can influence all areas of a health care facility, according to Talbot, assistant professor of medicine and preventative medicine and associate hospital epidemiologist at Vanderbilt University School of Medicine in Nashville, Tenn. Health care worker outbreaks are not localized to high-risk areas; neonatal ICUs, pediatric and geriatric wards and various units are at risk as well.

“Health care worker vaccination is not just a worker safety issue; it’s also a patient safety issue. We need to vaccinate our health care workers,” he added.

Why do they refuse?

Influenza kills 36,000 people in the United States each year, according to the CDC. Influenza complications are the cause of 200,000 hospitalizations each year. Five percent to 20% of the population contracts influenza each year.

HCWs with influenza can transmit the disease to patients in their care, many of whom are at an increased risk for influenza-related complications. Prior to the appearance of symptoms, people can carry the disease for 48 hours.

The NFID’s call to action cites one study that showed that vaccination among healthy individuals, including HCWs, younger than 65 years was cost-effective. It resulted in 25% fewer episodes of respiratory illness, 43% fewer days of sick leave from work due to respiratory illness and 44% fewer visits to physician’s offices for upper respiratory illness.

Considering all this, why are national immunization rates among health care workers at 38%? Some HCWs, according to Siegel, believe they are young and healthy and do not need the vaccine, while still others fear they will shed the vaccine virus to their immunocompromised patients. Many still have the misconception that the vaccine will cause the disease or are fearful of adverse events from the vaccine.

Realizing that they could shed the virus 24 hours before symptoms appear might encourage HCWs to receive the vaccine, Siegel said.

“I think there’s still a lot of misconceptions and fears and that sort of thing,” Siegel said. “I think it’s really the educational piece we have to work on, in addition to making the vaccine readily available.”

Before a hospital’s influenza campaign can be successful, supply and distribution problems need attention. “Before we can have a broader uptake and acceptance of signed declination, it’s critical that we have our supply and distribution problems solved,” Siegel said. – by Judith Rusk

For more information:

• CDC. Influenza vaccination of health-care personnel: recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP) MMWR. 2006;55(RR-2):1-16.
• Talbot TR, Bradley SF, Cosgrove SE, et al. Influenza vaccination of healthcare workers and vaccine allocation for healthcare workers during vaccine shortages. Infect Control Hosp Epidemiol. 2005;26:882-890. Available at: www.shea-online.org/Assets/files/HCW_Flu_Position_Paper_FINAL_9-28.pdf. Accessed February 28, 2006.
• For more information about the NFID’s “Influenza Immunization Among Health Care Workers Call to Action,” visit www.nfid.org/publications/calltoaction.pdf.
• To read the IDSA’s position on health care worker vaccination, visit www.idsociety.org/Content/NavigationMenu/Resources/Avian_Pandemic_Flu/
  Avian_Pandemic_Flu.htm.