Mandatory policy increased influenza vaccine uptake among HCWs

A mandatory program that asked health care workers in a multihospital health system to choose between vaccination and termination resulted in a dramatic increase in the number of employees protected against influenza in the 2008-2009 season, as well as fewer requests for vaccine exemptions compared with previous years.

The initiative achieved a 98.4% vaccine coverage rate among BJC HealthCare’s 25,980 active employees, representing a 43.4% increase from the organization’s 2006 vaccination rates and a 26.5% increase from 2007 rates.

“Key factors that supported the success of the program included consistent communication emphasizing patient safety and quality of care, coordinated campaigns, leadership support and medical director support to talk with any employee with concerns about the vaccine, on request,” the researchers wrote.

Beginning October 15, 2008, free vaccine was provided to employees at all facilities within the large Midwestern health care system, which included 11 acute care hospitals and three extended care facilities, as well as day care centers and other physician groups.

Employees were able to seek medical and religious exemptions, but required either a letter from a licensed physician or a personal letter stating a religious conviction opposed to vaccination. The presence of an ACIP recognized contraindication was necessary in order to be approved for medical exemption. These included hypersensitivity to eggs, prior hypersensitivity reaction to influenza vaccine, and history of Guillan-Barré syndrome. Despite recommendations that pregnant women be vaccinated against influenza, pregnancy was accepted as a valid exemption, if the request was made by a physician.

Human resources reviewed exemption requests, made decisions and informed employees of their status within five days. Those who remained unvaccinated without an exemption by December 15, 2008 were suspended without pay. Employees vaccinated by January 15, 2009 were permitted to return to work; those who remained unvaccinated without exemption were terminated for not meeting conditions of employment.

Overall, 99.96% of employees were compliant with the policy, and eight employees were terminated. A total of 372 employees requested a medical exemption, 321 of whom were granted the request. Among those who received medical exemption, 33% were approved on the basis of egg allergy, 26% due to prior allergic reaction, 5% due to history of Guillan-Barré syndrome and 36% had other conditions. Ninety employees received religious exemptions.

The researchers noted that fewer employees sought either type of exemption with the mandatory program in place than had signed declination statements in previous years.

“Exemption requests often reflected misinformation about the vaccine and about influenza among employees and among their physicians,” the researchers wrote. They noted that several requests were made on the basis of chemotherapy or other immunosuppressed states and pregnancy, despite the fact that ACIP considers these groups high risk and therefore a priority for receiving influenza vaccine. There was also a tendency for employees to seek religious exemption if their medical request was denied.

Rates of possible adverse events were low, at .08% (n=21), according to data collected in an occupational health database, and included sore arm (n=11), possible allergic reaction (n=5), and possible vagal response with fainting (n=1). The researchers also reported four adverse events with uncertain associations to the vaccine.

“A standardized form listing accepted contraindications and their definitions, with checkboxes and space for additional information and contact information, would simplify the request and review process for health care workers, their physicians and occupational staff,” the researchers wrote.

In an accompanying editorial, Andrew T. Pavia, MD, of the division of pediatric infectious diseases at the University of Utah, Salt Lake City, noted that rates of influenza vaccination among U.S. healthcare workers remain “unacceptably low” at around 44% in the 2006-2007 season.

Despite support for mandatory vaccination programs from organizations including the Infectious Diseases Society of America, the American College of Physicians and the National Foundation for Patient Safety, this method for improving vaccination coverage remains controversial. But Pavia contends that the debate is moot. “Intentions and principles do not protect patients; results are needed.”

He proposed raising the national target for vaccination coverage to 90%. “Organizations can then choose to achieve the target with less coercive methods if they can, or if necessary, choose to mandate vaccination.” – by Nicole Blazek

Babcock HM. Clin Infect Dis. 2010;50:459-464.

Pavia AT. Clin Infect Dis. 2010;50:465-467.

Health care workers really have no excuse for not receiving influenza vaccine, except for the accepted exclusions the health system allowed. All the procrastinating and other lame excuses proffered by employees are not acceptable when these same employees often become the main vector for nosocomial spread of a potentially devastating virus. Our own office has taken this same approach to influenza vaccines with our 70-plus employees for the last 10 years. Uptake is nearly 100%, and those few non-vaccinees who do become ill with influenza are prohibited from taking sick pay.

A shocking aspect in this study is the amazingly high rate of folks with a history of Guillan-Barré syndrome (n=16; normally 1 per 100,000 population) and allergic reactions to influenza vaccine (n=78; which is probably <1 in 10,000 as seen in the 0.08% reaction rate in their own vaccinated population). I think documentation of these two allegations should be scrutinized more thoroughly. This egocentricity, needle phobia or whatever is no longer acceptable for health care workers.

– Stan L. Block, MD

University of Kentucky