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Should health care workers be required to get flu vaccinations?

Mandatory policies increase participation at some hospitals, but are still controversial

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VANCOUVER, British Columbia — Nurses and other health care workers at Children’s Hospital and Medical Center in Omaha, Neb. — many of whom had routinely skipped getting flu vaccinations — have changed their tune.

Over the past several years, the hospital has instituted some new policies. Staffers, for example, are now required to sign an explicit form if they decline vaccination, acknowledging the possibility that not getting immunized could spread the flu virus to children. But the real kicker came when workers who passed up the vaccination were required to wear surgical masks throughout the flu season, says physician Archana Chatterjee of Creighton University in Omaha. In recent years, the rate of employee vaccination has risen from about half to 97 percent. “Wearing a mask for eight hours is not easy,” she says. “They realized what an onerous job that was.”

That may sound like coercion, but Chatterjee prefers the term “mandate.” In Vancouver, at the annual meeting of the Infectious Diseases Society of America (IDSA) that ran from October 21 to 24, people on both sides of the mandatory vaccination issue voiced some strong opinions.

No one denies that health care workers are in a unique position to stymie — or spread — flu and other diseases. “The [medical] literature is rife with healthcare workers’ [involvement] in reported outbreaks,” Chatterjee says.

Despite that reality, flu vaccination among all health care workers remains far from universal. The U.S. national rate has lingered at less than 50 percent for this group, according to an analysis of national survey data published April 2 in Mortality and Morbidity Weekly Report. The rate among nurses is slightly higher.

Some heavy hitters have joined the debate. The Society for Healthcare Epidemiology of America is calling for mandatory influenza vaccination of health care personnel — calling it a “professional and ethical responsibility,” according to a position paper appearing in the October Infection Control and Hospital Epidemiology.

IDSA has endorsed the statement, calling flu vaccination of health care staffers a safety issue that should be a condition of employment in health care facilities. “I basically think we are responsible for the health of the people we take care of,” says Richard Whitley, an infectious disease physician at the University of Alabama-Birmingham and outgoing IDSA president. If health care workers don’t get vaccinated, he says, “We’re not doing our jobs.”

But mandating vaccination has turned out to be far from simple.

In 2009, the state of New York attempted to make flu vaccination mandatory for all its health care workers. That effort failed when vaccine ran short and unions sued. 

The Service Employees International Union, which represents about 1 million health care workers, encourages its members to get vaccinated against the flu but opposes mandates. “Health care is based on trust,” says William Borwegen, SEIU director of occupational health and safety. “Patients have the right to refuse medical procedures and health care workers know this. It undermines the element of trust if you coerce them to do something they are basically willing to do voluntarily.” He says in many institutions, programs to encourage voluntary vaccination have achieved more than 80 percent coverage.

Infectious disease experts dispute the reliability of the voluntary approach. In Seattle, infectious disease physician Robert Rakita and his colleagues at the Virginia Mason Medical Center instituted a mandatory flu vaccination program a few years ago for their nearly 5,000 employees. It was the first to write in mandatory flu vaccination as a “fitness-for-duty requirement,” he says. In the first year of the program, the vaccination rate among employees rose to 97.6 percent after lingering below 50 percent in most preceding years using voluntary measures. Under the new program, people with medical or religious reasons for not getting vaccinated were required to wear a surgical mask, says Rakita, who is now at the University of Washington.

Mark Edwards, an attorney at the Hospital Corporation of America in Nashville, Tenn., which owns and operates hospitals, says the dispute over mandatory vaccinations for health care workers “has made a lot of lawyers very happy.” Courts have handed down mixed rulings on the matter, and the National Labor Relations Board in Washington, D.C., has not ruled on the issue. In some cases, the dispute might be resolved if addressed when employers bargain contracts with their unionized workers, Edwards says.

In any case, most people have a choice of getting the flu vaccine by injection or nasal spray, so fear of needles is typically no excuse, Rakita says. More often, staffers declining vaccination cite fears of adverse effects of the vaccine itself, he says.

Staffers at pediatric hospitals and clinics seem more receptive to mandatory flu vaccinations, data suggest. Chatterjee says this might result because health workers have a protective instinct toward children.

But Andrew Pavia, a physician at the University of Utah in Salt Lake City, says this receptivity to mandated vaccination might go deeper than that. “In children’s hospitals, we’ve seen complications from the flu in children. There’s a gut level response in children’s hospitals where workers recognize what influenza can look like.”

Citations

R. Rakita et al. Mandatory influenza vaccination of health care workers: A five years experience. Abstract 869. Infectious Diseases Society of America Annual Meeting, Vancouver, October 21-24, 2010.

A.Chatterjee et al.Improving influenza vaccination rates for healthcare workers. Abstract 1344. Infectious Diseases Society of America Annual Meeting, Vancouver, October 21-24, 2010.

CDC. Interim Results: Influenza A (H1N1) 2009 Monovalent and Seasonal Influenza Vaccination Coverage Among Health-Care Personnel --- United States, August 2009--January 2010. Morbidity and Mortality Weekly Report, Vol. 59, April 2, 2010. p.357.

A.J. Caban-Martinez et al. Sustained low influenza vaccination rates in US healthcare workers. Preventive Medicine, Vol. 50, April 2010, Pages 210-212. doi:10.1016/j.ypmed.2010.01.001

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