The trusted source for
healthcare information and
Two-thirds of hospital workers accept vaccine
Push for mandatory vaccines for HCWs continues
In an intense effort to improve influenza vaccination rates, more hospitals and health systems are moving toward mandatory policies for immunizing health care workers. But a closer look at vaccination rates reveals that hospitals are actually already vaccinating almost two-thirds of their employees (63%), while vaccinations lag at nursing homes and ambulatory care centers.
Only 36% of health care personnel at nursing homes and 40% at ambulatory care centers were vaccinated against influenza in the 2007-2008 season, according to a breakdown of data from the National Health Interview Survey.
"Overall, in hospitals, we've definitely seen an increase [in immunizations]," says Gary L. Euler, DrPH, an epidemiologist with the assessment branch of the Immunization Services Division of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention. "Hospitals in total have improved, whereas other places haven't."
Nursing homes and ambulatory care centers had about the same rate of immunization in 2007-2008 as in the 2003-2004 season, the survey data showed.
Influenza vaccination of health care workers has become a high-profile and contentious issue. In October, the Infectious Diseases Society of America (IDSA) issued a new position statement in favor of mandatory vaccination programs "as these programs are likely to be the most effective means to protect patients against the transmission of seasonal and H1N1 influenza by health care workers."
Health care workers who are not vaccinated due to medical contraindications, a religious exemption, or vaccine shortage should be required to wear masks or be reassigned away from direct patient care, the IDSA said.
Voluntary efforts simply weren't effective in ensuring a high level of flu vaccination, the IDSA board concluded. "The people who were most persuasive to the board were all those health care workers who were not getting vaccinated," says William Schaffner, MD, an infectious disease expert who is chairman of the Department of Preventive Medicine at Vanderbilt University in Nashville and secretary of the IDSA board.
Yet there has been some push-back to mandatory programs. A judge temporarily halted enforcement of the New York state regulation requiring flu vaccination of health care workers after three Albany emergency department nurses sued. Then, amid delays in production and delivery of H1N1 vaccine, New York Gov. David Paterson announced that it must be reserved for those at greatest risk of serious illness and death from influenza. The state's health commissioner rescinded the rule.
Some occupational health physicians have opposed mandatory vaccination policies as an unnecessarily punitive approach. Flu shots are not the Holy Grail of preventing transmission of influenza in hospitals, says Melanie Swift, MD, medical director of the Vanderbilt Occupational Health Clinic at Vanderbilt University in Nashville, TN.
"The available evidence - in fact the studies that they themselves refer to [in the IDSA statement] - are lukewarm to flu vaccination as a strategy to prevent disease and mortality even in residential patients of long-term care facilities," she says. "There's no evidence that just focusing on employee vaccine is going to make a difference to the patient."
Respiratory etiquette, masking coughing patients, swift identification and isolation of flu patients, and policies to discourage employees from coming to work while sick are some other methods of preventing the spread of influenza.
Some hospitals require flu vaccination as a condition of employment, which means employees who refuse but do not have medical contraindications may be terminated. Other hospitals require unvaccinated employees to wear masks throughout their shifts during the flu season, which lasts until May.
The mask policy is punitive, says Swift. "It's like a scarlet letter. What I find interesting about it is that right now we have circulating a virus for which none of us are vaccinated, and no one is suggesting that we all must wear a mask constantly," she says.
Meanwhile, the supply and demand equation for flu vaccine has been often unsettling. This fall, as manufacturers struggled to meet demand for both seasonal and novel H1N1 vaccine, some hospitals experienced delays in receiving their entire vaccine order. Delivery of the novel H1N1 vaccine was delayed and required health care facilities to prioritize which health care workers would be the first to receive it.
Supply affects vaccination rates. In 2004, when manufacturing problems led to a significant shortage, hospital vaccinations sunk to 42% of health care workers, according to the National Health Interview Survey. They were just 27% at nursing homes, where elderly residents are at greater risk from pneumonia-related complications. There were only two vaccine manufacturers producing vaccine for the U.S. market.
Expanding recommendations on flu vaccination and a strong push for vaccination of health care workers helped boost the demand for the vaccine. In 2003, flu vaccine supply peaked at 87 million. This year, CDC estimates that 114 million doses of seasonal flu vaccine will be available. There are six flu vaccine manufacturers.