Expert supports mandated flu shots for all HCWs

Voluntary vaccination programs not enough

A senior epidemiologist and flu expert at Johns Hopkins University School of Medicine is calling for mandatory vaccination of all health care workers as the best means of protecting patients and hospital staff from widespread outbreaks of the viral illness. Trish Perl, MD, MSc, says studies by other U.S. researchers show that voluntary vaccination programs don't do the job, and that each year nearly 40,000 Americans die from influenza, many elderly or ill with weakened immune systems that cannot readily fend off the disease.

Perl, who published her conclusions in the on-line journal Infection Control and Hospital Epidemiology in November, concludes that mass vaccination policies are required to prevent patients from accidentally contracting the virus directly from an infected medical staff worker or indirectly from other patients or visitors via medical staff.

'Time to go the extra step'

Previous research from Johns Hopkins, Perl writes, showed that annual flu shots have been almost 88% effective at reducing the risk of flu infection and that they reduced by one-half the number of deaths among hospital patients from the disease. Research shows that despite free and ready access to the vaccine, only 40% of all health care workers actually get a flu shot.

"We have gone as far as possible with vaccination programs emphasizing education and health promotion," says Perl, an associate professor of medicine and pathology at Johns Hopkins University School of Medicine in Baltimore. "It's now time to go the extra step, requiring active declination or even making vaccination a mandatory part of the job linked to patient safety, along with such tasks as keeping hands clean and getting mandatory TB tests."

Neither state nor federal law requires workers to provide medical details when they call in sick, so it is difficult to precisely link seasonal hospital absenteeism and high rates of non-vaccination, she notes.

"We need to close the very serious gap between knowledge and behavior that exists among health care workers," Perl argues, and it can be done, she says. In 2003, her team, along with occupational health services at Hopkins, vaccinated more than 70% of the 10,000-member hospital staff. "But we can do better and, ideally, at Hopkins and other hospitals, our objective would be to consistently have more than 90% of staff vaccinated each year."

Lack of time cited for not getting shots

According to Perl, numerous staff surveys from other hospitals have shown that the most common reason cited for not getting a vaccination is lack of time (47%). Surprisingly, a remarkably high number of staff, more than 30%, believed they could catch influenza from the vaccine itself, which is false.

Perl also notes from surveys that relying on people's self-awareness is not sufficient to prevent the flu from spreading. "One-half of infected health care workers have no idea when they are infected with influenza, often having few, if any, signs and symptoms, and making it impossible to ask all staff to stay home when they are feeling ill to prevent other people from catching their infection," she says.

Still, other studies have found that education campaigns can be effective at increasing vaccination rates among health care workers by as much as 60%. And to the surprise of those conducting these surveys, the reason most likely to motivate health care workers to get the shot is that it benefits patients, not themselves.

However, in the editorial, Perl concludes, "Shifting the message from self-interest to altruism in protecting patients may improve vaccination rates, but it won't fix the problem. From a hospital policy standpoint, this is a real patient safety issue and vaccination can be viewed as a means of protecting patients from influenza exposure and the related mortality seen among vulnerable populations. Vaccination should be presented as such to both health care workers and every hospital's leadership."

Perl notes that even without mandatory vaccination policies, other potential barriers to widespread vaccination can be helpful and should be implemented nationwide. Among her recommendations are free shots for all staff, easy access to flu shot clinics on site, flexible vaccination hours, emphasis on patient safety aspects of the program, education to counter beliefs that the shots can make you sick, and encouragement from hospital leaders to get the vaccine.

The next step, Perl says, is for health care professional associations, such as the Infectious Disease Society of America and the Joint Commission on Accreditation of Healthcare Organizations, to endorse mandatory flu shots.

One group, the Alexandria, VA-based Society for Health Care Epidemiology (SHEA), last month endorsed such a plan. However, Perl acknowledges that current federal workers' rights prevent employers from making vaccinations a requirement.

Perl says her proposal is open to discussion at Hopkins. "Ultimately, we want to make vaccination as mandatory for workers as the law allows in order to effectively accomplish what we cannot enforce," she says.

Precaution vs. liability

What risks are there for hospitals whose employees become ill, and what legal standing do hospitals have to require immunizations and employees have to refuse vaccines?

As far as a hospital's responsibility to protect patients and other employees from contracting the flu from a sick worker, "I think the ethical implications are that ill employees must be tested with rapid flu nasal swab, and if they are negative they work, and if they're not [negative] they do not," says James R. Hubler, MD, JD, clinical assistant professor of surgery at the University of Illinois College of Medicine at Peoria.

"Even universal precautions in a high-risk population may not provide enough protection," he adds. "A clinic that does not protect its patients would be at risk for lawsuits, but it would be nearly impossible to prove that they contracted the disease from a health care provider and not [out in the community]."

There is little case law pertaining to institutions' responsibilities should employees become ill as a result of a facility-wide immunization process. In one case in Louisiana, Guillory v. St. Jude Medical Center, a hospital technician was ruled to be due workers' compensation when she developed encephalomyelitis triggered by a hepatitis vaccination administered by her employer, because the inoculation program was within the scope of her employment. In a related case in Texas, a firefighter who became incapacitated from a swine flu vaccination was awarded workers' compensation even though he received the vaccination voluntarily, because his job was considered critical to the community in the event of a swine flu epidemic and the city offered the vaccine from a desire to vaccinate critical employees.

Lack of agreement on mandating vaccine

The Elk Grove Village, IL-based American College of Occupational and Environmental Medicine, in a new position statement, asserts that such vaccinations are not necessary and further opposes the use of declination statements (signed statements indicating the worker has opted not to have a vaccination) noting that there is "no evidence to suggest that such programs will increase compliance." The statement — Influenza Control Programs for Healthcare Workers — applies to seasonal influenza and is not necessarily appropriate during a major antigenic shift in the virus resulting in a pandemic situation.

However, SHEA has come out with a position paper of its own that recommends HCWs who decline flu immunization must sign a declination statement. Published in the November 2005 issue of Infection Control and Hospital Epidemiology, the paper is available on SHEA's web site. In a nutshell, SHEA recommends all health care workers be immunized against the flu annually unless they have a contraindication to the vaccine or actively decline vaccination. (See SHEA recommendations for components of flu shot programs, p. 5.)

[For more information, contact:

  • Trish Perl, MD, MSc, assistant professor of medicine, Johns Hopkins University School of Medicine, Division of Infectious Diseases; joint appointment, epidemiology, Johns Hopkins School of Public Health and Hygiene, Baltimore, MD. Phone: (410) 955-5000.]