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In the intensifying effort to immunize more health care workers against influenza, a precedent-setting battle is taking shape at Virginia Mason Medical Center (VMMC) in Seattle. In what is thought to be the first hospital in the United States to take such action, Virginia Mason officials have mandated annual flu shots as a condition of health care employment.

Flu fight: A move to mandate vaccination leads to nurse standoff

Flu fight: A move to mandate vaccination leads to nurse standoff

APIC: Mandates needed due to poor voluntary compliance

In the intensifying effort to immunize more health care workers against influenza, a precedent-setting battle is taking shape at Virginia Mason Medical Center (VMMC) in Seattle. In what is thought to be the first hospital in the United States to take such action, Virginia Mason officials have mandated annual flu shots as a condition of health care employment.

"The studies that have been done very clearly [indicate] that immunization of health care workers is really key, particularly when you have a vulnerable patient population," says Bob Rakita, MD, section chief of infectious disease at VMMC and a proponent of the hospital policy. "Our average inpatient [age] is over 68, so we have an older, vulnerable population. We thought we should do everything we could to focus on patient safety and, basically, save lives."

Unionized nurses at VMMC cried foul because such a mandate is not in their contract language. "We support health care providers and the public getting flu shots," says Anne Tan Piazza, director of government relations and communications at the Washington State Nurses Association (WSNA) in Seattle. "We absolutely believe that everyone should get a flu shot. What we object to is that nurses be forced to get a flu shot or be fired."

An arbitrator agreed with the breach-of-contract argument, but the issue is far from over. "The arbitrator found for the nursing union solely on that [contract stipulation] basis," Rakita says. "It has nothing to do with the merits of doing it.

"We’re still in discussion. Virginia Mason is still talking to the nursing union." The nurses could vote to accept the vaccination mandate as a provision of a renegotiated contract, but such a conciliatory move does not appear likely.

"I doubt it," says Barbara Frye, RN, director of labor relations at the WSNA. "We don’t believe that people should be forced to be immunized. We believe that educating people and making the vaccine available at reasonable times is the way to get compliance in health care. I am a nurse and I know that is the way you get compliance with medical people. You don’t tell people they are going to be fired. Threatening people as a firstline approach, in my view, is very inappropriate."

The Virginia Mason case is being closely watched by infection control professionals, many of whom have fought for years to increase historically poor compliance with annual worker flu immunizations. The patient safety movement and the highly publicized threat of pandemic flu are giving the issue increasing relevance and resonance. While on one level, it’s a classic labor-management dispute, the backdrop of larger issues gives the issue a certain volatility.

It doesn’t take a vivid imagination to see patient safety advocates jumping on perceived flu vaccination apathy in much the same way they lambasted hospitals for withholding infection rates.

"My guess is there are going to be laws," Rakita says. "There are already states that require workers to be immunized for long-term care facilities. I think eventually it will become regulated and that will take care of the legal challenges."

The path toward a mandatory influenza policy at the hospital began innocently enough, as the issue arose in a series of quality improvement meetings.

"One of the innovative things that Virginia Mason is doing is addressing leading principles,’ which are based on the Toyota production systems," he explains. A "rapid process improvement" workshop, formed as part of an effort to improve flu immunization rates, resulted in a controversial recommendation: Mandate it.

"We have done a whole bunch of stuff to promote flu vaccinations and our rates got up to about 55%," Rakita says. "Clearly, doing all that wasn’t working, and that was another reason we felt this should be mandatory."

The plan was to go mandatory last flu season, but the effort was undermined by the national vaccine shortage. Now supplies are in place but the standoff continues. "It’s kind of weird," Rakita says. "The nurses union says they strongly support flu immunization and all health care workers should get it; but at the same time they are trying to prevent it from coming about."

All other hospital workers are under the mandate, and the vaccine is being administered without any major snags. "Getting it to folks is not going to be a major logistical obstacle," he says. "It takes an effort, there is no question about it. This is something you have to decide you think is important. But it is imminently doable."

The Association for Professionals in Infection Control and Epidemiology recently came out in favor of mandatory flu shots, though not as a direct result of the ongoing battle at Virginia Mason. The board of directors of APIC voted to endorse mandatory influenza vaccination for health care professionals who have direct contact with patients.

"It concerns APIC that a mere 36% of [health care] professionals opt for vaccination," says Sue Sebasco, RN, BS, CIC, president of APIC. "Even those health care facilities that promote immunization through aggressive voluntary campaigns show that 30% to 50% of health care workers remain unvaccinated."

In taking such a bold stand, APIC went further than the Society for Healthcare Epidemiology of America (SHEA), which recommended in a recent position paper that all health care workers that refuse flu vaccine sign a declination form.1 The SHEA guidelines also address the difficult and ethical issue of allotting flu vaccine during the kind of shortages that occurred last season.

"We definitely support and promote mandatory immunization of health care workers who are in direct patient care," Sebasco says. "That is just a given. We are all about patient safety advocacy. We think the individual organization should have the opportunity to operationalize the mandate the best way they see fit."

As a practical matter, many ICPs may pursue the declination form option, but APIC thought it was important to put the mandatory option on the table, she adds. In any case, the time-honored carrot-laden approach of purely voluntary vaccine offerings appears to be losing favor. "We know that those programs don’t work," Sebasco says. "That’s the concern we have."

With APIC and SHEA addressing the issue straight on, the question arises whether other major medical associations and specialty groups will wade into the swiftly rising waters. If flu vaccination is truly a matter of patient safety, the issue goes well beyond the bailiwick of infection control and health care epidemiology.

"I have never seen a big recommendation from these [other medical] groups suggesting that their folks should get flu vaccine to protect patients," says Susan Kraska, RN, CIC, an ICP at Memorial Hospital in South Bend, IN. "Quite honestly, as important as it is, why aren’t the other health care organizations stepping up to the plate?"

Yet even long time proponents of health care worker flu immunization question whether mandatory policies are the solution to the longstanding problem. "I applaud [APIC’s] goals but the issue of mandatory’ annual vaccination clearly deserves further elaboration and discussion," says William Schaffner, MD, chairman of the department of preventive medicine at Vanderbilt University Medical Center in Nashville, TN. "Trying to work through all of the issues that the word mandatory’ implies will be very important. That’s why I think SHEA went the route of putting the emphasis on the informed declination statement."

Hospitals that adopt mandatory flu vaccination policies must be ready to enact consequences and deal with the real-world situations that may arise, warns David Weber, MD, co-author of the SHEA paper and director of epidemiology, occupational health, and environmental health and safety at University of North Carolina Hospitals in Chapel Hill. "Mandatory literally means that if you have one laser technician in the hospital and he doesn’t comply, you fire him," he says. "That could have enormous consequences. Your eye surgeon comes in to do surgery and is told all eye surgeries are cancelled for three weeks because we just fired our laser technician."

Moreover, many hospitals may be reluctant to tread into a legal minefield. "Certainly as indicated by the events in the state of Washington, we need to understand what our legal basis for this is," Schaffner says. "If it is presented as a patient safety issue, I think you can get favorable rulings from judges because they will defer to issues that relate to patient care and patient safety. The outcome of all those legal maneuvers — and we can predict that there will be more — are not straight forward. I don’t think there are very many hospitals that want to get themselves tied in a legal knot over an immunization policy."

Virginia Mason is locked in a knot of the Gordian variety, but has made no attempt to loosen its policy. On the contrary, while negotiations continue with unionized nurses, a mandatory policy with consequences stands for all other hospital employees — including physicians.

"It is a fitness for duty requirement," Rakita says. "It is really not that different from a lot of things we do anyway. PPDs [annual tuberculin skin tests] are required. There are potential consequences, but we are trying to do everything we can to make sure everybody understands the underlying rationale for doing this. The evidence shows it is important, and on the whole people are very supportive of it."

The evidence is indeed ample, and it is telling that the nurses’ union is not even arguing the patient safety issue.

In two separate studies in geriatric long-term care facilities, total patient mortality was significantly lower in those sites where health care workers were vaccinated when compared to sites where routine vaccination was not offered to health care workers (10% vs. 17% and 14% vs. 22%).2,3 Increased rates of health care worker vaccination also correspond with a significant decrease in the incidence of health care-associated influenza.4

While there are elements of the health care work force that remain suspicious of the safety of the annual influenza vaccine, such fears remain unsupported by scientific evidence. On the contrary, a study comparing receipt of flu vaccine vs. placebo revealed no significant difference in side effects.5

"It clearly showed that the only difference in side effects was local reaction — your arm got more sore with flu vaccine then it did with placebo," Rakita says. "There was absolutely no other difference in terms of adverse effects. That’s the kind of message we are trying to put out to people."

References

  1. Talbot TR, Bradley SF, Cosgrove SE, et al. SHEA Position Paper: Influenza Vaccination of Healthcare Workers and Vaccine Allocation for Healthcare Workers During Vaccine Shortages. Infect Control Hosp Epidemiol 2005; 26:882-890.
  2. Carman WF, Elder AG, Wallace LA, et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: A randomized controlled trial. Lancet 2000; 355:93-7.
  3. Potter J, Stott DJ, Roberts MA, et al. Influenza vaccination of health care workers in long-term care hospitals reduces the mortality of elderly patients. J Infect Dis 1997; 175:1-6.
  4. Salgado CD, Giannetta ET, Hayden FG, et al. Preventing nosocomial influenza by improving the vaccine acceptance rate of clinicians. Infect Control Hosp Epidemiol 2004; 25:923-8.
  5. Margolis KL, Nichol KL, Poland GA. Frequency of adverse reactions to influenza vaccine in the elderly: A randomized, placebo-controlled trial. JAMA 1990; 246:1139-1141.