Joint Commission considers mandating HCW flu shots

Field review sparks polarized response

Mandating seasonal health care worker flu vaccinations — an issue so contentious it led to open revolt in the first U.S. hospital that tried it — is being considered as a new standard by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

Though no action may result from the preliminary analysis that is under way, it is telling that JCAHO is considering taking on an issue that is an open mine field of labor/management, legal, and logistical issues.

According to a Joint Commission field review notice that closed for comment on Feb. 12, JCAHO is "interested in learning your thoughts about whether influenza vaccination should be made mandatory among caregivers in various health care settings, what categories of individuals should be vaccinated, whether the option to decline vaccination for legitimate or other reasons should be provided, and whether and how organizations can track declination rates."

The response was overwhelming and highly polarized, says Nancy Kupka, DNSc, MPH, RN, project director in the JCAHO division of standards and survey methods.

"A lot of people have written me e-mails giving very compelling arguments about how they have tried to launch flu immunization programs in their hospitals," she reports. "They have been doing this for years and they struggle to get people immunized. Then we have had people write and say, 'This is none of your business. This is an employee health issue. I am a health care worker and you have no right to tell me I need to take this immunization.'"

Such a standoff essentially is what happened after a flu immunization mandate was issued at Virginia Mason Medical Center (VMMC) in Seattle. Unionized nurses at VMMC cried foul because the mandate was not in their contract language. An arbitrator agreed with the breach-of-contract argument, but the issue remains unresolved.

Having made infection control and patient safety top priorities in recent years, the Joint Commission is serious about taking action on the controversial issue. Still, with fewer than 40% of workers immunized in a given year, it is an open question whether even JCAHO has the clout to issue a mandate in the face of such historical resistance.

"The reason we go for a field review is to get a sense of what the field can do, and what their views are," she says. "We are asking questions about both mandatory immunization and the use of declination statements. There are pros and cons to both. Virginia Mason Hospital can tell you what some of the cons are."

Looming pandemic highlights issue

The threat of H5N1 avian influenza mutating into a pandemic strain certainly gives the issue some buzz, but that is not what is spurring the JCAHO action. Seasonal flu kills 36,000 Americans a year and has shown to be transmitted from unvaccinated workers to patients. In an age of patient safety, there is a glaring disconnect in having large numbers of health care workers unvaccinated every flu season.

"This has been a problem for a long time, but being on the precipice of this pandemic has brought new highlights to it," Kupka says. "Many groups have been working toward coming out with recommendations for flu vaccine. Independent of the pandemic, it would be a good thing to do. "

Indeed, the Association for Professionals in Infection Control and Epidemiology has come out in favor of mandatory seasonal flu vaccinations for patient caregivers; the Society for Healthcare Epidemiology of America is calling for workers to sign off on declination statements if they turn down the shot; and the Centers for Disease Control and Prevention (CDC) was preparing new guidance on the issue at press time. The Joint Commission's position on the issue is particularly intriguing, since maintaining compliance with accrediting agencies draws the attention of administrators more than recommendations from a professional association or even the voluntary guidelines of the CDC.

"People who come to work sick can indeed give flu to their patients," Kupka says. "We feel this is a strong patient safety issue. We have always been a patient safety organization. People think we are a regulator but we are a patient safety organization."

The patient safety issue is reflected in the data. 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 compared to sites where routine vaccination was not offered to health care workers (10% vs. 17% and 14% vs. 22%).1,2 Increased rates of health care worker vaccination also correspond with a significant decrease in the incidence of health care-associated influenza.3 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.4

That said, the Joint Commission can't simply mandate something that is unachievable in health care. Even some strong proponents of flu immunization remind that mandatory policies must carry consequences — including the potentially disruptive measure of dismissing workers.

"What we strive for is the highest achievable standard," Kupka says. "If we come up with standards that nobody can reach, then we have not done any service. If we don't push the field forward — sometimes a little uncomfortably for them — then we have not done anybody a service either. The question is whether or not it is going to be mandatory. There is a big difference between saying you have to offer it to workers and saying you can't let somebody work if they haven't taken it."

Flu shots a national patient safety goal?

Rather than a formal standard, the Joint Commission could establish health care worker flu immunization as an annual patient safety goal. Such goals draw national attention and a high health care administrative priority. JCAHO already has established two annual goals related to infection control: compliance with CDC hand hygiene guidelines, and reporting unexpected patient deaths due to nosocomial infections as sentinel events.

"That really made the CDC [hand hygiene] recommendations come alive," Kupka says. "It was not necessarily the most popular thing to do, but it was an important step in health care."

Similarly, the Joint Commission adopted new infection control standards effective January 2005 that put the onus on top administrators to maintain effective programs to protect patients. "We really put more of an emphasis on implementation, on making changes, on evaluating those changes and putting the responsibility of that on leadership," she says. "[Infection control] is more of an emphasis in our survey process, it's more of an emphasis in our standards, and with the [new JCAHO] patient safety center it has become an emphasis there as well. "

Now that the field review has concluded, a review and analysis is under way of the responses. After a thorough review a recommendation may be made to go forward with a standard. "We are looking at this across programs that we accredit," Kupka says. "For each of our programs, we have a professional technical advisory committee that represents the industry. If we feel at that point that we are ready to go forward with the standard, we will take it to our board committee. The earliest it would go into effect is January 2007, which really means that organizations would have to tool up for flu season in 2007 at the earliest."


1. 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; 355:93-97.

2. 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.

3. Salgado CD, Giannetta ET, Hayden FG, et al. Preventing nosocomial influenza by improving the vaccine acceptance rate of clinicians. Infect Control Hosp Epidemiol 2004; 25:923-928.

4. Margolis KL, Nichol KL, Poland GA. Frequency of adverse reactions to influenza vaccine in the elderly: A randomized, placebo-controlled trial. JAMA 1990; 246:1,139-1,141.