Pressure builds forflu shot mandates

'Logical, ethical, administrative pitfalls'?

More health care workers responded to this season's push for influenza vaccination by rolling up their sleeves and getting the vaccine. By mid-November, 56% reported having gotten the vaccine and 7% said they definitely planned to get the vaccine, according to a web-based survey conducted for the Centers for Disease Control and Prevention. About 68% of hospital employees had received the vaccine, and another 5% said they definitely intended to be vaccinated, for a total of 73%.

But while that vaccination level was similar to last year and higher than rates that hovered near 40% in recent years, it wasn't enough to stem the call for mandatory programs, particularly within the infection control community. Unions and occupational medicine physicians continued to press for voluntary programs as the best way to boost vaccination.

Although some hospitals have been able to get vaccination rates above 80%, it requires such an intense focus and strong leadership involvement that a hospital must create an expectation that all employees will be vaccinated, says William Schaffner, MD, an infectious disease expert who is chairman of the Department of Preventive Medicine at Vanderbilt University in Nashville, TN. Most hospitals, however, can't reach that level, he asserts.

"[The survey] affirms my notion that the era of voluntary compliance is over. I think influenza immunization for all health care workers ought to be mandatory," he says. "We have been promoting health care workers immunization in a very intense way for 10 years. We have seen the national proportion of health care workers inch up but we're not making great progress. The thing that seems to get health care workers almost completely immunized is a mandatory policy."

However, Melanie Swift, MD, medical director of the Vanderbilt Occupational Health Clinic at Vanderbilt University in Nashville, TN, remains unconvinced about the merits of mandatory vaccination. In fact, studies have failed to demonstrate the benefits of vaccination on patient outcomes, even in long-term care settings, she says.

"Employer-mandated vaccinations are fraught with logical, ethical, and administrative pitfalls and constitute a false sense of security even though they may create the impression of strong action," Swift said as an author of recent comments to the U.S. Department of Health and Human Services on its draft Flu Action Plan from the American College of Occupational and Environmental Medicine (ACOEM). Swift is vice chair of ACOEM's Medical Center Occupational Health section.

Resources spent on vaccination programs "should not drain resources from other important programs to protect the health of workers," she cautioned.

Ironically, the most persuasive message to send to health care workers may be one of self- interest. According to the CDC survey, 85% of health care workers received the flu vaccine because they didn't want to get the flu. About 58% said they wanted to protect their family and friends. Transmission to patients was a concern for just 38% of health care workers, according to the survey, which is unpublished.

How high can you go?

One thing is clear: The pressure continues to grow for hospitals to improve health care worker immunization rates.

In Iowa, hospital rates of health care worker influenza immunization are publicly reported, along with health care associated infections. A number of hospitals have adopted mandatory vaccination programs, and the state touted a 91% vaccination rate in 2009-2010.

Wisconsin opted to promote voluntary programs that require health care workers to sign a declination form if they don't want to be vaccinated. The state's median rate rose to 72%. About 40 hospitals reached the state's target of 80% or more. The state provided feedback to hospitals and nursing homes and offered recommendations to improve rates.

"We want health care workers to do this because it's the right thing, and so far, it's working," Gwen Borlaug, CIC, MPH, infection control epidemiologist with the Wisconsin Division of Public Health, said in a statement.

The Maryland Partnership for Prevention in Baltimore has been promoting health care worker influenza immunization for about six years, with an emphasis on education and making vaccinations free and convenient. The partnership offers a free online toolkit to assist hospitals and other health care employers. (See

Hospital vaccination rates range from a low of about 30% to 100%, says Tiffany Tate, MHS, executive director of the partnership.

"We have been reluctant as an make that recommendation that [health care employers] should make it mandatory," she says. "But we do think people should really push for vaccinations and ask people to sign a declination form if they don't have the vaccine."

Meanwhile, the list of hospitals requiring influenza immunization continues to grow, says Deborah Wexler, MD, executive director of the Immunization Action Coalition in St. Paul, MN, which tracks mandatory programs on its "honor roll." (Those include institutions that allow declinations or exemptions for personal reasons.)

"We need every health care worker who can be vaccinated to be vaccinated," says Wexler. "That's how we're going to optimally protect the patients we take care of."