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APIC: "Ethical" duty to mandate HCW flu shots
Employee health group skeptical of data, efficacy
With low rates of influenza immunization among healthcare workers still more the national rule than the occasional exception, the nation's largest infection prevention group has toughened its mandatory policy and closed some opt-out loopholes.
The Association for Professionals in Infection Control and Epidemiology now recommends mandatory seasonal influenza immunization as a condition of employment within healthcare facilities. With patient safety in the balance, organizations should not be deterred by workers threatening to quit, APIC argues.
"In the organizations that have really stepped up to the plate and had a mandatory policy, a lot of people threatened that they were going to leave," says Linda Greene, RN, MPS, CIC, lead author of APIC's position paper and director of infection prevention and control at Rochester (NY) General Health System. "But what we have heard anecdotally is that they have lost very few of their employees. They may lose two or three nurses and they have 7000 employees. It's a minute number of people."
Another factor, is that hospitals that have gone to mandatory policies have thus far been able to hold the line, rather than reverting to a voluntary policy in the face of pressure from nurses and other health care worker union groups.
"In our literature search for this we found that everyone who has made a mandatory policy has not backed down," Greene says. "There is value to looking at these early adopters. They did it, it worked, and they did not have a lot of people leave employment. These mandatory policies really do work, and we are seeing more and more organizations saying, 'This is what we need to do.'"
AOHP has different tack on 'mandate'
The Association of Occupational Health Professionals in Healthcare (AOHP) opposes the APIC position, particularly any definition of "mandatory" as a condition of employment. Instead, in a new position paper posted on its website, the AOHP recommends that facilities be mandated to offer the vaccine.
"That kind of mandate [often] comes from the state governments, which say the facilities have to offer the influenza vaccine to their employees," says Mary Bliss, RN COHN, director of AOHP Region 3. "That is the position that AOHP is [taking]. We support that it be mandated that health care workers be offered the vaccine. The mandate falls on the facility."
AOHP "respects the individual HCW right to make an informed decision regarding declination of the influenza vaccine" but nevertheless encourages a strong emphasis on immunization programs, the position paper states. (See related story, below.) Declination forms are recommended to document lack of participation in the influenza vaccine program. The position was based on a survey of AOHP members, many of whom voiced concern about mandating a vaccine that changes every year and is known to lack a 100% efficacy.
"The vaccine is at best a guess," says Dee Tyler, RN, COHN-S, FAAOHN executive vice president of AOHP. "We don't know what the strains are going to be for a particular flu year, [so] mandating it as a condition of employment becomes something of a challenge. What happens if they have a reaction? How do you handle that under worker's comp? What will the employer's responsibility be?"
In addition the AOHP cites a recent Cochrane review paper that concluded "there are no accurate data on rates of laboratory-proven influenza in healthcare workers" and many of the studies showing a protective affect are "at high risk of bias."1
38% of workers not vaccinated
In citing its stronger position, APIC emphasized the current policy of voluntary vaccination has not been effective and that healthcare personnel have not achieved acceptable vaccination rates.
"We are finding that despite all of the efforts coverage levels are around 62%, [immunized] which really is only a marginal increase," Greene says. "If you look at the history of our position papers, we have gone from the entirely voluntary effort of going around with the [flu shot] carts, to informed declinations, and now to this very firm stance because clearly voluntary efforts have not been successful."
Rather than accepting some general philosophical or personal objection to being immunized, APIC says only employees that are medically contraindicated to the seasonal flu vaccine should be exempted. That said, the association left the matter of religious objections to be handled on a case by case basis, with the possibility of reassigning or masking employees if it is a legitimate issue.
"Certainly, one could understand religious beliefs if they are part of an organized religious effort with an authenticated [statement] that this religion truly does not believe in vaccines," Greene says. "There are ways that one could accommodate them and respect religious beliefs, but with the realization that patient protection comes first. Do they need to wear a mask during flu season or do we need to reassign them to an area where they are not exposed to highly vulnerable patients?"
The recommendations are published in APIC's newly-released position paper, "Influenza Vaccination Should Be a Condition of Employment for Healthcare Personnel, Unless Medically Contraindicated," (www.apic.org). The recommendations apply to acute care hospitals, long-term care and other facilities that employ healthcare personnel. The APIC paper states that the mandatory requirement should be part of a comprehensive strategy incorporating all of the recommendations of the Centers for Disease Control and Prevention's Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP).
Influenza results in an estimated 150,000 hospital admissions and 24,000 deaths annually. The most efficient way to decrease transmission of the illness to or from high-risk persons, such as hospitalized patients, is through vaccination of health care workers, APIC argues. Mandatory vaccination programs have proven to be the single most effective strategy to increase worker influenza vaccination rates.
"If you want to work in [a health care] organization you really need to get vaccinated because we believe it is that important," Greene says. "We believe it is an ethical responsibility. APIC is taking a leadership role because this is an issue that is very near and dear to the hearts of all of our members. They are very passionate about this."
AOHP supports worker right to decline vaccine
The Association of Occupational Health Professionals in Healthcare (AOHP) position on flu immunization of health care workers includes the following key points:
OSHA: Mandatory flu shots OK, but with a key caveat
In the continuing hue and cry over mandatory flu shots for health care workers, questions have arisen about the regulatory position of the Occupational Safety and Health Administration.
Can hospitals mandate that health care workers be immunized without running afoul of OSHA? The answer is "yes," with a key caveat, according to an OSHA position established in 2009.
In a "letter of interpretation" in response to a question about the increasingly popular but controversial policy, OSHA ruled that employers may mandate the vaccination as long as they don't retaliate against employees who have "a reasonable belief" that they would have a serious medical reaction to the vaccine. There's no mention of philosophical or religious beliefs, but if the worker claims to be at risk, for example, of "a serious reaction" to the flu vaccine, OSHA says they may be protected under "whistleblower" statutes.
The position was established during emergence of the H1N1 influenza A pandemic strain. The agency states: "OSHA does expect facilities providing healthcare services to perform a risk assessment of their workplace and encourages healthcare employers to offer both the seasonal and H1N1 vaccines. It is important to note that employees need to be properly informed of the benefits of the vaccinations. However, although OSHA does not specifically require employees to take the vaccines, an employer may do so. In that case, an employee who refuses vaccination because of a reasonable belief that he or she has a medical condition that creates a real danger of serious illness or death (such as serious reaction to the vaccine) may be protected under Section 11(c) of the Occupational Safety and Health Act of 1970 pertaining to whistle blower rights."