Nursing Leaders: Mandate Recommended Shots
Medical, religious exemptions must be documented
In what could be a turning point in the controversy over healthcare immunizations, the American Nurses Association (ANA) is calling on all nurses and their healthcare colleagues to be immunized against all recommended vaccine-preventable diseases unless they have verified medical or religious reasons for declining.
While other professional associations have made similar statements on healthcare vaccinations, the ANA speaks to the absolute critical group when it comes to vaccines and patient safety: nurses, says longtime vaccine advocate William Schaffner, MD, chairman of the department of preventive medicine at Vanderbilt University Medical Center in Nashville.
“Nurses have more face time with patients than any other healthcare discipline. From a patient safety point of view, that’s the group that is the most important to be vaccinated. It’s so urgent,” he tells Hospital Employee Health. “This strong statement by the ANA not only informs their members, but now individual healthcare facilities — hospitals, clinics, doctors’ offices — can cite this speaking to their personnel. We hope this will persuade them to be vaccinated. It has been no secret that, speaking generally, nurses have been one of the healthcare disciplines that has not supported comprehensive immunization as strongly as we would have hoped. Having ANA now speak to their members is very important.”
The ANA position statement calls for immunization with all vaccines currently recommended for healthcare workers by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP), which includes hepatitis B, influenza, measles, mumps, rubella, pertussis and varicella.1
Vaccine issues and arguments in healthcare have primarily focused on seasonal flu shots, which hospitals are increasingly mandating to achieve high compliance. However, the ANA action was prompted by the shocking return of vaccine-preventable diseases like measles, which has resurged in several highly publicized outbreaks in recent years. During the first seven months of 2015, 183 people from more than 20 states were reported to have measles, with five outbreaks resulting in the majority of those cases, the CDC reports.2 While these are primarily cases in public outbreaks, utter chaos can rapidly ensue if an undiagnosed of case of measles is admitted to a hospital. (See related story in this issue.)
ANA: ‘We were not doing a good job’
“Measles was definitely a significant factor in that so many of the people who were infected were unimmunized,” says Ruth Francis, MPH, MCHES, program specialist in the ANA’s nursing practice and work environment department. “That really brought home to us the fact that we were just not doing a very good job to make sure the public is educated. A way to do that is to ensure our nurses are fully immunized themselves and then we are leading by example and educating patients and parents to make sure that everyone is immunized. I think people take for granted that because others are immunized that they are protected through herd immunity. That actually is not the case if they themselves are not fully protected. The [measles] impact was just so huge and broad geographically it really made us realize we have some work to do in our communities.”
U.S. clinicians are becoming more suspicious of measles, but many providers have actually never seen an infection with a virus that was declared eliminated from the U.S. in 2000. How was that triumph undone? A key factor was publication of some erroneous, later-retracted “research” that attempted to link MMR (measles, mumps, rubella) vaccine administration to onset of autism in children.3 A misguided anti-vaccine movement complete with celebrities and the echo chamber of the Internet began to steer parents and children away from MMR immunization in the U.S. Travelers and foreign visitors from places where measles is still endemic also have also contributed to outbreaks, particularly when they are exposed to one of the groups who have refused vaccination.
In that regard, measles introductions are going to continue, so employee health departments should know the immune status of staff to avoid a mad scramble after a case is in the hospital.
“Though the WHO is promoting measles vaccination around the world, measles is going to be with us for some time,” Schaffner says. “It’s a small world so there will be importations into the U.S. [Measles] will come from aboard and also by unimmunized members of our population who [travel] and bring it home. So introductions will occur.”
Facilities should be rigorous at screening on hire for measles immunity, which has generally been considered two doses of MMR or birth before 1957 (and assumption of naturally acquired disease). People born before 1957 may be presumed to be immune, according to CDC guidelines — although in the event of an outbreak, the CDC recommends that healthcare workers born before 1957 receive two doses of MMR.
“When you do have an introduction into a healthcare facility, there are some healthcare workers born before 1957 who may be susceptible,” Schaffner says. “They are few, but they’re out there and in the event of an introduction the facility really has to investigate all contacts. Now programmatically we don’t worry about them on a day-to-day basis, but if Vanderbilt suddenly had an introduction of measles we would have to find out all the contacts of that patient, and even among the people born before 1957 we would probably do serologic testing to make sure that they were immune.”
Another employee health issue with measles comes up in the hiring of healthcare workers from countries where measles is still endemic. One option is to test for existing immunity, but in some cases it may be simpler to immunize them with MMR.
“Different healthcare facilities approach it differently,” Schaffner says. “The easiest way if you are at all uncertain about their past experience, just immunize them and there are virtually no hazards associated with that.”
Under the new ANA policy, healthcare personnel who request exemption from vaccinations for religious beliefs or medical contraindications should provide documentation from “the appropriate authority” supporting the request.
“For the exemptions the nurse needs to provide documentation from an authorized person — either a medical provider or a head of their church with a religious statement,” Francis says.
Individuals who are granted exemption “may be required to adopt measures or practices in the workplace to reduce the chance of disease transmission” to patients and others, the new policy indicates. Typically, these measures include wearing surgical masks or being assigned to non-patient care duties.
ANA’s position on immunization for healthcare personnel aligns with the newly revised Code of Ethics for Nurses with Interpretive Statements, which says RNs have an ethical responsibility to “model the same health maintenance and health promotion measures that they teach and research,” including immunization.
“The need to be immunized, I think, is seen as a good thing for all health professionals, especially if they are having contact with patients,” Francis says. “This is another way that professionals can be sure that their standard of practice is 100% and that’s where it should be. To be honest with you, we have not had any pushback on this so far. I know that other associations are equally in line with the CDC and ACIP recommendations. This is nothing new to the nurses and the ANA really feels strong about getting out there and making sure this happens.”
Indeed, the ANA action adds to a growing list of professional organizations calling for full immunization of healthcare workers with all recommended vaccines. In 2013, three major medical organizations — the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America, and the Pediatric Infectious Diseases Society — recommended that hospitals that do not achieve a 90% rate of immunization on an ACIP recommended vaccine for healthcare workers should mandate that vaccine.
“More and more facilities are moving toward mandatory programs,” says Hilary Babcock, MD, MPH, SHEA board member and infectious diseases professor at Washington University School of Medicine in St. Louis. “Occupational health professionals are in favor of achieving high vaccination rates [and] many recognize that mandatory programs are the best way to achieve those high levels.”
Indeed, similar recommendations are in place in a position statement by the Association of Occupational Health Professionals (AOHP). In a statement issued last year, the AOHP advocated mandating “that all healthcare personnel be offered ACIP-recommended immunizations at no charge. … AOHP believes that immunization of healthcare personnel is essential to their health and the health of their patients, and the organization is committed to promoting ACIP-recommended immunizations for healthcare workers.”
However, the association left the door slightly ajar with the caveat: “AOHP respects the individual healthcare worker’s right to make an informed decision regarding vaccinations and supports healthcare institutions in developing their own policies and practices to immunize their workforce consistent with the ACIP recommendations.”
Most states do not have a law requiring vaccination of healthcare workers, leaving the onus on hospitals and healthcare facilities to develop their own policies, the ANA notes. While it’s well known that getting healthcare workers immunized for seasonal flu is a challenge, the ANA cites some partial data that suggests many workers are not taking the other vaccines, either. Although data were not broken out for individual vaccines, an ANA health risk appraisal found that only 55% to 75% of nurses have received the full schedule of all recommended vaccines.
“The percentage of workers who are not immunized is higher than we would like it to be, but certainly it is increasing and facilities are making it mandatory for workers to work in different areas,” Francis says. “But we still have some work to do and we know there are some workers who are not protected.”
Many are certainly not protected against pertussis, another resurging disease that poses a risk to patients such as pregnant women and newborns. The level of immunization in healthcare workers has been estimated at below 40%, though the CDC has recommended the Tdap vaccine for a decade. Though admitting they had little data to support the move, the CDC recently reported that employee health professionals can consider revaccinating workers with Tdap if they are facing a pertussis outbreak. (See related story in this issue.)
“If there is a vaccine that healthcare facilities really need to pay attention to it’s Tdap because they are probably not up to snuff,” Schaffner says. “The recommendation is all healthcare workers should get a dose of Tdap, and lots of institutions have still not geared up to do that. Our occupational health service took a two-pronged approach. They focused first on everybody that worked in the children’s hospital and also added all emergency personnel and obstetrics. Those were our first [groups] and then the second prong was to provide it during everyone’s annual update.”
Given the threat of pertussis to infants and other high-risk patients, mandatory policies may pick up momentum on Tdap. At one health system, a mandated policy — even allowing for legitimate medical and religious declinations — resulted in a pertussis vaccination rate of 98%.4
With so many groups now on board, if healthcare worker vaccine rates don’t improve, the call for mandates may extend to federal regulations. CMS included many healthcare worker vaccines in its final hospital infection control survey issued last year. However, they were listed for information only, as CMS does not have the current authority to cite for failure to vaccinate. That said, many think vaccinations and other items on the CMS survey could eventually be required as conditions of participation, meaning compliance could affect reimbursement rates.
“[SHEA] would support including vaccination rates as a quality metric, without necessarily requiring that a specific strategy be used to achieve it,” says Babcock.
The ANA hopes it does not come to that.
“There really are some challenges when you make it regulatory,” Francis says. “Who ends up being the police to make sure that it happens? Is there a financial impact or licensure impact if it is not adhered to? My hope is that people will come on board with a strong statement and see the value of [immunizations] rather than needing a regulation.”
REFERENCES
- American Nurses Association. Position Statement on Immunizations. July 21, 2015: http://bit.ly/1hsszCU
- Centers for Disease Control and Prevention. Measles cases and outbreaks from January 1 to August 21, 2015. http://1.usa.gov/1hR3aN8
- Editors of The Lancet: Retraction—Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 2010;375:445.
- Esolen LM and Kilheeney KL. A mandatory campaign to vaccinate health care workers against pertussis. Am J Infect Control 2013; 41:740-742.
This could be a turning point in the controversy over healthcare immunizations.
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