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By Gary Evans, Senior Staff Writer
With a new study finding that virtually none of the nation’s 150 Veterans Health Administration hospitals have mandatory flu shot policies for healthcare workers — leaving vaccination rates languishing in the 55% range — the VA system is considering a vaccine mandate to protect patients and coworkers, Hospital Infection Control & Prevention has learned.
Given the repeated calls by leading medical groups for mandatory flu vaccination of healthcare workers to protect patients, the issue has taken on an air of historical inevitability that suggests the controversial matter is all but resolved. Not by a literal long shot. The recently published study1 suggests that healthcare worker immunization levels at VA hospitals have plateaued well below the Department of Health and Human Services goal of a 90% of healthcare workers vaccination rate by 2020. Overall flu vaccination rates for healthcare workers nationally were estimated at 75%, but exceed 95% at facilities with mandatory policies, the authors reported.
Researchers at the University of Michigan Medical School and the Ann Arbor VA Healthcare System surveyed infection preventionists at 386 non-VA hospitals and 77 VA facilities. Of the non-VA hospitals, 43% of the IPs responding said their facility mandated flu vaccination of all healthcare providers. Though the hospitals were not named, a 1.3% level of mandatory policies at the VA hospitals translates to a single outlier among the 77 federal facilities. Something short of a mandate appears to be in place at many hospitals, though the survey did not ask respondents to go into detail about the specifics of their policies. Overall, about one-fifth of hospitals without mandatory policies said unvaccinated staff had to sign declination forms and/or wear a mask while seeing patients during flu season. For example, the Ann Arbor VA has such a masking policy for caregivers who decline immunization.
There are also pockets of entrenched resistance, as 28% of the IPs at VA hospitals said worker unions were a factor in the lack of a flu vaccine requirement. That could set the stage for labor negotiations and legal challenges if a mandate is enacted. Currently, the VA system does not have a national policy to mandate flu immunization of healthcare workers, and many hospitals are apparently waiting for the green light before pushing such policies. More than half of IPs in the 77 VA hospitals said they could not mandate the vaccine because they were part of a federal system that had no such national directive.
Since the survey was taken in 2013 the VA system has continued to encourage its hospitals to work toward near-universal vaccination by 2020, but voluntary immunization efforts historically have shown little evidence of the kind of dramatic, sustainable increase that would be necessary to take the health system from 55% to a 90% vaccination rate.
“I can tell you in conversations with our people at the Ann Arbor VA that they believe there have been recent developments at the [VHA] National Leadership Council — they may be moving toward mandatory vaccination of VA employees in the near future,” says M. Todd Greene, PhD, MPH, lead author of the study and a research investigator at the University of Michigan and the Ann Arbor VA.
There are tens of thousands of healthcare workers in the VA system, so mandating the seasonal flu shot would no doubt be controversial. It would also be a monumental endorsement of public health in the face of a national anti-vaccine movement that has brought measles out of exile and threatens to erode critical coverage of other vaccines. The VA national office had not responded to a request for comment as this issue of HIC went to press, but it is no secret the VA has been considering a mandate for several years — particularly after it fell well short of an 80% immunization goal in 2011.2 Among the obstacles that have been cited are that the VA is larger than any organization that has implemented mandatory flu vaccination, adequate supply of vaccine could be an issue, and there are limited data definitively linking vaccination of healthcare workers with reduced influenza-related illness in patients.3 Another factor is the unwillingness of some hospital administrators to open this can of worms, as about 22% of those surveyed overall said simply that hospital leadership would not mandate the vaccine.
“To put it bluntly, American hospitals have a lot of work to do,” says Sanjay Saint, MD, MPH, senior author of the study and director of the University of Michigan Patient Safety Enhancement Program.
In that regard, the VA system may conclude that it is time to get on the right side of history as more and more facilities mandate seasonal flu shots. Among the continuing calls for mandatory flu vaccine policies were two by highly influential groups in 2015: the American Nurses Association and the American Academy of Pediatrics (AAP).4,5 (For more information, see the October 2015 issue of HIC.)
The AAP vigorously reiterated a prior call for mandatory influenza vaccination of healthcare workers, saying religious or philosophical objections to immunizations do not override the ethical imperative to protect patients.
“Unless you have a medical problem, there is, in my opinion, no excuse — zero, none — for healthcare workers not to be vaccinated,” says Jeffrey R. Starke, MD, co-author of the AAP statement and chief of infection control at Texas Children’s Hospital in Houston.
Frustrated pediatricians are taking a similar hardline with patients that refuse to vaccinate their children, with 21% of the physicians going rogue against the standing AAP policy by “dismissing” families that balk at routine immunizations.6
On the healthcare worker issue, the AAP takes something of a “no caregiver is an island” stance, arguing that individuals embedded in societies and groups cannot consider their illness in isolation.
“Employees of healthcare institutions are obligated to honor the requirement of causing no harm and to act in the best interests of the health of their patients,” the AAP stated. “Medical exemptions to required influenza immunization (i.e. severe allergy to a vaccine component) should be kept at a minimum to ensure high coverage rates and granted only on an individual basis. Granting specific medical exemptions is constitutionally required, but states do not have to grant philosophical or religious opt-outs.”
The AAP calls for the development of “consistent policies” for exempted healthcare workers like wearing a mask if non-vaccinated.
“Mandating influenza vaccine for all healthcare workers is ethical, just, and necessary,” the AAP argued. “Hospital-acquired influenza has been shown to have a particularly high mortality rate, with a median of 16% among all patients and a range of 33% to 60% in high-risk groups such as transplant recipients and patients in the ICU.”7
Influenza vaccination of healthcare workers has the potential to reduce both morbidity and mortality among patients, the AAP noted. While there have been influenza outbreaks and even patient deaths linked to non-immunized flu-infected workers, the quality of the evidence supporting a protective effect in overall populations has been moderate at best.8 A 2013 Cochrane review concluded that there were “no accurate data” supporting the vaccination of healthcare workers to prevent laboratory-confirmed influenza in long-term care residents age 60 years and older.9
“Specifically, the authors did not find a significant decrease in respiratory illness or in deaths related to respiratory illness,” the AAP noted.
While influenza vaccine efficacy will vary year to year depending on the match with circulating strains, it seems clear enough that healthcare workers acquire flu and infect patients and coworkers. In a prospective surveillance study of laboratory-confirmed influenza among hospitalized adults in a network of Canadian hospitals from 2006 to 2012, 17.3% of influenza cases were healthcare-associated.10
Starke has seen such cases firsthand for both influenza and other respiratory infections.
“I have done infection control at Texas Children’s for 20 years and we have clearly had incidences where we had a transmission of viruses to children from ill healthcare workers,” he says. “There’s no question about it. It’s not a question of if it happens — it does. The bigger question is, how often does it happen?”
There is clear evidence of the devastating consequences of hospital-acquired influenza in high-risk populations. In a NICU outbreak, six babies were infected and one died. Some among the poorly immunized group of caregivers admitted working while ill, with only 14% reporting they stayed home with an influenza-like illness.11 In an outbreak in a bone marrow transplant unit, six patients developed pneumonia and two died.12 Five staff members developed influenza-like illness during the outbreak, and overall there were seven cases of occupationally-acquired influenza in a staff with paltry immunization rates.
Voluntary programs have proved largely ineffective, in part because healthcare workers have persistent misconceptions about the risks and benefits of the influenza vaccine. The most commonly reported barriers to vaccination were concerns about vaccine safety and effectiveness and low perceived susceptibility to influenza. Some continue to believe the long-dismissed concern that the vaccine actually causes flu. As a result healthcare workers fail to lead by example if they recommend universal immunization to their patients but do not require it of themselves. Furthermore, unvaccinated healthcare workers fuel the growing public distrust and fear of vaccines, which has resulted in the resounding resurgence of preventable diseases, the AAP noted.
For IPs facing immunization issues and the commonly reported problem of healthcare workers reporting for duty with flu or other respiratory and symptomatic infections, there is still one old-school safety net: hand hygiene. At Texas Children’s, a major institutional effort pushed compliance with hand washing toward 100%, drastically reducing hospital-acquired respiratory infections in patients, Starke says. The all-out effort included a marketing component with slogans and pens, involvement of patients and families, and tying hand hygiene compliance to an employee bonus program.
“The vast majority of respiratory viruses are transmitted through direct contact,” he says. “In fact, they are not particularly airborne — though influenza is a little different in that it can be spread through droplets through the air that can go several feet. But if every healthcare worker got immunized for flu and then if we really do a superb job with hand hygiene, we would block the vast majority of transmission of viruses from healthcare workers to patients.”
Financial Disclosure: Senior Writer Gary Evans, Associate Managing Editor Dana Spector and Nurse Planner Kay Ball report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Consulting Editor Patrick Joseph, MD, is laboratory director of Genomic Health Inc, CareDx Clinical Laboratory, and Siemens Clinical Laboratory.