HHS panel solicits EH perspective on controversial flu vaccination issue

'We are the interface between the policy and practice'

A proposed federal action plan is targeting influenza vaccination of health care workers, and occupational health physicians will be represented on the working group that is considering new recommendations — including possible mandates.

The American College of Occupational and Environmental Medicine (ACOEM) is a key stakeholder as the U.S. Department of Health and Human Services' inter-agency working group considers new strategies to increase immunization rates.

After all, occupational health physicians and employee health nurses are often the ones who coordinate the flu vaccination campaigns, notes Melanie Swift, MD, medical director of the Vanderbilt Occupational Health Clinic at Vanderbilt University in Nashville, TN, and vice chair of ACOEM's Medical Center Occupational Health section.

"You need that experience at the table. We are the interface between the policy and practice," says Swift, who may be representing ACOEM as a liaison member. "We see firsthand the impact of policies like this on workers. To exclude us from that conversation would be to miss an incredibly vital piece of the picture."

ACOEM's position differs from that of the infection control organizations mentioned in the action plan. (The action plan is available at www.hhs.gov/ash/initiatives/hai/tier2_flu.)

In a 2008 position statement, ACOEM advocated using "a comprehensive approach...encompassing education, vaccination, and infection control practices" to improve influenza vaccination of health care workers. However, ACOEM did not endorse a mandatory approach that would lead to punitive consequences:

"Education and adherence to infection control practices should be mandatory. Immunization is safe but variably effective and is not a panacea for respiratory virus transmission in the health care setting...Current evidence regarding the benefit of influenza vaccination in HCW as a tool to protect patients is inadequate to override the worker's autonomy to refuse vaccination." (The guidance is available at www.acoem.org.)

HHS will likely also solicit input through a stakeholders meeting in the spring, says Ray Strikas, MD, medical officer and seasonal influenza coordinator for the National Vaccine Program Office and co-chair of the inter-agency working group. "We'll make recommendations in concert with the many partners in organized health care," he says.

Will Joint Commission up the ante?

The greatest impact of the HHS action plan may come from the Center for Medicare & Medicaid Services (CMS) or The Joint Commission accrediting body.

A Joint Commission standard requires hospitals to offer influenza vaccination on-site and to educate staff and affiliated "licensed independent practitioners." They also must monitor their vaccination rates and seek to improve them.

The draft HHS action plan suggests encouraging The Joint Commission to create a performance measure based on the percentage of health care personnel who are vaccinated against influenza and to establish a specific vaccination goal. Healthy People 2010 set a goal of vaccinating 60% of health care workers; the proposed 2020 goal is 90%.

According to a survey sponsored by the Centers for Disease Control and Prevention and conducted by the RAND Corp., in the 2009-2010 flu season, about 74% of hospital-based health care workers received either the seasonal or H1N1 flu vaccine (or both). Vaccination rates were lower in other health care settings. Nurses and physicians were the most likely to be vaccinated, and non-clinical support staff were the least likely to receive the vaccine.

"The Joint Commission views the vaccination of health care workers as a very important issue and we are currently in the discussion stage about the issues [in the action plan]," Ken Powers, spokesperson for The Joint Commission, told HEH in an e-mail response.

Does HCW vaccination save lives?

The first stage of the action plan involves reviewing existing evidence on influenza immunization, identifying current state statutes and developing model policies or statutes, Strikas says.

Alexandra Stewart, JD, an assistant research professor in the Department of Health Policy at the George Washington University School of Public Health and Health Services in Washington, DC, will research the pros and cons of an immunization mandate, Strikas says.

Stewart published a commentary in the New England Journal of Medicine in November 2009 stating that a New York rule mandating influenza immunization of health care workers would likely be ruled constitutional. (The rule was suspended when there was a delay in vaccine supply during the H1N1 pandemic.)

"I believe that the state's right to compel health care workers to receive vaccinations will supersede their individual rights because of the state's substantial relation to protection of the public health and safety," Stewart wrote.1

However, a recent Cochrane Review raised questions about whether the research really shows a patient safety benefit from influenza immunization of health care workers. A review of five studies found all were "at high risk of bias."2

Even so, the studies did not show an effect for influenza immunization of health care workers on laboratory-confirmed influenza, pneumonia (a possible complication of influenza), or deaths from pneumonia among people who were 60 or older and living in long-term care facilities.

There was some association between immunization and influenza-like illness or mortality from all causes among elderly long-term care residents, but the authors questioned the significance of that finding. "These non-specific outcomes are difficult to interpret because influenza-like illness includes many pathogens, and winter influenza contributes less than 10% to all-cause mortality in individuals 60 or older," the authors stated.

"We conclude there is no evidence that vaccinating health care workers prevents influenza in elderly residents in long-term care facilities," they stated.

The authors suggested future research should use high-quality, randomized control trials, and should test combinations of interventions, including hand-washing, masks, early detection of influenza, anti-viral prophylaxis, isolation of patients, restrictions on visitors and policies to discourage health care workers with influenza-like symptoms from coming to work.

Common metrics needed

Demonstrating an actual benefit to patients is important before subjecting employees to a mandate that requires not one-time but annual vaccination, says Swift. Hospitals that implement mandatory policies also should collect data on nosocomial flu before and after the policy change to gauge the impact, she says.

"It's very important that we not lose sight of the intent of these policies and ensure we have metrics in place to evaluate their success and failure – namely, nosocomial flu rates," she says.

While it's not yet clear whether HHS will recommend flu vaccine mandates for health care workers, Strikas says other measures still will be emphasized, such as education of health care workers about influenza. "Multiple approaches are necessary to get this done," he says.

Meanwhile, health care facilities need a more standardized approach to measuring influenza vaccination, including a common definition of health care personnel and method of measuring rates, he says.

In 2010-2011, about 160 million doses of flu vaccine will be available. "We have the opportunity with relatively abundant vaccine this year and [many strategies] to do a much better job of getting people vaccinated," he says.


1. Stewart AM. Mandatory vaccination of health care workers. N Engl J Med 2009;361:2015-2017. Available online at www.nejm.org/doi/full/10.1056/NEJMp0910151.

2. Thomas RE, Jefferson T, and Lasserson TJ. Influenza vaccination for healthcare workers who work with the elderly: Systematic review. Cochrane Database of Systematic Reviews 2010;doi:10.1016/j.vaccine.2010.09.085. Available online at www2.cochrane.org/reviews/en/ab005187.html . Accessed on October 13, 2010.