Push for HCW vaccine mandates goes beyond flu
'When you make something mandatory, it happens'
Health care workers should be required to receive all vaccinations — not just seasonal flu shots — recommended by federal public health authorities, according to a consensus of three leading infection prevention organizations, Hospital Employee Health has learned.
Under this broader approach, employers would mandate measles, mumps, rubella (MMR), varicella, pertussis and hepatitis B vaccines, in addition to the annual influenza vaccine.
The organizations — the Infectious Diseases Society of America (IDSA), the Society for Healthcare Epidemiology of America (SHEA), and the Pediatric Infectious Diseases Society — were poised to issue a joint statement as this issue of HEH went to press. They were expected to endorse hospital mandates for all vaccinations recommended by the Advisory Committee on Immunization Practices, an expert panel that advises the Centers for Disease Control and Prevention.
Voluntary programs are "somewhat successful, but they don't reach the level of universality," says W. Charles Huskins, MD, MSc, consultant in pediatric infectious diseases at the Mayo Clinic in Rochester, MN, and a liaison from SHEA to the CDC's Healthcare Infection Control Practices Advisory Committee (HICPAC). "When you make something mandatory, it happens."
That has been clear from the dramatic effects of mandatory influenza vaccination policies. Infection preventionists pushed for mandates, and several organizations issued position statements in 2010 and 2011 calling for influenza immunization to be a condition of employment for health care workers.
Hospitals responded either by creating a mandate or putting greater resources into voluntary programs, and the vaccination rates of health care workers rose dramatically. In the 2012-2013 flu season, 30% of hospitals had a mandatory influenza vaccination policy, and the overall vaccination rate in hospitals was 83%.1
Outbreaks drive immunization effort
Recent outbreaks of measles, mumps and pertussis have placed a greater emphasis on other vaccines for health care workers. State laws vary, but most do not require hospital employees to be vaccinated.
By 2011, only about one in four (26.8%) health care workers had received a Tdap booster to protect against pertussis, according to the CDC.2 Yet pertussis is a growing problem nationally, including nosocomial outbreaks in which health care workers were infected and transmitted pertussis to vulnerable patients.
Concerned about the reemergence of pertussis, Geisinger Health System in Danville, PA, made Tdap a condition of employment in 2010. A committee considered requests for exemptions and granted 314: 307 medical, 7 religious, one ethical. Only one person was fired. The health system recently reported a pertussis vaccination rate of 97.8%.3
The severe pertussis illness of a Geisinger pediatrician also brought home the importance of vaccination, says Lisa Esolen, MD, system medical director of infection prevention and control and health services.
"Our goal was only to protect our staff and our patients," says Esolen. "Pertussis has been on the rise here and nationally, and we didn't want to accept responsibility for spreading it to one patient. One patient getting sick with this was not acceptable."
Mandatory Tdap policies are becoming more common elsewhere. A 2013 survey by the Michigan Department of Community Health found that 29% of the state's hospitals required the Tdap booster for at least some employees, such as those with direct patient care or in high-risk areas. That was more than twice the rate of 11% from a survey just two years earlier.
Health care workers have high rates of measles, mumps and rubella (MMR) vaccination, but those born before 1957 have been presumed to be immune. CDC is now encouraging health care facilities to vaccinate those employees who do not have laboratory evidence of immunity, a history of lab-confirmed disease, or two doses of the MMR vaccine.4
A 2009 measles outbreak in a Pennsylvania hospital revealed gaps in immunity. Five people, including a previously vaccinated emergency physician, acquired measles from an unvaccinated child who was initially misdiagnosed. The hospital reviewed the records of 168 potentially exposed employees and found that 72 (43%) had no documented measles immunity.5
Influenza mandates have received the greatest attention nationally. But if mandates are effective, they should cover all recommended vaccines, contends Tom Talbot, MD, MPH, chief hospital epidemiologist at the Vanderbilt University Medical Center in Nashville, TN, and a member of HICPAC. "Why just single out flu?" he says. "Shouldn't this apply to all vaccine-preventable diseases and recommended vaccinations?"
'Vaccination is invasive'
Some occupational medicine physicians advocate a more nuanced approach, based on the specific disease.
Varicella and measles are airborne diseases, and occupational exposures can result in furloughs of susceptible, exposed workers, notes Melanie Swift, MD, director of the Vanderbilt Occupational Health Clinic.
Following an exposure, for example, employees without documentation of immunity would have to be placed on leave until their immunity could be verified, she notes. "Any found to lack antibody would have to remain out for the entire incubation period, because at that point it's too late for vaccination to protect them," she says. "That's an unsafe situation for patients and an unnecessary business interruption for the employer."
A mandate for a pertussis booster (Tdap) might be appropriate for health care workers who have contact with newborns or the neonatal intensive care units, she says. Tdap is recommended for all health care workers, but most would be at low risk for pertussis, she notes.
Hepatitis B vaccine is designed to protect workers. The U.S. Occupational Safety and Health Administration requires health care employers to offer the vaccine to all employees who have occupational exposure, but allows employees to decline the vaccine.
The IDSA-SHEA-PIDS statement is expected to encourage employers to make those vaccinations mandatory. Swift objects to a hepatitis B mandate, as well as mandates for the annual influenza vaccine. Influenza is typically widespread in a community and could easily be transmitted by family members and visitors, who aren't required to be vaccinated, she notes. And the influenza vaccine has varying effectiveness, she says.
In general, Swift advocates a conservative approach to mandatory vaccination policies. "Vaccination is invasive and comes with varying risks depending on the vaccine," she says. "A mandate essentially robs an individual of their autonomy over what goes into their body. I think the evidence [of benefit] should be extremely solid if you are going to force people to be vaccinated for the intended purpose of benefitting someone else."
Policies designed to protect patients
However, some hospitals have already adopted broader mandates in the name of patient safety. In 2011, for example, the Texas legislature approved a new provision of the state's Health and Safety Code that requires health care facilities to "develop, implement, and enforce a policy to protect its patients from vaccine preventable diseases." The law requires HCW vaccines "specified by the facility based on the level of risk the individual presents to patients by the individual's routine and direct exposure to patients."
Paris (TX) Regional Medical Center decided to mandate vaccination against MMR, varicella, pertussis and influenza among employees who work in patient care areas. A medical exemption requires a note from a physician and a declination based on religious beliefs requires a signature from a clergy person. Employees with exemptions may need to wear a mask or other protective equipment, based on the disease and the potential for exposure, says employee health nurse Diane Nation, RN, BSN.
As the new policy unfolded in 2012, Nation worked laboriously to document every immunization and titer and offer necessary vaccination. Some employees needed titers for varicella, some needed titers for mumps or measles. Although hepatitis B vaccine remains voluntary, Nation also drew titers and offered additional HBV vaccination.
Now the hospital has detailed immunization records on all employees and volunteers, and virtually all of them are protected. "Safety is the number one initiative of our CEO," says Nation. "It's a culture that we have here at our hospital that I'm so proud to be a part of."
Marshfield (WI) Clinic requires an annual flu vaccine, MMR, varicella, Tdap and hepatitis B. Laboratory workers must receive the meningitis and tularemia vaccine and veterinarians receive the rabies vaccine. "If you work in health care, this has got to be part of what you do," says Bruce Cunha, RN, MS, COHN-S, manager of Employee Health and Safety.
Cunha also draws titers to check for immunity. After all, previous vaccinations could have been mishandled, he says. At Marshfield, refrigerator temperatures are monitored and vaccines are kept out of the refrigerator only for limited time, he says.
For all but the flu vaccine, the documentation of immunity will be lasting, Cunha notes. "Once we give you that piece of paper, you shouldn't have to have anything done again, no matter where you go," he says.
- Centers for Disease Control and Prevention. Influenza vaccination coverage among health-care personnel — United States, 201213 Influenza Season. MMWR 2013; 62:781-786.
- CDC. Non-influenza vaccination coverage among adults United States, 2011. MMWR 2013; 62:66-72.
- Esolen LM and Kilheeney KL. A mandatory campaign to vaccinate health care workers against pertussis. Am J Infect Control 2013; 41:740-742.
- McLean HQ, Fiebelkorn AP, Temte JL, et al. Prevention of measles, rubella, congenital rubella syndrome and mumps, 2013: Summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2013; 62(RR04):1-34.
- CDC. Hospital-associated measles outbreak Pennsylvania, March-April 2009. MMWR 2012; 61:30-32.