Is a mandatory flu vaccine policy on the horizon for health care workers?
Is a mandatory flu vaccine policy on the horizon for health care workers?
CDC panels look at declination policy
Pressure is building on hospitals to obtain signed declination statements from health care workers who choose not to receive the influenza vaccine.
Two federal advisory panels considered the declination policy as just another possible strategy to boost vaccination rates and monitor employee response to vaccination efforts. But some employee health professionals worry that it would become a de facto guideline and would create a new paperwork burden as they struggle to track down employees and verify their vaccination status.
In June, the Healthcare Infection Control Practices Advisory Committee (HICPAC), a panel of experts that reports to the Centers for Disease Control and Prevention (CDC), narrowly voted to include the declination policy among its recommendations to boost influenza vaccination of health care workers. It would carry a "category II" rating, which means it is based on expert opinion. The CDC is planning to focus recommendations on health care workers because of their historically low levels of vaccination. About 36% of health care workers with patient contact received the vaccine last year, according to the Behavioral Risk Factor Surveillance System survey. That figure mirrors findings from surveys during nonshortage years.
At press time, the Advisory Committee on Immunization Practices (ACIP) was scheduled to consider the declination policy as well.
A CDC recommendation carries weight, particularly because the Joint Commission on Accreditation of Healthcare Organizations requires hospitals to comply with applicable guidelines and regulations.
"It becomes an accreditation issue," notes William Buchta, MD, MPH, medical director of the Employee Occupational Health Service at the Mayo Clinic in Rochester, MN, which has achieved a 76% vaccination rate. "It might as well be an OSHA mandate."
The issue gained even more momentum with the congressional testimony of Andrew Pavia, MD, chair of the Task Force on Pandemic Influenza of the Infectious Disease Society of America.
Among his strategies for improving preparedness for influenza and pandemic influenza, Pavia called for mandatory health care worker vaccination. "To improve patient safety, prevent unnecessary deaths and disease, and provide an example to patients, we believe that annual flu vaccination should be required for all health care workers who have contact with patients, with options to waive vaccination after signing an appropriate waiver," he said.
Occupational medicine physicians plan to issue their own statement countering this sentiment, which they say wrongly blames employees for spread of disease and diverts scarce resources.
The board of directors of the American College of Occupational and Environmental Medicine (ACOEM) approved a resolution last year opposing mandatory influenza vaccination with declination. "It’s a waste of time, and it’s sending the wrong message to employees that doing the paperwork is more important than actually preventing influenza," adds Buchta, who has helped craft a position statement that will be considered by the ACOEM board. "It just becomes a paper chase."
The Joint Commission is concerned about the issue of health care worker influenza immunization and may issue a draft standard, if there is evidence that hospital patients or nursing home residents are at risk of transmission of influenza from their caregivers, says Robert Wise, MD, vice president in the Joint Commission’s Division of Standards and Survey Methods.
"This is really going to be driven by the scientific data," he says. "We will look more at the issues of safety and quality of care and less about the politics."
There is widespread agreement that more health care workers need to receive their annual flu vaccines. Amid efforts to improve pandemic influenza preparedness, those concerns have magnified.
In June, HICPAC considered the wording of a joint statement to be issued as part of CDC’s 2005-2006 influenza recommendations by ACIP.
HICPAC members favored strong recommendations for hospitals to offer free influenza vaccinations to health care workers and to promote strategies to improve vaccination rates. For example, one proposed recommendation stated that hospitals should, "require all health care workers, including students, to participate in an influenza prevention program which includes education and provides annual vaccination."
HICPAC executive secretary Michele Pearson, MD, a CDC medical epidemiologist, emphasized that the definition of health care worker included nonemployees, such as physicians. Some hospitals have tied influenza vaccination to physician credentialing, HICPAC members said.
The draft wording of another recommendation would "require health care workers who decline influenza vaccination for reasons other than medical contraindications to sign a declination statement that will be maintained in the employee’s health record."
Final wording is likely to remove the word "require" and the designation of the employee health record. But discussion focused on the need for declinations.
Michael Tapper, MD, chief of infectious diseases at Lenox Hill Hospital in New York City and a HICPAC member, noted that the bloodborne pathogens standard requires health care workers to sign a declination if they don’t receive the hepatitis B vaccine. One study of hepatitis B vaccination among health care workers found that overall 66.5% received the three doses of the vaccine, with a high of 75% among health care workers with greater potential exposure to body fluids, such as nurses and phlebotomists, and a low of 45% among those at low risk, such as dietary or clerical staff.1 "I’m a great believer in mandatory declination [for those who decline the vaccine]," Tapper said. "It is the best model I’m aware of for getting participation."
Declinations also provide a way for hospitals to demonstrate that they have offered the vaccine to employees and provided education about its benefits, notes William Schaffner, MD, chair of the department of preventive medicine at Vanderbilt University in Nashville, TN.
"This is a device not only to clarify the record keeping, but also to motivate institutions to do an absolutely 100% effort and to bring this forcefully to the attention of health care workers," adds Schaffner, who is a liaison member of ACIP representing the Infectious Disease Society of America and the National Foundation for Infectious Diseases.
The intent is to put pressure on health care facilities, he says. "We have demonstrated that doing it in a less vigorous fashion results in an unacceptably low rate of health care worker immunization of about 30%. That should be an embarrassment," he explains.
Yet health care workers may not respond well to a vaccination program that has punitive overtones, says Bill Borwegen, MPH, health and safety director of the Service Employees International Union in Washington, DC. Instead, HICPAC should set standards for the content of education programs about influenza vaccination, with an interactive format that allows health care workers to ask questions and dispel misinformation, he says. "The way you improve vaccination for flu is with a comprehensive, well-thought-out education program, and you make [vaccination] very convenient for workers," Borwegen notes.
In fact, CDC needs input from health care workers themselves — or at least from occupational health professionals, he adds. "They don’t have the perspective that they need to have."
Mark Russi, MD, MPH, who represents the ACOEM before HICPAC, argued against the declination policy. "I actually feel that requiring a declination on a yearly basis diverts resources to a time-consuming task," said Russi, who is associate professor of medicine and public health at the Yale University School of Medicine and director of occupational health at Yale-New Haven (CT) Hospital.
The Mayo Clinic is implementing an "enhanced program of influenza vaccination in units that treat immunocompromised patients as a way to gauge attitudes toward the vaccine. Employees in bone marrow transplant and solid organ transplant units, pediatrics, and some intensive care units will complete a survey asking if they received the vaccine and, if not, why they didn’t.
For those high-risk areas, the survey is likely to show high compliance, Buchta notes. Last year, despite the vaccine shortage, 74% of the employees in those targeted areas received the vaccine, he says.
Buchta says he’s hoping for 90% vaccination of health care workers caring for the most vulnerable patients. "We don’t have to get 100% compliance to achieve our goals. We’ll get herd immunity from 80% or more."
Reference
1. Mahoney FJ, Stewart K, Hu H, et al. Progress toward the elimination of hepatitis B virus transmission among health care workers in the United States. Arch Intern Med 1997; 22:2,601-2,605.
Pressure is building on hospitals to obtain signed declination statements from health care workers who choose not to receive the influenza vaccine. Two federal advisory panels considered the declination policy as just another possible strategy to boost vaccination rates and monitor employee response to vaccination efforts. But some employee health professionals worry that it would become a de facto guideline and would create a new paperwork burden as they struggle to track down employees and verify their vaccination status.Subscribe Now for Access
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