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Mandatory Flu Shots Gain Traction as the Future of Influenza Prevention

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   June 02, 2010

Every year, medical facilities plead with employees to get their annual influenza vaccinations. Some initiate campaigns as early as August, explaining the value of receiving the flu shot as well as the patient safety implications and worker safety benefits.

But despite even the most rigorous efforts, medical facilities often struggle to get flu shot rates over 50%.

A CDC report published April 2 indicated that by mid-January, nearly 62% of healthcare workers had been vaccinated against seasonal influenza, although only 37% had been vaccinated against H1N1 influenza. In previous years, rates have never been above 49%.

However, the CDC reported a 97.6% vaccination rate among facilities requiring seasonal flu shots, compared to 64.5% in facilities that only recommended the vaccine. Only 11.1% of facilities had a required policy.

Two particularly large hospital systems have taken on the challenge of implementing a mandatory flu shot policy within the past two years and have seen their compliance rates improve to as high as 98%. Although a mandatory policy eliminates the constant struggle to convince employees to get the shot, it's not without its own barriers.

In 2008, St. Louis–based BJC HealthCare, one of the largest nonprofit healthcare organizations in the United States with nearly 26,000 employees, made influenza vaccines a condition of employment. After years of voluntary vaccination programs that included incentives, leadership champions, and declination statements, BJC still could not climb above a 71% vaccination rate, according to Hilary M. Babcock, MD, MPH, assistant professor of medicine and medical director of occupational health (infectious diseases) at Barnes-Jewish and St. Louis Children's Hospitals, both in St. Louis and members of BJC HealthCare.

"[We] really just thought that we had pretty much exhausted all of the voluntary efforts," Babcock says. "Despite all of these many years of trying, we really hadn't gotten to where we wanted to be. So that's really what drove the decision to decide on the mandatory policy. We really felt it was an important patient safety issue to get our staff vaccinated."

BJC allowed exemptions for medical reasons (e.g., egg allergies, prior allergic reactions, and history of Guillain-Barré syndrome) and religious reasons only. The system successfully vaccinated 25,561 of its workforce members, a 98.4% vaccination rate, with only 90 religious exemptions and 321 medical exemptions.

In November 2009, the Hospital Corporation of America (HCA) in Nashville implemented a mandatory policy that required employees who could infect or become infected by a patient to get the seasonal flu vaccine or wear a surgical mask in patient care areas. Prior to the 2009 flu season, vaccination rates had varied from 20% to 74%.

HCA is one of the largest systems in the country with 163 hospitals, 112 outpatient centers, and 368 physician practices in 20 states. Under the mandatory policy, seasonal flu shots were offered to 140,599 employees, and 96% complied.

Communicating your policy
Simply making influenza vaccines mandatory does not replace the need for continued communication of the policy.

At BJC, each facility within the system was responsible for communicating the policy, answering individual questions, and continuing education about the vaccine. Most of the larger facilities established town hall meetings that included an infectious disease specialist, an occupational health professional, an infection prevention nurse, an HR representative, and someone from the legal team to answer questions and talk about the policy, says Babcock.

Babcock notes that it's probably even more important that communication of a mandatory policy is very clear and is presented to employees early in the year rather than weeks before flu season.

"As soon as you decide this is what you are going to do, [it's important] that you start talking about it and publicizing it and making it clear what the process is for an exemption, that you have people available to talk to those who have concerns about the vaccine so they can have their concerns addressed and alleviated in a timely and reasonable fashion," she says.

Ultimately, BJC terminated eight employees—two worked in information services in the corporate offices, and the other six included a patient care technician, a paramedic, a laboratory technician, a nurse, a sitter, and a physical therapist.

Using exemption forms
One of the most important aspects of the mandatory vaccination policy is ensuring that there is enough room for medical and religious exemptions.

Babcock recommends developing a form that lists medical contraindications for exemption (e.g. egg allergies, previous reactions) rather than an open letter from a doctor.

"We got a lot of letters that didn't give us enough information for us to make a decision. With forms, it's a little bit easier to have that information in front of you," she says.

Religious exemptions required a written letter from the employee that stated a religious conviction opposing the vaccination. That letter was reviewed by HR, and employees were notified within five days if they were exempt.

Timing is everything
BJC was fortuitous and perhaps a little foresightful with the implementation of its mandatory policy. Because the health system implemented the policy in 2008, before H1N1 emerged in April 2009, it easily rolled the H1N1 vaccine into the requirements once it became available.

"Again, that went pretty smoothly, but by that point we already had a mandatory program, so people had sort of wrapped their minds around that to start with," Babcock says.

However, healthcare facilities that are considering a mandatory vaccination policy for the 2010–2011 flu season won't run into the problem of forcing employees to take two shots. On February 22, the FDA decided to follow the World Health Organization's advice and fold the H1N1 vaccine into next year's seasonal vaccine, meaning there will be only one shot for both viruses.

This, coupled with increased attention to pandemic influenza and patient and worker safety, could mean mandatory vaccinations are the future.

"I think that there is increasing expectation that healthcare workers will be vaccinated, and it's becoming more and more of a patient safety issue, similar to other vaccination requirements for healthcare workers," says Babcock. "There are just certain duties that as healthcare workers we take on to protect our patients, so this is just becoming one of them."

Evan Sweeney is an editorial assistant at HCPro. He manages and writes for Briefings on Infection Control, a monthly newsletter directed at IC compliance. He also blogs for OSHA Healthcare Advisor, a resource center for infection control and safety professionals, and regularly contributes to Medical Environment Update and OSHA Watch, which focus on healthcare employee safety and health.

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