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Mandates Beat Voluntary Programs for Flu Vaccination of Hospital Staff

Keller, Daniel M. PhD

doi: 10.1097/01.COT.0000392687.19134.2b
A nurse administers a vaccination to a female health care professional in this CDC photo

A nurse administers a vaccination to a female health care professional in this CDC photo

VANCOUVER—Hospitals have had success getting their staffs vaccinated against influenza, some by coercion, some by persuasion. However, they do it, vaccination is good for their patients and has other benefits as well, said Robert Rakita, MD, previously of Virginia Mason Medical Center in Seattle and now in the Department of Medicine at the University of Washington in Seattle.

“Influenza vaccination of health care workers has been shown to reduce morbidity and mortality in their patients,” he said.

Flu vaccine is not as effective in the elderly or those with chronic medical conditions, including cancer and other immunosuppressed states. And since these patients are also likely to be hospitalized and in contact with health care workers, they can be at high risk from the flu.

Other patients may also benefit, as well as health care workers and their families. Less flu disease may also reduce absenteeism and facilitate staffing during flu season.

Virginia Mason has achieved a greater than 98% rate of influenza vaccination of health care workers through a program of mandatory vaccination. Significant planning was initially required, but now the program is routinely integrated into the hospital's culture of safety.

Dr. Rakita noted that for almost 25 years, the Centers for Disease Control and Prevention and other authorities have recommended influenza vaccine for health care workers. However, nationwide their vaccination rate was 49% in the 2007-2008 season, and for 2009-2010 it was 62% for seasonal flu and only 37% for H1N1.

Speaking here at the most recent Infectious Diseases Society of America (IDSA) Annual Meeting, Dr. Rakita said that to encourage vaccination, the medical center in the past has used education, easy access to vaccine, peer vaccinators, and promotional programs.

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Specifics of Mandatory Vaccination

Mandatory vaccination, a “fitness for duty requirement,” went into effect for the 2005-'06 season for the approximately 4,700 staff serving Virginia Mason's 336-bed multispecialty, tertiary care hospital and regional clinics.

The mandate applied to everyone who worked at the medical center, including health care workers, staff, students, physicians, outside contractors, and other outside personnel.

To facilitate the program, the institution conducted a campaign consisting of information sessions, an online learning module, flu “champions,” and an annual fall kickoff event with the Seattle Seahawks football team. Vaccines were delivered at the employee health service, by peer vaccinators, by a mobile cart, and even at a drive-through vaccination station. Both injectable and intranasal vaccines were available.

The mandatory vaccination program showed dramatic success. Before it, from 2002 to 2004, vaccination rates ranged from 29.5% (in a year of vaccine shortage) to 54%. But in 2005 with mandatory vaccination, the rate jumped to 97.6% and has consistently been above 98.5% since then for a staff now numbering about 5,000.

The rate does not reach 100% because the institution allows accommodations for medical or religious reasons and because of contract provisions for unionized nurses, which resulted in litigation since the union held that the issue was subject to collective bargaining.

Nonetheless, 96% of nurses participate. Less than 1% of staff have refused for medical or religious reasons each year. Any staff member who refuses vaccination is required to wear a mask at work during flu season to reduce cough-related spread of flu. Only nine staff have left or been fired because of the mandate since its inception.

The costs of the program relate to vaccine purchase, storage, delivery, and tracking staff for vaccination (and at Virginia Mason, litigation with the nurses' union).

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‘Lead by Example’

Infectious diseases specialist Aaron Glatt, MD, President and CEO of St. Joseph Hospital in Bethpage, NY, told OT, “This is a tried and proven method to prevent the spread of a potentially fatal infectious disease” and added that health care workers, “really need to understand that they are vectors for this potential transmission, and it's an obligation on the health care worker that they should get vaccinated unless there's a medical contraindication.”

Putting his money where his mouth is, he has offered to pay for a pizza party for his entire hospital if it reaches 100% of personnel getting vaccinated. Putting his arm where his mouth is by publicly vaccinating himself in front of the hospital staff, Dr. Glatt said, “I think it's very important that we lead by example.”

He said he is all in favor of mandates even though they are coercive, but the concept is “just like my employees wash their hands before touching patients.” He said he believes people sometimes need to be urged or coerced to do the right thing, so, “as long as you're doing it within the framework of what's appropriate, ethical, and legal, I think those are good things.”

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Voluntary Approach Goes Only So Far

Because of reported initial unpopularity of mandates and occasional legal challenges, Children's Hospital and Medical Center (CHMC) in Omaha, Nebraska tried a variety of approaches from 1998 to 2009 to increase flu vaccination rates among health care workers.

Free vaccination has been offered throughout this period, but still, vaccination rates averaged only 52% through 2002. In 2003 a designated employee health nurse was recruited, and the rate increased to 67% that year, although fell to 55% during the vaccine shortage in 2004.

CHMC made incremental enhancements to the annual vaccination campaign from 2003 onwards, including walk-in times as well as scheduled appointments for vaccination for all shifts, taking a “flu cart” to patient areas, Saturday sessions for employees and their families, providing vaccine at affiliated clinics, recruiting helpers and advocates in various departments, disseminating information, and using signed declination forms.

From 2005 onward, rates increased each year, from 68% to 78%, 82%, and 86% through 2008. Finally, the center made vaccination mandatory in 2009, and the rate hit 97%.

Anyone exempted for medical reasons was required to wear a mask, and the declination form clearly stated that refusal put patients and co-workers at risk.

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Employee Engagement

Archana Chatterjee, MD, PhD, CHMC Chief of the Division of Pediatric Infectious Diseases, Professor of Pediatrics at Creighton University School of Medicine in Omaha, and hospital epidemiologist, said that employee engagement and making changes to the program resulted in increasing rates of vaccination without a mandate in place.

She said that when the mandate was instituted there were no protests. “In previous years we had worked with the employees to engage them, to respond to their concerns, to educate them, and that's what resulted in relatively high rates of immunization,” she said, adding that health care workers may feel more protective of children than of adult patients and may therefore be more agreeable to vaccination.

The 460-bed Children's Hospital of Philadelphia (CHOP) plus its several outpatient sites also mandated flu vaccination, beginning in the 2009-'10 season, for all staff working in a building in which clinical care was delivered.

Using a random sample of the 8,093 health care workers (14,50 clinical; 100 nonclinical), Kristen Feemster, MD, MPH, MSHP, of the Division of Infectious Diseases at CHOP and Assistant Professor at the University of Pennsylvania School of Medicine, assessed attitudes towards vaccination and towards a mandate and determined predictors of agreement with the mandate.

In the 2008-09 season, before the mandate, the flu vaccination rate was 92% and rose to 99.3% under the mandate in 2009-10. Only 46.5% of clinical staff completed the 20-item questionnaire vs 73.6% of nonclinical staff. Dr. Feemster reported at the IDSA meeting that 91% of respondents said they felt that they received information from CHOP needed to make a decision about vaccination.

Even though nonclinical staff had not been targeted in previous vaccination programs, Dr. Feemster said she “found no difference between clinical and nonclinical staff in their agreement with the mandate when we considered flu and flu vaccine attitudes and beliefs.”

Of those accepting the flu vaccine, 90.2% said they had been vaccinated previously, and of those, the majority cited protection of themselves, family, and patients, job responsibility, and the education received at work as reasons for their decision.

Of those not getting vaccinated, reasons included not being at high risk, fear of side effects, and a belief that the vaccine is not effective.

Although 72% felt that the mandate was coercive, 96% agreed that the mandated policy was important for protecting patients, and 74% agreed with its implementation. Despite receiving information about the risks of influenza and the safety and efficacy of flu vaccines, some staff still reported misconceptions regarding vaccination.

From her results, Dr. Feemster suggested that vaccination rates may be increased by capitalizing on people's beliefs regarding protection and their feelings of ethical responsibility.

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No Threshold

Universal vaccination of all hospital staff is a reasonable goal. Andrew Pavia, MD, Chair of the Pandemic Influenza Task Force for IDSA and Chief of the Division of Pediatric Infectious Diseases at the University of Utah in Salt Lake City, said that the Centers for Disease Control and Prevention have developed good modeling data “that show that there isn't a threshold effect for vaccine coverage—that you get an added benefit the higher you go as it approaches 100%.”

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Policy Statements

Both the IDSA and the Society for Healthcare Epidemiology of America have published policy statements supporting mandatory vaccination programs—posted at and, respectively.

© 2010 Lippincott Williams & Wilkins, Inc.
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