Oct 10, 2008 (CIDRAP News) – In the face of chronic low influenza vaccination rates among healthcare workers, the leading US society of infection control professionals says it's time to require medically eligible workers to either get the immunization or sign a form saying they understand the risks to patients if they skip it.
"As part of a comprehensive strategy, we recommend that influenza vaccine be required annually for all healthcare personnel with direct patient care," the Association for Professionals in Infection Control and Epidemiology (APIC) said in a policy statement released yesterday.
"Organizations should adopt a system in which an informed declination is obtained from employees that decline for other than medical reasons," the statement continues. "This information should be utilized by the facility to develop improvement strategies for the following vaccine season."
APIC urges vaccination for all medical and nonmedical personnel in contact with patients or patient samples, including physicians, nurses, physical therapists, dieticians, religious workers, and cleaning, kitchen, and laboratory personnel.
Voluntary programs haven't worked
Recent national survey data show that only 42% of healthcare workers receive an annual flu shot, and the rate has not risen significantly in the past decade, the APIC statement notes. Long-standing recommendations from APIC, the Centers for Disease Control and Prevention, and other national organizations have made little difference.
"Voluntary efforts are clearly not effective—it's time for hospitals and other healthcare facilities to require influenza immunization," said Linda R. Greene, RN, MPS, CIC, lead author of APIC's position statement, in a press release.
The policy statement notes that health workers can transmit the flu virus to others before they have any symptoms. Further, it says multiple studies show that 70% of health workers continue to work even when sick with the flu.
A multifaceted approach
APIC has strongly advocated flu shots for healthcare workers for years, along with a variety of strategies to promote them, but this is the first time the organization has used the word "require," Greene told CIDRAP News in an interview.
She said the declination form is the major new element in APIC's recommendation, but emphasized that it should be just part of a broad strategy for encouraging immunization.
"This isn't just a declination that says, 'I don't want to get it and here's the reason.' It's an informed declination, where the employee really understands that by refusing to get the vaccine for other than medical reasons, they're not only putting their patients at risk, but also themselves and their family and the community as a whole," said Greene, who is director of infection prevention for Rochester General Health Systems in Rochester, N.Y.
"This is the idea of active declination—it's not just a form that's floating around and you're supposed to sign it sometime; you actually have a conversation about why this is important for you," she added.
But other measures must be linked with informed declination, she said.
There is only limited evidence on how well declination forms work, she said. "But what we see is that declination alone, if you're not going to employ the other measures, has not necessarily been particularly effective," yielding only modest increases in immunization rates.
For example, her institution used a declination approach last year, but it was not coupled with "a tremendously proactive statement about putting patients at risk." The result was that the immunization rate increased about 10%, she said.
Getting administrators' buy-in
Greene hopes for much better results with a more comprehensive approach this year. "This year our approach is very robust. The administration is encouraging it, the CEO sent a letter to employees, we're going to post our [immunization] rates weekly. Managers must ensure that employees who didn’t get the vaccine are told of the risks to patients.
"Our goal is at least 75% and hopefully higher; but what we're seeing already is tremendous interest."
Greene said a key part of promoting flu immunization is enlisting the support of a facility's administration and other departments, so "it's not just sitting in occupational health." Administrators can promote the effort by using the flu immunization rate as an important indicator of safety and quality for the facility, she said.
In New York state, informed declination has been used successfully with hepatitis B vaccine for healthcare workers, Greene said. "We've found that we have a very, very high acceptance rate for the hepatitis vaccine." The vaccine is offered to direct-care workers when they are hired, and they see it as a benefit for protecting themselves, she added.
Some institutions now require workers to get a flu shot as a condition for being hired, but APIC decided not go that far in its recommendation, Greene said.
Taking a stronger stance
As for the timing of the new policy, Greene said a combination of factors was at work. They included many new studies about flu and flu immunization in recent years. Also, some other professional societies had taken much stronger positions on the issue than APIC had.
"Some of my colleagues here said it would really help us if APIC had a much stronger statement," she said. At the same time, the Joint Commission on Accreditation of Healthcare Organizations has challenged facilities to exceed the 42% immunization rate.
"I think we're going to see some results," Greene said. "I think we'll be surprised and pleased to see that vaccine rates will increase and continue to increase."
APIC position paper on flu immunization for healthcare personnel