First hospital to mandate flu vaccination reports on challenges, success

Aug 3, 2010 (CIDRAP News) – Mandatory flu vaccination policies for healthcare workers require big investments in time and resources and the commitment to navigate difficult legal issues, but they can pay off in participation rates as high as 98% and in increased efficiency, according to a study from Seattle's Virginia Mason Medical Center, the first US hospital to adopt such a mandate.

Given perennially low flu vaccine uptake in healthcare providers, more infection control officials are eyeing mandatory vaccination to raise coverage rates. Seasonal flu vaccination rates typically hover around 44% for healthcare workers, and facilities that have made intensive efforts to boost rates beyond that have had only modest success.

Last year New York became the first state in the nation to mandate flu vaccination for healthcare workers, but it rescinded its policy at the start of the flu season because at that time the pandemic H1N1 vaccine was in short supply. The state's law also faced legal challenges from unions.

Virginia Mason's vaccination mandate, launched during the 2005-06 flu season, affected 5,000 employees. The new report on the first 5 years of the policy appears in the September issue of Infection Control and Hospital Epidemiology.

In the 2003-04 flu season, which was 2 years before Virginia Mason adopted its policy, about 54% of healthcare workers were immunized. After the first year of the requirement the rate rose to 97.6%, and it reached 98.9% in the 2009-10 season.

The researchers detailed the steps the facility took to adopt its mandatory flu vaccine policy, which started gaining momentum after a workshop on improving flu vaccine coverage in employees. Virginia Mason's board of trustees approved the step, and hospital administrators set up a multidisciplinary task force to lead and implement the new policy.

They used multiple vaccine delivery systems, including flu vaccine carts and drive-through vaccination stations, and offered employees several vaccine choices, from thimerosal-free formulations to the intranasal version.

Healthcare workers could apply for medical or religious exemptions. Those who stated they had egg allergies were offered skin tests and vaccination at the hospital's allergy laboratory. Employees who received exemptions were required to wear surgical masks during the entire influenza season, mainly to prevent transmitting flu to patients.

Virginia Mason approved 31 exemptions during the first year of the mandatory requirement, and the authors said that number has remained stable. Only a handful of workers have left the hospital because of the policy.

The Washington State Nurses Association filed a grievance over the policy, and an arbitrator ruled in the nurses' favor, agreeing with the union's stance that the new requirement should have been negotiated as part of the union's bargaining agreement with the hospital. Despite the ruling and that unionized nurses aren't currently required to be vaccinated, nearly 96% of them received the vaccine last flu season.

Nurses electing not to receive the vaccine are still required to wear masks during flu season. The union filed an unfair labor practices charge against the hospital, stating that the mask policy was punitive, but an administrative law judge upheld the policy as an infection control measure. The union has appealed the ruling to the National Labor Relations Board.

The authors calculated that a "significant amount of human and financial resources" were required to institute the mandate, including employee time, the cost of the materials, storage of the vaccine, and efforts to track participation. They put the vaccine cost at $70,000, enough to vaccinate about 6,000 employees.

The group wrote that the keys to successful implementation of the mandate were strong support from the hospital leadership.

"Many objections to implementation of the program were raised, and without a strong endorsement from the CEO, president, and governing board, it is unlikely that the program would have been successful," the report says.

The mandate also required extensive communication, the use of multiple staff focus groups, and a good infrastructure for delivering large quantities of vaccine and tracking employee compliance.

In the seasons after the initial launch, the cost and efforts involved in the administration eased, they wrote. For example, a kickoff activity in 2008 vaccinated resulted in the vaccination of about 1,000 workers in one day.

Researchers didn't find that the policy significantly affected employee sick-leave patterns, which they said are affected by a large number of factors aside from vaccination alone.

The authors concluded that their success with the mandatory policy bodes well for other healthcare institutions and that the programs benefit both employees and patients.

In an accompanying editorial, Thomas R. Talbot, MD, and William Schaffner, MD, both from the departments of medicine and preventive medicine at Vanderbilt University in Nashville, Tenn., praised Virginia Mason for its "trailblazing" efforts.

They said the program is especially innovative because, for example, it encompasses everyone who works at the hospital, not just those who are directly employed there or provide direct patient care. Talbot is chief hospital epidemiologist at Vanderbilt University Medical Center, and Schaffner, who has also served as a hospital epidemiologist, is the president of the National Foundation for Infectious Diseases.

Talbot and Schaffner said an increasing number of facilities are following Virginia Mason's lead, but warned that innovators can often face tough challenges, such as the actions of the nurses union. However, they added that the nurses' actions don't seem to reflect an antivaccine stance, and they lauded the high vaccination levels among Virginia Mason's nursing staff.

The commentators said the debate over mandatory flu vaccination for healthcare workers resembles past discussions about childhood vaccinations, pointing out that voluntary efforts to get kids vaccinated plateaued at about 65% before vaccinations were made a requirement for daycare and school.

After years of only modest improvements from intensive efforts to raise healthcare worker vaccination rates, mandatory policies may be the most effective course for bettering coverage, Talbot and Schaffner wrote. "Low healthcare worker influenza vaccination rates can no longer be tolerated, because our patients and our coworkers are at risk."

Meanwhile, US Department of Health and Human (HHS) officials have asked their vaccine advisors to explore mandatory flu vaccination for healthcare workers in advance of possibly issuing guidance. And an official with the US Centers for Disease Control and Prevention (CDC) recently said the agency is reworking its flu vaccine pitch to healthcare workers and will focus messages away from guilt and more toward using immunization as a way to "leave work at work" and protect employees and their families.

Rakita RM, Hagar BA, Crome P, et al. Mandatory influenza vaccination of healthcare workers: a 5-year study. Infect Control Hosp Epidemiol 2010 Sep;31(9) [Abstract]

Talbot TR, Schaffner W. On being first: Virginia Mason Medical Center and mandatory influenza vaccination of healthcare workers. Infect Control Hosp Epidemiol 2010 Sep;31(9) [Citation]

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