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HCW flu shot rates rise as mandates spread
One in 10 HCWs must comply with flu vaccine
More health care workers received the flu vaccine last season than ever before, but that has not eased the pressure to boost immunization rates. Health care workers who fail to get their flu vaccine increasingly face additional infection control burdens, possible termination or public rebuke.
Last spring, in an editorial titled "They Should Know Better," The New York Times took health care workers to task and advocated mandatory vaccination, saying: "We were disturbed to learn that health care workers shunned the swine flu vaccine in droves. Their training and skills will be essential if there is a dangerous flu outbreak. They, of all people, should know how important it is for them to get vaccinated and that the risk of serious side effects is negligible."
The Immunization Action Coalition's "honor roll" now lists about 45 hospitals and health systems with mandatory programs. In a survey of about 1,500 health care workers sponsored by the Centers for Disease Control and Prevention, one in 10 reported that their employer required influenza vaccination.
"We can't simply rely on employee incentives to really get influenza coverage rates in the numbers that make a difference above 90 percent," says Mary Quirk, a consultant to the coalition. "The data really demonstrate that requiring vaccination is a very important component."
Yet pushback against mandatory policies continues. Four HCA hospitals in California challenged a mandatory policy that required unvaccinated health care workers including those with medical contraindications to wear masks throughout their shifts and identifying marks on their badges. An arbitrator ruled that the hospitals could maintain the flu vaccination policy but must negotiate with the union about how to enforce it. The Service Employees International Union (SEIU) has won other battles against mandatory influenza policies, including one at the University of Iowa Hospitals and Clinics. The union's argument against mandatory policies was further fueled by a report by the Centers for Disease Control and Prevention that the H1N1 vaccine was 62% effective.
"If the vaccine was effective, you could maybe make the argument that [mandates] made sense," says Bill Borwegen, MPH, SEIU health and safety director. "To fire people for not getting a vaccine that's not all that effective, it's just massive overreach."
Hospital rate hits 74%
In the 2009-2010 flu season, about 74% of hospital-based health care workers received either the seasonal or H1N1 flu vaccine (or both), according to a survey commissioned by CDC. That is far higher than the 40% coverage rate that was previously cited for health care workers overall.
The vaccinations were highly sought after as the H1N1 pandemic struck last fall. But despite recommendations from CDC to continue vaccinations through the winter, few health care workers received vaccines after January, the survey showed.
Although the vaccine was considered to be an excellent match with the prevailing H1N1 virus, the vaccine effectiveness was lower than expected. That means a substantial number of health care workers still were susceptible to H1N1 despite vaccination. And that is why some occupational health physicians have not supported mandatory policies that include punitive actions.
Employee health professionals need to "do everything we can to encourage people to get the flu vaccine," says Mark Russi, MD, chair of the Medical Center Occupational Health section of the American College of Occupational and Environmental Medicine (ACOEM) and director of occupational health at Yale-New Haven Hospital. "Most of us at ACOEM have stopped short of saying we should fire people who don't get the flu vaccine."
There's no question, however, that the mandatory programs immediately increase flu vaccination rates. Among health care workers who reported employer mandates, 97% said they received the seasonal and H1N1 vaccines. If there was no mandate, 71% received the seasonal vaccine and 50% reported receiving the H1N1 vaccine. "Obviously mandates make a huge difference," says Carla Black, PhD, a CDC epidemiologist who helped coordinate the survey, which was conducted by the RAND Corp. of Santa Monica, CA.
The primary reason health care workers said they failed to get vaccinated was their belief that they didn't need the vaccine "I never get sick."
"They don't realize they can be colonized and transmit the virus to patients and family members and not even know it," says Gary Euler, DrPH, a CDC epidemiologist with the Assessment Branch of the Immunization Services Division. "They need to be more altruistic in considering vaccination."
Asymptomatic disease a concern
Asymptomatic transmission of influenza is a concern for health care workers including those who have been vaccinated but still contract the disease.
A seroprevalence study of 140 health care workers in Japan found that 28% had titers indicative of infection but only one reported having had influenza-like illness. These infections occurred despite the widespread use of masks or N95 respirators among the health care workers, the researchers said in their abstract, which was presented at the 2010 International Conference on Emerging Infectious Diseases in Atlanta in July.1
Although the influenza vaccine has gaps in its effectiveness, it remains the best tool to protect health care workers from influenza, says William Schaffner, MD, chairman of the Department of Preventive Medicine at Vanderbilt University in Nashville.
"I think we all have to remember that influenza has a very good vaccine but not a perfect vaccine," he says. "Even when you have a perfect match, as we did with H1N1 last year, you will not be able to protect everyone optimally. That's just a realization of the science of the influenza vaccine at this time. Sixty-two percent effective for $15 [per dose] is about the best track record in preventive medicine today. Our obligation is to protect our patients."
The 2010-2011 vaccine will include H1N1, but it also will contain H3N2 and influenza B antigens. For the first time, the CDC's Advisory Committee on Immunization Practices has recommended universal vaccination flu vaccination of everyone six months old or older. Although this will increase demand for the flu vaccine, the CDC says it does not anticipate any supply problems this year.