Occupational Health

Occupational Health
A Shot in the Arm?

By Jennifer Schraag

Occupational Health and Safety within the healthcare community has evolved, but current requests arent being met by the majority of healthcare workers. The debate on annual influenza immunizations continues to stir and healthcare workers are now facing mandates, mixed messages, and even termination threats for noncompliance.

The Centers for Disease Control and Prevention (CDC) has recommended annual influenza vaccination for healthcare workers (HCWs) with direct patient contact since 1984 and for all HCWs since 1993.1 The flu causes 200,000 hospitalizations and 36,000 deaths annually nationwide.2

Occupationally acquired infectious diseases are an acknowledged peril among HCWs. Moreover, the estimated annual death rate for HCWs from occupational events including infection is 17 to 57 per 1 million workers.3

Influenza vaccination has been proven to reduce influenza infection in HCWs by 88 percent and decreases work absence due to respiratory illness by 28 percent.1 Still, annual influenza immunization rates among HCWs in the United States remain poor, despite the known risk. In fact, coverage among HCWs in the United States in 2003 was 40.1 percent.2

Julie Gerberding, MD, MPH, director of the CDC, chastised the medical community for its low rates of influenza vaccination compliance during a September news briefing. It is at worst, embarrassing, and at best, tragic, that less than 50 percent of HCWs in this country get vaccinated annually, she says. Ardis Hoven, MD, a member of the American Medical Association (AMA) board of trustees, also spoke at the September press conference. Every single doctor and nurse in America needs to make getting vaccinated a priority, he adds.

The call for annual vaccination goes far beyond the doctors and nurses of the world, Everybody in the healthcare institution should be immunized, affirms William Schaffner, MD, who serves as chairman of the department of preventive medicine and of the infection control committee at Vanderbilt University Medical Center. In fact, it has been suggested that coverage of 80 percent of all HCWs may be necessary to provide herd immunity to prevent healthcare-associated transmission of influenza.1

So just why do so many HCWs continue to shrug off the vaccination? Findings from a survey conducted at the University of Texas Health Science Center at Houston analyzed the beliefs and actions related to immunization recommendations of 1,000 registered nurses (RNs).4 The survey found reasons for declination included concerns about side effects, lack of concern about getting the illness, and doubts about its effectiveness.

There is a huge disconnect among HCWs on the rationale for the influenza vaccination, says Thomas R. Talbot, MD, MPH, assistant professor of medicine and preventive medicine and associate hospital epidemiologist with Vanderbilt University Medical Center. One of the biggest reasons we hear is Well, Im healthy, I dont get the flu, Im not in one of those risk groups, so I shouldnt get the vaccine. There is not an ample recognition that a huge percent of people can have influenza infection and not have symptoms or have very mild symptoms.

For some reason were very conscientious on patient safety issues like washing our hands and other things, but we havent made that connect with the flu vaccine. We really have to emphasize that it is a patient safety issue. I think it has to be done very carefully and tactfully we need to be careful on how we role out that message, but I think it is a message that needs to be rolled out.

Schaffner agrees, adding, I think we in public health and in infection control, in the past, have not been sufficiently clear to our HCW colleagues about why it is were recommending every HCW be vaccinated annually. We need to address certain myths, he adds. The most prominent of which is remarkably persistent the myth that you can get the flu from the flu vaccine. It is held onto tenaciously. We must be able to persuade our colleagues, educate them, and bring them reassurance.

The Society for Healthcare Epidemiology of America (SHEA) recently released a position paper detailing its position on influenza vaccination for HCWs. SHEAs statement provides recommendations for a multifaceted program aimed at providing targeted education, increasing vaccine access, and emphasizing the ethical responsibility HCWs have to protect themselves, their patients, and their colleagues as part of institutional patient and employee safety programs. The recommendations apply to all types of healthcare facilities.

When planning and implementing an effective immunization program to increase HCW vaccination rates, SHEA proposes it contain the following components:

  • Provide targeted education annually to all HCWs about the severity of influenza, particularly among high risk patients, and about the safety of influenza vaccination;
  • Inform HCWs of the importance of influenza vaccination in promoting patient and employee safety; Provide vaccine at no cost and at convenient locations and times;
  • Recommend that HCWs sign a declination each year if they refuse influenza vaccination after participating in an educational program or if they have medical contraindications to the vaccine;
  • Perform surveillance of rates of vaccine uptake by medical unit as well as identification of patients with healthcare-associated influenza to assess the impact of the vaccination program.

A German study evaluated the effectiveness of facility involvement and campaigns in increasing vaccination compliance.5 Of the 25 German hospitals surveyed, the researchers found the proportion of hospitals actively offering influenza vaccination increased from 48 percent in 1997/98 to 92 percent in 2001/02, however, vaccination coverage of all staff in 1997 was 3.3 percent and only increased to 8.4 percent in 2001-2002. Recommendations are ignored extensively, the researchers wrote, but poster campaigns and managing board commitment had significant impact in the increases that were found, the researchers noted.

Administrative support has the potential to make or break a successful program, according to the National Foundation for Infectious Diseases (NFID)s comprehensive report, Improving Influenza Vaccination Rates in Health Care Workers: Strategies to Increase Protection for Workers and Patients. The report states the majority of healthcare facilities with successful immunization guidelines or initiatives incorporate the following interventions:

  • Secure commitment to HCW influenza vaccination from top management;
  • Develop a policy statement affirming the institutions commitment;
  • Educate HCWs about the benefits of vaccination for themselves and their patients;
  • Make influenza vaccine easily accessible;
  • Repeat the influenza immunization program annually.

The American College of Occupational and Environmental Medicine (ACOEM) also endorses a multi-faceted influenza control program in all healthcare facilities and strongly encourages healthcare organizations to facilitate participation by providing influenza vaccine, associated supplies and services, and/or prophylactic medication at no expense to the employee.6

Taking It to the Next Level

Seven U.S. states including Alabama, Arkansas, Kentucky, Maine, Maryland, New Hampshire, Pennsylvania, and Rhode Island have enacted various influenza immunization mandates for HCWs in long-term care facilities and occasionally in acute-care hospitals, allowing for appropriate exemptions. In addition, the province of Ontario also mandates influenza immunization of all HCWs.7

Should such mandates be implemented? The short answer is no, says Schaffner, who serves as a NFID board member. Making an immunization mandatory is a very complex, elaborate, and torturous process. What I would like to do is make the annual influenza immunization of all HCWs part of the professional ethics of all HCWs such that they will absolutely do it.

In terms of implementation, I do favor using an informed declination form for those who choose not to be vaccinated, Schaffner continues. The use of the informed declination would oblige healthcare institutions to provide sufficient resources to their occupational health service so that absolutely every HCW would have a contact, would be educated, and would be given a very specific opportunity to get the vaccine. It would also let the HCW know that we all in the healthcare profession take this very, very seriously, and that if you decline the vaccine, you have to actually sign a piece of paper that says I understand I have been offered the vaccine, its free, I understand it is important for me, and more importantly, it is important to my patients, but nonetheless, I decline. That, I think, makes it a much more serious annual event. I think it will encourage large institutions to put more resources into bringing the vaccine to HCWs and it will also make the whole process more serious for the HCW themselves.

ACOEM states it discourages generalized policies requiring mandatory compliance with employee vaccination or prophylactic medication. According to the ACOEM statement, Influenza control can be successful with creative programs that employ the carrot rather than the stick while still respecting the rights of both patients and employees.

Talbot, who is also chairman of the SHEA Healthcare Worker Influenza Task Force, says he believes the word mandatory is viewed in many different ways.

As we put forth in the statement, all HCWs should be offered the vaccine, should be actively educated on why we need the vaccine for patient safety dispelling the myths surrounding why people fear they will get the flu from the vaccine. Then, after all thats done and youve made sure that healthcare facilities have made a very dedicated effort at providing this making sure it is easy access, and providing it free of charge then the HCW can still say no, but they need to actively decline that. They need to understand all the aspects that go into that. So, some people argue thats not truly mandatory, he says.

Its always hard to make something mandatory. The biggest care needs to be taken in educating workers as to why that decision is being made, Talbot points out.

While the use of active declination to increase influenza vaccination rates has not been tested specifically, it is currently a component of HCW hepatitis B vaccination programs as required by the Occupational Safety and Health Administration (OSHA)s Bloodborne Pathogens Standard.2 As a result of enhanced vaccination programs that include active declination and the implementation of standard precautions, HCW vaccination rates have increased and healthcare-associated hepatitis B infection rates in HCWs have declined by 98 percent.

According to Schaffner, ACIP, in conjunction with HICPAC, is preparing to issue a joint statement strongly affirming the use of the informed declination form. I think when this is issued, this is now going to become, very quickly, a standard of practice, Schaffner notes.

The Threat is Looming

The Washington State Nurses Association (WSNA) recently won an arbitration decision against Virginia Mason Medical Center (VMMC), stopping the hospital from forcing registered nurses to receive flu shots. The hospitals attempted unilaterally-implemented policy made annual influenza vaccination a condition of employment threatening termination for any employee who did not comply.

The arbitrators decision found that the employer violated the terms and the very purpose of the collective bargaining agreement between WSNA and VMMC and ordered VMMC to cease and desist its intended implementation of the flu immunization policy and remove such condition of employment from its Fitness for Duty policy.

While WSNA strongly supports flu vaccination and encourages nurses to receive them annually, the Association also holds steadfast on vaccination being of personal choice.

Heightening the argument is recent legislation, Biodefense and Pandemic Vaccine and Drug Development Act of 2005 (S. 1873), which passed out of the U.S. Senate HELP Committee one day after it was introduced.8 The proposed legislation strips Americans of the right to a trial by jury if harmed by an experimental or licensed drug or vaccine that they are forced by the government to take whenever federal health officials declare a public health emergency.

Should healthcare really threaten its employees with termination if their HCWs refuse the shot? That is tricky, says Talbot. That is why we like the strategy of making sure you do everything you can to improve access, making sure you do everything you can to improve education and dispel all these myths, and really make an institutionally-committed effort from the top down with resources.

WSNA states it opposes any healthcare facility threatening to fire people if they do not submit to the mandatory vaccination especially in the absence of a declared public health emergency and a recommendation for mandatory vaccination by the CDC.

Schaffner agrees, Im very uncomfortable about that (the threat of termination). That is one of the reasons why I am averse, at least at this moment, to mandates. Mandates have this ominous force of law and very severe repercussions. I think were obliged to bring our message to the HCWs in a very persuasive fashion. I think if we do that in an assertive fashion, we ought to be able to get HCW immunization rates up to 90 percent or above. I think we can do this without mandates.

Seven Truths of HCW Influenza Vaccination

  • The first truth: influenza infection is a serious illness causing significant morbidity and mortality adversely affecting the public health on an annual basis.
  • The second truth: influenza-infected HCWs can transmit this deadly virus to their vulnerable patients.
  • The third truth: influenza vaccination of HCWs saves money for employees and employers and prevents workplace disruption.
  • The fourth truth: influenza vaccination of HCWs is already recommended by the CDC and is the standard of care.
  • The fifth truth: immunization requirements are effective and work in increasing vaccination rates.
  • The sixth truth: HCWs and healthcare systems have an ethical and moral duty to protect vulnerable patients from transmissible diseases.
  • The seventh truth: the healthcare system will either lead or be lambasted.

Source: Poland, G.A., et al. Requiring influenza vaccination for healthcare workers: seven truths we must accept. Vaccine 23:2251-55, 2005.

On the Horizon

Another HCW vaccination may be coming down the road, according to William Schaffner, MD. He says there are currently two manufacturers that have produced an acellular pertussis vaccine that has been included with tetanus and diphtheria for adults and adolescents. The Advisory Committee on Immunization Practices (ACIP) is in the process of formulating recommendations for adults, and more specifically, HCWs.

I anticipate some recommendations for the use of TDaP in HCWs, exactly what form that recommendation will take, I am not sure, but I am sure we are going to get something. Schaffner says the document should be ready sometime in the summer of 2006.

As Schaffner points out, the majority of hospitals do not provide the 10-year tetanus boosters for HCWs because it is not considered an occupationally related recommendation. However, Schaffner adds, if you add acellular pertussis, it will be the pertussis component that has the occupational component to it.


1. Talbot, T.R, et al. SHEA position paper: Influenza vaccination of healthcare workers and vaccine allocation for healthcare workers during vaccine shortage. www.sheaonline.org/Assets/files/HCW_Flu_Position_Paper_FINAL_9-28.pdf (accessed Oct. 19, 2005).

2. Centers for Disease Control and Prevention (CDC). Interventions to increase influenza vaccination of healthcare workersCalifornia and Minnesota. MMWR Morb Mortal Wkly Rep. 4;54(8):196-9, Mar 2005. www.cdc.gov/mmwr/preview/mmwrhtml/mm5408a2.htm 

3. Sepkowitz KA, Eisenberg L. Occupational deaths among healthcare workers. Emerg Infect Dis. 11(7):1003-8, July, 2005.

4. McEwen M, Farren E. Actions and beliefs related to hepatitis B and influenza immunization among registered nurses in Texas. Public Health Nurs. 22(3):230-9, May-June, 2005.

5. Hallauer JF, Neuschaefer-Rube N. Influenza vaccination of hospital staff in Germany: a five-year survey on vaccination coverage and policies: identified deficits in influenza immunisation campaigns for hospital employees. Soz Praventivmed. 50(1):38-44, 2005.

6. American College of Occupational and Environmental Medicine. ACOEM Position Statement on Influenza Control Programs for Healthcare Workers. July 30, 2005. www.acoem.org/guidelines/article.asp?ID=86accessed (accessed Oct. 21,2005).

7. Poland, G.A., et al. Requiring influenza vaccination for healthcare workers: seven truths we must accept. Vaccine 23:2251-55, 2005.

8. National Vaccine Information Center. Congress set to pass law eliminating liability for vaccine injuries. Oct. 19, 2005. www.nvic.org./PressReleases/101905Burrbill.htm (accessed Oct. 21, 2005).

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