Mandatory Vaccination of Healthcare Workers

By Karin Lillis

Loyola University Medical Center recently grabbed national headlines when a top official released results of a study that said mandatory flu vaccines for healthcare workers don't produce a "mass exodus" of employees. While sporadic healthcare systems nationwide have fired workers for refusing flu shots, requiring workers to get the vaccine doesn't lead to a rash of employee resignations.

Jorge P. Parada, MD, MPH, FACP, FIDSA, director of Loyola's infection control program, presented the results at the 2013 Association for Professionals in Infection Control and Epidemiology meeting, held in June in Fort Lauderdale. Parada recently spoke with Infection Control Today and shared his insights on mandatory flu vaccines. The hospital launched its mandatory vaccination program in 2009.

Q: As one of the early adopters of mandatory flu vaccines, what was the climate like at the time?
A: There was fear and trepidation. Some people were angry. Others were joyful because we were doing things for our patients. It was kind of all over the place. It was a novel idea. Leadership despite their solidarity was scared. They thought there would be pushback. There was one group of people that was in favor of it and vocally supportive. We had a lot who were shocked and they said so. At one of the meetings one of our heavy-hitting cardiovascular surgeons said he did not want to get the flu shot, and no one could make him. A pulmonologist told him if he did not get the flu shot, he would stop referring patients to him for lung transplants, because he said the cardiovascular surgeon was a danger (to the pulmonologist's patients). One of the pillars of medicine is 'first do no harm.' On average, the flu vaccine works about 70 percent of the time that's a pretty big reduction in risk. If we can do that with a shot, that's a freebie. Why even put our patients at risk? Our staff were also coming in sick and only calling off when they were ready to die. The last thing we needed is someone getting patients and coworkers sick. Although the swine flu made it easier for us to implement (our mandatory vaccine program) at least we believe it did I had advocated for mandatory flu vaccines for a number of years. The last thing we want to do is give patients something they didn't have in the first place. We had to do anything we could to reduce the number of staff with the flu. Also since staff are at high risk for catching the flu, we had a fiduciary responsibility to do what we can to protect our staff.

Q: How successful was Loyola before it launched the mandatory program?
A: A while back, the CDC declared a goal of getting 60 percent of healthcare workers vaccinated. In 2007-2008, the national average was 42 percent. At Loyola, after a big push and making the vaccine easily available, we broke the 60 percent mark (that season). We redoubled our efforts the following season, but got nowhere. I had doubts that we'd get much better than that, (so we needed to try something new). (Illinois Emergency Response System is divided into 11 regions) and one hospital is charged with coordinating an emergency response to a national epidemic, bioterrorism or non-biologic events. As one of (those) hospitals, we get extra federal funding. With that funding comes requirements including drills for mass mobilization. We pushed the idea to do a vaccination drill during flu season and actually offer the flu shot. In a 24-hour period, we vaccinated something like 4,000 people in about 8,000 workers. At that time, we also introduced active declination. If someone wasn't going to get the shot, they had to sign a form saying they were declining the shot.  Between the drill and active declination, our vaccine rates rose to 72 percent to 73 percent. The national average was about 48 percent. (But that was) the ceiling if we don't didn't something more mandatory. We had pitched mandatory vaccination to leadership just before the swine flu outbreak and they had already agreed to it. I think the swine flu outbreak gave them more courage. As far as we know, we were the third academic medical center in the county to go to mandatory flu vaccinations. Certainly when we were planning all of this, no other institution had done it.

Q: What are your rates now?
A: In the last four years, our vaccination rate is 99 percent. Except for the first year, we did not have to let staff go. In 2009, 99.2 percent of our staff received the vaccination and 0.7 percent were exempted this is out of nearly 8,000 people. Nine employees a tenth of a percent refused. We know at least five of them had jobs lined up already and had given notice well in advance; they just said they were not getting the flu shot. Technically, we had to put them down as (refusing) the vaccine, but we could have dropped them because technically they were not really our employees anymore. In 2010, a single person chose to leave we still had a 99.2 percent vaccination rate and 0.7 percent exempted. In 2011, no one was terminated. In 2012, we had five people who refused the vaccination three volunteers who reconsidered and returned to Loyola and two staff members. They were really equivalent to 20 percent of an FTE  one-fifth of a person was terminated. (An employee can ask for exemption) for medical or religious reasons, but we set that bar high. We wouldn't let people just say, 'I swear, I have an egg allergy.' They have to get a letter from their physician; we wanted formal documentation and reserved the right to do allergy testing. We didn't do any, but we reserved that right. It was astounding how many egg allergies (claimed during active declination) vanished.

Q: To what factors do you attribute to your high success rate?
A: We did a huge amount of outreach town hall meetings on different shifts. We made sure we got to all kinds of staff and did our best to explain why we were implementing mandatory flu vaccines. We admitted it was an imperfect vaccine and there are some years it works better than others (it might work for one of two strains). A huge educational effort helped a lot our employees came to see there were reasons. We are not saying the shot will save the world; there are limitations, but there are measures we can take to protect staff and patients. We have a lot of vulnerable, high-acuity patients. Loyola has the largest proportion of ICU beds in the region 140 of 500-some and we're one of the leading transplant centers in the Midwest. We also emphasized staff are at risk; we want to protect them and their families. One reason healthcare workers are typically reluctant to get the flu shot is they don't think getting the flu will affect them. These are relatively healthy adults the basic healthcare worker and support people, nurses, doctors, cafeteria, transporters typically have little risk or bad flu complications. But when the swine flu hit, there were reports of young, overweight people dying and pregnant women becoming quite ill. In October 2009, the Centers for Disease Control and Prevention (CDC) put out a report reviewing the first 700 cases of swine flu among pregnant women 100 were hospitalized and 28 patients died. That's an extremely bad outcome. Suddenly people who didn't consider themselves at risk thought they could be. The fear factor was probably another contributor. In 2008, Loyola had gone through some downsizing in trying to become leaner and meaner, and not get hurt by the economic downturn. A lot of people didn't want to have any black mark on their names.

Q: In several states, there are laws that make flu vaccines mandatory for healthcare workers, but a Wisconsin lawmaker is trying to ban that practice. What are your thoughts?
A: Driving the measure are lot of people who really don't understand the situation and therefore react to pressure groups. It saddens me to see within the healthcare profession one of the more vocal groups against mandatory vaccinations in many different states and settings have been nursing union. They see it as an infringement on workers' rights.  The vaccine is overwhelmingly safe, and millions of people hundreds of millions have received the vaccine. We know the flu is dangerous 36,000 people a year die from the flu. That's the equivalent of having a 9/11 catastrophe every month of every year. It's not a trivial disease. If we look at some of the data, even normal, run-of-the-mill flu presents a highest risk among the very young and senior citizens kids under five and adults 55 and over. It really skyrockets when you consider the over-65 population.

Q: What's the climate like now?
A: What's changed tremendously is the number of healthcare institutions that have gone to mandatory flu vaccinations. We're no longer the oddball place. There are quite a few area (facilities) in Chicagoland. Loyola joined Trinity Health a larger organization with many hospitals and centered in Michigan. Trinity introduced mandatory flu vaccines systemwide this past flu season. It's now not just a Loyola decision it's a trinity decision. No doubt, this is where we're going nationally. Just like people look up hospital infection rates for elective hip replacements, I envision patients looking up the same information for flu shots. They'll start saying they won't go to a hospital that doesn't vaccinate healthcare workers and they would be right.

Karin Lillis is a freelance writer.

Reference:
APIC. Mandatory flu vaccination of healthcare personnel does not lead to worker exodus. Accessible at: http://www.apic.org/For-Media/News-Releases/Article?id=2c5a4b78-8a4f-43a3-87bd-757bf8026032.