Occupational Health


Occupational Health
A Shot in the Arm?

By Jennifer Schraag

Occupational Health and Safety withinthe healthcare community has evolved, but current requests arent being met bythe majority of healthcare workers. The debate on annual influenza immunizationscontinues to stir and healthcare workers are now facing mandates, mixedmessages, and even termination threats for noncompliance.

The Centers for Disease Control and Prevention (CDC) hasrecommended annual influenza vaccination for healthcare workers (HCWs) withdirect patient contact since 1984 and for all HCWs since 1993.1 The flu causes200,000 hospitalizations and 36,000 deaths annually nationwide.2

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

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

Julie Gerberding, MD, MPH, director of the CDC, chastised themedical community for its low rates of influenza vaccination compliance during aSeptember 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 singledoctor and nurse in America needs to make getting vaccinated a priority, headds.

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

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

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

For some reason were very conscientious on patientsafety issues like washing our hands and other things, but we havent madethat connect with the flu vaccine. We really have to emphasize that it is apatient 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 amessage that needs to be rolled out.

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

The Society for Healthcare Epidemiology of America (SHEA)recently released a position paper detailing its position on influenzavaccination for HCWs. SHEAs statement provides recommendations for amultifaceted program aimed at providing targeted education, increasing vaccineaccess, and emphasizing the ethical responsibility HCWs have to protectthemselves, their patients, and their colleagues as part of institutionalpatient and employee safety programs. The recommendations apply to all types ofhealthcare facilities.

When planning and implementing an effective immunizationprogram to increase HCW vaccination rates, SHEA proposes it contain thefollowing components:

  • Provide targeted educationannually to all HCWs about the severity of influenza, particularly among highrisk patients, and about the safety of influenza vaccination;

  • Inform HCWs of the importanceof influenza vaccination in promoting patient and employee safety; Provide vaccine at no cost and at convenient locations andtimes;

  • Recommend that HCWs sign adeclination each year if they refuse influenza vaccination after participatingin an educational program or if they have medical contraindications to thevaccine;

  • Perform surveillance of ratesof vaccine uptake by medical unit as well as identification of patients withhealthcare-associated influenza to assess the impact of the vaccination program.

A German study evaluated the effectiveness of facilityinvolvement and campaigns in increasing vaccination compliance.5 Of the 25German hospitals surveyed, the researchers found the proportion of hospitalsactively offering influenza vaccination increased from 48 percent in 1997/98 to92 percent in 2001/02, however, vaccination coverage of all staff in 1997 was3.3 percent and only increased to 8.4 percent in 2001-2002. Recommendationsare ignored extensively, the researchers wrote, but poster campaigns andmanaging board commitment had significant impact in the increases that werefound, the researchers noted.

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

  • Secure commitment to HCWinfluenza vaccination from top management;

  • Develop a policy statementaffirming the institutions commitment;

  • Educate HCWs about the benefitsof vaccination for themselves and their patients;

  • Make influenza vaccine easilyaccessible;

  • Repeat the influenzaimmunization program annually.

The American College of Occupational and EnvironmentalMedicine (ACOEM) also endorses a multi-faceted influenza control program in allhealthcare facilities and strongly encourages healthcare organizations tofacilitate participation by providing influenza vaccine, associated supplies andservices, 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 enactedvarious influenza immunization mandates for HCWs in long-term care facilities andoccasionally in acute-care hospitals, allowing for appropriate exemptions. Inaddition, the province of Ontario also mandates influenza immunization of all HCWs.7

Should such mandates be implemented? The short answer isno, says Schaffner, who serves as a NFID board member. Making animmunization mandatory is a very complex, elaborate, and torturous process. What I would like to do is make the annual influenzaimmunization of all HCWs part of the professional ethics of all HCWs such thatthey will absolutely do it.

In terms of implementation, I do favor using an informeddeclination form for those who choose not to be vaccinated, Schaffnercontinues. The use of the informed declination would oblige healthcareinstitutions to provide sufficient resources to their occupational healthservice 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 alsolet the HCW know that we all in the healthcare profession take this very, veryseriously, and that if you decline the vaccine, you have to actually sign apiece of paper that says I understand I have been offered the vaccine, itsfree, I understand it is important for me, and more importantly, it is importantto my patients, but nonetheless, I decline. That, I think, makes it a muchmore serious annual event. I think it will encourage large institutions to putmore resources into bringing the vaccine to HCWs and it will also make the wholeprocess more serious for the HCW themselves.

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

Talbot, who is also chairman of the SHEA Healthcare WorkerInfluenza Task Force, says he believes the word mandatory is viewed inmany different ways.

As we put forth in the statement, all HCWs should beoffered the vaccine, should be actively educated on why we need the vaccine forpatient safety dispelling the myths surrounding why people fear they willget the flu from the vaccine. Then, after all thats done and youve madesure that healthcare facilities have made a very dedicated effort at providingthis making sure it is easy access, and providing it free of charge thenthe HCW can still say no, but they need to actively decline that. They need tounderstand all the aspects that go into that. So, some people argue thats nottruly mandatory, he says.

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

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

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

The Threat is Looming

The Washington State Nurses Association (WSNA) recently won anarbitration decision against Virginia Mason Medical Center (VMMC), stopping thehospital from forcing registered nurses to receive flu shots. The hospitalsattempted unilaterally-implemented policy made annual influenza vaccination acondition of employment threatening termination for any employee who did notcomply.

The arbitrators decision found that the employer violatedthe terms and the very purpose of the collective bargaining agreement betweenWSNA and VMMC and ordered VMMC to cease and desist its intendedimplementation of the flu immunization policy and remove such condition ofemployment from its Fitness for Duty policy.

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

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

Should healthcare really threaten its employees withtermination 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 toimprove access, making sure you do everything you can to improve education anddispel all these myths, and really make an institutionally-committed effort fromthe top down with resources.

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

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

Seven Truths of HCW Influenza Vaccination

  • The first truth: influenza infection is a serious illnesscausing significant morbidity and mortality adversely affecting the publichealth on an annual basis.

  • The second truth: influenza-infected HCWs can transmit thisdeadly virus to their vulnerable patients.

  • The third truth: influenza vaccination of HCWs saves money foremployees and employers and prevents workplace disruption.

  • The fourth truth: influenza vaccination of HCWs is alreadyrecommended by the CDC and is the standard of care.

  • The fifth truth: immunization requirements are effective andwork in increasing vaccination rates.

  • The sixth truth: HCWs and healthcare systems have an ethicaland moral duty to protect vulnerable patients from transmissible diseases.

  • The seventh truth: the healthcare system will either lead orbe 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, accordingto William Schaffner, MD. He says there are currently two manufacturers thathave produced an acellular pertussis vaccine that has been included with tetanusand diphtheria for adults and adolescents. The Advisory Committee on Immunization Practices (ACIP) is inthe process of formulating recommendations for adults, and more specifically,HCWs.

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

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


1. Talbot, T.R, et al. SHEA position paper: Influenzavaccination of healthcare workers and vaccine allocation for healthcare workersduring 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 healthcareworkersCalifornia 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 amonghealthcare workers. Emerg Infect Dis.11(7):1003-8, July, 2005.

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

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

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

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

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

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