Despite Opposition, Mandatory Vaccine Program a Success

A mandatory influenza vaccination program for all employees in a large Midwestern health care organization increased the rate of immunization to more than 98%, according to a study.

Previous, nonmandatory efforts in this organization as well as in other health care facilities across the country have had much more limited efficacy. The average influenza vaccination rate among U.S. health care workers was only 44% in recent years, said Dr. Hilary M. Babcock of Washington University, St. Louis, and her associates.

They reported the first study in the medical literature to describe outcomes of a multihospital health care organization's mandatory vaccination program. The program, an initiative focused on patient safety, required seasonal influenza vaccination as a condition of employment for clinical and nonclinical staff, contracted clinical personnel, and volunteers.

The program was implemented for the 2008-2009 flu season at BJC HealthCare, a network with approximately 26,000 employees working at 11 acute care hospitals and 3 extended care facilities, as well as day care centers, physician group practices, occupational medicine providers, home care providers, and behavioral health services in urban, suburban, and rural settings.

Employees were offered free immunizations, including thimerosal-free and intranasal formulations, at multiple locations and times in each facility. They were encouraged to review educational materials emphasizing patient safety and to consult with a medical director to discuss any concerns. They could request medical or religious exemptions using a standardized declination statement.

“Exemption requests often reflected misinformation about the vaccine…. Several requests cited chemotherapy or an immunosuppressed state as reasons not to get the vaccine, even though these groups are at high risk for complications from influenza and are specifically recommended to be vaccinated. Several requests cited pregnancy, although the vaccine is recommended during pregnancy,” the investigators noted.

Declination requests were reviewed by medical and human resources personnel, then accepted or denied. Employees who were neither vaccinated nor exempted by mid-December were suspended without pay. Those who were still not vaccinated nor exempted by mid-January were terminated for failing to meet the conditions of their employment.

A total of 25,561 employees were vaccinated (98.4%). All the physicians in the network were immunized, including all 907 residents and fellows, said Dr. Babcock, who is also medical director of occupational health at Barnes-Jewish and St. Louis Children's Hospitals, and her colleagues.

Another 321 employees (1.24%) received medical exemptions for reasons such as allergy to eggs, prior allergic reaction to a vaccine, or a history of Guillain-Barré syndrome. Ninety employees (0.35%) received religious exemptions. Eight employees (0.03%) were terminated.

This represents a 43% increase in the vaccination rate compared with the rate in 2006 and a 27% increase compared with 2007 at BJC HealthCare, Dr. Babcock and her associates said (Clin. Infect. Dis. 2010;50:459-64).

In an editorial, Dr. Andrew T. Pavia of the division of pediatric infectious diseases at the University of Utah, Salt Lake City, agreed that this program was “highly successful,” particularly when compared with the “very modest” success of efforts over the past 10 years to increase the “unacceptably low” rate of vaccination among U.S. health care workers.

“Mandatory vaccination policies have been endorsed by several organizations, including the New York State Department of Health, the Infectious Diseases Society of America, the American College of Physicians, the Association for Professionals in Infection Control and Epidemiology, and the National Foundation for Patient Safety,” he noted.

Although “some of the largest and most prestigious” health care organizations in the nation have adopted mandatory vaccination policies. “mandatory vaccination has also generated vigorous debate and opposition, including legal challenges,” Dr. Pavia said (Clin. Infect. Dis. 2010;50:465-7). “The debate should focus on results, not intentions or methods. Health care organizations should be expected to achieve influenza vaccine coverage that optimizes patient safety and to make data on coverage readily available t he noted.

“I propose 90% coverage as an appropriate target. Organizations can then choose to achieve the target with less coercive methods if they can or, if necessary, choose to mandate vaccination,” Dr. Pavia said.

Disclosures: Dr. Babcock and her associates reported no potential conflicts of interest. Dr. Pavia reported serving as a consultant to NexBio.