Are They Up to the Challenge?

Having encouraged 1.1 million health care workers to be immunized last year, Joint Commission Resources' second Flu Vaccination Challenge has bigger goals this time around.

• By Jerry Laws
• Oct 01, 2009

They're the front lines and the heart of the nation's defense against the H1N1 flu, and the care they provide will be vital during the 2009/2010 U.S. flu season. How well the employees of about 5,000 hospitals can perform their duties may depend on those individuals' willingness to receive flu vaccinations, as health care professional associations and leaders of this year's Joint Commission Resources Flu Vaccination Challenge 2009-2010 strongly encourage.

One year ago, the initial Challenge sought to raise the national average vaccination rate of 42 percent among hospital staffers. About 1,700 hospitals took part, with 1.1 million workers being vaccinated and 78 percent of the participating hospitals increasing their vaccination rates. However, an average 37 percent of the health care workers at participating hospitals were not vaccinated, according to JCR. Its second Challenge asks participating facilities to reach a rate of 65, 75, or 90 percent, and it includes employees of ambulatory care and long-term care facilities across the country. Th ose employees probably are vaccinated at a rate below the hospital workers' 42 percent rate of a year ago, as is true of the general public, said Dr. William Schaffner, chairman of the Department of Preventive Medicine and professor of Infectious Diseases at Vanderbilt University School of Medicine, and Barbara M. Soule, RN, practice leader, Infection Prevention and Control Services, at Joint Commission Resources (JCR).

"I haven't seen data on that, I'm not sure who's collecting it," Soule said. "But I would say that we get so much patient care in ambulatory settings now and we have so many patients in long-term care facilities that we really can't ignore the health care workers in those settings."

More than 5,100 ambulatory surgical centers that serve Medicare patients are in operation in the United States, and there are additional centers that do not serve Medicare patients, according to a February 2009 Government Accountability Office report.

The Joint Commission defines "health care worker" as everyone who provides treatment, care, or services in a health care organization. Th is definition includes students, volunteers, cafeteria workers, custodial services, and more — not just the doctors and nurses. "What we would like to do is provide what we call a cocoon of protection for patients. Once they enter the environment of the health care facility, that's one place they should never acquire the influenza virus," said Schaffner, a well-known proponent of vaccination who is acting as a spokesman for the Challenge.

The Challenge is focused on seasonal flu, not pandemic H1N1, which is the looming and complicating factor in the 2009/2010 flu season. Federal and world health officials have been informing the public and the health care community for months about H1N1, offering specific guidance to employers, schools, and health facilities about hand washing, vaccines, and care of infected people. The authorities continue to say most patients infected with H1N1 recover fully within a week, even without medical treatment, and do not recommend antivirals be administered to healthy patients with uncomplicated illness.

The smaller employee populations of ambulatory care and long-term care facilities should make it easier for them to achieve the goals of 65, 75, or even 90 percent, said Schaffner, who admits this Challenge is tougher for all participants. "We've reached the people who are most receptive to our message. For each increment of our increased success, we're going to work a little bit harder. We're going to have to work at little bit harder as we get higher," he said. "It requires substantial institutional commitment, starting from the top. Senior administrative staffneed to be not only committed to it, but openly committed to it. And they need to give the occupational health and infection control and others resources in order to get the job done."

Best Inducements: Carrot or Stick?

CDC has recommended annual flu vaccinations for all health care workers since 1993. Major health care associations including the Society for Healthcare Epidemiology of America (SHEA) and the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) generally endorse this position, although SHEA's position paper recommends annual vaccinations unless a worker has a contraindication to the vaccine or actively declines vaccination. Healthare facilities should actively promote vaccination, working to dispel myths about vaccines, improving access to them, and providing them at no cost, the paper states.

APIC's October 2008 position paper recommends requiring flu vaccination annually for all health care personnel with direct patient care, but, again, employees could decline for other than medical reasons; that information "should be utilized by the facility to develop improvement strategies for the following vaccine season," the paper says.

The New York State Department of Health adopted an emergency regulation Aug. 13 making immunization against flu virus(es) a precondition to employment and on an annual basis. Health care facilities in the state must provide vaccinations at no cost, and the regulation states annual flu vaccinations must take place by Nov. 30 each year. The regulation applies to paid and unpaid personnel employed or affiliated with a health care facility, including contract staff, students, and volunteers; however, staffers who have no direct contact with patients and whose activities could not expose patients or others who have direct contact with patients are exempt.

The Challenge takes an entirely positive approach, with its "carrot" being JCR recognition for those who achieve their goals.

Soule and Schaffner agreed peer pressure, family encouragement, and community support all may play a role in overcoming a worker's reluctance to be vaccinated.

"I don't think there's one single best approach," Soule said. "In health care organizations, some people respond really well to peer pressure: Someone will say, 'Oh, I'm getting the shot. You get the shot.' Others, their families say, 'Okay, did you get your vaccine yet?' The types of inducements vary depending on what the individual feels is important in their life."

Similarly, personal reasons explain why a health professional chooses not to be vaccinated. "I think the single most important reason is that we still have not been able to educate all health care workers that this is a patient safety issue. Namely," Schaffner said, "that by getting vaccinated themselves, they will not give their viruses to their patients, who are, of course, already sick. And no health care worker wants to do that. So I think that is a major barrier. We still have to provide that information. Another reason is that many health care workers are, relatively speaking, young and healthy, and they haven't figured out that influenza vaccine is important to them and their own health. Th ere are the other kinds of reasons; for example, there are some health care workers who don't like inoculations. And there are some who are just too busy. The list goes on. None of those reasons are valid. It's terribly important that every health care worker as a professional and ethical obligation be vaccinated against influenza each and every year."

Challenge 2009-2010 will continue through May 2010. JCR will release its results in August or September 2010, in time for next year's flu season.

This article originally appeared in the October 2009 issue of Occupational Health & Safety.