Mandatory Immunization's Growing Appeal

Many U.S. health care providers already require employees to accept vaccinations. Henry Ford Health System requires measles, mumps, rubella, and tuberculosis vaccinations, with no opt-outs allowed.

Within a decade, America's large hospital systems probably will be requiring their employees to be vaccinated against influenza if they provide direct patient care, the doctors leading flu prevention efforts at two large Detroit health systems predict. Both of their organizations, the Henry Ford Health System and Detroit Medical Center, took that step in August 2010, announcing a new policy for the 2010-2011 flu season that requires employees to be vaccinated or to wear a surgical mask whenever they are within 6 feet of a patient. The third partner in the initiative is the Barbara Ann Karmanos Cancer Center.

"It's been sort of a national momentum to move mandatory health care vaccines to the forefront because national immunization rates, even with vigorous voluntary campaigns, have been only 30 to 40 percent. At Henry Ford we're a little better than that, we had reached over 50 percent – but that's still half the health care workers unimmunized," said Dr. Allison Weinmann, a Henry Ford Health System infectious diseases specialist who heads flu preparations this year for the system's hospitals, ambulatory centers, and 24,000 employees.

"Most people are very receptive. I've personally gone out to several of those peripheral sites, and every peripheral site now has its own flu committee," she said Sept. 9. "We'll be naming a flu czar, and we also have a systemwide flu meeting attended by all kinds of people: pharmacists, people that order surgical masks, supply people, employee health, infectious disease, infection control. We're meeting on a very regular basis. If people can't come, we hook them up by phone or by video link so everybody knows what's going on. All of the information is shared within the system. Any wisdom we gain from one site we share through the system site."

Weinmann noted that many U.S. health care providers already require employees to accept vaccinations. Henry Ford Health System has required measles, mumps, rubella, and tuberculosis vaccinations for some time and does not allow an opt-out choice for those. "The irony is that the risk to patients from staff transmitting those infections is not nearly the risk that influenza is," she added. "I think this is just the beginning, and over the next year or so, every major health system is going to make it mandatory."

She said these three organizations are the first in southeastern Michigan to adopt such a policy, however. Dr. Keith S. Kaye, MD, MPH, corporate director of infection prevention, epidemiology, and antimicrobial stewardship at Detroit Medical Center (DMC) and Wayne State University professor of medicine, said he believes nationwide adoption of mandatory flu immunization policies will take another five to 10 years. "I think that there's a wave now, there's momentum,” he said Sept. 9, about one week before DMC held the first event in its series of mass flu immunization clinics for employees this fall.

"I can see eventually CDC will come out with stronger recommendations that all health care workers get vaccinated. I imagine we're going to see that, and I wouldn't be surprised if [mandatory is universal] within five or 10 years," Kaye said. "A year and a half or two years ago, if you'd told me we would have a mandatory vaccination policy by now, I wouldn't have believed it. But I think our leadership has been very aggressive. Going in and partnering with Henry Ford pushed leadership to make this a priority, as well. It's sort of been taking on a little bit of a life of its own that's quite impressive."

DMC operates seven hospitals. Kaye said the vaccination policy affects from 2,000 to 4,000 of its employees. The staff's immunization rate improved in recent years but was near the national average, 40 percent, before the policy was implemented, he said.

"This year we are targeting what we consider our highest-risk areas, which include intensive care units, the emergency department, our pediatric units, and our obstetrics floors. We see this as a major change in culture and would like to evolve to a mandatory policy for all floors of the hospitals, but this year our leadership decided to target highest-risk areas first," said Kaye.

He said he hopes the policy produces an immunization rate in those units at or near 100 percent and also sparks an improved rate among employees in other units of the hospitals.

Flu Surveillance
Employees have responded positively at both DMC and Henry Ford Health System, Kaye and Weinmann said. "I think we anticipated a lot more dissension and problems, but it's actually not been too bad," said Kaye. "So far, so good." Employees affected by the DMC policy this year have until mid-November to be vaccinated.

Asked why they decided to give workers an option to wear surgical masks rather than accept vaccination, Kaye said, "We know that some people are unable to take the vaccine because of religious reasons or severe allergies, although they're rare. There are just some people who cannot get the vaccine, though we know that's going to be very few. If you really are morally or ethically opposed to getting the vaccination, there is an option that's safe for patients."

He and Weinmann said studies have shown patients can acquire flu infections from hospital staffers. The DMC high-risk units where the policy is in effect this year treat thousands of patients during every flu season. "We are very attuned to flu acquired in our hospitals," Kaye said. "It's very infrequent, but when it happens, it's a big deal. It's always hard to be certain whether it occurred because of a visitor or a staff member, but clearly, it's a terrible thing if it happens. We're very much on the watch for it. If there's any concern that it's happening, we do a thorough investigation. So far it's infrequent, and that's good."

Lessons of the H1N1 Pandemic
Only one flu shot is needed this year, and it protects against three viruses: the 2009 H1N1 virus, influenza A (H3N2) and influenza B. Both Kaye and Weinmann said the date by which affected employees must be vaccinated depends on the availability of vaccine and also when flu activity becomes apparent in their area. For Henry Ford Health System, the date probably will be around Dec. 1, Weinmann said.

CDC has reported there were 57 million U.S. H1N1 cases during the past flu season and 257,000 hospitalizations. While some say the H1N1 flu pandemic was overblown, Kaye and Weinmann don't see it that way. And they said such criticism isn't hurting their efforts this year. "We certainly did see a lot of very severe cases of influenza last year among young healthy people, as many others did around the nation," Weinmann said. "Although it wasn't as severe as was predicted, it was severe in that we don't ordinarily see young, healthy people in the ICU and very sick. I think that sobered a lot of people."

Kaye said skeptics will cite the 2009-2010 flu experience as a reason not to be vaccinated this year, but he said publicity about the H1N1 pandemic and health care organizations' response to it in 2009-2010 did help people learn more about vaccination and influenza. Part of the reason the past flu season wasn't so bad was that public health organizations were successful at getting high-risk people vaccinated for H1N1, he added. He agreed with Weinmann that, in fact, that flu season was not mild: Several pregnant women and young children died in the area, and there were some very sick otherwise healthy people because of H1N1, Kaye said. As a result, he said, people are now more open to being vaccinated because they appreciate the seriousness of the flu.

Their health systems informed employees about the policy through e-mails and e-newsletters, presentations by infection control leaders to employee groups, talks in nursing forums, messages on monitors inside the facilities, posters, and more. "We have a very active team of several infectious disease people. It really is a team effort," Weinmann said. "It's a big initiative that requires a lot of people to coordinate, but it's working well so far.

"It's a lot of employees, and we want to make sure everything runs smoothly," she added. "We don't want someone to turn out for the vaccine and we have to say, 'Gosh, we don't have any.' We want to be able to tell people, when vaccine is available, where they can go to get it."

This article originally appeared in the November 2010 issue of Occupational Health & Safety.

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