Mandatory Influenza Vaccination Successfully Increased Vaccination Rates

Laurie Barclay, MD

February 11, 2010

February 11, 2010 — A mandatory influenza vaccination campaign at a large healthcare organization successfully increased vaccination rates, according to a report in the February 15 issue of Clinical Infectious Diseases.

"Influenza vaccination of health care workers has been recommended since 1984," write Hilary M. Babcock, MD, MPH, assistant professor of medicine at Washington University School of Medicine and medical director of occupational health (infectious diseases) at Barnes-Jewish and St. Louis Children's Hospitals in St. Louis, Missouri, and colleagues. "Multiple strategies to enhance vaccination rates have been suggested, but national rates have remained low."

At BJC HealthCare, a large Midwestern healthcare organization with approximately 26,000 employees, organizational vaccination rates remained below target levels. In 2008, therefore, influenza vaccination was made a condition of employment for all employees, although medical or religious exemptions could be requested.

"As a patient safety initiative, we knew the flu shot was safe and effective, and the best way to protect patients was to be sure that employees were vaccinated," Dr. Babcock said in a news release.

Occupational health nurses and their medical directors reviewed medical exemption requests; predetermined medical contraindications included hypersensitivity to eggs, previous hypersensitivity reaction to influenza vaccine, and history of Guillain-Barré syndrome.

Employees who were neither exempted nor vaccinated by December 15, 2008, were not scheduled for work, and those still unvaccinated and not exempted by January 15, 2009, were terminated. Of 25,980 active employees, 25,561 (98.4%) were vaccinated, 90 (0.3%) received religious exemptions, 321 (1.2%) received medical exemptions, and 8 employees (0.03%) were neither vaccinated nor exempted.

Of the medical exemptions, 107 employees (33%) were allergic to eggs, 83 (26%) had a previous allergic reaction or allergy to other vaccine component, 15 (5%) had a history of Guillain-Barré syndrome, and 116 employees (36%) had other medical exemptions, including 14 who were pregnant.

Smooth Execution, Fears Allayed

"Some of the requests for medical exemptions reflected misinformation about the vaccine and influenza," Dr. Babcock said. "Overall, the program went very smoothly, [and] we were able to talk with the people who had concerns about the vaccine and allay their fears. A large number of employees were really glad that we had made it mandatory and that coworkers were being vaccinated."

The study authors note that the experience at BJC HealthCare may not be completely generalizable, that economic factors at the time of the study may have limited the number of employees willing to lose their jobs, and that not all physicians affiliated with BJC HealthCare are employed by the organization and, therefore, were not covered by the policy.

"A mandatory influenza vaccination campaign successfully increased vaccination rates," the study authors conclude. "Fewer employees sought medical or religious exemptions than had signed declination statements during the previous year. A standardized medical exemption request form would simplify the request and review process for employees, their physicians, and occupational health and will be used next year."

In an accompanying editorial commentary, Andrew T. Pavia, from the University of Utah, Salt Lake City, notes that of all the strategies to improve vaccination rates, the policy of mandatory vaccination has generated the most controversy.

"The policy pits the ethical principle of normalfeasance against individual autonomy," Dr. Pavia writes. "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.... Mandatory vaccination has also generated vigorous debate and opposition, including legal challenges."

The study authors have disclosed no relevant financial relationships.

Clin Infect Dis. 2010;50:459-464, 465-467. Abstract

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