January 03, 2017
The estimated influenza vaccination coverage among U.S. healthcare personnel during the 2015-2016 influenza season was 80%, according to the Centers for Disease Control and Prevention (CDC). However, noted the CDC, coverage jumped to 96% in health systems where vaccination was required. That bested the 90% goal set by the federal government’s Healthy People 2020 initiative and supported the views of Jeffrey Starke, MD, an infection control officer at Texas Children’s Hospital in Houston, who wants flu shots to be mandated at health systems across the country.
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Dr. Starke believes influenza coverage among healthcare providers remains unacceptably low and, as the height of the flu season is set to begin, reminded medical workers that it’s not too late to protect themselves from infection. He recently shared why there’s justification on several levels for mandating vaccination for all healthcare workers and argued that all medical professionals have moral and ethical responsibilities to get their flu shots.
Why is preventing flu in healthcare workers critically important?
There are multiple reasons. The first and most obvious is the duty to protect patients. Even if providers don’t have overt flu symptoms, they can still have mild disease, be contagious, and transmit the virus to patients. Secondly, the incredible drive healthcare workers have to care for patients often causes them to come to work when they’re ill. The worst offenders are physicians. That’s positive in the sense that they have a strong work ethic, but healthcare systems typically aren’t designed to take into account that physicians are going to get sick and will need coverage. So vaccination in part prevents healthcare workers from showing up to work when they shouldn’t. The other factor that providers forget about is that their performance suffers when they’re sick. Studies from other industries have shown that workers who aren’t feeling well don’t think as clearly and their reaction times are slower.
Should healthcare workers be required to get flu shots?
I think so, but mandate has taken on different meanings. For example, here at Texas Children’s, flu immunization is mandated, but there is no recourse for employees who aren’t vaccinated. Barnes-Jewish health system in St. Louis was one of the first to make vaccination truly mandatory by allowing only medical exemptions. Health systems that have mandated vaccination programs in place, with serious consequences for workers who don’t get vaccinated, have found that the number of employees who end up being fired or incurring severe penalties is extraordinary low. The American Academy of Pediatrics has published a paper about the medical, legal, ethical, and moral rationales for why mandatory vaccination makes sense. I don’t think any reasonable person can argue that it shouldn’t be mandatory.
What’s the coverage rate at your hospital?
We’ve never had a truly mandatory program in place, because action is not taken against employees who don’t get vaccinated. About 10 years ago, maybe 60% of workers were immunized, so we decided that something needed to be done to increase that rate. There were the typical concerns among the hospital’s staff, such as the false beliefs that the flu shot can make you sick and that individuals with egg allergy shouldn’t be vaccinated. Those misconceptions had to be corrected. We tried education initiatives, which are important, but they’re not sufficient to solve most public health problems. We also polled our workers to determine specific barriers to vaccination and discovered that inconvenience was one of them. To solve that issue, personnel from the employee health department visited individual units to administer vaccines. That intervention increased healthcare immunization rates to around 75%, which was pretty good, but not good enough. We eventually provided an economic incentive to increase coverage even more.
Was that program successful?
Yes, to a degree. Our hospital has an end-of-year bonus program for employees. The entire institution has to meet certain goals in various categories for everyone to get a piece of the payment. Administration decided to tie facility-wide influenza coverage of 90% to the bonus, and the staff achieved the goal. For a voluntary immunization program, that’s pretty good. But is it good enough? It means that 1 out of every 10 healthcare workers who interacts with patients still isn’t protected from the flu. I think that’s completely inadequate, but 90% compliance is a level that many organizations present as target coverage rate. If we’d employ a truly mandated program that has serious consequences for non-vaccination, our coverage would approach 100%.
Was there additional benefit to incentivizing the hospital’s employees?
There was a peer-pressure component to the program — department managers had one more reason to ensure everyone in their units got vaccinated. Interestingly, the vaccination rate among physicians also increased when the economic incentive program was introduced, even though they didn't benefit financially. It became obvious that the program had established a new culture across the health system, and that’s a great thing. The dictum of health care is First Do Know Harm. When a healthcare worker has the flu, they have tremendous potential to do harm. In the end, how can healthcare workers tell patients to get vaccinated if they don’t do it themselves?