A matter of patient safety
AAP policy calls for mandatory flu shots for health care workers
- Copyright © 2010 by the American Academy of Pediatrics
The Academy has released a new policy statement that recommends the implementation of a mandatory influenza immunization policy for all health care personnel (HCP) (available mid-September at www.pediatrics.aappublications.org/cgi/content/abstract/peds.2010-2376v1).
The Academy has recommended for years that all HCP be immunized annually against influenza, including HCP in ambulatory settings (Pediatrics 2007;120:650-655OpenUrl). Annual immunization of HCP is a matter of patient safety and is necessary to significantly reduce health care-associated influenza infections. It is well-known that HCP can transmit influenza virus to patients and coworkers before the onset of symptoms and during symptomatic illness. Such infections are common, contribute to patient morbidity and mortality, and create a financial burden on health care systems.
The Academy joins other membership organizations that also have called for mandatory annual influenza immunization for HCP. They include 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. Many hospitals and some health care systems, including the clinical centers of the National Institutes of Health, already have adopted mandatory immunization policies.
Mandatory programs shown to be effective
Mandatory immunization is not a novel concept. Many health care facilities require certain vaccines and a tuberculin skin test as conditions for working in specific areas of the institution or for employment.
Despite the efforts of many organizations to improve influenza immunization rates with the use of voluntary programs that include intensified efforts to educate HCP and provide free vaccine, the percentage of HCP voluntarily receiving the vaccine each year remains unacceptably low at near 40%. The Joint Commission estimates that influenza immunization rates of 80% or higher are essential to provide the herd immunity necessary to substantially reduce health care-associated influenza infections.
During the 2009-’10 influenza season, it was recommended that HCP receive both the seasonal trivalent influenza vaccine and the 2009 influenza A (H1N1) vaccine. Data collected by the Centers for Disease Control and Prevention (CDC) indicate that an employer recommendation was associated with two- and four-fold higher coverage rates for seasonal and 2009 H1N1 influenza vaccination, respectively, when compared with employers who made no recommendation. However, coverage rates for both influenza vaccines improved by three- to eight-fold when employers required influenza immunization of HCP.
In other reported data from four different employers who mandated immunization, coverage rates among HCP were documented to be 88%-99%, demonstrating the effectiveness of a required influenza immunization policy.
Employees of health care institutions have an ethical and professional obligation to act in the best interest of their patients’ health. Recognized medical and religious exemptions to mandated influenza immunization can be granted on an individual basis, so requiring influenza immunization for HCP is ethically justified. A policy also is needed for the management of personnel granted an exemption.
Voluntary programs may lead to an immediate increase in immunization rates, but these efforts have failed to show a lasting effect. HCP continue to have misconceptions regarding the risks and benefits of influenza vaccine and the risk of influenza infection for themselves, their patients and their families. Influenza vaccine is safe, effective and cost-effective. Health care organizations must work to assuage common fears and misconceptions about the influenza virus and the vaccine.
The Academy believes the three generally accepted criteria needed to justify mandatory status for a public health intervention have been met:
There should be clear medical value from the intervention to the individual.
The public health benefit of the mandatory intervention must be clear to justify the infringement on personal liberties.
A mandate must be considered the only option.
Key factors to maximize success of a mandatory policy include:
having full support of health care leadership;
customizing the plan for each institution;
making vaccine free to all HCP;
publicizing the program to HCP;
offering convenient times and locations for education and immunization administration, preferably within the institution;
using a universal form with defined acceptable medical and religious exemptions; and
creating a clear institutional policy for management of employees who are exempted from immunization.
The data clearly show that an influenza vaccine mandate is necessary and long overdue. Mandatory influenza immunization programs for HCP will benefit the health of employees, their patients and members of the community.
Immunizing all HCP also will serve as an example to patients, highlighting the safety and effectiveness of annual immunization. HCP fail to lead by example if they recommend universal immunization, including influenza vaccine, to their patients, but do not require it of themselves. For the prevention and control of influenza, now is the time to put the health and safety of the patient first.
Recommendation for Mandatory Influenza Immunization of All Health Care Personnel will be published in the October issue of Pediatrics and is available in mid-September at www.pediatrics.aappublications.org/cgi/content/abstract/peds.2010-2376v1.
The Academy has developed implementation guidance on supply, payment, coding and liability issues. These documents can be found at www.aapredbook.org/implementation.
Dr. Bernstein is a member of the AAP Committee on Infectious Diseases, and Dr. Bocchini is former chair of the committee.