By Joyce K. Lammert, M.D.
In 2004, I joined my colleagues at Virginia Mason Medical Center in a workshop to examine ways to improve delivery of influenza vaccine to patients and staff.
This experience seems all the more relevant in light of the recent emergence of 2009-H1N1 (swine) influenza infections worldwide.
We found that three facts from the medical literature were striking: Influenza vaccine is safe and effective in healthy adults, immunizing health care workers results in a safer environment for patients, and voluntary programs to immunize health care workers have had limited success. One of my colleagues at the workshop asked why mandatory influenza vaccination of our employees wasn't a policy at VMMC, a multispecialty clinic and 336-bed tertiary care hospital in Seattle, with 480 physicians and a staff with 5,000 full-time equivalents. The room fell silent; she had a good point.
Soon after this meeting, my colleagues and I sent a recommendation to our management committee asking that it consider mandating influenza vaccination of all employees, from volunteers to maintenance staff. The committee agreed with our recommendation, and influenza vaccination became a “fitness for duty” requirement at VMMC. The vaccine shortage that year prevented us from carrying out the policy, so we spent the 2004–2005 influenza season launching a respiratory etiquette campaign.
We also began planning our influenza immunization campaign for the 2005–2006 season. We learned from focus groups and other inquiries that many members of the staff did not understand the seriousness of influenza.
Mandatory vaccination of health care workers is important because voluntary vaccination programs have demonstrated limited efficacy. For example, after a voluntary program was launched in 1985 at the Minnesota Veterans Affairs Medical Center, including mobile carts and an education campaign, the immunization rate increased from 25% of health care workers that year to 46% in 1996 and to 65% in 2004 (MMWR 2004;54:196-9). But that left 35% of health care workers unvaccinated.
Educational efforts are not always effective. In a survey of registered nurses at the Mayo Clinic in Rochester, Minn., which has a long-standing, multifaceted flu vaccination program, 90% of respondents said they had exposure to educational bulletins and 85% felt they knew what they needed to make a good decision, yet only 7% gave correct answers to more than 85% of the knowledge questions on the survey (Infect. Control Hosp. Epidemiol. 2008;29:99-106).
At VMMC, we decided to include all employees in the program. Staff who have not been immunized by a set date receive notices, are asked to complete an education module, and then undergo further education and one-on-one discussions. Those who don't get vaccinated by the deadline can be terminated.
This policy went into effect in the 2005–2006 influenza season. During that time we lost a handful of people who chose to leave or were terminated. Staff can request an accommodation on religious or medical grounds; if this is approved, they must wear a mask at work during the influenza season.
The policy is inclusive: We include all outside contractors, vendors, volunteers, students, and community providers, which requires about 1,000 additional vaccinations each fall.
Our statistics speak for themselves. Since 2005–2006 we have had 98%–99% of our staff immunized, and the others use protective masks during the influenza season. The national average is about 45%, and the most successful voluntary programs have rates of 80% or less.
Joyce K. Lammert, M.D., is chief of the department of medicine at Virginia Mason Medical Center, Seattle.