American College of Physicians: Internal Medicine — Doctors for Adults ®

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Should vaccinations be required for health care workers?

From the July-August ACP Observer, copyright © 2004 by the American College of Physicians.

NEW ORLEANS—Faced with apathy about flu vaccinations, some physicians are advocating a new strategy in the war against the often-lethal virus: mandatory influenza vaccinations for everyone who works in a health care setting.

At an Annual Session presentation on immunizations, Gregory A. Poland, FACP, made a case for requiring—not merely recommending—annual flu vaccinations for all health care professionals. That's because data have shown that health care workers aren't stepping up and getting the vaccine, he said. Despite recommendations from organizations like the CDC, only about 36% of health care workers are immunized against the flu.

Dr. Poland is director of the Mayo Vaccine Research Group at the Mayo Clinic in Rochester, Minn., and Chair of ACP's Adult Immunization Initiative Physician Advisory Board. He said that extensive data show that the vaccine not only improves patient safety, but decreases costs and improves public health.

"Voluntary programs don't work," he said. "Mandatory vaccines are the next step in programs that are already in place in most health care settings for workers."

Transmission and deadly outbreaks

On a practical level, mandatory vaccinations would go a long way to prevent the transmission of influenza to patients and staff from symptomatic and asymptomatic health care workers.

Influenza is the sixth leading cause of death for older Americans and infects 5% to 10% of elderly Americans every year. The flu leads to 300,000 hospitalizations and kills 30,000 to 40,000 Americans every year.

Despite those statistics, many in both the public and the medical profession view the flu as a mundane problem. That perception, Dr. Poland explained, hurts immunization rates among both patients and physicians.

Dr. Poland described one 1998 influenza A outbreak that affected patients in a bone marrow transplant unit. The 30-bed ward had 25 confirmed flu cases, with seven cases identified in one week. Six of those patients developed pneumonia, and two of them died.

It was later discovered that only 12% of the health care workers in the unit had received a flu vaccination. Despite losing two pneumonia patients from one ward to a largely preventable disease, relatively few of the hospital's employees were vaccinated the next year.

"Despite all the negative publicity and an extensive education program," Dr. Poland said, "42% of the workers in the bone marrow transplant unit still failed to get the vaccine the next year."

The right thing to do

While the idea of requiring health care workers to get the flu vaccine may strike some as radical, Dr. Poland said data show that it's the responsible thing to do.

He was one of several physicians who in February introduced a resolution to the Advisory Committee on Immunization Practices, a group that advises the CDC. The resolution stated that health care workers should be immunized against influenza. And last November, the College signed on to a call for action from the National Foundation for Infectious Diseases that also advocated universal flu immunization among health care workers.

Dr. Poland acknowledged that the notion of a mandatory vaccine raises questions about those who can't be vaccinated—because of an allergy or other contraindication—or refuse to get the vaccination. Would they be able, for example, to continue to work in a hospital? If they continue to work and infect a patient, what are the legal ramifications for the provider and the hospital or practice?

Several states—including Arkansas, Maryland and Kentucky—already have laws requiring that vaccine be offered to health care workers in long-term care facilities, while pending legislation in Maryland would require all workers in acute and long-term care settings to be immunized. All of the states have opt-out provisions for workers with contraindications.

Mandatory programs are the only way, Dr. Poland claimed, to protect patient health.

"We will lead or be lambasted on this issue," he said. "We must take responsibility for curbing yearly epidemics that profoundly influence the health of our patients, our health care workers and even global health."

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