Published 28 October 2008, doi:10.1136/bmj.a2142
Cite this as: BMJ 2008;337:a2142

Head to Head

Should influenza immunisation be mandatory for healthcare workers? Yes

¹ University of Iowa Carver College of Medicine, Department of Internal Medicine, Infectious Diseases Division, 200 Hawkins Drive, Iowa City, IA 52242, United States

Charles Helms and Philip Polgreen believe that mandatory immunisation is necessary to achieve good uptake, but David Isaacs and Julie Leask (doi:10.1136/bmj.a2140) argue that it infringes autonomy and could backfire

Influenza is an important cause of morbidity and mortality worldwide. Health care associated influenza occurs in acute and long term healthcare facilities, affecting both patients and staff and disrupting delivery of care.^{1 2} There is evidence that vaccinating long term care healthcare workers reduces mortality among long term care patients and that vaccinating hospital workers decreases the rate of nosocomial influenza in hospitalised patients.^{3 4 5 6} Moreover, an economic evaluation of immunisation of healthcare workers in the UK found that it is cost saving.⁷ In addition, further studies show that healthcare worker vaccination reduces absenteeism.^{8 9 10}

Based on available evidence, public health authorities have strongly recommended vaccination of healthcare workers to protect patients and healthcare workers in healthcare settings.¹¹ Despite these recommendations, overall rates of influenza immunisation among healthcare workers worldwide are disappointingly low, 40% or less.^{1 7 11 12} Such rates suggest that patients and healthcare workers are at increased risk of health care associated influenza. This situation poses a serious, recurring threat to the safety of patients and to the delivery of health services during influenza outbreaks. Recently, recommendations and standards for immunising healthcare workers against influenza have been re-examined, re-emphasised, and strengthened. For example, public health and health industry advisory bodies in the US, including the Centers for Disease Control and Prevention, the National Quality Forum, and the Joint Commission on Accreditation of Health-Care Organizations have all sent a clear message that influenza immunisation is important and that rates need to be increased.^{13 14 15}

This consensus should encourage and facilitate innovative efforts to improve the performance of healthcare facilities and workers. Hopefully, use of evidence based interventions to increase immunisation rates—such as offering free vaccine, staff education, sending reminders, and improving access for staff at the job site^{11 13 16}—will be increased. Thus far, implementation of these evidence based interventions has been encouraged, but not required.

Voluntary action is insufficient

The Infectious Diseases Society of America and others recently suggested that voluntary approaches to immunisation have failed and that mandatory influenza immunisation programmes for healthcare workers are needed.^{17 18} The effective use of mandatory approaches to increase immunisation rates is not without precedent. Examples include the US requirements for children to be immunised before starting school and vaccination of healthcare workers against hepatitis B.

Some countries already have mandatory influenza immunisation programmes for healthcare workers. The province of Ontario, Canada, introduced regulations in 2004 requiring annual influenza immunisation for workers in long term care.¹⁹ At least four US states have policies requiring influenza immunisation of workers in nursing homes, hospitals, or both unless the workers have medical, religious, or philosophical reasons for exemption.²⁰

Recently, interest has focused on mandatory programmes coupling a requirement for influenza immunisation and use of a form to document a healthcare worker’s decision to decline immunisation. Thus far, it seems as if simply requiring healthcare workers to sign a statement is not enough. For example, a recent study examining the effectiveness of refusal statements (without mandatory immunisation) in 22 US hospitals found only modest increases in vaccination rates.²¹ In contrast, Virginia Mason Medical Center in Washington state made immunisation of healthcare workers compulsory and accepted refusals only from staff with legitimate medical or religious reasons. The vaccination rate in this hospital increased to 98%.²² These two reports suggest that mandatory immunisation may be critical to reach the highest immunisation rates.

Approaches based on voluntary compliance with recommendations for influenza immunisation of healthcare workers have failed in the long term. The addition of mandatory approaches to improve patient safety in this situation is both reasonable and overdue.

Benefits outweigh harm

Critics of mandating vaccination base their opposition on the ethical principles of liberty, autonomy, choice, and self determination. Although these are important considerations, we believe that the risk of harm to a patient from influenza in the healthcare setting is far greater than the risk of harm to healthcare workers from immunisation. Moreover, in this era when healthcare institutions and healthcare professions publicly acknowledge their responsibility for patient safety, we think that arguments for autonomy of healthcare workers will not be persuasive, especially to patients who every year are harmed by preventable influenza in the healthcare setting. When considering the safety of patients, we believe the greatest societal good would be derived from mandatory influenza immunisation of healthcare workers.

Cite this as: BMJ 2008;337:a2142

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This article is based on a paper presented at the 11th national immunisation conference, Public Health Association Australia in Gold Coast, Australia on 17 September 2008.

Competing interests: CMH received a travel grant from Aventis Pasteur. PMP has been a member of the emerging trends in seasonal influenza advisory panel of Roche Laboratories.

References

1. Weber DJ, Rutala WA. Vaccines for health care workers (section 4). In: Plotkin S, Orenstein W, Offit P, eds. Vaccine. 5th ed. Philadelphia: Saunders Elsevier,2008:1453-77.
2. Cunney RJ, Bialachowski A, Thornley D, Smaill FM, Pennie RA. An outbreak of influenza A in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2000;21:449-54.[CrossRef][Web of Science][Medline]
3. Potter J, Stott J, Roberts MA, Elder AG, O’Donnell B, Knight PV, et al. Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients. J Infect Dis 1997;175:1-6.[Web of Science][Medline]
4. Carman WF, Elder AG, Wallace LA, McAulay K, Walker A, Murray G, et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial. The Lancet 2000;355:93-97.
5. Salgado CD, Giannetta ET, Hayden FG, Farr BM. Preventing nosocomial influenza by improving the vaccine acceptance rate of clinicians. Infect Control Hosp Epidemiol 2004;25:923-8.[CrossRef][Web of Science][Medline]
6. Hayward AC, Harling R, Wetten S, Johnson AM, Munro S, Smedley J, et al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomized controlled trial. BMJ 2006;333:1241.[Abstract/Free Full Text]
7. Burls A, Jordan R, Barton P, Olowokure B, Wake B, Albon E, et al. Vaccinating healthcare workers against influenza to protect the vulnerable—is it a good use of healthcare resources? A systematic review of the evidence and an economic evaluation. Vaccine 2006;24:4212-21.[CrossRef][Web of Science][Medline]
8. Wilde JA, McMillan JA, Serwint J, Butta J, O’Riordan MA, Steinhoff MC. Effectiveness of influenza vaccine in health care professionals. JAMA 1999;281:908-13.[Abstract/Free Full Text]
9. Weingarten S, Staniloff H, Ault M, Miles, P, Baumberger M, Meyer RD. Do hospital employees benefit from the influenza vaccine? A placebo-controlled clinical trial. J Gen Intern Med 1988;3:32-7.[Web of Science][Medline]
10. Saxen H, Virtanen M. Randomized, placebo-controlled double blind study of the efficacy of influenza immunization on absenteeism of health care workers. Pediatr Infect Dis J 1999;18:779-83.[CrossRef][Web of Science][Medline]
11. Pearson ML, Bridges CB, Harper SA. Influenza vaccination for health-care personnel: recommendations of the healthcare infection control practices advisory committee (HICPAC) and the advisory committee on immunization practices (ACP). MMWRRecomm Rep 2006;55(RR-2):1-16.
12. Bull AN, Bennett N, Pitcher HC, Russo PL, Richards MJ. Influenza vaccine coverage among health care workers in Victorian public hospitals. Med J Aust 2007;186:185-6.[Web of Science][Medline]
13. Fiore AE, Shay DK, Broder K, Iskander JK, Uyeki TM, Mootrey G, et al. Prevention and control of influenza: recommendations of the advisory committee on immunization practices (ACIP). MMWR Recomm Rep 2008;57(RR-7):1-60.[Medline]
14. National Quality Forum. Safe practices for better healthcare—2006 update. www.qualityforum.org/publications/reports/safe_practices_2006.asp.
15. Joint Commission Accreditation Program. Hospital infection prevention and control, 2008. www.jointcommission.org/NR/rdonlyres/38BEBD6D-59D7-4314-9E2B-3C4571F92159/0/HAP_IC.pdf.
16. Talbot TR. Improving rates of influenza vaccination among healthcare workers: Educate; motivate; mandate? Infect Control Hosp Epidemiol 2008;29:107-10.[CrossRef][Web of Science][Medline]
17. Poland GA, Tosh P, Jacobson RM. Requiring influenza vaccination for health care workers: seven truths we must accept. Vaccine 2005;23:2251-5.[CrossRef][Web of Science][Medline]
18. Infectious Diseases Society of America. Pandemic and seasonal influenza: principles for US action. 2007. www.idsociety.org/influenza.htm.
19. A guide to the control of respiratory infection outbreaks in long-term care homes. Ontario: Public Health Division and Long-Term Care Homes Branch, Ministry of Health and Long-Term Care, 2004.
20. Centers for Diseases Control and Prevention. State immunization laws for healthcare workers and patients. www2a.cdc.gov/nip/stateVaccApp/StateVaccsApp/default.asp.
21. Polgreen PM, Septimus EJ, Parry MF, Beekmann SE, Cavanaugh JE, Srinivasan A, et al. Relationship of influenza vaccination declination statements and influenza vaccination rates for health care workers in 22 US hospitals. Infect Control Hosp Epidemiol 2008;29:675-7.[CrossRef][Web of Science][Medline]
22. Hagar BA. 2007 National influenza vaccine summit immunization excellence awards—Virginia Mason Medical Center’s mandatory vaccination campaign. www.preventinfluenza.org/summits/2007/Session_Four/Hagar_2007.pdf.

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