Don’t forget healthcare workers are required to have other mandatory immunizations, so why isn’t the influenza vaccination included?

KEYWORDS:

• Influenza
• vaccination
• healthcare workers

There are two principal models of seasonal influenza vaccination provision to hospital healthcare workers (HCWs): voluntary and mandatory. In a voluntary system, multiple and layered strategies are used to encourage vaccination acceptance. Campaigns traditionally include the use of mobile vaccination carts, email/intranet reminders, posters, in-service events, vaccination incentives, and signed declinations forms. On the other end of the spectrum is mandatory vaccination, which has gained popularity particularly in the United States as the solution to poor vaccination rates [1]. In this model, all HCWs must be vaccinated unless with exemptible reasons (in some settings) such as medical contraindications. Theoretically, a mandatory model ensures a definite level of vaccination since it removes the variability of personal attitudes and other behavior barriers [2].

There is a growing body of literature focused on the introduction of HCW influenza vaccination mandates. Some have approached the issue with an ethical imperative lens. The argument is framed around the fact that staff members follow the decree to ‘first do no harm’ and should therefore take all reasonable actions to reduce transmission of disease in the context of providing care to vulnerable patients. This obligation to do no harm should not be linked to institutions using coercion, but rather institutions acknowledging the rights of patients to have a safe healthcare environment [3]. The obligation is further tied to the understanding that patients in the healthcare setting are often vulnerable to influenza, whether they be the very old, young or because they are pregnant or have a chronic or underlying immunosuppressant condition. These patients trust that the institutions they are attending have taken all necessary steps to ensure a safe environment, whether it be through environmental cleaning, sterilization, hand hygiene, respiratory etiquette, or occupational vaccination.

The traditional argument used in response to the suggestion of mandating influenza vaccination, is the concern that it will impinge on HCWs’ rights to ‘autonomy.’ However, this argument is somewhat confusing as for many years HCWs have been required to provide evidence of protection against other vaccine-preventable diseases like hepatitis B, diphtheria, measles, tetanus, varicella etc. If the staff member is not protected and wants to work in a high-risk area (i.e. intensive care, antenatal, oncology) then they are ‘required’ to comply with the policy requirements (i.e. receive the vaccines) [4].

More recently there has been a growing commentary that is hinged to the idea that the influenza vaccine is not sufficiently robust to warrant moving to a mandatory immunization requirement [5]. Proponents highlight that the effectiveness of the current influenza vaccine has been exaggerated in the medical literature and media and therefore given the limitations, the introduction of mandatory programs is not appropriate. Some have gone onto suggest that even though other vaccine-preventable diseases are uncommon, mandatory vaccination should still be considered first for infections where the vaccines are highly effective, like measles. As part of this argument, healthcare institutions should continue to recommend the influenza vaccine to staff members (and recommended to patients and their families) but efforts should also be made to strengthen other prevention strategies such as hygiene.

While it will be extremely rare to find someone, who would refute the rational for HCWs to receive the influenza vaccine, not everybody agrees with the suggestion of making it mandatory requirement. So here lies the problem, what is our next step? Firstly, let’s explore the status quo: remaining with a voluntary approach. It is now well established that organizations need to use multicomponent programs to improve influenza uptake. Components must address: access (free vaccination, flexible, and convenient worksite vaccine programs delivered at different shifts, times, days); knowledge (education programs aimed at improving understanding the rational for influenza vaccination delivered via in-service, posters, flyers, lectures, etc.); reminders (providing information about time/place of the vaccine service delivered via posters, email, text messages); incentives (while perhaps not a core component, there are often riots when the lollypops are not available); and management (provisions of resources/staff, declination forms, training, feedback, and evaluation) [6]. A recent study has even gone so far as to offer a day off work to HCWs who receive the vaccine (median vaccine uptake rate 66.7%, range 38.9–80%) [7]. In addition to these strategies, there is the option of establishing a key performance indicator and linking it to hospital funding (or a slap on the wrist) or using public reporting of hospital immunization coverage rates for staff vaccination as incentives to push hospital CEOs to improve rates. To support these voluntary program, it has also been suggested that we also: improve staff compliance with hand hygiene, cough etiquette, and with the use of masks/respirators and (re)educate staff members about taking time off work if unwell to reduce the number of staff who are working while unwell with respiratory illnesses (‘presenteeism’). While not dismissing the value of the idea of (re)educating staff members to stay away from work when unwell, when was the last time someone stayed away from work at a hospital short of being confined to a bed because of near terminal illness. We also must remember that a proportion of HCWs will have subclinical infections, thus constituting an ‘obscure pool for the transmission of the infection to those hospitalized’ [8].

Voluntary HCW influenza immunization programs, although improved over the last decades, still are not achieving the acceptable uptake rates. This low uptake of vaccination in HCWs does not seem to be the result of a failure to push from administrators and government authorities. Nor are the culprits a lack of vaccines or money to pay for them. So, do we just run bigger and better voluntary programs? Do we have the capacity, resources, and staff member determination to run voluntary programs with more elements such as education sessions, better incentives such as days off? Probably some hospitals could do this but not all organizations have the capacity [6]. Are we going to be able to persuade those staff who do not receive the vaccine because they believe they are ‘fit and healthy’ to get vaccinated? Or are we at the point of proclaiming that voluntary programs will never succeed and that we need to develop new programs and/or legislation requiring influenza vaccination for HCWs.

The published observational studies focused on documenting the introduction of mandates for HCW influenza vaccination all suggest that these programs increase rates. According to a 2016–2017 CDC report, vaccination was highest among HCW who were required by their employer to be vaccinated (98.3%). In comparison, vaccination rates among HCW from settings in which vaccination was not required, promoted, or offered on-site were observed to be as low as 45.8% [9]. Further evidence for the impact of mandates can be found in the paper by Rakita et al. who documented coverage rates of 98% for approximately 5000 HCW over a 4-year period, compared with a 54% vaccination rate prior to the mandate [10]. A similar finding was reported by Helms et al. who showed that at the end of 4 years, hospitals with a mandate had achieved a 96% vaccination rate compared with 87% in hospitals without a mandate (p < 0.001) [11].

The decision to shift from a voluntary-based program to having mandatory requirements for staff influenza vaccination is not going to be made lightly and will probably take a couple of years to implement. For hospitals contemplating the introduction of a mandatory influenza vaccination directive, it is important that they consider the resources and organizational support required and the level of leadership commitment and staff support at the organization. To move forward with the introduction of mandatory policies, it has been suggested that elements need to be addressed: (1) providing and communicating a solid evidence base supporting the policy directive; (2) addressing the concerns of staff about the vaccine; (3) ensuring awareness amongst staff about the need to protect patients; and (4) addressing the logistical challenges of enforcing an annual vaccination [10]. Senior leadership commitment, early delivery of education, commitment of resources, and accountability of frontline staff have all been identified as factors that are key to the success of mandatory HCW influenza immunization programs [12].

While the number of published reports of hospitals successfully introducing policies increases each year, mandatory vaccination remains a controversial strategy that pits HCW autonomy against patient safety. In addition, there will be those in the field that will point to the fact that there remains empirical uncertainty regarding the impact of HCW influenza vaccination on patient outcomes. Despite the growing body of literature, there is currently insufficient evidence related to the impact of these mandates on clinical outcomes among HCW and patients. In a recent systematic review of the effect of these mandates on vaccination rates [13], only two of the included studies reported on absenteeism in HCW, and none of the included studies examined patient outcomes. However, as noted by Pitts et al. in their systematic review, this lack of evidence of an effect of mandates for HCW influenza vaccination on patient (and staff) outcomes does not mean there is absolute lack of effect [14]. Common sense (and the published literature [15]) all agree that influenza immunization is the primary method for prevention of morbidity and mortality associated with influenza infection.

When framing the argument for mandating influenza vaccination, I fall back to the paradigm that hospitals can’t keep doing what they are doing. There must be a point when we realize that our voluntary programs are not cutting it and that we need to move forward. Patient safety has long been recognized as a right and occupational vaccination should be part of that commitment alongside hand hygiene and other healthcare associated infection prevention strategies. Making influenza vaccination mandatory is not going to be easy. There are going to be financial, structural, and attitudinal barriers to overcome to implement policies either within a single institution or across a state. But it is time that our healthcare systems take responsibility and step up the challenge. Lastly, if someone tries to use the argument that unlike other mandated vaccines, influenza is required each year, I would suggest that they roll up their sleeve for the influenza vaccine while they are doing their mandatory yearly fire extinguisher safety training.

Declaration of interest

H Seale has previously received funding from vaccine companies (BioCSL, Seqirus, GlaxoSmithKline and Sanofi Pasteur) for investigator driven research, and funding for travel to present at state-based meetings/conferences. The author has no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

A reviewer on this manuscript has disclosed that they have received grant funding from Pfizer Inc., and Merck & Co., Inc. Peer reviewers on this manuscript have no other relevant financial or other relationships to disclose.

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Funding

This manuscript was not funded.