Mandatory Vaccinations for Healthcare Employees Work

As we enter an influenza season that might be complicated by not only the presence of coronavirus disease 2019 (COVID-19) but also a possible vaccination for COVID the question arises: Will mandatory vaccination for healthcare workers be necessary?

Two studies published in the American Journal of Infection Control,that look at compliance with flu vaccination, answer that question with an emphatic “Yes!” One study looks at what happened at a large healthcare institution in the Midwest—BJC Healthcare in St. Louis—that made employment for healthcare personnel contingent on them getting the flu vaccine. The other looks at what’s going on in a hospital in Switzerland in which getting the flu vaccine isn’t mandatory. One is a success story; the other, not so much.

BJC Healthcare implemented a mandatory flu vaccination policy during the 2008-2009 flu season. Before the policy, about 70% of healthcare workers were vaccinated, according to the study. After the policy’s implementation, that immediately jumped to 98.4% the subsequent year and remained above the 97% level during the next 9 years.

In the meantime, religious and medical exemptions from getting vaccinated decreased at the healthcare system’s academic medical systems and remained the same at the community hospitals that it owns. In addition, employees began to get the flu vaccine earlier in the flu season and employee opposition to the mandatory policy hasn’t grown since it started.

“Implementation of a mandatory influenza vaccination policy has produced sustained increases in staff vaccination coverage that greatly exceeded immunization coverage produced by alternative approaches to encourage and promote vaccination,” write the BJC investigators. “Implementation of a mandatory vaccination policy has allowed the organization to exceed the 2020 national objective for healthcare personnel immunization coverage during 10 influenza seasons.”

Meanwhile results from the study conducted at the University Hospital Basel, Switzerland were underwhelming, as the Swiss investigators note. They’re thinking of making healthcare worker employment contingent on getting a flu vaccine.

“Mandatory influenza vaccination of HCWs was introduced in the United States a decade ago with excellent results, improving vaccination rates to more than 90%,” the Swiss study states. “Both administrative and attitudinal barriers to vaccination need to be addressed prior to such policy change. The right of self-determination was one of the most important reasons for non-vaccination in our study pointing to the challenges ahead prior to the introduction of a mandatory influenza-vaccination policy.”

The Swiss investigators surveyed 1454 healthcare workers (HCW) from 2007 to 2019, finding a range for vaccinations in those years from 14.7% to 31%. The study states that that 31% demonstrates that far too few HCWs get the flu vaccine, but it actually represents a minor success in terms of the study’s goals. That was the rate of HCWs at the hospital who got the vaccine for the 2013/2014 flu season. The rate for the prior flu season was 14.7%.

Investigators launched an all-out campaign to encourage more HCWs to get the vaccine, with the goal of reaching at least 30%. So, in that sense, the campaign was successful. Still, a “vaccine uptake of 31% is still unacceptably low, given that 25% of HCW are infected with influenza each year,” the Switzerland study states. And when HCWs are infected, they can pass that infection on to patients. In the following seasons, HCW vaccination rates remained stable, ranging from 26% to 28%.

During the 2013/2014 flu vaccination campaign, the Swiss hospital offered free vaccinations that were easily accessible to all employees, as well as educational lectures and handouts that addressed misconceptions about the flu vaccine. In addition, peers and role models at the hospital also tried to raise awareness of the importance of compliance.

The reasons for not being vaccinated were compared between 4 different groups: nurses, physicians, and HCWs other than physicians or nurses with or without patient contact.

Eighteen-point-eight percent of HCWs surveyed said that they had had negative experiences with the flu vaccine, mainly related to side effects. Then came perceived vaccine failure (55.8%), the lack of vaccine availability (5%). The side effects that were reported included pain at the puncture site (9.8%), muscular pain 6.8%, general malaise (6.5%), discomfort 3.2%, headache 3.1%, and fever 2.1%.

“We have found higher vaccination coverage in physicians (as compared to other occupational groups) and employees of an internal medicine ward,” the study states. It continues: “Higher vaccination rates among physicians may be an indication that our current educational campaigns are better suited for physicians than nursing staff, leading to higher acceptance rates among physicians as compared to other professions.”

Meanwhile, over the 12-year period since its mandatory flu policy, the employee population of BJC Healthcare grew from about 26,000 to about 31,000. The system comprises 15 acute care hospitals in rural, urban, and suburban locations.

During the two years before the mandatory vaccination policy, the peak dates for employee compliance were October 30 and November 1. When the mandatory policy was implemented the next year, the peak date was October 15, and now it occurs in late September or early October.

Earlier vaccination “increases the likelihood staff are vaccinated and have sufficient time to develop immunity before significant community transmission of seasonal influenza begins.”

The study also states that one of the purposes of the mandatory flu vaccination policy “was to increase employee vaccination rates to enhance herd immunity and protect patients, visitors, and staff who have not been immunized.”

In order for a mandatory vaccination program to work, it’s crucial that a healthcare organization’s leaders push for that outcome, the study states. Even to the point of terminating employees who refuse to get vaccinated if they don’t have a legitimate religious or medical reason for not doing so.

“Leaders throughout the organization have endorsed the goal of vaccinating employees and are aware of the annual immunization requirement, publicize its existence and facilitate the use of occupational health and internal resources to further this aim,” the study states.