Alex Hartlage: Photo by Andrew Collings.

Five years ago, I made the decision to enter medical school to become a physician and healthcare advocate. Implicit in this decision was the understanding that I would take the necessary actions needed to protect and improve the health of those under my care and within my community. One of these actions is annual influenza vaccination.

Every year, thousands of individuals die or require hospitalization due to complications from influenza infection. In many of these cases, patients contract the disease through direct contact with an infected healthcare provider or hospital employee while receiving treatment for an unrelated illness. This disheartening reality has prompted numerous professional organizations, including the American College of Physicians and the Veteran’s Health Administration, to endorse annual influenza vaccination as a mandatory requirement for all healthcare personnel.

The rationale for such a policy is straightforward. Due to their daily interactions with ill patients, healthcare personnel are at a heightened risk for acquiring influenza, which can then be passed to coworkers or patients receiving their care. Vaccination is one of the most effective safeguards against the contraction and spread of influenza, but many patients are ineligible for this basic intervention because they are either too young or do not possess a functional immune system owing to the nature of their disease or treatment. Thus, the only protection available for these susceptible individuals is that they do not come into contact with an infected individual carrying the potentially lethal virus.

Unfortunately, influenza vaccination rates for healthcare workers have failed to reach the critical threshold to establish herd immunity, necessary to protect these at-risk individuals. According to the latest Morbidity and Mortality Report published by the Centers for Disease Control and Prevention, the overall vaccination coverage rate for healthcare personnel in the United States was 78.4%, well below the Healthy People 2020 annual target goal of 90%. Coverage rates noticeably varied based on healthcare setting. The highest coverage was observed by those employed by hospitals (91.9%) and the lowest by those working in long-term care settings (67.4%). Poor immunization rates for those working in long-term care settings are particularly alarming because of the high frequency of interactions amongst patients and healthcare personnel in this environment and the susceptibility of this patient population (typically elderly individuals with underlying health issues) to severe influenza complications.

The challenge for adoption of immunization use is not vaccine efficacy. Growing evidence confirms that hospitals with higher vaccination rates have lower incidences of hospital-acquired infections, including those caused by the influenza virus. A recent meta-analysis estimated a 29% reduction in deaths from all-causes and 42% reduction in influenza-like illnesses in places where influenza vaccination of healthcare personnel is in place. Furthermore, consistent benefits have been observed in long-term care settings such as nursing homes when high rates of vaccination coverage are present.

The real challenge is in creating a healthcare environment that recognizes the value of influenza vaccination and takes reasonable approaches to improve coverage for providers. For many institutions, mandatory vaccination has been the most successful strategy. Across the country, hospitals that require vaccination have substantially higher rates of vaccine coverage compared to those that do not. In this past season coverage was substantially higher in settings where vaccination was mandated (94.8%) compared to those without a requirement (47-76%). A recent multi-institutional study showed that, in addition to increases in immunization coverage, mandatory vaccination resulted in a 30% decrease in days lost due to illness, improving staffing during critical periods of healthcare personnel shortage.

Because of the potential dangers posed by hospital-acquired influenza, some institutions have even begun mandating vaccination for all employees, contractors, and affiliated staff regardless of whether they engage in direct patient contact. Such a strategy was adopted in 2009 by Loyola University Medical Center in Chicago with encouraging success. In the first year of program implementation, 99.2% of employees complied with the policy, 0.7% were exempted for medical or religious reasons, and 0.1% chose to forfeit their employment. These findings were sustained over the subsequent 4 years of study and were not associated with excessive rates of voluntary termination. Dr. Jorge Parada, who leads the immunization program at Loyola, argues that this is a fundamental safety precaution that everyone must take. “Just as construction workers must wear steel-toed boots and hard hats on job sites as a condition of employment, we believe that healthcare workers should get a flu shot to work in a hospital,” he said regarding the program’s findings.

Despite these benefits, mandatory vaccination is used in less than half of US healthcare settings. At least some of this resistance is driven by ethical concerns about the healthcare worker’s right to individual autonomy and freedom from excessive coercion or undue burden. Although it is important to acknowledge these arguments, it is necessary to evaluate them in the larger context of patient care and safety. Workers are entitled to a reasonable degree of personal autonomy, but that right should not be weighed higher than the ethical responsibility to protect patients from undue harm, especially when the physical and financial burden placed on personnel by vaccination is minimal. In much the same way that hand hygiene is deemed essential before all patient contact, so should influenza vaccination be considered standard operating procedure because of its value to patient health and safety.

Mandatory vaccination policies can improve influenza coverage rates. That much is clear. But what these policies reflect about us as a healthcare system and culture is equally as meaningful. The time is now to remind ourselves of our obligation to each other and the value we place on protecting patient health. If you’re a healthcare administrator, please consider the benefits of a mandatory vaccination policy for influenza. If you’re a healthcare provider or employee at a healthcare institution, please pursue annual vaccination regardless of whether you are required to do so. Immunization works best when we all take part. Please join in this collective call to action – our patients are worth it.

Alex S. Hartlage
MD/PhD candidate
The Ohio State University College of Medicine

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