Washington state hospital sees 96% compliance with flu shots

In 1998, 19 infants in a Canadian neonatal intensive care unit were infected with influenza, and one died. Only 15% of the hospital's staff was immunized, and health care workers were the likely source of the spread, according to an article in Infection Control and Hospital Epidemiology.

It's precisely this type of tragedy that top officials at Seattle's Virginia Mason Medical Center hoped to avoid in 2004 when they announced that all employees -- including 390 physicians -- would have to be vaccinated, provide a medical or religious exemption, or find work elsewhere.

After being slowed by vaccine shortages, a legal dispute and ethical concerns, Virginia Mason announced in December 2005 that 96% of its 5,000 employees had received the influenza vaccine. Hospital officials fired a handful of employees who refused the vaccine.

While the figure fell short of Virginia Mason's 100% goal, it is more than double the 36% national health care worker immunization rate the Centers for Disease Control and Prevention documented in 2003.

"In the months and years to come, we'll see [Virginia Mason] as a leader," said Greg Poland, MD, director of the Mayo Clinic's Vaccine Research Group and a leading advocate for more aggressive health care worker immunization programs.

The CDC estimates that influenza and flu-related complications annually kill 36,000 people, 90% of whom are elderly. More than 114,000 people are hospitalized for influenza yearly, the CDC says, though it's unclear how big a role doctors and other health care workers play in spreading the disease.

Three other health systems have aggressive flu vaccine programs, but what sets apart Virginia Mason's plan is that it targets all staff and requires immunization as a condition of employment.

"We're talking about everyone," said Joyce Lammert, MD, Virginia Mason's chief of medicine. "People who answer phones, people who do the billing. It was hard to figure out where to draw the line, and we thought it would be better to have our patients protected, regardless."

Making vaccines a condition of employment is controversial. The Washington State Nurses Assn., which represents more than 600 nurses employed by Virginia Mason, sued to stop the hospital from firing union members who refused the flu vaccine. In January, a U.S. District Court upheld an arbitrator's ruling that the plan violated the collective bargaining agreement.

The hospital has appealed the ruling to the 9th U.S. Circuit Court of Appeals, arguing that it "has the right to establish a staff influenza immunization requirement as a safety measure for the protection of its patients and staff," according to a Virginia Mason statement.

The nurses' union disagrees.

"Education, accessibility and incentives, not brute force, are the best way to encourage people to comply" with a flu vaccine drive, said Barbara Frye, RN, WSNA's labor relations director. Ultimately, close to 90% of the 600 unionized nurses were vaccinated; those who didn't must wear masks when in contact with patients. The WSNA has filed an unfair labor practice charge with the National Labor Relations Board over the mask policy, arguing that there's no evidence the masks prevent the spread of flu.

Lawsuits aside, experts argue that educational initiatives alone largely have failed in boosting vaccination rates. "There's been no report of sustained high levels of immunization in voluntary, passive programs," Dr. Poland said, noting that even the best such efforts missed 30% to 50% of health care workers.

Many hospitals and clinics require physicians and other health care workers to receive immunizations for rubella, chicken pox, hepatitis B and other diseases.

"We've already done it for all the others," said Sue Sebazco, RN, president of the Assn. for Professionals in Infection Control and Epidemiology, a 10,000-member group composed largely of nurses. "Why haven't we done it for the flu? We need to be there, and we probably should have been there before."

Ethical obligations

Physicians and other health care workers are ethically obliged to protect patients, and receiving the flu vaccine is one way of doing that, according to Thomas R. McCormick, PhD, a senior lecturer emeritus at the University of Washington's Dept. of Medical History and Ethics.

"As we have more of an evidence-based understanding of medicine, then the implications of that knowledge create burdens that were not previously there," Dr. McCormick said, arguing that this obligation extends to health care organizations.

Still, many oppose a "get your flu shot or get out" approach.

"I'm one of the few people left in America who still think this country's about freedom," said Meryl Nass, MD, a board member of the Alliance for Human Research Protection, who says the flu vaccine is not "risk-free" and that the CDC's 36,000 fatality figure might be overblown. "People should be able to make these decisions for themselves."

AMA policy strongly encourages physicians to be immunized and says hospitals should "have a system for measuring and maximizing the rate of influenza immunization for health care workers," but the policy does not directly address mandates such as Virginia Mason's.

At press time, the CDC's Advisory Committee on Immunization Practices was set to release guidelines on health care worker immunization, according to a CDC spokeswoman.