Vaccine compliance: Only one way to improve it?
Experts ponder reasons for low HCW acceptance
Health care worker compliance with vaccination programs varies by hospital, "but in general, it’s miserable," says one national expert who maintains that hospitals’ "passive" attempts to get workers vaccinated are ineffective and should be replaced by policies that make vaccination a condition of employment
All health care workers should be immune against varicella, measles-mumps-rubella, and influenza, as well as hepatitis B, says Gregory A. Poland, MD, chief of the Mayo Vaccine Research Group and associate professor of medicine at the Mayo Clinic and Foundation in Rochester, MN, and chair of the National Coalition for Adult Immunization in Bethesda, MD.
Poland says he would support a federal law requiring HCW immunity against those diseases. At the very least, hospitals should consider offering all recommended worker immunizations in the same manner as they do for hepatitis B, which the bloodborne pathogens standard mandates offering to all workers who risk exposure.
"If I had my way, that should be the standard of care, recognizing that there are people who have medical contraindications or medical and philosophical objections to that. For example, the program I would run would be like the one for hepatitis B. We would encourage and record for everybody that they get the vaccination, or they sign a declination statement," he says.
Hospitals are doing a good job offering workers hepatitis B vaccine, "but that’s because there is a very definite program that is an active program, not a passive one," says Poland, who explains that a passive program is one that does not enforce strict vaccination policies.
"Most of the influenza programs, for example, are passive programs. At most what hospitals will do is wheel around a cart."
In 1993, the federal Centers for Disease Control and Prevention (CDC) in Atlanta surveyed more than 800 hospitals and found poor compliance across the board with the Advisory Committee on Immunization Practices’ (ACIP) recommendations for HCW vaccinations. (See related story in Hospital Employee Health, November 1994, pp. 146-148.)
ACIP, a panel of experts that periodically reviews guidelines on vaccinations and prophylaxis for the CDC, recommends use of certain immunobiologics for HCWs, as well as for specific patient groups in hospitals.
Survey results showed that about 80% of hospitals had written vaccination policies covering various personnel categories, but policies differed as to which vaccines were included in the program. No hospital had a comprehensive vaccination program for HCWs.
Current ACIP recommendations require two doses of measles vaccine for new staff and all those born in and after 1957, and at least one dose for current staff. Measles-mumps-rubella (MMR) is the vaccine of choice.
Hepatitis B vaccination must be offered by federal mandate, and ACIP recommends that influenza vaccine be offered to all personnel before flu season, with special emphasis on staff who care for high-risk patient groups.
Hepatitis A vaccine presently is not recommended for routine administration to HCWs, except for laboratory workers who are exposed to live virus. Varicella vaccine is recommended for all susceptible hospital personnel.
Poland says three main factors account for poor compliance with vaccination programs. First, "it takes a while for vaccines to become incorporated into routine practice, and the varicella vaccine has been available for only a year or two. We’ve had measles vaccine since the 60s, and we still don’t as a nation ensure that all of our health care workers have immunity to measles."
Second, financial considerations often impede development of active vaccination programs, he says.
"All the health care institutions say, Oh no, look at the cost of giving hepatitis B [vaccine]. Do we really want to take on another vaccine, and then another one?’ They don’t recognize the longer-term consequences of not doing that," Poland explains.
The third factor is that HCWs often don’t acknowledge the severity of the diseases they could contract if not vaccinated, both for themselves and their patients.
Influenza is an example. When Poland lectures at meetings of nurses and physicians, he often asks for a show of hands of those who have been vaccinated against influenza.
"Generally, between 20% and 50% at the most 60% of the audience will raise their hands, and you know that 40% of them don’t have a contraindication for it," he says. "That’s because health care workers in particular grossly underestimate the seriousness of influenza. It is shocking, in fact."
Most of Poland’s vaccination recommendations for HCWs correspond to current CDC guidelines, except that he supports hepatitis A vaccine for any personnel who are exposed to active cases, in addition to lab workers exposed to live virus.1 (See chart detailing Poland’s recommendations, p. 114.)
Poland says his guidelines will be incorporated into updated CDC recommendations to be released later this year, but Walter W. Williams, MD, MPH, chief of the adult vaccine preventable diseases branch of the CDC’s National Immunization Program, did not confirm whether the agency’s hepatitis A recommendation will be changed. He says a joint statement from the Hospital Infection Control Practices Advisory Committee and ACIP will be issued this year, which will in part consolidate and update HCW immunization guidelines.
Vaccination programs are a cost-effective prevention technology, Williams says.
"It’s one of the most important aspects of a comprehensive infection control program, not only for health care workers but also for patients with whom they may have contact," he explains. "The issue is an easy one just because hospitals are places where people come with illnesses, so there’s always the risk for transmission of vaccine-preventable diseases from patients to personnel and also from personnel to patients."
If every hospital would "do the right thing" and implement aggressive vaccination programs, "it would be great," Williams adds, "but it’s not happening."
Part of the issue involves the decision of whether to mandate vaccination as a condition of employment or to recommend that employees take vaccine. Most hospitals choose to recommend rather than mandate.
"When they leave it as a recommendation, often there is a problem with compliance unless they have an aggressive outreach program," Williams states. "It’s been shown any number of times in studies that if an institution wants to make sure its personnel are vaccinated against influenza, it can do so by having an aggressive outreach program. But when you make something a job requirement, then you open the [issues] of labor unions and state laws. It’s not just a simple thing. The CDC has consistently commented that when vaccination programs are mandated, then compliance improves, and the position of the CDC is to do everything you can to improve compliance."
Making vaccination acceptance a condition of employment is about the only effective means of boosting compliance, says Kathleen VanDoren, RN, BSN, COHN-S, executive president of the Reston, VA-based Association of Occupational Health Professionals in Healthcare (AOHP).
"Compliance is poor unless you put some kind of a strong condition to it," VanDoren states. "If the employee health department is given the option to suspend for noncompliance, that puts a bite into it."
Nonetheless, employee health practitioners cannot enforce such policies without administrative backup, she points out. Telling employees they will be suspended or terminated if they refuse to comply, unless they have a medical contraindication or religious objection to the vaccine, does no good without follow-through.
"Administrators need to stand behind employee health services and follow through by terminating if that’s what they say they will do. They have to be willing to go as far as they need to go, up to and including termination. Administration will do that if they really feel that employee health is an important department or if they understand the need for and the seriousness of vaccination," she adds.
EHPs can educate administrators on those issues and perhaps point out that unvaccinated employees can open a "Pandora’s box," VanDoren says. "The public is so sue-happy that all you need is for it to become known that the hospital let an employee slide by [without being vaccinated] and that a patient got sick as a result, and you have a negligence suit."
Reference
1. Poland GA. Update on immunizations: Optimizing vaccine use. Presented at the 23rd annual educational conference and international meeting of the Association for Professionals In Infection Control and Epidemiology. Atlanta; June 1996.
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