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H1N1 (Swine Flu): Mandatory Policy Increased Influenza Vaccinations Among Healthcare Workers

February 22, 2010

A mandatory program that asked health care workers (HCW) in a multihospital health system to choose between vaccination and termination resulted in a dramatic increase in the number of employees protected against influenza in the 2008-2009 season, as well as fewer requests for vaccine exemptions compared with previous years.

  • The initiative achieved a 98.4% vaccine coverage rate among BJC HealthCare’s 25,980 active employees, representing a 43.4% increase from the organization’s 2006 vaccination rates and a 26.5% increase from 2007 rates.

“Key factors that supported the success of the program included consistent communication emphasizing patient safety and quality of care, coordinated campaigns, leadership support and medical director support to talk with any employee with concerns about the vaccine, on request,” the researchers wrote.

Beginning October 15, 2008, free vaccine was provided to employees at all facilities within the large Midwestern health care system, which included 11 acute care hospitals and three extended care facilities, as well as day care centers and other physician groups.

Employees were able to seek medical and religious exemptions, but required either a letter from a licensed physician or a personal letter stating a religious conviction opposed to vaccination. The presence of an ACIP recognized contraindication was necessary in order to be approved for medical exemption. These included hypersensitivity to eggs, prior hypersensitivity reaction to influenza vaccine, and history of Guillan-Barré syndrome. Despite recommendations that pregnant women be vaccinated against influenza, pregnancy was accepted as a valid exemption, if the request was made by a physician.

Human resources reviewed exemption requests, made decisions and informed employees of their status within five days. Those who remained unvaccinated without an exemption by December 15, 2008 were suspended without pay. Employees vaccinated by January 15, 2009 were permitted to return to work; those who remained unvaccinated without exemption were terminated for not meeting conditions of employment.

  • Overall, 99.96% of employees were compliant with the policy.
  • Eight employees were terminated.
  • A total of 372 employees requested a medical exemption, 321 of whom were granted the request.
  • Among those who received medical exemption, 33% were approved on the basis of egg allergy, 26% due to prior allergic reaction, 5% due to history of Guillan-Barré syndrome and 36% had other conditions.
  • Ninety employees received religious exemptions.

The researchers noted that fewer employees sought either type of exemption with the mandatory program in place than had signed declination statements in previous years.  “Exemption requests often reflected misinformation about the vaccine and about influenza among employees and among their physicians,” the researchers wrote. They noted that several requests were made on the basis of chemotherapy or other immunosuppressed states and pregnancy, despite the fact that ACIP considers these groups high risk and therefore a priority for receiving influenza vaccine. There was also a tendency for employees to seek religious exemption if their medical request was denied.

Rates of possible adverse events were low, at .08% (n=21), according to data collected in an occupational health database, and included sore arm (n=11), possible allergic reaction (n=5), and possible vagal response with fainting (n=1). The researchers also reported four adverse events with uncertain associations to the vaccine.

Babcock HM. Clin Infect Dis. 2010;50:459-464 and Pavia AT. Clin Infect Dis. 2010;50:465-467.

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