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The Mandate Debate: How Can We Increase Clinicians' Flu Vaccination Rates?

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If the golden rule of medicine is “First, do no harm,” some experts in infectious diseases think the majority of clinicians are dropping the ball—at least when it comes to influenza vaccination. For years, the rate of vaccination against flu among health care personnel has been “unacceptably low,” in the words of Neil Fishman, MD, President of the Society for Healthcare Epidemiology of America (SHEA), “despite Herculean efforts to increase it.”

Now, SHEA and other professional medical organizations think it may be time to take the gloves off (figuratively, of course). The organization recently published a position paper in Infection Control and Hospital Epidemiology in which it “endorses a policy in which annual influenza vaccination is a condition of both initial and continued [health care personnel] employment and/or professional privileges.” The recommendation applies to all health care providers (and other workers) in all settings, as well as students and volunteers.

Within two weeks of that paper’s release, the American Academy of Pediatrics (AAP) published its own policy statement recommending “implementation of a mandatory influenza immunization policy for all health care personnel.” Is this the way the wind is blowing—and how long and how fiercely will it blow?

Dismal Rates of Coverage

The call for mandatory influenza vaccination for health care providers may puzzle those who wonder how extensive the problem actually is. But surveys have shown that rates of flu vaccination among health care workers consistently hover at or below 50%: According to the National Health Interview Survey, rates did not improve significantly between the 2003-2004 and 2007-2008 influenza seasons (44.8% and 49.0%, respectively). A 2009 analysis by the RAND Corporation found that just 53% of surveyed health care workers reported receiving the vaccine during the previous flu season.

In January of this year, the CDC did announce that an estimated 62% of health care personnel had received the seasonal influenza vaccine during the 2009-2010 season—perhaps (pure speculation) because even those suspicious of the 2009 H1N1 vaccine felt the need for some layer of protection from flu and related illnesses. By comparison, the rate of coverage for the H1N1 vaccine was just 37% among health care workers, and only 35% reported receiving both vaccines. (Recall that health care providers were given priority status for the H1N1 vaccine, due to the nature of their work and greater potential for exposure to the virus.)

“One of the questions I’m frequently asked is, ‘What’s the rate among doctors? What’s the rate among nurses?’” says Gregory A. Poland, MD, who was one of two liaisons from the Infectious Diseases Society of America (IDSA) on the writing committee for the SHEA position paper, which has been endorsed by IDSA. “No one knows, nationally. We know that when we look at all health care workers in the US, the majority doesn’t get seasonal influenza vaccine. Between 50% and 60% of them don’t get it.”

There are bright spots; for example, in 2008, the American Academy of Physician Assistants (AAPA) included a question about flu vaccine coverage on one of its surveys. “I’m happy to say [the rate] was higher than I expected,” reports AAPA President Patrick Killeen, MS, PA-C. “Where the general population was at around 39% or 40%, among the PA population, 67% said they had received their flu vaccine.”

Underestimating the Disease

Overall, the available data suggest that most health care providers tend not to receive their annual influenza vaccination—which begs the question, why not? Some of it may have to do with a sense of invincibility; health care providers may see themselves as younger and healthier than other people—and therefore, less likely to become ill.

“Sometimes, it’s framed as altruism: ‘I’ll save the vaccine for my patients,’” Poland says. “But more often, it’s [because] they don’t understand that they need it and/or they’re afraid of side effects.”

Killeen points out that most people who do not get vaccinated against influenza cite safety issues or fear of getting the flu from the vaccine as their reason—and that includes health care workers, who should be better informed. “It’s concerning, because we perpetuate that miseducation, not only for ourselves,” he says. “That belief system is then passed on to our patients.”

Another issue may be the perceptions people have about flu versus those they have about vaccines. Although a causal relationship has never been established, there was an increase in cases of Guillain-Barré syndrome, and 25 deaths, during a government program to immunize people against swine flu in the 1970s. Whether the cause was the vaccine or the influenza itself, and whether people were directly affected, “that memory doesn’t go away,” as Killeen says.

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