VANCOUVER, B.C. – At a time when only about half of health care workers are immunized against influenza, a concerted effort by a hospital in Omaha, Neb., led to a remarkable upswing in the number of employees there who got a flu shot, without being mandated to do so, according to Dr. Archana Chatterjee.

More convenient vaccination scheduling made it easier for hospital workers to get vaccinated.

Through common sense approaches like offering employees shots after hours and on weekends, and requiring those who refused a shot to wear a surgical mask, Children’s Hospital and Medical Center saw its health care worker vaccination rates climb steadily from about 52% in 2002 to 86% in 2008.

To get the remaining holdouts, the hospital did enact a mandate in 2009, but "I think the important thing is that we did not have protests; we did not have people refusing vaccinations when it came to the mandate in 2009," Dr. Chatterjee said at the annual meeting of the Infectious Diseases Society of America.

There were no legal challenges to the mandate or widespread employee dissatisfaction, unlike at other institutions. Today, the vaccination rate at the hospital is about 97% among the 1,860 employees. Health care workers at the hospital are not unionized, said Dr. Chatterjee, a hospital epidemiologist and pediatrics professor at Creighton University, Omaha.

"I think the reason [there were no protests] is that in previous years, we had worked with the employees to respond to their concerns [and to] educate them. That’s what resulted in relatively high rates of immunization against influenza, even before the mandate was put in place," she said.

Dr. Chatterjee gave an example of the education efforts. "We had a surgeon who thought he never had influenza. Those are the kinds of myths that we have to dispel to help people recognize that influenza can be mild or even asymptomatic in some people," but they are still able to spread it, she said.

Other steps included not charging for the shots, taking the shot cart to where people were working on the patient floors and having coworker colleagues administer the vaccine, offering vaccinations during annual physicals, and putting reminders about flu shots on the hospital’s computer system.

Also, "last year there was a request to provide vaccine to family members, and we actually did do that, as well, at various venues at various times." Dr. Chatterjee said that the key to the program’s success was that "we were responsive to the issues that were being raised. There was something that they saw changed as a result of bringing that issue to us," she said.

The hospital also updated the form employees must sign if they refused the vaccine.

"The original form just said 'I refuse to have the vaccine'," Dr. Chatterjee said.

The updated one "made it very clear that if they refuse the vaccine, they are putting their patients at risk and putting their coworkers at risk," she said.

The form also requires employees to wear a surgical mask throughout the influenza season if they refuse the vaccine, even if they produce a medical exemption.

The updated refusal form states that "those who do not comply with the mask requirement will be subject to corrective action up to and including termination."

When employees ignored the order, "we would get reports from people saying, 'You know xyz has not been vaccinated and is not wearing a mask'?"; everyone on the unit knew who was not vaccinated.

In those cases, infection control nurses would visit the workers and remind them that they had signed the document.

"A couple of people actually started [wearing the masks] and then realized what an onerous job wearing a mask for the entire shift was. Those medical exemptions quickly disappeared," Dr. Chatterjee said.

"It was pretty clear to us that there were some key changes that made big differences, and the mask issue was one of those," she said.

Dr. Andrew Pavia, chief of the division of infectious disease in the department of pediatrics at the University of Utah, Salt Lake City, noted that such voluntary programs go only so far in raising vaccination rates. "The best possible voluntary programs only get health care worker vaccination rates into the mid-80% range. This is the reason that so many health care organizations have endorsed mandatory immunization."

There isn't an adequate percentage below 100% at which you stop transmission, and "so we need to target something that approaches 100%. It appears, right now, that mandatory immunization is the policy that works."

Dr. Chatterjee and Dr. Pavia reported having no conflicts of interest.

Common Sense Policy Boosts Vaccination of Health Care Workers