Making clinicians get flu shots: More important than simply preventing the flu

I was recently speaking to the clinical leaders of a mid-sized hospital, and a senior administrator posed the question, “should we require our doctors and nurses to get flu shots?” The answer, I said, is yes, and it isn’t just to prevent the flu. It’s to get into the habit of making our folks do the right thing when it comes to patient safety.

Preventing the flu is very important. In the face of a significant bump in flu cases, in the last couple of weeks we’ve seen several states declared public health emergencies. Hundreds of hospitals have placed restrictions on visitors, including banning kids from visiting their parents. These are prudent steps: influenza can be an unpleasant inconvenience for a healthy person, but, for older and immunosuppressed patients, it can be a killer. The CDC estimates the number of yearly deaths from flu to be in the thousands; in a bad year like this one, it’s likely to be in the tens of thousands.

While one would hope that the professionalism of clinicians would drive them to vaccinate on behalf of their patients’ welfare (and most do – CDC data shows that about two-thirds of hospital workers get the vaccine), it’s not enough.

Sorry folks, but this one should not be a choice. It should be a mandate.

At UCSF Medical Center, where I work, we began requiring vaccination three years ago. Clinicians can refuse the vaccine, but if they do they must wear masks throughout flu season – for infection prevention and, I suspect, to act as an awkward disincentive. Along with the requirement, we make it easy to get vaccinated – during flu season, you can’t walk down a hospital hallway without bumping into someone wielding a needle. We now vaccinate about 15,000 individuals yearly. The program has been highly effective, with overall vaccine rates over 90%, and, according to my Occupational Medicine colleagues, no recent cases of clinician-to-patient (or visa versa) transmission, versus several per year in the pre-mandate days.

While we’re in the minority, we’re certainly not alone in taking a more hard-line approach to vaccination. A 2011 CDC survey found that more than 400 US hospitals (about 10 percent) now require flu vaccine for employees; 29 of them fire unvaccinated employees. According to a recent Associated Press report, in the last few months, at least 15 nurses in four states have been fired for refusing vaccines. Beginning this year, the Joint Commission is requiring its accredited hospitals to have a program to promote healthcare worker vaccination and demonstrate incremental yearly improvements, with a goal of a 90 percent vaccination rate by 2020. Medicare now requires that hospitals report their healthcare worker vaccination rates, and it plans to make these data publicly available (on in the next couple of years.

Some healthcare personnel object to the vaccines because they are worried about side effects (which are rare) or efficacy (the vaccine is 62 percent protective). (In fact, an early-release article in today’s JAMA refutes all the usual arguments.) Yet the larger objection seems to be a philosophical, libertarian one. One nurse in Indiana who was fired for refusing the vaccine spoke of “the injustice of being forced to put something in my body.”