The Real Nurse Jackie

Mandatory vaccinations vs. voluntary — not for wimps!

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OK, so I know it's not influenza season yet, but you all are supposed to be ordering your supplies right about now. So let's talk about that controversial topic: mandatory healthcare worker influenza vaccination.

I can hear the arguments for both sides already. But I say the case is clear.

Yearly, the Immunization Action Coalition recognizes stellar examples of influenza vaccination mandates in healthcare settings and places honorees on the “Honor Roll for Patient Safety.” The following national societies and associations are on this prestigious honor roll. These are some pretty smart cookies, if I say so myself.

The American Medical Directors Association supports a mandatory annual influenza vaccination for every long-term healthcare worker who has direct patient contact unless a medical contraindication or religious objection exists. The American Academy of Family Physicians supports annual mandatory influenza immunization for healthcare personnel, except for religious or medical reasons (not personal preferences).

The American Academy of Pediatrics released a policy statement that recommends the implementation of a mandatory influenza immunization policy for all healthcare personnel. The American College of Physicians has a policy that states that an annual influenza vaccine should be required for every healthcare worker with direct patient care activities unless a medical contraindication to influenza immunization exists or a religious objection to immunization exists.

The American Hospital Association released a statement that stated: To protect the lives and welfare of patients and hospital employees, the AHA's Board of Trustees recently approved a policy supporting mandatory patient safety policies. They require an influenza vaccination, or if the person opts not to get one, she or he should be required to wear a mask in the presence of patients across healthcare settings during flu season. (Yes, whether the healthcare worker is ill or not, they must wear a mask during the entire flu season.) 

The American Pharmacists Association supports an annual influenza vaccination as a condition of employment, training or volunteering, within an organization that provides pharmacy services or operates a pharmacy or pharmacy department (unless a valid medical or religious reason precludes vaccination). The Association for Professionals in Infection Control and Epidemiology recommends that acute care hospitals, long-term care, and other facilities that employ healthcare personnel require annual influenza immunization as a condition of employment unless there are compelling medical contraindications. 

The Infectious Disease Society of America supports universal immunization of healthcare workers against influenza by health care institutions (inpatient and outpatient) through mandatory vaccination programs. (It revised its position to specify that annual influenza vaccination should be a condition of initial and continued employment and/or professional privilege; and to remove declination for religious reasons.) The National Foundation for Infectious Diseases supports the public statements supporting mandatory healthcare worker influenza vaccination policies.

The National Patient Safety Foundation supports mandatory flu vaccines for all healthcare workers. The Society for Healthcare Epidemiology of America has a position paper that views influenza vaccination of healthcare personnel as a core patient and healthcare practitioner (HCP) safety practice with which noncompliance should not be tolerated. SHEA adds that annual influenza vaccination should be a condition of both initial and continued HCP employment and/or professional privileges. SHEA recommends that only exemptions due to recognized medical contraindications to influenza vaccination be considered.

All of these positions do come with the caveat that protects the healthcare worker. In the case of a medical contraindication (or, most, with a religious objection), she or he has a right to opt out.

Basically, all of the association/societies statements concluded that mandatory flu vaccination is an essential part of a comprehensive strategy that includes strict attention to important infection prevention practices such as hand hygiene and respiratory etiquette. Individuals exempted from annual vaccination due to medical or religious contraindications must be educated on the importance of careful adherence to all of the non-vaccine related healthcare infection control prevention strategies, including hand hygiene and cough etiquette. Further, they may be required to wear a surgical mask when in contact with patients or susceptible employees.

Research backs it up

A 2010 study that looked at a mandatory influenza vaccination program at Virginia Mason Medical Center over a five-year (2005-2010) period; (Rakita RM, Hagar BA, Crome P, Lammert JK. Mandatory Influenza Vaccination of Healthcare Workers: A 5-Year Study. Infect Control Hosp Epidemiol. 2010 Sep;31(9):881-8.), concluded that “a mandatory influenza vaccination program for HCWs is feasible, results in extremely high vaccination rates, and can be sustained over the course of several years.”

But not everyone supports the “Mandatory Mandate.” One of the national provider associations supports the idea of offering annual flu vaccines but does not agree with making them mandatory. Now, I do appreciate that it supports immunization, but when all of the experts say mandatory is the way to go, I need to understand any objections.

They state three reasons why not. One is that some staff may have objections for religious or cultural beliefs. Two is costs and what type of financial burdens might exist. Third is a concern about the impact on the workforce situation. 

I have to argue with these points on a practical level. I really can't speak to a cultural belief related to not getting immunized in order to save a frail elder's life. I am not educated in that area.

But most of the statements, and the one that matters the most in long term care — AMDA's — does call for an “opt out” for religious objections. There are several religions that do not allow conventional medical treatment. If employees can show they are a member of that religion, they can opt out. They would instead have to wear a mask (changing it every few hours as a wet mask is no longer a barrier) throughout the day.

The price of non-compliance

Now, let's look at cost. Many will argue that the cost of a vaccination outweighs the cost of not vaccinating. First, masks are not that inexpensive, especially when an employee needs to wear several a shift from October through March. Next, when an outbreak occurs, because your employees are bringing in the flu and passing it on to your vulnerable residents (whom they are supposed to be protecting) and other non-vaccinated staff members, let's watch the costs skyrocket.

While I believe that offering antivirals is sort of putting on your seatbelt after the accident occurred, that is the standard of practice with an outbreak. Who pays for that? It comes out of the facility budget. Oh, and now we have extra infection control costs from disinfectants to respiratory isolation, all courtesy of the facility budget.

And when half the staff is out sick, add on overtime and temp labor. Are ya' doing the math yet? The cost of a flu shot for prevention or a mountain of costs because you didn't?

Let's dissect the third objection: workforce. I look back to what the Society for Healthcare Epidemiology of America states: that noncompliance should not be tolerated. And if everyone is mandated, meaning that no matter what healthcare setting you work in you have to be immunized, I don't think people would leave the profession after all of their training because they have to get a flu shot. And it doesn't have to be the traditional flu shot anymore if it's the actual “shot” they're afraid of. We now have an inhaled immunization and an intradermal immunization.

And, sorry, but if some unethical “weenies” would risk my residents lives because they are too afraid of a flu shot despite all of the evidence that it won't hurt them and won't make them sick etc., this is not someone I would want taking care of my residents. Would you?

Just keeping it real,

Nurse Jackie

The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC — a real life long-term care nurse who is also the director of clinical affairs for the American Medical Directors Association. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. She has not starred in her own national television series — yet.

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The Real Nurse Jackie

The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, a 2012 APEX Award of Excellence winner for Blog Writing. Vance is a real life long-term care nurse who also is the director of clinical affairs for AMDA - The Society for Post-Acute and Long-Term Care Medicine. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates.

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