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Influenza vaccination for pregnant health care workers

Advanced Search Abstract Background. Influenza vaccination of health care workers has been recommended since 1984.

Multiple strategies to enhance vaccination rates have been suggested, but national rates have remained low. Because organizational vaccination rates remained below target levels, influenza vaccination was made a condition of employment for all employees in 2008.

Medical or religious exemptions could be requested. Medical exemption requests were reviewed by occupational health nurses and their medical directors. Employees who were neither vaccinated nor exempted by 15 December 2008 were not scheduled for work.

Employees still not vaccinated or exempt by 15 January 2009 were terminated. Many requests reflected misinformation about the vaccine. A mandatory influenza vaccination campaign successfully increased vaccination rates. Fewer employees sought medical or religious exemptions than had signed declination statements during the previous year.

  • Granted medical exemptions could be permanent or temporary 1 year only;
  • Because influenza vaccines are recommended annually for all adults, pregnant women should be vaccinated even if they received an influenza vaccine during a previous pregnancy;
  • Lancet Infect Dis 2017;17;
  • Pregnant women who get a flu vaccine are also helping to protect their babies from flu illness for the first several months after their birth, when they are too young to get vaccinated;
  • Maternal mortality in the epidemic of Asian influenza, New York City, 1957.

A standardized medical exemption request form would simplify the request and review process for employees, their physicians, and occupational health and will be used next year. It is the leading cause of vaccine-preventable death in the United States every year [ 3 ].

The risk of complications associated with influenza is higher among older persons, young children, and patients with underlying medical conditions [ 24 ]. Infected people may shed virus before symptoms develop [ 5—8 ], and health care workers often work while sick. Outbreaks of influenza in hospitals have been well described [ 349—12 ].

Women's Health Care Physicians

Influenza vaccination of health care workers reduces employee illness and absenteeism [ 413—15 ]. Influenza vaccination for pregnant health care workers nursing home settings, vaccination of health care workers has been shown to decrease morbidity and mortality among nursing home residents [ 16—18 ]. The impact of vaccination of workers in acute care settings is more difficult to study because of the short duration of most hospitalizations.

Other evidence for the importance of herd immunity on influenza rates comes from a Japanese study in which the vaccination of school children against influenza resulted in decreased mortality associated with pneumonia or influenza in the general population [ 19 ].

Annual influenza vaccination was first recommended for health care workers by the Advisory Committee on Immunization Practices in 1984 [ 32021 ].

The Society for Healthcare Epidemiology [ 22 ], the Association for Professionals in Infection Control [ 11 ], and the Infectious Disease Society of America [ 23 ] also strongly endorse health care worker vaccination. Recommended practices to improve vaccination rates include making the vaccine available without charge to employees at multiple convenient sites and times, using incentives and rewards, and having visible leadership support [ 2124—27 ]. More recently, declination statements have been suggested as a way to increase vaccination rates.

The impact of these statements is still being studied [ 28—30 ]. Despite these efforts, vaccination rates among health care workers remain low across the United States; the influenza vaccination rate among US health care workers during 2006—2007 was 44.

Mandatory vaccination is a controversial strategy that pits health care worker autonomy against patient safety [ 31—36 ].

Improving influenza immunization in pregnant women and healthcare workers.

Other vaccines, such as measles, mumps, and rubella vaccine and varicella vaccine, are already required by many health care facilities, as is annual tuberculin skin testing.

Virginia Mason Hospital Seattle, WA implemented a mandatory influenza vaccination program in 2004, and there have been media reports of other individual hospitals instituting similar programs. There are no reports in the literature of large multihospital systems implementing a mandatory influenza vaccination policy.

Annual influenza campaigns at BJC HealthCare include free vaccine available at multiple sites and times, extensive publicity, incentives and educational programs, and more recently, declination statements.

In 2007, influenza vaccination rates were added to the BJC patient safety and quality scorecard used at all hospitals in the organization. Hospital leaders receive incentives based on their hospital's performance on scorecard measures. Hospitals are located in urban, suburban, and influenza vaccination for pregnant health care workers settings and range from 40 to 1250 beds.

Of the acute care hospitals, 1 adult and 1 pediatric facility are teaching hospitals. BJC Occupational Health Services coordinates and standardizes occupational health programs through the Council of Occupational Health Professionals, which includes a representative from each facility.

Bimonthly council meetings are designed for education, policy, and procedure standardization, coordination of occupational health and safety surveillance, and development of interventions throughout BJC. Each facility uses the centralized BJC occupational health database for tracking employee vaccinations, immune status, and occupational injuries and exposures.

The database includes demographic and job information on all BJC employees. In 2008, as a patient safety initiative, influenza vaccination was made a condition of employment for all BJC employees, regardless of job function, including clinical and nonclinical staff, contracted clinical personnel, and volunteers.

Hospital-employed physicians, including hospitalists, residents, and fellows, were included in the policy. Louis, MO and are not covered by the policy. The multidisciplinary implementation team met regularly before and during the vaccination campaign to ensure timely, consistent, and coordinated communication and responses to any issues that arose. Free vaccine, including thimerosal-free and intranasal preparations, was available at multiple locations at all facilities starting 15 October 2008.

Influenza info for Health Professionals

Vaccinations were tracked at each facility in real time. Feedback was provided not less than weekly to managers at the facilities. Managers interacted with their staff to ascertain reasons for noncompliance and to provide coaching about influenza, the vaccine, and the consequences of noncompliance. Employees who were neither vaccinated nor exempted by 15 December 2008 were suspended without pay. Those who were vaccinated before 15 January 2009 could return to work.

  • Multiple strategies to enhance vaccination rates have been suggested, but national rates have remained low;
  • The mandatory program markedly increased vaccination rates across all facilities;
  • Safety of influenza immunization during pregnancy for the fetus and the neonate.

Employees still not vaccinated or exempt by 15 January 2009 were terminated for failure to meet their conditions of employment. Religious accommodations required a letter from the employee to Human Resources that stated a religious conviction opposed to vaccination.

Employees were notified within 5 days whether their request had been granted. Medical exemptions required a letter from a licensed physician MD or DO that stated a medical contraindication to influenza vaccination. Predetermined accepted medical contraindications were based on the Advisory Committee on Immunization Practices recommendations [ 3 ]. Pregnancy was accepted as a medical influenza vaccination for pregnant health care workers if requested by the employee's physician, despite the vaccine being recommended during pregnancy, because the vaccine is listed as a category C agent.

Occupational health nurses reviewed other reasons on a case-by-case basis with assistance from their medical director as needed. Employees received a form within 5 days that stated whether their request had been granted.

Denials included an explanation of the reason for denial on the form. Second requests with clarifications could be submitted for review. Some physicians who had written exemption request letters were contacted directly by the facility occupational health medical director for clarification or at the request of the employee.

Granted medical exemptions could be permanent or temporary 1 year only. Concerned employees not meeting criteria for exemption could discuss their concerns with the occupational health nurses or medical directors. Employees who were granted an exemption were encouraged to wear an isolation mask while providing patient care during the influenza season to avoid contracting or transmitting influenza.

No specific enforcement was put in place, and no data on compliance were collected. Results Of 25,980 active employees, 25,561 98. Medical exemptions were granted to 321 employees 1. Religious accommodations were granted to 90 employees 0. Overall, 25,974 employees 99. Only 8 employees 0.

All of these trainees complied with the new policy: Vaccination rates in 2008 increased by 43. The National Health Interview Survey rates of influenza vaccination among health care workers during 1997—2006 are shown with the trend line.

Should healthcare workers be vaccinated?

Of 372 requested medical exemptions, 321 86. The other 6 noncompliant employees were from 4 acute care hospitals: The remaining hospitals and service organizations had no noncompliant employees. Two employees were per diem employees, 3 were part-time, and 3 were full-time employees. The median duration of employment before termination was 37.

Of these employees, most did not submit an exemption request. One employee submitted a request for a religious exemption 2 days before termination, after being unable to obtain a doctor's note stating a medical contraindication; the request was denied. Adverse events reported by employees were tracked in the occupational health database. Eleven reported a sore arm. Five reported a possible allergic reaction, and 1 reported a possible vagal response with fainting.

Four events of uncertain relation to the vaccine were also reported by employees, including 2 cases of fever and myalgias, 1 with upper respiratory symptoms, and 1 case of a new neurologic syndrome diagnosed as chronic inflammatory demyelinating polyneuropathy, which could not be objectively linked to the influenza vaccine because of several other potential antecedent triggers.

Discussion The mandatory vaccination program successfully increased vaccination rates at a large multihospital health care organization. Efforts during previous years included most recommended practices to maximize vaccination rates, including free, easily available vaccine, incentives, and leadership support.

Despite these efforts, rates were still suboptimal Figure 1. The mandatory program markedly increased vaccination rates across all facilities. 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 program was established as a patient safety initiative; thus, no prospective attempts were made to link to absenteeism. Because of the way that employees are reimbursed for time off work, we were unable to distinguish between sick time and vacation time and, thus, could not assess the impact of the program influenza vaccination for pregnant health care workers absenteeism. In addition, the year that the program was implemented had a mild influenza season; therefore, finding reduced absenteeism would be difficult to link to the vaccination program.

Influenza Vaccination During Pregnancy

Few other organizations have established mandatory influenza vaccination programs. Several smaller hospitals were mentioned in the media for attempting mandatory campaigns, but no details have been published. To our knowledge, this is the first report of a large multihospital health care organization implementing a mandatory influenza vaccination program.

Some programs allow health care workers to sign declination forms stating that they understand the risks of not receiving the influenza vaccine to themselves, their patients, and their families. Declination statements have recently been publicized as a potentially valuable strategy for increasing vaccination rates [ 112122 ], but data on their efficacy are mixed [ 28—30 ]. We found that many fewer employees sought medical or religious exemptions than had signed declination statements in previous years.

Requests for religious exemptions were reviewed by Human Resources at each facility. The letter from the employee had to state a sincere religious conviction opposed to vaccination.