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December 5, 2005

When Education Doesn’t Work

What Will Persuade Health Care Workers to Get their Flu Shots?

What if a low-cost, safe and effective AIDS vaccine had been developed decades ago, but fewer than half of health care workers bothered to be immunized? 

Nutty, right? And yet, according to Gregory A. Poland, MD, a comparable scenario is played out every year in U.S. health care facilities—with the influenza vaccine.

Poland, MD, director of the Vaccine Research Group at Mayo Clinic, spoke November 30 at the Johns Hopkins Bloomberg School of Public Health about his personal crusade: He wants influenza immunizations to be made mandatory for all health care workers who come in contact with patients.

“The elderly, the very young—the most vulnerable members of society—are arrayed trustingly around us health care workers, and yet we continue to walk into NICUs [neonatal intensive care units] and bone-marrow transplant units with a deadly disease, the flu,” Poland said.

Poland said that mandating flu immunizations for health care workers would halve the U.S. health care system’s yearly all-cause mortality rate. “The needs and safety of patients come first,” he said. “I don’t believe personal preference should supersede patient safety.”

Voluntary educational campaigns have failed, according to Poland. He would like to see flu immunization become a requirement for health care workers getting their licenses renewed each year. “We would like to believe education works,” he said, “but it doesn’t. The immunization rate for health care workers is consistently below 40 percent.”

Why are health care workers so reluctant to get themselves immunized? According to Poland, workers don’t believe they’re at risk and are ignorant of the risk they present to patients. Fifteen percent are afraid of needles. And—this one drives him to distraction—some believe the vaccine will give them the flu.

The canard about the flu vaccination making people sick, Poland said, was put to rest by the Mayo Clinic in a 1990 study. Each participant received either a flu shot or a placebo and then, after a certain time interval, the same participants were administered whichever substance they hadn’t received the first time. None of the participants could tell the researchers when they’d gotten the vaccine and when the placebo.

Poland next presented what he calls the “seven truths we must accept” before we can intelligently debate mandatory influenza vaccinations for health care workers.

1. Influenza infection is a serious illness causing significant morbidity and mortality adversely affecting the public health each year. The data are clear: Influenza infects fully one-third of Americans during a typical season and kills 36,000 each year, about three times the number of people that AIDS kills. “One out of every 10,000 Americans alive today will die this year from influenza,” he said.

2. Influenza-infected health care workers can transmit this deadly virus to vulnerable patients. “Health care workers with the flu walk into the NICU, and babies die,” Poland said and he cited studies showing that over 70 percent of infected health care workers continue to come to work and interact with patients while suffering from the flu. And that doesn’t include all the infected health care workers whoare asymptomatic and don't know they're ill but are still shedding plenty of virus.

3. Influenza vaccination of health care workers saves money for employees and employers and prevents workplace disruption. Poland cited studies that show that working adults who were immunized were 88 percent less likely to get the flu, had 25 percent fewer upper respiratory infections and took 43 percent fewer sick days.

4. Influenza vaccination of health care workers is already recommended by the Center for Disease Control and Prevention and is now the standard of care. Seven U.S. states now mandate health care workers in critical- and acute-care settings to be immunized, and 15 states have made it mandatory for health care workers working in long-term care. Poland pointed out that health care workers already must meet many continuing medical education (CME) and licensing requirements if they want to keep in practice. Why not add yearly flu immunization as a condition for job promotion and license renewal? “I warn every institution I talk to,” he said. “This is the standard of care and if you don’t follow it, a bright lawyer will take advantage of that fact.”

5. Immunization requirements increase vaccination rates. Poland again made it clear: “Voluntary immunization programs have never resulted in high rates of vaccination.” Further, he noted that our society already mandates that health care workers be immunized for hepatitis B and for rubella, “even though most U.S. health workers will never see a case of rubella.”

6. Health care workers and health care systems have an ethical and moral duty to protect vulnerable patients from transmissible diseases. “I believe that soon we will also have a legal duty to do this,” he said. Legislators are also talking about going public with hospitals’ nosocomial (caused by health care workers) flu rates and about preventing unvaccinated workers from coming into contact with patients.

7. The health care system either will lead or be lambasted. Poland ended by saying, “Either state legislators or insurance companies are going to make us do this anyway. Tear down this wall of unfounded fears. If you do, American medicine will follow.” —Rod Graham