As an expected surge of H1N1 approaches with the upcoming flu season, New York State and some individual hospital systems have started to implement policies requiring health care workers to get flu vaccinations -- a move which organized labor groups will be opposing, as they say it could be used as a tactic to limit proper respirator use and could cause some health care workers to lose their jobs when they are most needed during a surge of H1N1.
A union source said he expects unions will meet with management or file grievances and take concerns to the National Labor Relations Board, if necessary, to oppose such mandatory policies. Virginia Mason Medical Center in Washington State was the first to implement a mandatory policy, but was required to change it after a United States District Court ruling. However, the facility continues to require those who are not vaccinated to wear masks -- a tactic other hospitals are starting to use as well, which union sources are comparing to a "scarlet letter" for health care workers.
Service Employees International Union Local 199 recently won a "temporary victory" in combating a mandatory flu shot policy at the University of Iowa hospitals. The union had filed an injunction on the grounds that the mandatory policy violated labor law, but it has now been withdrawn after the university hospitals' administration agreed to suspend the planned mandatory vaccination program.
Unions are now keying in on a precedent-setting move in New York and are "actively trying to help turn that around," said the union source. The New York State Department of Health recently implemented an emergency regulation requiring health care personnel to get the seasonal flu shot, along with the H1N1 vaccine, when it becomes available. Another organized labor source said he thinks the move, the first by a state, has undermined patient safety in New York by demoralizing health care workers and has led some facilities to minimize other safety measures, including those required in federal guidelines.
The source said the NYS health department specifically has ignored OSHA, NIOSH and CDC guidance requiring health care workers to use N95 respirators and, instead, has focused on requiring vaccinations -- which he deems a "pea shooter approach" and a less-effective protection measure. The New York State Nurses Association has also criticized the policy, as staff recently stated that there is no simple solution to prevent the spread of flu infection.
While the department has required workers to be vaccinated or risk losing their jobs on the grounds that it will improve infection control, it also continues to call for surgical masks -- instead of N95 respirators -- to protect against H1N1 this fall, the NYSNA noted in a recent open letter to NYS Commissioner of Health Richard Daines. The NYSNA is urging the NYS DOH to update its guidelines to require fit-tested N95 respirators for workers in contact with suspected flu cases.
The first union source notes that unions are in favor of workers being vaccinated, but support voluntary and educational programs to encourage it -- many of which have high rates of compliance -- as opposed to mandatory vaccinations.
According to the Centers for Disease Control and Prevention, the nationwide vaccination rate for health care workers was around 42 percent during the 2005/2006 flu season.
Though New York is currently the only state to mandate vaccinations, other individual hospitals have started to implement similar policies.
The Loyola University Health System has mandated that health care workers get vaccinated -- save for those who cannot for religion or a medical condition -- or face losing their jobs. The policy applies only for the seasonal flu vaccine, as the supply and timing of the H1N1 shot is uncertain. It's a policy that the university system has considered implementing for years, but finally moved forward with due to the emergence of H1N1 and the expectation of a very severe flu season this fall, said a Loyola spokesperson. A release announcing the new policy noted that 73 percent of Loyola hospital workers got the seasonal flu shot last year, and the goal is to achieve 100 percent compliance this fall.
While New York State and Loyola have required workers to get vaccinated or risk getting fired, some other hospitals that are requiring vaccinations are allowing those who refuse to, instead, regularly wear surgical masks. The union source said the tactic punishes workers for not complying with hospital requirements. "It's primarily a punitive policy," the union source said. "There's no public health rationale for having people wear surgical masks if they don't get a flu vaccination under the guise of protecting patients."
The source estimated that at least 15 hospital or hospital systems have recently implemented policies requiring health care workers to be vaccinated.
The Hospital Corporation of America (HCA) system -- which covers 163 hospitals nationwide -- is also in the process of implementing a policy where health care workers are required to either get the seasonal flu shot or wear a surgical mask when they are around patients, said an HCA spokesperson. He said statistics show that vaccinations are the "best way to protect patients and staff." The threat of H1N1 also contributes to the need for health care workers to get vaccinated to help avoid staffing shortages during a busy flu season, he added. The spokesperson said employees have generally understood the need for the policy to protect workers and patients, noting that employees have been turning out in record numbers to get the vaccine.
The union source said that the H1N1 vaccination is expected to only be about 50 percent effective, so workers could still get the flu and would need to wear proper respiratory protection to ensure safety. Plus, some areas have reported delays in receiving the seasonal flu vaccine, which may prevent some institutions from requiring seasonal flu shots. The Marshfield Clinic in Wisconsin had decided to require workers to get a seasonal vaccination, but the program was put on hold when management learned it was unable to obtain enough flu shots and the institution's board of directors voted to modify the plan.
An infection control group is also looking at the issue. The Society for Healthcare Epidemiology of America (SHEA) is putting together a group to look into mandatory vaccinations, said SHEA president Mark Rupp. He noted he thinks the "pendulum is swinging towards a more stringent approach to this, requiring vaccination." However, he said it will be difficult to require vaccinations this flu season due to logistical issues, such as difficulties for some institutions in securing seasonal flu shots while production has slowed to focus on the H1N1 vaccine. Nevertheless, he said the "hard-line approach" some institutions are undertaking may be positive for some health care facilities. "Clearly, if you have enough vaccine where you can vaccinate all of your health care workers at the present time, I see that it might be a very useful way to proceed," he added.
Linda Kusek, an associate project coordinator in the department of health research at The Joint Commission, also noted that more hospitals have started looking at mandatory vaccinations. "There's certainly more attention focused on it now and hopefully that will translate into higher vaccination rates," she said. The Joint Commission produced a monograph that examines the pros and cons of mandatory policies, incentives and disincentives, called "Providing a Safer Environment for Health Care Personnel and Patients Through Influenza Vaccination." Kusek said most organizations use multiple strategies to increase vaccination rates.
The monograph found that researchers are mixed about whether mandatory vaccinations would be beneficial to health care workers. One author quoted in the materials noted that it could potentially minimize other infection control measures and create a "false sense of security" at facilities. Another researcher highlighted in the monograph countered that immunity to diseases that can be prevented by vaccines are a key component of infection control.
Kusek also noted that some hospitals have implemented incentives and disincentives to improve vaccination rates, such as making employees eligible for a bonus after receiving a vaccination or, on the other hand, withholding raises if an employee does not get a shot. Kusek said it is unclear which approach has been the most beneficial.
The American Hospital Association isn't taking a firm stance on the issue. An AHA source said the group supports increasing vaccination rates, but is unsure if mandating flu shots is the way to proceed and noted other strategies have been put into place by hospitals to maximize the number of employees that are vaccinated. "It's really a decision that the hospital has to make with its staff," she said. -- Sara Ditta