As flu season approaches, West Virginia's largest hospital has given its employees a choice: Get a flu shot, or get another job.
Charleston Area Medical Center wants to get roughly 6,000 workers immunized against seasonal flu to protect patients from the ailment, just as health care workers there are currently required to get vaccinations against everything from measles to rubella.
A mandatory flu shot policy like CAMC's is rare for U.S. hospitals, but it may soon become more common. A New York State law that takes effect this month requires hospitals to provide records showing all their workers have seasonal flu vaccinations or face fines, and the impending arrival of a swine flu vaccine has policymakers looking for ways to get it to large numbers of people in a short amount of time.
CAMC decided to adopt the new policy this year after steadily increasing its vaccination rate among staff members to about 70 percent, according to Director of Epidemiology Terrie Lee.
The hospital had previously asked all employees to get shots or sign forms explaining why they refused, but even that presented problems.
"We have around 6,000 employees, and that's a lot of time to spend paper chasing," Lee said.
Now, employees with a reason for declining, such as allergies, can file by Sept. 15 for an exemption. Everyone else has to get a vaccination by Dec. 15.
"The number one reason for this is to protect our patients," Lee said. "There are plenty of studies showing hospitals with higher flu vaccination compliance rates have fewer patient deaths."
In 2007, the Infectious Diseases Society of America called for such mandatory policies, saying that on average, fewer than 40 percent of health care workers nationwide get flu shots every year.
Despite such calls, hospitals where employees must get flu shots as a condition of employment are so rare an American Hospital Association expert can't name another besides CAMC.
"As we listen to our hospitals and people in the state associations, vaccination for the flu has not been mandatory," said James Bentley, the association's senior vice president for strategic policy planning.
The American College of Occupational and Environmental Medicine has called for sustained and rigorous promotion of flu vaccines while stopping short of endorsing mandatory shots.
"If you're going to make anything mandatory, make education mandatory," said Dr. Mark Russi, director of occupational health at Yale-New Haven Hospital in Connecticut and a member of the American college's Council of Scientific Advisors. "It's important to make sure you're reaching everyone in an appropriate way and explaining that this is not a hazardous vaccine and that it's generally 70 to 90 percent effective."
A mandate can seem faster to implement than an education effort, and states may follow the example of New York.
The New York regulation, which took effect Aug. 13, requires hospitals and other health care facilities to provide proof that their workers are vaccinated, or face fines of $2,000 for the first offense and up to $5,000 for subsequent offenses, according to state health department spokeswoman Claire Pospisil.
"Health care workers are already required to get immunized against measles and rubella and a TB skin test," Pospisil said. "This regulation just adds to what's already in the public health law."
The regulation was opposed by the New York State Nurses Association, which objected to the law's lack of provisions for health care workers who don't want shots for religious or philosophical reasons.
The association says it supports health care workers being immunized, but opposes mandatory policies, a position that may complicate the spread of initiatives like the one at CAMC.
Virginia Mason Medical Center in Seattle is cited by many, including CAMC's Lee, as a national model in vaccination policies for its workers. In 2004, it decided to require seasonal flu vaccinations, but that policy was successfully challenged by the union representing nurses at the hospital.
The nurses objected not to the vaccinations, but to what they said was a change in the terms of employment covered under the collective bargaining agreement, and an arbitrator agreed.
Despite that, Virginia Mason has maintained a vaccination rate among workers of 99 percent or so for the last four seasons, according to Dr. Joyce Lammert, chief of the Department of Medicine.
The hospital has also found a side benefit.
Vaccinating thousands of people in a short period of time is a good way to establish procedures that may be used in the event of a pandemic, Lammert said.
Fears of a pandemic, particularly tied to the H1N1 or swine flu virus, are spurring renewed discussion of mandatory flu vaccine polices around the country, Russi said.
A vaccine for swine flu won't be available until this fall, though, and making it mandatory would mean addressing the concerns of many that it could be unsafe. Even hospitals encouraging the seasonal flu vaccine have to address fears that it will make recipients sick, or that it's not necessary for young, healthy people.
Those objections, along with concerns on religious or philosophical lines, have made many health care facilities wary of instituting a mandatory policy, the AHA's Bentley said.
"Most institutions I have familiarity with say, 'We aren't going to require it because that gets into all kinds of other issues and we don't have time to take those on,'" he said.