New Law Requires Health Workers' Vaccination
Public Health Feature – August 2012
Tex Med. 2012;108(8):25-29.
By Crystal Conde
St. David's HealthCare Chief Medical Officer Thomas Knight, MD, faced the devastation of influenza early in his career. As an internal medicine resident in 1985, he watched a 34-year-old pregnant woman in the intensive care unit (ICU) succumb to acute respiratory distress syndrome.
Dr. Knight says the woman's death left an imprint on his memory that will forever endure. Her child survived; physicians delivered the baby in the ICU.
The experience inspired Dr. Knight to champion immunization against preventable diseases among the public and health care workers.
"You only have to see one patient die from a vaccine-preventable disease for it to affect you significantly as a physician. As I recall, the woman hadn't received the influenza vaccine. Her death likely could have been prevented," he said.
The woman's death is a reminder of the health complications that can occur when people aren't vaccinated against preventable diseases. Vulnerable patients – infants, the elderly, the chronically ill, and pregnant women – are at increased risk of contracting preventable diseases. The Centers for Disease Control and Prevention (CDC) reports the number of seasonal influenza-associated deaths varies each year because flu seasons are unpredictable and often fluctuate in length and severity. Therefore, a single estimate can't be used to summarize influenza-associated deaths. Instead, a range of estimated deaths illustrates the variability and unpredictability of flu. In the most recent figures available, CDC estimates that from the 1976-77 season to the 2006-07 flu season, flu-associated deaths ranged from a low of about 3,000 to a high of about 49,000.
Unfortunately, low rates of influenza immunization among health care workers contribute to some influenza outbreaks in hospitals and long-term care facilities. The Texas Medical Association believes the hospital should be a place where people go to get better, not a place where they should worry about contracting a vaccine-preventable disease.
TMA policy strongly endorses immunizing all physicians with the recommended vaccines available for preventable, communicable diseases. Also, TMA, CDC, the Advisory Committee on Immunization Practices (ACIP), and the Healthcare Infection Control Practices Advisory Committee recommend annual flu shots for all U.S. health care workers. TMA also supports ACIP's recommendation that all health care workers who have direct patient contact in hospitals or clinics receive a dose of tetanus-diphtheria-pertussis (Tdap) vaccine.
A new law, supported by TMA, the Texas Pediatric Society (TPS), and the Texas Academy of Family Physicians (TAFP), will help physicians reduce the chance of patients picking up a flu bug or something worse while in a health care facility. Senate Bill 7 by Sen. Jane Nelson (R-Flower Mound) requires health care facilities, including nursing homes, statewide to implement preventable disease immunization policies for health care workers by Sept. 1.
"We heard testimony from health advocates across the state that reinforced our belief that these policies will have a positive impact on the health and well-being of Texas patients and their physicians," Senator Nelson said.
Under the law, employees can be exempt from the vaccine policy for health reasons, but they must take extra precautions such as wearing masks when working around patients. The law also allows health care facilities to bar exempt employees from the facilities during public health emergencies.
"Health care workers who are not immunized against influenza and other diseases may unknowingly spread these diseases to the patients in their care," said Charles Lerner, MD, past chair of the TMA Committee on Infectious Diseases. He says immunization against vaccine-preventable diseases is "the simplest, least expensive, and wisest way to protect patients from exposure to an infected health care worker."
Rep. John Zerwas, MD (R-Richmond), a Houston anesthesiologist who sponsored SB 7 in the House, hopes the new law will "benefit Texas patients by eliminating or minimizing the transference of vaccine-preventable diseases."
Dr. Zerwas adds that support from TMA and other health care organizations helped pass SB 7.
"TMA is well respected among members of the legislature and has a powerful, credible voice that's influential in promoting legislation that will improve the overall health of the state's residents," he said.
Dr. Lerner, epidemiologist for San Antonio's Methodist Healthcare System, believes vaccinating all health care workers is the cornerstone of a strong patient safety program. The requirements of the new law are in patients' best interests and encourage hospitals to do what's right, he says.
"Vaccination is one of the most important parts of an infection control program and perhaps one of the most important actions any of us can take to keep ourselves healthy and perhaps more importantly to keep from making those around us sick," he said.
Unvaccinated Workers Pose Risk
Instances of unvaccinated health care workers implicated in hospital outbreaks of influenza are well documented. In 1998, one patient in a U.S. university-affiliated neonatal intensive care unit died from influenza, according to "An Outbreak of Influenza A in a Neonatal Intensive Care Unit," published in the July 2000 journal Infection Control and Hospital Epidemiology. The outbreak infected 19 infants. Only 15 percent of the health professionals working in the unit received flu shots that year.
An influenza outbreak can occur unexpectedly, as it did in 2001 in a Spanish hospital. Flu reportedly hadn't been circulating in the community. Nevertheless, 31 percent of health care workers and 13 percent of patients in the hospital developed influenza. One patient who had AIDS and contracted influenza died. Only 7 percent of the hospital's health care workers had received the flu vaccine that year.
CDC data show influenza vaccination of health care workers increases dramatically when employers require the immunization. According to CDC, 63.5 percent of health care workers were vaccinated against flu during the 2010-11 influenza season, up slightly from 61.9 percent during 2009-10.
CDC notes coverage jumped to 98 percent among health care workers whose employers required the flu vaccine and was only 58 percent among those whose employers didn't require the vaccine. CDC reports facilities that offered free vaccinations on site for multiple days experienced increased flu vaccination coverage among health care workers.
Erica Swegler, MD, chair of the TMA Committee on Infectious Diseases and a Keller family physician, says her passionate advocacy of vaccination against preventable diseases compelled her to testify in support of SB 7 on behalf of TMA, TPS, and TAFP. The clinics in Keller and North Richland Hills where she practices have had a verbal policy on health care worker vaccination in place for about five years. Under the policy, physicians and staff members receive the Tdap, hepatitis B, and influenza vaccines.
"We're in the process of codifying our vaccination policy to ensure it's part of the written procedures our practice locations adhere to," she said.
Both clinics achieved 100-percent compliance for Tdap vaccination and 83-percent compliance this season for influenza vaccination. Dr. Swegler says neither practice location tracks the reasons employees decline the flu shot.
Studies have examined the reasons for traditionally low flu vaccination rates among health care workers. According to "Policies and Practices for Improving Influenza Immunization Rates Among Healthcare Workers," published in 2004 in Infection Control and Hospital Epidemiology, about 38 percent of the respondents worked at health care facilities with written policies on employee influenza vaccination, and only 2 percent worked at facilities with mandatory influenza vaccination. Vaccine cost was a reported barrier for 7 percent of respondents. Sixty-eight percent of respondents cited fear of side effects, and 53 percent cited perceived ineffectiveness of the flu vaccine as barriers to vaccination.
Dr. Swegler says she hopes hospital policies will increase vaccination rates among health care workers and will inspire physicians in private practice to develop and implement health care worker immunization policies.
"Physicians took an oath to do no harm. When physicians and other health professionals don't get vaccinated, they're putting themselves and their patients at unnecessary risk," she said.
Prevention in Practice
By law, health care facilities must implement a policy to protect patients from vaccine-preventable diseases by Sept. 1. The legislation defines vaccine-preventable diseases as those included in the most current ACIP recommendations.
Policies developed by health care facilities under the law apply to an employee of a health care facility, a person providing direct patient care under a contract with a health care facility, or someone to whom a health care facility has granted privileges to provide direct patient care. It's up to the hospital or other health care facility to develop a vaccine-preventable diseases policy that:
- Specifies the vaccines health care workers must receive based on the level of risk they pose to patients by their routine and direct exposure to patients;
- Requires covered individuals to receive vaccines for the vaccine-preventable diseases specified by the facility;
- Requires the health care facility to maintain a written or electronic record of each health care worker's compliance with or exemption from the policy;
- Includes disciplinary actions the health care facility can take against a health care worker who fails to comply with the policy; and
- Includes procedures for verifying whether a health care worker has complied with the policy and for exemption from the required vaccines for the medical conditions identified as contraindications or precautions by CDC.
The law directs health care facilities to include procedures exempt health care workers must follow to protect patients from exposure to disease based on the level of risk the workers present to patients through routine and direct exposure to patients. Procedures could include using protective medical equipment, such as masks.
The law also says policies should prohibit discrimination or retaliatory action against a health care worker who is exempt from the required vaccines for the medical conditions identified as contraindications or precautions by CDC. The law authorizes, but doesn't require, health care facility immunization policies to include procedures for health care workers to be exempt from the required vaccines based on reasons of conscience, including religious beliefs.
The Texas Department of State Health Services (DSHS) is responsible for adopting rules necessary to implement the new law and has authority to make sure hospitals comply with the new law. To view the rules, visit www.dshs.state.tx.us/hfp/draft.aspx.
According to Christine Mann, DSHS assistant press officer, typically, when DSHS finds a facility in violation of the law, the facility must submit a plan of correction stating how and when it will be in compliance.
"Our ultimate goal is achieving compliance by working with hospitals to correct mistakes and protect patient safety. When assessing administrative penalties, the department considers a hospital's previous violations; the seriousness of the violation; any threat to the health, safety and rights of the hospital's patients; and the demonstrated good faith of the hospital," she said.
Ms. Mann says 670 hospitals licensed under the Texas Health and Safety Code are subject to the law requiring implementation of a vaccine-preventable diseases policy. Additionally, she notes the following facilities, licensed under the Texas Health and Safety Code, must comply with the new law:
- 532 end-stage renal disease facilities,
- 410 ambulatory surgical centers,
- 55 birthing centers,
- 40 freestanding emergency medical care facilities,
- 39 abortion facilities, and
- 13 special care facilities.
Edward Septimus, MD, medical director of the Infection Prevention and Epidemiology Clinical Services Group with HCA Holdings, Inc., works with many hospitals and health care facilities nationwide to guide them on best practices for promoting infectious disease prevention.
Dr. Septimus has "zero tolerance for transmission of preventable disease." In 2009, HCA began requiring health care workers who treat patients in its facilities to be vaccinated against influenza or to wear a mask if they choose not to receive the flu shot. Dr. Septimus says such policies are a positive first step in reducing the spread of preventable disease in health care facilities. As a result of the policy, HCA facilities have achieved more than 90-percent influenza vaccination compliance among health care workers for the past three years.
Dr. Septimus describes the new law under SB 7 as "progressive," providing facilities with an ideal opportunity to revise or expand their policies.
While many hospitals have some type of health care worker immunization policy that may require influenza vaccination, they may not address other vaccine-preventable diseases.
"The individual facilities will include in their policies the immunizations they deem appropriate. The ACIP-recommended vaccines that may be wise for health care workers to receive include Tdap, varicella, hepatitis B, and measles-mumps-rubella," he said.
Dr. Septimus, president of the Texas Infectious Disease Society, says hospitals can also include in their vaccine-preventable diseases policies a requirement that independent physicians who have privileges at the facilities, not just hospital employees, be encouraged to receive specified vaccines recommended by ACIP.
But tracking compliance with the policies could be tricky, he says.
The law states health care facilities must maintain a written or electronic record of each health care worker's compliance with or exemption from the immunization policy. The policy also has to include procedures for verifying whether a health care worker has complied with the immunization requirements.
"If independent physicians are required to receive the specified vaccines under the policy, who's going to track and verify their compliance? Hospitals may have a system for tracking vaccination compliance among employees, but they'll have to figure out how to track others without creating a burden on the facilities and physicians," he said.
According to Dr. Septimus, at press time HCA was examining the details of its preventable diseases vaccination policy for health workers and determining how it would be implemented to comply with the law.
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.
Protect Your Patients, Yourself
TMA offers a poster you can hang in your office to remind all health care workers to get a flu shot each year. The poster declares: "Protect your patients. Protect yourself & family. Get a flu shot."
To order copies, contact Tammy Wishard by telephone at (800) 880-1300, ext. 1470, or (512) 370-1470, or by email.
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