The study's lead author, infectious disease specialist Hilary Babcock, M.D., says the success of the mandatory program demonstrates it is possible to implement a vaccination campaign on a large scale in a health-care setting.

"As a patient safety initiative, we knew the flu shot was safe and effective, and the best way to protect patients was to be sure that employees were vaccinated," she says.

For 10 years, BJC -- affiliated with Washington University School of Medicine -- offered the influenza vaccine free of charge to its employees, conducted extensive education campaigns about the benefits of the shot and provided incentives to employees. While vaccination rates were consistently above the national average, they remained below BJC's target of 80 percent. The nonprofit health care organization includes 13 hospitals in St. Louis, southern Illinois and mid-Missouri.

In 2006, 54 percent of BJC employees received the influenza vaccine, only slightly above average for health-care workers nationwide. In 2007, BJC employees who declined to get a flu shot were asked to sign a statement saying they understood the risk to themselves, their patients and their families. That year, the vaccination rose to 71 percent, still below BJC's target rate.

Then in 2008, with a focus on patient safety, BJC made the influenza vaccine mandatory for all its employees, regardless of whether they worked directly with patients. Again, the health system provided educational programs about the benefits of the vaccine and made the shot available at no charge to employees at multiple times and locations.

Employees could request religious or medical exemptions, which were reviewed by human resources and occupational health nurses, respectively. Interestingly, many fewer employees sought medical or religious exemptions than had signed declination statements in the previous year.

Overall, 25,561 (98.4 percent) of BJC employees received an influenza vaccine in 2008. In addition, 90 employees (.3 percent) received religious exemptions, and 321 (1.2 percent) received medical exemptions. Medical exemptions included severe allergy to eggs, prior allergic reactions to the flu vaccine and a history of Guillain-Barré syndrome.

"Some of the requests for medical exemptions reflected misinformation about the vaccine and influenza," says Babcock, an associate professor of medicine, who conducted the study with senior author Keith Woeltje, M.D., Ph.D., associate professor of medicine. For example, some requests cited asthma, cancer or a suppressed immune system, even though these conditions increase the risk of flu-related complications and are reasons to get vaccinated.

In all, eight employees were terminated because they were not vaccinated or granted an exemption. Most of these employees did not submit an exemption request.

Babcock attributes success of the program to the support of hospital leadership and consistent communication from BJC staff that emphasized patient safety. "Overall, the program went very smoothly," she says. "We were able to talk with the people who had concerns about the vaccine and allay their fears. A large number of employees were really glad that we had made it mandatory and that co-workers were being vaccinated."

At the two teaching hospitals that are part of BJC HealthCare, Barnes-Jewish Hospital and St. Louis Children's Hospital, all 907 medical residents and fellows complied with the mandatory policy; five received medical or religious exemptions.

Although physicians employed by BJC were required to get the flu shot, most physicians affiliated with BJC HealthCare are in private practice or are employed by Washington University School of Medicine and are not covered by the mandatory policy.

In the United States, influenza is associated with 36,000 deaths and more than 200,000 hospitalizations each year, and it is the leading cause of vaccine-preventable death. Other vaccines, including those for the measles, mumps, rubella and chicken pox, already are required by many health-care organizations, including BJC.

Babcock says she now plans to collect data for the 2009 flu season, when employees have been required to get both the seasonal flu vaccine and the H1N1 vaccine.

Note: If no author is given, the source is cited instead.

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