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作者：Laurie Barclay, MD  
出處：WebMD醫學新聞

　　February 11, 2010 — 根據2月15日Clinical Infectious Diseases期刊中的一篇報告，在大型健康照護組織中強制施打流感疫苗成功地增加了接種比率。
　　
　　密蘇里州聖路易Barnes-Jewish暨聖路易兒童醫院職業健康(感染症)主任、華盛頓大學醫學院醫學助理教授Hilary M. Babcock醫師等人寫道，自從1984年以來，建議對健康照護工作者施打流感疫苗，曾有許多提升接種率的策略，但是全國接種率依舊偏低。
　　
　　中西部一個大型健康照護組織、有將近26,000名員工的BJC HealthCare中，該組織的疫苗接種率依舊低於目標值，因此，2008年時，將施打流感疫苗列入雇用條件中，除非有醫療或宗教因素才可申請免除施打。
　　
　　Babcock醫師在新聞稿中表示，身為病患安全提倡者，我們知道流感疫苗是安全且有效的，保護病患的最佳方法就是確保所有員工接種疫苗。
　　
　　職業健康護士與他們的醫療主任回顧這些豁免施打的請求；事先定義的醫療禁忌症包括對雞蛋過敏、曾經對流感疫苗有過敏反應、有格林-巴利症候群(Guillain-Barre syndrome)病史。
　　
　　在2008年12月15日之前，未施打或者未獲得豁免的員工將不會被排定工作，若到2009年1月15日仍然未施打或者未獲得豁免，則終止契約。25,980名員工中，25,561人(98.4%)接種疫苗，90人(0.3%)獲得宗教豁免，321人(1.2%)獲得醫療豁免，8人(0.03%)沒有接種疫苗也沒有獲得豁免。
　　
　　醫療豁免中，107人(33%)對雞蛋過敏、83人(26%)曾經對流感疫苗或其中成份有過敏反應、15人(5%)有格林-巴利症候群病史、116人(36%)屬於其他情況，包括14名懷孕。
　　
　　【順利完成且減少恐懼】
　　Babcock醫師表示，有一些醫療豁免請求反映出了對於疫苗和流感的錯誤認知，整體而言，計畫進行得很順利，我們可以和每個對於疫苗有顧慮者懇談且減少他們的恐懼，大部份員工實際上很高興我們推行強制施打，讓同仁也都接種。
　　
　　研究作者們指出，BJC HealthCare的經驗可能無法完全一般化，研究當時的經濟因素可能讓員工不願意(因為未打疫苗)失去工作，並非所有BJC HealthCare的醫師都是受雇於該組織，因此不受這項規定規範。
　　
　　研究作者們結論表示，強制施打流感疫苗活動成功地增加了接種率，尋求醫療或宗教豁免的員工比前一年簽署拒絕聲明者少，標準化的醫療豁免申請表簡化了員工的申請與審核過程，醫師們與職業健康護士明年也會延用。
　　
　　鹽湖城猶他大學的Andrew T. Pavia醫師在編輯評論中表示，所有策略都是為了改善疫苗接種率，強制施打疫苗的政策素有爭議。
　　
　　Pavia醫師寫道，這個政策讓正常履行義務與個人自主之間的倫理原則相對，強制施打疫苗政策已經有許多機構贊同，包括紐約州健康部、美國感染症協會、美國醫師學院、感染控制與流行病學專業人員協會、國家病患安全基金會等。強制施打疫苗也引起了諸多辯論和反對，包括了法律上的挑戰。
　　
　　研究作者們皆宣告沒有相關財務關係。


Mandatory Influenza Vaccination Successfully Increased Vaccination Rates

By Laurie Barclay, MD
Medscape Medical News

February 11, 2010 — A mandatory influenza vaccination campaign at a large healthcare organization successfully increased vaccination rates, according to a report in the February 15 issue of Clinical Infectious Diseases.

"Influenza vaccination of health care workers has been recommended since 1984," write Hilary M. Babcock, MD, MPH, assistant professor of medicine at Washington University School of Medicine and medical director of occupational health (infectious diseases) at Barnes-Jewish and St. Louis Children's Hospitals in St. Louis, Missouri, and colleagues. "Multiple strategies to enhance vaccination rates have been suggested, but national rates have remained low."

At BJC HealthCare, a large Midwestern healthcare organization with approximately 26,000 employees, organizational vaccination rates remained below target levels. In 2008, therefore, influenza vaccination was made a condition of employment for all employees, although medical or religious exemptions could be requested.

"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," Dr. Babcock said in a news release.

Occupational health nurses and their medical directors reviewed medical exemption requests; predetermined medical contraindications included hypersensitivity to eggs, previous hypersensitivity reaction to influenza vaccine, and history of Guillain-Barre syndrome.

Employees who were neither exempted nor vaccinated by December 15, 2008, were not scheduled for work, and those still unvaccinated and not exempted by January 15, 2009, were terminated. Of 25,980 active employees, 25,561 (98.4%) were vaccinated, 90 (0.3%) received religious exemptions, 321 (1.2%) received medical exemptions, and 8 employees (0.03%) were neither vaccinated nor exempted.

Of the medical exemptions, 107 employees (33%) were allergic to eggs, 83 (26%) had a previous allergic reaction or allergy to other vaccine component, 15 (5%) had a history of Guillain-Barre syndrome, and 116 employees (36%) had other medical exemptions, including 14 who were pregnant.

Smooth Execution, Fears Allayed

"Some of the requests for medical exemptions reflected misinformation about the vaccine and influenza," Dr. Babcock said. "Overall, the program went very smoothly, [and] 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 coworkers were being vaccinated."

The study authors note that the experience at BJC HealthCare may not be completely generalizable, that economic factors at the time of the study may have limited the number of employees willing to lose their jobs, and that not all physicians affiliated with BJC HealthCare are employed by the organization and, therefore, were not covered by the policy.

"A mandatory influenza vaccination campaign successfully increased vaccination rates," the study authors conclude. "Fewer employees sought medical or religious exemptions than had signed declination statements during the previous year. A standardized medical exemption request form would simplify the request and review process for employees, their physicians, and occupational health and will be used next year."

In an accompanying editorial commentary, Andrew T. Pavia, from the University of Utah, Salt Lake City, notes that of all the strategies to improve vaccination rates, the policy of mandatory vaccination has generated the most controversy.

"The policy pits the ethical principle of normalfeasance against individual autonomy," Dr. Pavia writes. "Mandatory vaccination policies have been endorsed by several organizations, including the New York State Department of Health, the Infectious Diseases Society of America, the American College of Physicians, the Association for Professionals in Infection Control and Epidemiology, and the National Foundation for Patient Safety.... Mandatory vaccination has also generated vigorous debate and opposition, including legal challenges."

The study authors have disclosed no relevant financial relationships.

Clin Infect Dis. 2010;50:459-464, 465-467.