"I believe this is going to become something in the future that all hospitals are going to consider doing," Cutler added.
The trend raises ethical and legal questions about balancing employee autonomy and the needs of patients, whose weakened bodies make them less able to fight off a virus that kills thousands each year or to benefit from the vaccine.
Proponents of mandatory vaccination argue that health workers, who must get other vaccines such as measles before they can work, have a responsibility to protect patients. Some nursing organizations have fought the rules, saying that they should be part of negotiated contracts and that employees should be able to decide for themselves whether they need the vaccines.
Part of the rationale for giving the shots to virtually everyone - the Centers for Disease Control and Prevention recommends the vaccine for everyone older than six months - is the concept of herd immunity. The shot is not 100 percent effective in any group, but it works best in people with strong immune systems - the young and healthy. These are the people the virus is usually least likely to kill, but the object is to keep them from giving it to others. Plus, flu is contagious a day before people have symptoms, so they cannot just stay home to contain the virus.
Virginia Mason Medical Center in Seattle pioneered mandatory vaccination in 2005. It so far has fired only two employees, although seven more left voluntarily. About 50 hospitals or health systems now require employees to get flu shots, according to the Immunization Action Coalition.
New York state's health commissioner last year issued an edict requiring health-care workers to be vaccinated against flu. His department later abandoned the rule in the face of legal challenges and short vaccine supply. "Patients in hospitals and other health-care settings have the right to expect that they will not be infected by their health-care worker with a preventable disease which could be fatal," Commissioner Richard F. Daines said last year. He has not announced his plans for this flu season.
The New York State Nurses Association received calls from more than a thousand nurses upset about the regulation, said Eileen Avery, associate director of education, practice, and research. Some considered the requirement a violation of their civil rights. Others had concerns about vaccines, especially the H1N1 vaccine, and thought there was insufficient evidence that vaccinating them would prevent spread of the disease. Hospitals, she said, treated nurses "harshly," putting labels on their badges and keeping them out of work.
"Nurses' rights in making this decision were totally not looked at," she said.
Nonetheless, the idea is taking hold. Last week, the Society for Healthcare Epidemiology of America (SHEA) came out in favor of mandatory flu vaccines for health workers and received the endorsement of the Infectious Diseases Society of America. The Department of Defense requires shots for health workers at its facilities, and the National Patient Safety Foundation also supports mandatory flu vaccinations for health workers.
The University of Pennsylvania will hold a conference on mandatory vaccines later this month.
Last year, Children's Hospital of Philadelphia and the three-hospital University of Pennsylvania Health System made flu shots mandatory for their workers. Nine employees ended up leaving Children's because of the policy. No one was fired at Penn, but a handful of employees were suspended for refusing the shots, said Judy Schueler, vice president of organizational development and human resources. This year, Abington Memorial Hospital also is requiring employees to be vaccinated.
Most other hospitals in the region strongly encourage employees to get flu vaccines. Some require employees who do not want the vaccine to sign a form declining it. Lourdes Health System is considering mandatory vaccination in critical units, and Cancer Treatment Centers of America and Lehigh Valley Health Network said they were looking into requirements.
Greg Poland, a Mayo Clinic infectious-disease specialist who has been campaigning for mandatory flu shots for health workers for years, said the shots were "unquestionably a patient-safety issue." He said he thinks health institutions have been unduly fearful of employee reaction. He finds it "remarkable" that "entities entrusted with and privileged to care for the public health are not doing something that the data show is beneficial to the health and welfare of patients because of fear of employee pushback."
Studies show that employee vaccination prevents transmission of disease to patients and reduces overall patient death rates, according to the SHEA position statement.
Neil Fishman, director of health-care epidemiology and infection prevention for Penn's health system and president of SHEA, said Penn could not get voluntary vaccination rates above 55 percent. In 2007, he said, 15 nurses and several physicians who worked in an intensive-care unit got the flu. They did not give it to patients, but the potential was there.
Penn bioethicist Arthur Caplan says there is no ethical reason not to require employee vaccinations. When workers ask, "Don't I have any rights?" he answers that patient rights trump those of employees. Codes of ethics for health workers typically require them to put the interests of patients above their own and to protect the vulnerable and the weak. Plus, he said, "you have a duty to do no harm."
Contact staff writer Stacey Burling at 215-854-4944 or email@example.com.