Six employees at Flagstaff Medical Center refused to take a required flu shots and are no longer working at the hospital.

And FMC is not alone. A survey by federal Centers for Disease Control researchers found that in 2011, more than 400 U.S. hospitals required flu vaccinations for their employees and 29 hospitals fired unvaccinated employees.

"If you don't want to do it, you shouldn't work in that environment," medical ethicist Art Caplan told the Associated Press. "Patients should demand that their health care provider gets flu shots -- and they should ask them."

Lynn Belcher, chief nursing officer and vice president of nursing services at FMC, said that flu vaccines are required for all staff at the hospital.

The hospital allows for two exemptions on religious and medical grounds. Staff seeking an exemption must fill out a form and have it signed by a physician or a licensed religious leader.

"One thing that didn't get exempted was 'I just don't want a flu shot,'" Belcher said. "There were a few ... who questioned the CDC's scientific evidence and questioned the use of the flu shot."

FMC policy requires termination for staff who do not comply and who do not have an appropriate exemption.

Starla Collins, spokesperson for the hospital, said that six people are no longer working at the hospital in the wake of the hospital instituting the policy requiring flu shots.

According to a statement from FMC: " The employees who chose not to get the vaccination and/or did not meet the standards for the exemption for not getting the vaccine no longer met the conditions for employment and were out of compliance and therefore could not work at FMC."

Belcher added that some resigned without being fired, feeling that strongly about not getting the flu vaccine. The majority of the exemptions sought fit under the accepted exemption guidelines.

FMC has about 2,000 employees in Flagstaff, and about 90 percent are now vaccinated.

HIGHEST RATE AMONG PHARMACISTS

According to the most recent federal data, about 63 percent of U.S. health care workers had flu shots as of November. That's up from previous years, but the government wants 90 percent coverage of health care workers by 2020.

The highest rate, about 88 percent, was among pharmacists, followed by doctors at 84 percent, and nurses, 82 percent. Fewer than half of nursing assistants and aides are vaccinated, Dr. Carolyn Bridges, associate director for adult immunization at the CDC, told the Associated Press.

Some hospitals have achieved 90 percent but many fall short. A government health advisory panel has urged those below 90 percent to consider a mandatory program.

Also, the accreditation body over hospitals requires them to offer flu vaccines to workers, and those failing to do that and improve vaccination rates could lose accreditation.

Mandates for vaccinating health care workers against other diseases, including measles, mumps and hepatitis, are widely accepted. But some workers have less faith that flu shots work -- partly because there are several types of flu virus that often differ each season and manufacturers must reformulate vaccines to try and match the circulating strains.

Cancer nurse Joyce Gingerich is among the skeptics and says her decision to avoid the shot is mostly "a personal thing." She's among seven employees at IU Health Goshen Hospital in northern Indiana who were recently fired for refusing flu shots. Gingerich said she gets other vaccinations but thinks it should be a choice. She opposes "the injustice of being forced to put something in my body."

FOUGHT TO THE BITTER END

Belcher of FMC said that some employees fought the issue to the bitter end and were fired.

"We were prepared to take that step if need be," Belcher said.

Belcher said that while the hospital understands the concept of individual rights, it must be counterbalanced with the importance of focusing on the good of the whole.

"We didn't do this overnight," she said, adding that requiring the vaccines is a trend across the country.

Prior to the requirement, there was about 60 to 70 percent of staff who had already elected to receive the vaccine, which is below the 90 percent standard suggested. After the requirement, 100 percent of the employees without an exemption have been vaccinated.

UNIONS WANT VOLUNTARY COMPLIANCE

Several states have laws or regulations requiring flu vaccination for health care workers but only three -- Arkansas, Maine and Rhode Island -- spell out penalties for those who refuse, according to Alexandra Stewart, a George Washington University expert in immunization and co-author of a study appearing this month in the journal Vaccine.

Rhode Island's regulation, enacted in December, may be the toughest and is being challenged in court by a health workers union. The rule allows exemptions for religious or medical reasons, but requires unvaccinated workers in contact with patients to wear face masks during flu season. Employees who refuse the masks can be fined $100 and may face a complaint or reprimand for unprofessional conduct that could result in losing their professional license.

Some Rhode Island hospitals post signs announcing that workers wearing masks have not received flu shots. Opponents say the masks violate their health privacy.

"We really strongly support the goal of increasing vaccination rates among health care workers and among the population as a whole," but it should be voluntary, said SEIU Healthcare Employees Union spokesman Chas Walker.

Supporters of health care worker mandates note that to protect public health, courts have endorsed forced vaccination laws affecting the general population during disease outbreaks, and have upheld vaccination requirements for schoolchildren.

Cases involving flu vaccine mandates for health workers have had less success. A 2009 New York state regulation mandating health care worker vaccinations for swine flu and seasonal flu was challenged in court but was later rescinded because of a vaccine shortage. And labor unions have challenged individual hospital mandates enacted without collective bargaining; an appeals court upheld that argument in 2007 in a widely cited case involving Virginia Mason Hospital in Seattle.

Calhoun, the Illinois nurse, says she is unsure of her options.

"Most of the hospitals in my area are all implementing these policies," she said. "This conflict could end the career I have dedicated myself to."

The Associated Press contributed to this story.

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