Issue: February 2013
Perspective from Theodore C. Eickhoff, MD
February 01, 2013
13 min read

Flu vaccination rates in HCWs: Room for improvement

Issue: February 2013
Perspective from Theodore C. Eickhoff, MD
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Compared with a 36% overall influenza vaccination coverage rate among health care workers in 2006, the mid-season coverage rate for 2012-2013 has increased to about 63% — on the path to nearing the Healthy People 2020 target goal of 90%, according to the CDC.

As of press time, influenza activity remains elevated in most areas of the United States after an early start to the season. “The only thing predictable about the flu is that it’s unpredictable. Only time will tell us how long our season lasts and how moderate or severe the season will be,” Thomas Frieden, MD, director the CDC, said during a recent media briefing on influenza activity in the United States.

Despite pleas from numerous organizations for all health care workers (HCWs) to get vaccinated against influenza — the CDC has recommended HCW influenza vaccination since 1981 — the rates remain low among those working in long-term care facilities (48.7%), among assistants/aides (43.4%) and nonclinical support staff (54.5%).

According to the most recent data from the CDC’s Internet Panel Survey on Health Care Personnel Flu Vaccination, the most common reasons for HCWs to not get the vaccine were “they do not want vaccination” and “they believe that vaccination is ineffective.”

William Schaffner, MD, said there are many institutions that have a mandatory influenza vaccination program in place across all hospitals and clinics.

Photo courtesy of Vanderbilt University

"Another reason [patients give for choosing to not get the vaccine] is that you can get ill from the vaccine and that there are side effects of various kinds, which blend into ‘you get flu from the flu vaccine,’” William Schaffner, MD, professor and chairman of the department of preventive medicine and professor of medicine in the department of infectious diseases at Vanderbilt University School of Medicine, told Infectious Disease News. “Considering that we give flu vaccine in the US alone to the tune of 120 million doses, obviously it can’t be that unsafe. We do this annually, never mind the doses that are given around the world.”

Schaffner also said patients who claim they have gotten influenza from a flu vaccine “is completely erroneous. You may get a sore arm or the nasal vaccine will give you a sore throat or a runny nose, but these are temporary inconveniences and are in no comparison to getting influenza, let alone transmitting it to an already ill patient.”

In an interview with Infectious Disease News, Edward J. Septimus, MD, FIDSA, FACP, FSHEA, medical director of infection prevention and epidemiology clinical services with HCA Healthcare System, said all health care professionals should set the platform for urgency around the fact that immunization is a patient safety issue.

“There needs to be education to dispel the myths about vaccination, which are still widely prevalent out there,” Septimus said.

Gregory A. Poland, MD, Director, Vaccine Research Group, Mayo Clinic, said that all HCWs should get the influenza vaccine.

“Influenza vaccines are not perfect, but they are the best preventive measure that we have,” Poland said in an interview with Infectious Disease News. “We should make [influenza vaccines] mandatory because it is a patient safety and quality of care issue. It’s not necessarily that we or someone else is trying to say that we know better about protecting your own health. It’s that we have standards and we place patient interests above our own interests and are willing to do anything within the realm of what’s safe to protect patients.”

Review essential interventions

In a recent viewpoint published in JAMA, Thomas R. Talbot, MD, and H. Keipp Talbot, MD, MPH, both of Vanderbilt University School of Medicine, said: “Following last year’s season of low activity, influenza is surging across the country. With influenza intensifying, it is important to review essential interventions that prevent influenza transmission at home, at work and in health care facilities.”

According to the researchers, there are key actions that should be undertaken to prevent the spread of influenza. While the basic infection control practices (hand hygiene, cough etiquette and social distancing) are important prevention methods, they said that additional measures to limit transmission of influenza in health care settings are essential.

Edward J. Septimus

Edward J.

These additional measures include screening patients on arrival to the hospital to assess for respiratory symptoms, keeping infected patients away from other ill patients and ensuring that visitors and [HCWs] do not visit or work while ill — known as presenteeism.

“Influenza…is unique among respiratory viral pathogens in that another effective intervention to prevent transmission exists: Vaccination,” they wrote. “The increasing incidence of influenza across the United States should remind all clinicians about the key methods for transmission prevention, including vaccination. Misperceptions about influenza vaccine are common and often deeply rooted; for the protection of patients, colleagues, and loved ones, these perceptions must continue to be addressed, and the approach should be to immunize, immunize, immunize!”

Mandatory vaccination program feasible

“A key component of a successful vaccination program is that you have to have your executives on board — the local executive leadership helping to drive these programs,” Septimus said. “The top executives need to be onboard, health care workers need to be educated, and there has to be some accountability for patient safety.”

The first large, mandatory influenza vaccination program occurred at the Virginia Mason Medical Center (VMMC) in Seattle.

In a 2010 study published in Infection Control and Hospital Epidemiology, Robert M. Rakita, MD, clinical professor of medicine at the University of Washington, and colleagues report 5-year data on the vaccination program that mandated all HCWs to either get vaccinated or to wear a mask at work during influenza season. The program initially faced resistance, but eventually led to vaccination rates that remained above 98% since program implementation.

“They had a passionate senior administrator who was avid about patient safety, and they implemented their program in a very rigorous fashion,” Schaffner said. “They were very firm in their program and had to discharge some people who elected to not be vaccinated. There is always a fair amount of resistance during the first year of implementation, but by the third or fourth season, it’s all routine.”

Since that time, other hospitals have followed suit. At BJC HealthCare in St. Louis, vaccination rates reached 98.4% after mandatory implementation of the influenza vaccine.

Similarly, Hospital Corporation of America (HCA) achieved a 96.4% overall vaccination rate after introducing their policy during the 2009-2010 season. The program was multifaceted and required influenza vaccination but also allowed for declination of vaccination for any reason. HCWs that declined vaccination were then required to wear a mask.  

We teach cough etiquette and hand hygiene. All of this is part of an influenza bundle that we certainly have advocated in our program,” Septimus said. “It’s not just about vaccines. Vaccines are only a part of it.” He said an effective flu program needs to be multifaceted. HCA’s program includes:

  • Healthcare Workers: Seasonal flu vaccination; stay home when ill; select appropriate personal protective equipment when caring for known or suspected flu cases; and appropriate use of antiviral medications.
  • Patients: Early recognition, separation and droplet precautions for suspected or confirmed cases; surgical masks when being transported; and use effective antiviral medications.
  • Everybody: Compulsive hand hygiene and compulsive respiratory etiquette.

Besides these patient safety initiatives, Septimus and colleagues across HCA institutions set up an influenza Gmail account, in which any HCW could send in questions that would be answered 24/7. Subject content experts were there to answer all questions immediately. 

“There are many institutions, including HCA, that have instituted a program across all hospitals and clinics that are going smoothly,” Schaffner said. “I believe it’s because they are very rigorous.”

At Schaffner’s institution, Vanderbilt University Medical Center in Tennessee, a committee has been assigned to implement a universal influenza vaccination program. Schaffner said the committee is working to learn from the many other institutions that have mandatory programs established. “We are currently working on all the elements of the program. Exactly what form it will take is unclear,” he said.

Reduction in employee absence rates

During a presentation at the most recent ID Week meeting in San Diego, Heather Young, MD, of the Denver Health Medical Center, presented findings from a study that assessed the implementation of a universal influenza vaccination policy in 2011.

According to background information in the study, about 25% of HCWs contract influenza each year, and in turn, employee absence rates increase during influenza season. The policy required all HCWs and contractors with direct contact with patients to be vaccinated with the influenza vaccine by Dec. 1, 2011. Influenza activity rates were compared between the 2006-2007 and 2011-2012 influenza seasons. Both seasons were classified as mild and with low activity by the CDC.

For the 2011-2012 influenza season, 98% of HCWs received influenza vaccination. Compared with a mean HCW absence rate of 9.14 per 100 employees during 2006-2007, the absence rate was 6.15 per 100 employees per month in 2011-2012 (P=.0004).

“Universal influenza vaccination was associated with lower employee absences in 2 years with comparable low influenza activity. The data suggest that universal influenza vaccination may keep the workforce healthier,” Young told Infectious Disease News.

Medical societies back mandatory vaccination

In 2010, the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America endorsed mandatory vaccination policies for all HCWs to reduce the risk for infection between patients and employees.

“SHEA views influenza vaccination of [health care personnel] as a core patient and [health care personnel] safety practice with which noncompliance should not be tolerated,” wrote researchers representing SHEA. “It is the professional and ethical responsibility of [health care personnel] and the institutions within which they work to prevent the spread of infectious pathogens to their patients through evidence-based infection prevention practices, including influenza vaccination.”

According to the two organizations, the only exceptions should include people with medical contraindications for receipt of the vaccine. In several studies, results indicated that a 100% vaccination rate among health care personnel in acute care settings triggered a 43% decline in risk for influenza among patients. This decrease appeared even higher — 60% — among nursing home patients, the panel wrote. Furthermore, other study data highlighted the cost-effectiveness of HCW vaccination as a prevention strategy.

HCWs as advocates

With the proper education, monitoring and access to free vaccination, HCWs have the ability to be advocates for the influenza vaccine for their patients — to lead by example.

According to Schaffner, it is important for clinicians to be vaccine advocates. “Annual immunization against influenza by health care workers is both a professional and ethical responsibility and it should be clearly accepted and undertaken with enthusiasm. It is a patient safety issue,” he said. “There is both an ethical and professional reason to get vaccinated — no excuses.

“Underlying it all, our colleagues in occupational health service and we in infection control are concerned that people do not have a sufficient understanding that this is a patient safety issue. They are only thinking in terms of personal protection rather than patient protection. They would accept the vaccine if patient protection were a more dominant thing on their minds,” he said.

Poland said that there are millions of patients across the nation who are sick with the flu and if HCWs are not protected, they get infected. “If that happens, they’ll spread it to other vulnerable patients and other staff members. We then have to say, requirements for influenza vaccination make the point that it isn’t about you, it’s about the patient.” — by Jennifer Henry

Quan K. Infect Control Hosp Epidemiol. 2012;33:63-70.
Rakita R. Infect Control Hosp Epidemiol. 
Septimus E. JAMA. 2011; 305:999-1000.
Talbot TR. JAMA. 2013;doi:10.1001/jama.
Young H. #95. Presented at: ID Week; Oct. 17-21, 2012; San Diego.
For more information:

Gregory A. Poland, MD, can be reached at
William Schaffner, MD, can be reached at Preventive Medicine; 1500 21st Avenue South, Ste 2600; Nashville, TN  37212; email:
Edward A. Septimus, MD, can be reached at 4257 Albans Street; Houston, TX 77005; email:
Heather Young, MD, did not provide contact information.

Disclosures: Poland is the chair of a Safety Evaluation Committee for investigational vaccine trials being conducted by Merck Research Laboratories. Poland offers consultative advice on vaccine development to Avianax, CSL Biotherapies, Dynavax, Merck & Co. Inc., Novartis Vaccines and Therapeutics, PAXVAX Inc., and Sanofi Pasteur. These activities have been reviewed by the Mayo Clinic Conflict of Interest Review Board and are conducted in compliance with Mayo Clinic Conflict of Interest policies. Schaffner and Septimus report no relevant
financial disclosures.