June 01, 2018
3 min read

Mandatory flu vaccination policies increase in most US hospitals

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Over the past 4 years, the number of hospitals in the United States requiring annual influenza vaccinations for health care personnel has significantly increased, according to data published today in JAMA.

The increase was driven by non-Veterans Affairs (VA) hospitals, more than two-thirds of which had mandatory influenza vaccine policies in place in 2017, M. Todd Greene, MD, PhD, assistant research scientist in the division of hospital medicine at the University of Michigan Medical School, and colleagues reported. However, mandatory immunizations remain low in VA hospitals, with less than 5% requiring vaccinations for health care personnel (HCP).

“Mandating influenza vaccination remains a controversial topic, with uncertainty of the effectiveness of HCP influenza vaccination in reducing patient morbidity and mortality, different conclusions regarding the grading of the evidence, and numerous legal and ethical precedents to be carefully considered,” Greene and colleagues wrote. “Still, over the past several years, HCP influenza vaccination coverage rates have continuously been greater than 95% among HCP required by their employer to be vaccinated.”

The CDC’ s Advisory Committee on Immunization Practices recommends that all HCP receive annual influenza vaccinations. Data from a MMWR published in September showed that 78.6% of all HCP surveyed in the U.S. were vaccinated during the 2016-2017 season. Coverage rates were even higher — 96.7% — among HCP who worked in facilities that mandate vaccination.

For their study, which is part of an ongoing project assessing interventions for health care-associated infections, Greene and colleagues examined data from two nationally representative surveys conducted in 2013 and 2017 to compare the proportion of hospitals with mandatory influenza vaccination policies for HCP. The surveys were completed by infection preventionists at 403 non-VA hospitals and 80 VA hospitals in 2013, and 530 non-VA hospitals and 73 VA hospitals in 2017.

Among all responding hospitals, mandatory influenza vaccination policies increased 24% (95% CI, 18.4-30.2), from 37.1% in 2013 to 61.4% in 2017. When limiting the data to non-VA hospitals, mandatory vaccination policies increased 25.1% (95% CI, 18.8-31.4), from 44.3% to 69.4%. In contrast, there was no significant increase in the proportion of VA hospitals requiring influenza vaccinations, which was 1.3% in 2013 and 4.1% in 2017.

All 368 hospitals with mandatory influenza vaccination policies also provided staff with options to decline vaccination, although acceptable reasons for not receiving the vaccine varied. Overall, 96.2% of hospitals allowed HCP to decline vaccination for medical contraindications, 78% allowed HCP to decline vaccination for religious reasons and 12.8% of hospitals did not require a reason. More than 80% of hospitals with mandatory vaccination policies required unvaccinated HCP to use a mask when providing care to patients during an influenza season. Nearly three-quarters of hospitals had no set penalties for noncompliance with hospital vaccination policies.


Although most VA hospitals did not have formal mandate at the time of the surveys, Greene and colleagues reported that the VA issued a directive in September stating that all HCP are expected to be vaccinated or wear a mask throughout the influenza season to prevent transmission. Even in the absence of a mandate, the researchers noted that some VA hospitals have been able to improve HCP vaccination rates using other interventions, such as the use of mobile carts to facilitate vaccine delivery and time-off incentives for vaccinated HCP. Nevertheless, mandatory policies may be best way to increase uptake, according to Greene.

“Studies have shown that vaccination mandates, coupled with an option of declining vaccination in favor of wearing a mask, are most effective in reaching high percentages of vaccination,” he said in a press release.

Hilary Babcock
Hilary M. Babcock

In a related editorial, Hilary M. Babcock, MD, MPH, associate professor of medicine in the division of infectious diseases at Washington University School of Medicine, highlighted several “caveats” of the study. For example, the survey question in 2013 was worded differently than the one in 2017, and some hospitals responding to the survey in 2013 were not the same hospitals responding in 2017. This prevented researchers from being able to make a direct comparison, according to Babcock. In addition, there was no clear definition of a “mandate” and no data on the association between mandatory vaccine policies and patient outcomes. However, Babcock noted that the VA’s recent directive presents an “excellent opportunity” for researchers to investigate correlations between HCP vaccination and nosocomial influenza infections.

“While the assumption that decreasing the risk of influenza in HCP will result in decreased risk of influenza in patients cared for by those HCP is common sense, for acute-care settings, it is still largely an assumption,” she wrote. “Hopefully, the Veterans Health Administration will combine this initiative with thoughtful, planned, patient outcome assessments to help define the anticipated benefit of these efforts.” – by Stephanie Viguers

Disclosures: Babcock reports no relevant financial disclosures. Greene reports receiving grants from Blue Cross Blue Shield of Michigan Foundation and the U.S. Department of Veterans Affairs Patient Safety Center of Inquiry. Please see the study for all other authors’ relevant financial disclosures.