Pushing flu shot declination statements irks some HCWs

But efforts can boost flu vaccination rates

You may be able to boost your influenza vaccination rates by requiring health care workers to sign mandatory declination statements. But declinations themselves may put a negative tone to the annual campaign.

Those are some conclusions of employee health professionals as they calculated the successes and challenges of the past influenza season.

A growing number of organizations have called for the use of declination statements to improve health care worker immunization. The Society for Healthcare Epidemiology of America (SHEA) included declination statements in its recommendations for influenza vaccination. Even the American Nurses Association has endorsed declination statements, as long as they are used to track the reasons for declining the vaccine and do not have a punitive element.

"We think the declination form opens the dialogue and provide opportunity for education," says Nancy Hughes, MS, RN, director of the Center for Occupational and Environmental Health at the American Nurses Association in Silver Spring, MD.

The wording of declination statements may vary from inquisitive (asking why they chose not to receive the vaccine) to chastising. Typically, health care workers acknowledge that failing to get the vaccine put them, their families, and their patients at risk for influenza. (For a copy of the SHEA sample declination statement, see box below.)

Declination of Annual
Influenza Vaccination

I understand that due to my occupational exposure, I may be at risk of acquiring influenza infection. In addition, I may spread influenza to my patients, other healthcare workers, and my family, even if I have no symptoms. This can result in serious infection, particularly in persons at high risk for influenza complications.

I have received education about the effectiveness of influenza vaccination as well as the adverse events. I have also been given the opportunity to be vaccinated with influenza vaccine, at no charge to myself. However, I decline influenza vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring influenza, potentially resulting in transmission to my patients. If in the future I want to be vaccinated with influenza vaccine, I can receive the vaccine at no charge to me.

Employee's Name: ____________________
Witness Name: ________________________
Employee's Signature: ___________________
Witness Signature: _____________________
Date: ____ / ______ / _______

Source: Society for Hospital Epidemiology of America, www.shea-online.org.

To test the impact of declination statements, Mayo Clinic in Rochester, MN, selected 500 nurses who had not received the vaccine by the end of November. Half received an e-mail reminding them to get the vaccine and referring them to educational links on the intranet. The other half received the e-mail with voting buttons that asked them if they planned to get the vaccine. If not, they were asked to indicate that they had read the declination statement and were declining the vaccine.

About three months later, Mayo surveyed the nurses. About 40% in both groups responded. About equal numbers said they were more inclined to receive the vaccine after the e-mail (14% in the declination group vs. 17% in the no-declination group), but about one in five (22%) in the declination group said they had been irritated by the e-mail.

"Adding the declination statement had no positive impact on likelihood of subsequently getting vaccinated," says Bill Buchta, MD, MPH, medical director of the Employee Occupational Health Service. "We did not see a groundswell of response to a declination statement. In fact, they tended to be less likely to get vaccinated after reading the e-mail."

Of course, that does not mean that declination statements don't work. The Mayo declination was not mandatory, as it is as other hospitals. Although there is little data on declination statements, hospitals report higher vaccination statements after using them.

"It does give you pause for thought," says Buchta. "At what cost are you doing that? Are you alienating your employees unnecessarily?"

Making a statement about flu

Declination statements have a practical component beyond urging health care workers to be vaccinated. They help track vaccinations and the reasons for declining, which are aspects of the Joint Commission's standard on influenza immunization of health care workers.

"I think it sends a message that we're really serious about this," says Trish Perl, MD, MSc, hospital epidemiologist at Johns Hopkins Hospital in Baltimore and past president of SHEA.

After using declination statements, health care worker vaccinations tripled at the clinics of Allina Hospitals and Clinics in Minneapolis — from about 500 doses to 1,898, says Karen Ferrara, RN, MPH, COHN-S, employee health and safety consultant. A couple of the health system's smaller hospitals have had similar success.

However, Allina hasn't implemented mandatory declination statements systemwide because of the logistical difficulty of monitoring the program. Instead, the health system has surveyed employees in low compliance areas to ask why they didn't receive the vaccine or why they believe their co-workers didn't receive the vaccine.

Employees are not identified by name in the surveys. "We're trying to use that to get over some barriers we have," Ferrara says.

The surveys showed that about 10% of employees had gotten the vaccine elsewhere. The main reason for not getting vaccinated: 'I'm healthy and I don't need it.'

Ferrara plans to provide more education about influenza infection — and the possibility of asymptomatic transmission. Future campaigns also will use "flu deputies" in each unit to make the vaccine as accessible as possible.