CDC: Use declination statements on flu vaccine

Pressure grows to document why HCWs decline

Hospitals are feeling even greater pressure to ask health care workers to sign declination statements if they don't receive the influenza vaccine.

In its 2007-2008 guidelines for seasonal influenza, the Advisory Committee on Immuniza-tion Practices called on hospitals to "obtain signed declinations from personnel who decline influenza vaccination for reasons other than medical contraindications." The expert panel develops recommendations that are adopted by the Centers for Disease Control and Prevention. (For a full excerpt from the guidelines, see article at the end.)

Some states are mandating the reporting of influenza immunization rates of health care workers and are strongly recommending the use of declination statements. For example, the Minnesota Department of Health is promoting the use of declination statements and may make use of the statements a quality goal by 2010.

"There's definitely pressure to move in this direction," says William Buchta, MD, MPH, medical director of the Employee Occupational Health Service at the Mayo Clinic in Rochester, MN, and co-author of a position statement by the American College of Occupational and Environmental Medicine opposing declination statements.

Buchta conducted a small pilot study of declination statements at Mayo and found that they did not influence health care workers to receive the vaccine. Mayo already vaccinates about 75% of its health care workers.

The declination statements are just one tool to improve health care worker influenza immunization rates, says Anthony Fiore, MD, MPH, medical epidemiologist at CDC and an author of the ACIP recommendations.

The National Health Interview Survey indicates that only 34% of health care workers received the flu vaccine in 2005. The vaccine shortage clearly affected immunization rates that year, but Fiore notes the need to attain much higher vaccination coverage.

The advisory panel chose to highlight the importance of health care worker immunization in this year's recommendations, he says. "We wanted to bring it to the forefront and say this is a problem," he says.

Putting patients at risk?

In a declination statement, health care workers acknowledge that they have been offered the vaccine. They may be asked to indicate their reason for declining. But sometimes the sharp wording of statements requires them to acknowledge that they are knowingly putting their patients at risk. For example, the sample form provided by the Minnesota Department of Health states: "I am eligible for the flu shot but do not wish to have the influenza vaccine given to me. I understand that my refusal of it may put patients, visitors, and family, with whom I have contact, at risk should I contract the flu."

Before adopting that language, Buchta advises, hospitals should seek legal and risk management advice.

Not everyone views declination statements as a critical strategy. The Joint Commission requires hospitals to monitor their health care worker influenza immunization rates and take steps toward improved coverage. But the accreditation body doesn't specifically require declination statements.

The Council on State Governments' Health States Initiative recently released a briefing document for state legislators on influenza immunization of health care workers. It recommends legislative action to ensure free access to vaccines and education of health care workers and to require health care facilities to report influenza vaccination rates. It does not mention declination statements.

"It is the employees' right to weigh the risks and benefits and decide whether this is right for them," says Buchta. "Most people will make the right decision."

CDC: Vaccinate all health care workers

This is an excerpt from the Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2007. The recommendations are available at

All health care personnel (HCP), as well as those in training for health care professions, should be vaccinated annually against influenza. Persons working in health care settings who should be vaccinated include physicians, nurses, and other workers in both hospital and outpatient care settings, medical emergency response workers (e.g., paramedics and emergency medical technicians), employees of nursing home and chronic care facilities who have contact with patients or residents, and students in these professions who will have contact with patients.

Facilities that employ HCP should provide vaccine to workers by using approaches that have been demonstrated to be effective in increasing vaccination coverage. Health care administrators should consider the level of vaccination coverage among HCP to be one measure of a patient safety quality program and obtain signed declinations from personnel who decline influenza vaccination for reasons other than medical contraindications. Influenza vaccination rates among HCP within facilities should be regularly measured and reported, and ward-, unit-, and specialty-specific coverage rates should be provided to staff and administration). Studies have demonstrated that organized campaigns can attain higher rates of vaccination among HCP with moderate effort and using strategies that increase vaccine acceptance.

Efforts to increase vaccination coverage among HCP are supported by various national accrediting and professional organizations and in certain states by statute. The Joint Commission has approved an infection control standard that requires accredited organizations to offer influenza vaccinations to staff, including volunteers and licensed independent practitioners with close patient contact. The standard became an accreditation requirement beginning Jan. 1, 2007. In addition, the Infectious Diseases Society of America recently recommended mandatory vaccination for HCP, with a provision for declination of vaccination based on religious or medical reasons. Fifteen states have regulations regarding vaccination of HCP in long-term care facilities, three states require that health care facilities offer influenza vaccination to HCP, and three states require that HCP either receive influenza vaccination or indicate a religious, medical, or philosophical reason for not being vaccinated.