JCAHO standard targets resistance to HCW flu vaccinations

Does new standard have teeth?

Having made infection control and patient safety top priorities in recent years, the Joint Commission on Accreditation of Healthcare Organizations is now taking on the thorny issue of flu vaccinations for health care workers in a new standard that becomes effective next year.

It appears the Joint Commission has no immediate expectation for hospitals to meet some benchmark immunization rate, but does expect the standard to begin pushing national rates out of the anemic 40% range.

"The current rates are abysmally low," says Robert Wise, MD, JCAHO vice president of the division of standards and survey methods. "The standard is set up essentially as a CQI project, where the organization has to have a program, has to evaluate its rates, has to understand why there is a problem, and it has to improve it. This is a standard now; [noncompliance] would be a problem."

The Joint Commission standard requires accredited organizations to offer influenza vaccinations to staff, which includes volunteers and licensed independent practitioners with close patient contact. The standard will become an accreditation requirement beginning Jan. 1, 2007, for the critical access hospital, hospital, and long-term care accreditation programs. Organizations will be required to:

  • establish an annual influenza vaccination program that includes at least staff and licensed independent practitioners;
  • provide access to influenza vaccinations on site;
  • educate staff and licensed independent practitioners about flu vaccination; nonvaccine control measures (such as the use of appropriate precautions); and diagnosis, transmission, and potential impact of influenza;
  • annually evaluate vaccination rates and reasons for nonparticipation in the organization's immunization program;
  • implement enhancements to the program to increase participation.

JCAHO follows CDC action

The Joint Commission developed the standard in response to recommendations by the Centers for Disease Control and Prevention (CDC), making the reduction of influenza transmission from health care professionals to patients a top priority in the United States. While the CDC has urged annual influenza vaccination for health care workers since 1981, CDC guidelines published earlier this year call for stronger steps to increase influenza vaccination of health care workers.1

In issuing the standard, JCAHO cited estimates that influenza causes 36,000 deaths and more than 200,000 hospitalizations on average in the United States a year. Furthermore, health care-associated transmission of influenza has been documented among many patient populations in a variety of clinical settings, and patient infections have been linked to unvaccinated health care workers.

In two separate studies in geriatric long-term care facilities, total patient mortality was significantly lower in those sites where health care workers were vaccinated compared to sites where routine vaccination was not offered to health care workers (10% vs. 17% and 14% vs. 22%)2,3. Increased rates of health care worker vaccination also correspond with a significant decrease in the incidence of health care-associated influenza.

"It has been demonstrated epidemiologically that patients are getting flu from health care workers," Wise says. "One of the particular problems is that by the time that the health care worker is symptomatic they have already been infectious for a couple of days. The only way to deal with that is to get the vaccine. If you tell someone to stop coming to work when they have symptoms, it is not going to work. It is too late. "

Will standard change historic problem?

In recent years, the Joint Commission has issued tougher standards and patient safety goals focused on infection control, but it is an open question whether JCAHO has built enough momentum to take on the entrenched resistance to seasonal flu vaccination by health care workers. Moreover, many of those recalcitrant workers are nurses, the very backbone of the health care delivery system. The reasons typically given for refusing vaccination are the perception that they pose no risk to patients, fear of vaccine side effects, fear of needles, or belief that the vaccine causes the flu. While there are elements of the health care work force that remain suspicious of the safety of the annual influenza vaccine, such fears remain unsupported by scientific evidence. On the contrary, a study comparing receipt of flu vaccine vs. placebo revealed no significant difference in side effects.4

In an age of patient safety — which the Joint Commission is now emphasizing in many of its standards and accreditation activities — there is a glaring disconnect in having large numbers of health care workers unvaccinated every flu season. "Certainly people have looked at it from an employee health point of view — all the time lost from work, etc.," Wise says. "But one of the areas that the CDC has particularly [emphasized] is transmission from the health care worker to the patient. "

But does the Joint Commission standard go far enough to really solve the problem?

The Association for Professionals in Infection Control and Epidemiology has come out in favor of mandatory seasonal flu vaccinations for patient caregivers; the Society for Healthcare Epidemiology of America is calling for workers to sign off on declination statements if they turn down the shot; and the Centers for Disease Control and Prevention also puts declination statements on the table as an option.5

The CDC language is somewhat equivocal, noting "the independent contribution of signed declination statements to improving HCP [health care personnel] vaccination has not been studied. However, obtaining declination statements from health care workers who refuse vaccination for reasons other than medical contraindications can assist facilities in identifying personnel who might require targeted education or other interventions to overcome barriers to vaccine acceptance. In addition, collection of such information will allow health care facilities to determine what proportion of their staff are reached and offered vaccine."

The Joint Commission's new standard requires hospitals to offer flu vaccine but stops short of requiring declination statements. Instead, hospitals are to annually evaluate vaccination rates and reasons for nonparticipation and implement program enhancements to improve participation.

The declination dilemma

"Declination statements are not required," Wise explains. "That was one of the most hotly debated issues. The question was whether declination statements truly added to improving the rates or do they just add a burden on the hospital."

Rather than filing a declination form for individual workers, hospitals can assess reasons for noncompliance through surveys, he notes. "It's a lot less burdensome."

Indeed, he adds the Joint Commission does not see enforcement of the standard to be a complicated matter. "You either know your rates or you don't. You need to know your [immunization] rates," Wise says. "You need to demonstrate what are potentially the issues about why you do have a better rate. Then you need to do something to enhance the program to increase it. "

JCAHO had a major impact on hand hygiene practices in the nation's hospitals after it made CDC recommendations for alcohol hand rubs a national patient safety goal. "That is a particularly powerful one, at least from a process point of view," Wise says. "If you go into almost any hospital now you will see the alcohol hand rub containers. The CDC has done two surveys and is finding that well over 90% of all hospitals are now using alcohol-based hand rubs. The issue that has come up is, are we able then to go from that process indicator to an outcome? Are the people really using the [hand hygiene] material? There has not been really a good method yet to measure that. People are taking a look at that inside the Joint Commission."

At any rate, we will now see if a similar impact holds true for flu vaccination. And given the regulatory nature of the times, there is always the possibility that flu immunization rates could be reported as a process measure in state and federal laws regarding hospital quality. "Whether it will [carry the same importance] as MRSA [methicillin-resistant Staphylococcus aureus] infection or something like that, I leave it up to the experts," Wise says. "But it is an important process measure that may [reflect] the overall culture of the organization."


1. Centers for Disease Control and Prevention. Influenza Vaccination of Health-Care Personnel Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP) MMWR 2006; 55:1-16.

2. Carman WF, Elder AG, Wallace LA, et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: A randomized controlled trial. Lancet 2000; 355:93-97.

3. Potter J, Stott DJ, Roberts MA, et al. Influenza vaccination of health care workers in long-term care hospitals reduces the mortality of elderly patients. J Infect Dis 1997; 175:1-6.

4. Margolis KL, Nichol KL, Poland GA. Frequency of adverse reactions to influenza vaccine in the elderly: A randomized, placebo-controlled trial. JAMA 1990; 246:1,139-1,141.

5. Talbot TR, Bradley SF, Cosgrove SE, et al. SHEA Position Paper: Influenza Vaccination of Healthcare Workers and Vaccine Allocation for Healthcare Workers During Vaccine Shortages. Infect Control Hosp Epidemiol 2005; 26:882-890.