CDC: Collect declinations on influenza vaccine

Push continues to improve immunization rates

It's official: The Centers for Disease Control and Prevention (CDC) has recommended collecting declination statements from health care workers who do not receive the flu vaccine, along with other measures to improve flu vaccination rates.

The new recommendation will place greater pressure on hospitals to track health care workers who do not receive the vaccine.

"We want health care facilities to be even more aggressive in protecting their staff and patients from influenza," Denise Cardo, MD, chief of the CDC's division of healthcare quality promotion, said in a statement.

There's widespread agreement that more health care workers need to get the annual flu vaccine. Nationally, only about 40% receive the vaccine, CDC surveys show. Amid the specter of a flu pandemic and rising concern about deaths from complications of seasonal influenza, vaccination of health care workers has become a priority.

But how to improve rates has proved to be controversial. Employee health professionals and union advocates say that declination statements have not been shown as a tool to boost vaccination rates and place a punitive tone on vaccination campaigns.

The CDC missed the mark by failing to emphasize education as a method for improving vaccination, says Bill Borwegen, MPH, health and safety director of the Service Employees International Union (SEIU). While the CDC recommends education of staff, the agency doesn't provide any details.

"Our experience is that employers pay incredibly short shrift to education," says Borwegen. "Some employers just put a slip in an employee's paycheck. They don't have a commitment to the kind of education that would change behavior and get people vaccinated."

The American College of Occupational and Environmental Medicine (ACOEM) also has taken a position against declination statements and mandatory flu vaccination.

"The rights of the patient must be weighed against the rights of employees," ACOEM said in its statement. "There may be work settings, such as an organ transplant unit, in which the patients are so immunocompromised that any risk of nosocomial transmission warrants administrative action. In such a setting, the unvaccinated employee might be offered temporary reassignment during the influenza season, but such action could not be justified in all health care settings."

Getting tough on influenza

The CDC recommendations reflect a growing momentum toward stricter policies on influenza immunization.

In the Feb. 9 Morbidity and Mortality Weekly Report, the CDC published the recommendations of two federal advisory panels, the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP).1 Their positions mirror those of two infection control professional organizations, the Association for Professionals in Infection Control and Epidemiology (APIC) and the Society for Healthcare Epidemiology of America (SHEA).

HICPAC also recommended using health care worker flu vaccination rates as a quality measure in states that mandate public reporting of health care-associated infections. The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, recently released a proposed standard targeting flu vaccination.

"Extremely high vaccination rates among health care workers are very important in decreasing patient mortality," says Trish Perl, MD, MSc, president of SHEA, which conducted a teleconference to promote influenza vaccination of health care workers. "SHEA determined we must strive for universal vaccination of health care workers."

Health care workers continue to work even when they are ill with influenza-like symptoms, says Tom Talbot, MD, MPH, associate hospital epidemiologist at the Vanderbilt University School of Medicine in Nashville, TN, citing a study showing that only about a third of health care workers in a Glasgow, Scotland, hospital who were seropositive for influenza had taken sick leave.2 In some cases, the health care workers may have been asymptomatic, he notes.

Studies also show that higher levels of health care worker vaccination are associated with lower patient mortality rates, he says.

Requiring health care workers to sign a statement declining the vaccine is just one strategy to focus attention on the importance of vaccination, he says. "I don't think declination in itself is the ultimate solution. But it forces the health care institution to ensure that they've enhanced their program," Talbot says.


1. Centers for Disease Control and Prevention. Influenza vaccination of healthcare 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. Elder AG, O'Donnell B, McCruden EA, et al. Incidence and recall of influenza in a cohort of Glasgow healthcare workers during the 1993-4 epidemic: Results of serum testing and questionnaire. Br Med J 1996; 313(7,067):1,241-1,242.

Recommendations for Improving HCW Flu Vaccination
  • Educate health care personnel (HCP) regarding the benefits of influenza vaccination and the potential health consequences of influenza illness for themselves and their patients, the epidemiology and modes of transmission, diagnosis, treatment, and nonvaccine infection control strategies, in accordance with their level of responsibility in preventing health care-associated influenza.
  • Offer influenza vaccine annually to all eligible HCP to protect staff, patients, and family members and to decrease HCP absenteeism. Use of either available vaccine (inactivated or live, attenuated influenza vaccine [LAIV]) is recommended for eligible persons. During periods when inactivated vaccine is in short supply, use of LAIV is especially encouraged when feasible for eligible HCP.
  • Provide influenza vaccination to HCP at the work site at no cost as one component of employee health programs. Use strategies that have been demonstrated to increase influenza vaccine acceptance, including vaccination clinics, mobile carts, vaccination access during all work shifts, and modeling and support by institutional leaders.
  • Obtain a signed declination from HCP who decline influenza vaccination for reasons other than medical contraindications.
  • Monitor HCP influenza vaccination coverage and declination at regular intervals during influenza season and provide feedback of ward-, unit-, and specialty-specific rates to staff and administration.
  • Use the level of HCP influenza vaccination coverage as one measure of a patient safety quality program.

Source: Centers for Disease Control and Prevention. Influenza vaccination of health care personnel: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the Advisory Committee on Immunization Practices; Atlanta.