CDC toughens stance on HCW flu shots: Is a Joint Commission standard next?

CDC calls for declination statements, JCAHO mulls standard

Issuing a recommendation that soon may become a health care accreditation requirement, the Centers for Disease Control and Prevention is calling for workers who decline seasonal flu shots to sign off on declination statements unless they have medical contraindications.

The CDC decision was much anticipated, as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is expected to follow suit if it issues a standard on worker flu shots. The JCAHO is mulling whether to adopt a specific standard on the issue, citing patient safety concerns and historic health care worker apathy and resistance. While mandating flu vaccination still is under discussion, it appears more likely that the Joint Commission will follow the CDC’s lead and codify the declination statement recommendation.

"The Joint Commission is a very powerful force for hospitals," says Ken Sands, MD, vice president of health care quality at Beth Israel Deaconess Medical Center in Boston. "If the Joint Commission is to in fact make this a standard, then I think this would do a lot to motivate hospitals to improve their compliance rates."

The new CDC flu recommendations were issued by the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP).1 In addition, HICPAC previously recommended that health worker flu immunization rates be used as a health care quality measure in those states that mandate public reporting of health care-associated infections.

"This is all part of the general trend for there to be more transparency around hospital performance," Sands says. "Hospitals should be prepared to have their influenza vaccination [rates] become more a matter of public record. There are states putting legislation into effect requiring health care worker vaccination. The language in most states [on this] is a requirement that you receive the vaccine or that there be evidence of declination."

A convergence of forces — including patient safety and looming pandemic flu — is making seasonal flu immunization of health care workers a lightning-rod issue. The current energy surrounding the topic puts the historical view in pitiful contrast: The CDC has had a standing recommendation to give flu vaccine to workers for 25 years and yet national immunization rates hover in the 40% range. In the face of such clear evidence of historical failure, groups such as the Association for Professionals in Infection Control and Epidemiology have taken the position that flu shots should be mandatory for health care workers.

The CDC did not go that far, recommending instead a multifaceted approach that uses the declination statements as its primary teeth. While the Joint Commission is likely to step up and put some more clout behind the issue, hospitals that have already gone to mandatory policies may believe they have gone "a bridge too far" given the CDC’s more conservative stance. For example, infection control professionals at Virginia Mason Medical Center in Seattle are embroiled in a labor/management dispute with their nurses after enacting a mandatory policy that makes flu immunization a condition of employment. Their troubles did not go unnoticed.

"I think they were extremely instructive as pioneers," says William Schaffner, MD, a liaison member of ACIP and chairman of the department of preventive medicine at Vanderbilt University School of Medicine in Nashville, TN. "They were so committed that they tried out mandatory [immunization]. I think many of us learned from that experience that mandatory was likely to raise more issues that might slow down the process."

It is a process that Schaffner — a longtime proponent of universal flu vaccination of health care workers — sees moving full speed ahead. Indeed, through written in the typically understated fashion of a CDC guideline, the recently issued HICPAC/ ACIP recommendations could catch fire in the hands of other groups that have been waiting for the CDC to take a stand on the controversial issue.

"The CDC does not write in banner headlines; it’s our job to put the headline on the story," says Schaffner. "It is a forceful document that really promotes the notion [of flu immunization] both on the institutional side and for the individual. There are a lot of partners — the National Foundation for Infectious Diseases, for example — that are ready to take this document and use it and promote it to make both health care administrators and individual health care workers aware."

The inclusion of active declination statements — which apply a measure of accountability to both the individual worker and the institution — drew immediate notice. However, the involvement of top administrators ultimately may play a bigger role, Schaffner says.

Send in the suits

"The informed declination statement should not be the focus," Schaffner says. "It is a method that is recommended among others. One of the absolute critical elements is the force with which the administration applies the concepts here. I have come to believe that the commitment of the top administration to this program is absolutely essential."

Such a commitment may be expressed in the form of messages to workers and publicized receipt of flu shots by top administrators. Money talks nicely as well.

"They should provide the resources so that occupational health can get the job done, and that includes resources to enable occupational health to go to laggard units within the institution and ask those managers, What’s happening? Why hasn’t your unit performed better?’" Schaffner says.

The CDC guidelines state that monitoring vaccination coverage by facility area (e.g., ward or unit) or occupational group allows facilities to identify where vaccination levels are low and interventions should be targeted. However, "the independent contribution of signed declination statements to improving HCP [health care personnel] vaccination has not been studied," the CDC guidelines concede. "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."

Others take a less charitable view of the declination recommendation, wondering if it amounts to more paperwork than true progress. "We, like most facilities in the country offer flu vaccine free to employees," says Susan Kraska, RN, CIC, an ICP at Memorial Hospital of South Bend, IN. "We have vaccine clinics around the clock. We take vaccine to the employees. We have education blitzes, competitions, offer prizes to the group with the highest percentage of vaccinated employees, etc. This still only results in about 50%-60% of employees opting to be vaccinated. Facilities who have mandated flu vaccine, legally had to offer a declination and did so. The result was not increased immunizations but rather increased paperwork."

Kraska sees a much larger malaise undermining the issue, arguing that ICPs and health care epidemiologists have been carrying the water for years for an issue that should draw national emphasis from all manner of medical groups. "The day has arrived when we really need to challenge our health care professional organization colleagues to hop aboard," she says. "Patient safety rests in all of our hands and I have not heard the voices of AMA, ANA, AORN, CCRN, etc eteras encouraging their members to receive the flu vaccine to protect their patients. This does not belong solely on the shoulders of health care facilities or a lone ICP or employee health nurse."

However, in the absence of such a national campaign, there is the good news that the use of declination statements has translated to positive change in some hospitals. "[Our] flu vaccination program is mandatory and we provide a declination form with several options for employees to choose," says Susan Sutherland, RN, an employee health manager at the University of California Davis Medical Center in Sacramento. "We have 8,000 employees, and our percentage over the last few years was 30%, maybe 35%, vaccinated. I’m now calculating numbers and we have had a dramatic increase to 74%. [There is paperwork], but I found our program can be vastly improved from all the paperwork. So [declination statements] were a beneficial educational tool for us."

However, Sutherland also stressed that many "carrot" approaches remain in her program, including having contests and generally trying to make the issue fun and nonpunitive.

Whither patient safety?

Overall, declination statements can be a part – but only a part — of a comprehensive approach to improving flu immunization rates in health care workers, says the lead author of a position paper on the issue by the Society for Healthcare Epidemiology of America (SHEA). In opting for declination statements, the CDC essentially endorsed the SHEA position paper.

"I think the key thing with any influenza vaccination program for health care workers is that it has to be multifaceted," says Tom Talbot, MD, MPH, lead author of the SHEA paper and associate hospital epidemiologist at Vanderbilt. "I do not think that active declination in itself will be as effective at ensuring that unless as part of that declination it puts the onus back on the facility to make sure [they have educated workers that this is a patient safety issue]."

Indeed, Talbot sees much of the historic problem rooted in a disconnect between patient safety and employee health. Flu immunization of medical workers still is largely viewed as a personal decision regarding one’s own health. Yet there is no lack of evidence that nonimmunized health care workers visit flu upon their vulnerable patients. The CDC guidelines cite six different studies in stating that, "influenza outbreaks in hospitals and long-term care facilities have been associated with low vaccination rates among HCP. In addition, higher vaccination levels among staff have been associated with a lower incidence of nosocomial influenza cases."

"I don’t think that message has been brought home nearly enough," Talbot says. "Health care providers are doing so many other things for patient safety — [they] wash their hands in order not to spread bacteria. But I don’t think that part of the flu message has gotten out. Our goal is to integrate [the patient safety message] into all parts of training and education for all levels of health care workers — medical students, nurses, housekeepers."


  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.