Why do workers just say no’ to flu shots?

Looking at those who decline and sign

Infection control professionals adopting policies requiring workers to sign declination statements if they forgo influenza vaccination can expect to run into a persistent group of "refuseniks" with varied reasons for their recalcitrance.

At least that’s the experience reported at Wake Forest University School of Medicine in Winston-Salem, NC, where declination statements have been part of an aggressive flu immunization program for several years. But even as health care immunization rates soar to 70% and beyond — figures most hospitals would view with abject envy — there remains that troubling, stubborn 25% or so who just say "no" on their declination statement.

"I would say for the most part it is basically the same group," says Scott Spillmann, MD, a medical epidemiologist at Wake Forest. "We are trying to peel back the layers of the onion. Fear of side effects is the most [common reason]. People are still worried about getting the flu, though we tell them you cannot get the flu [from the vaccine]. There are still a group of people who are just afraid of injections. They just don’t want the needle period, and if they can avoid a needle, they will. Some people are morally opposed. Others will give multiple reasons. The biggest thing that doesn’t relate to medical [contraindication] is, they just don’t want it."

That is the reality in a voluntary world, and adopting a mandatory policy is a "hot potato" that is a little too fraught with intrigue for hospital administration’s taste, he adds. Thus the hospital continues to push a multifaceted flu immunization effort that requires workers to sign off on declination statements, an approach recently recommended by the Centers for Disease Control and Prevention.

The Wake Forest declination statement is strongly worded, stating directly that, "I realize I am eligible for the flu shot and that my refusal of it may put patients, visitors, and family with whom I have contact, at risk should I contract the flu." (See form.)

"For those who just don’t want the vaccine we ask them to basically state that I know I may be putting myself and others at risk," Spillmann says.

Declination statements only are part of an aggressive program that ignores no sector of the work force. For example, a flu vaccination campaign targeted at new employees is currently yielding an immunization rate of 83%, he notes.

"There are challenges and opportunities, [but at least] epidemiologists still have job security," Spillmann jokes. "It takes inside, outside, top, bottom, everywhere, everybody throughout the organization to make this happen. We have been able to make it a part of our culture. Our very top leaders are very supportive."

In describing his program recently in Atlanta at the CDC National Immunization Conference, Spillmann shared a telling anecdote about flu vaccine decisions and patient consequences.

"In the children’s unit a few years ago, the [health care workers] said basically in a block vote that, We are not getting the vaccine,’" he says. "Then they had cases where their patients contracted influenza. The next year, they all got [vaccinated]. So it was a learning experience. They saw what the results were based on their actions. Fortunately, the children survived, but it was still unnerving."