American Hospital Association backs mandatory flu shots

Egg allergy may not be a contraindication

Hospitals geared up for their annual influenza immunization campaigns this fall with a greater emphasis on mandatory policies to achieve the highest possible coverage of employees. An advisory from the American Hospital Association gave a push toward mandatory vaccination of health care workers.

In contrast, the American Medical Association endorsed "universal vaccination" but stopped short of advocating mandatory policies, stating that the medical staff should determine the structure of the programs.

Meanwhile, exemptions to immunization may narrow as a federal advisory panel said many people with egg allergy can still receive the influenza vaccine.1

The panel listed trivalent inactivated vaccine (TIV) as a possible alternative for some people with mild reactions. (See algorithm, p. 110)

In its advisory, the AHA stated: "To protect the lives and welfare of patients and hospital employees, the American Hospital Association's Board of Trustees recently approved a policy supporting mandatory patient safety policies that require either influenza vaccination or wearing a mask in the presence of patients across health care settings during flu season. This policy aims to achieve the highest possible level of protection."

The AHA responded to recommendations from major infection control organizations, including the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America, says Nancy Foster, AHA's vice president for quality and patient safety.

"While the resources needed to implement a mandatory policy are significant, especially in terms of financial and personnel resources, the benefits of protecting vulnerable patients and reducing employee illness and absenteeism far outweigh the costs," the AHA advisory states. "Further, employee resistance can be overcome through careful education and open communication between hospital leadership and staff, as well as policies that permit certain reasonable exclusions and allow employees who cannot receive influenza."

Pushback from HCWs

Even as it becomes more common, mandatory influenza immunization remains controversial. The American College of Occupational and Environmental Medicine advocates comprehensive voluntary programs, and unions representing health care workers have successfully challenged the mandates as an imposition of a condition of employment without collective bargaining.

Even vaccinated employees sometimes bristle at the "vaccinate or be fired" approach. At St. Jude Children's Research Hospital in Memphis, TN, where more than 90% of health care workers receive the seasonal flu vaccine without a mandatory program, a survey of employees showed ambivalence about a mandate. A third (33.5%) of health care workers who reported receiving the vaccine over the past five years said they opposed mandating the vaccine.2

Further, requirements for unvaccinated health care workers to wear masks seem punitive rather than patient safety-oriented, says Bill Borwegen, MPH, health and safety director of the Service Employees International Union (SEIU). Health care workers were not required to wear masks during routine patient contact when there was no vaccine available in the early months of the H1N1 pandemic, and some hospitals even failed to provide N95 respirators to protect health care workers when they were recommended by the Centers for Disease Control and Prevention, he says.

"Their prioritization [of a vaccine mandate] seems to be based more on a power dynamic in the workplace than a true effort to make the workplace safer," he says.

Yet Foster says the AHA position is based on unpublished data from hospitals that implemented mandatory policies and saw a reduction in influenza cases.

"As we have learned about the evidence from our colleagues in infection control, the evidence now is pretty substantial that inadvertently our employees can transmit flu to our very vulnerable patients," she says.

The patient safety goal is paramount, says Foster, though acknowledging that hospitals may need to work with employees or their unions to develop mandatory policies. "Every hospital has to work through the appropriate processes to adopt substantial changes in their employee policies," she says. "For some, it may involve a negotiation with a union, for some it may involve other steps. Our board is asking the hospital leadership to begin to engage in that process.

While the influenza vaccine varies in effectiveness, that's not an ethical excuse for health care workers to decline vaccination, says Matthew Wynia, MD, MPH, director of the Institute for Ethics and the Center for Patient Safety at the American Medical Association in Chicago.

"It's always more protective than not having the vaccine at all," says Wynia. "It always provides some protection. The question is the degree of protection."

Egg allergy and vaccination

Fewer employees may receive exemptions from flu vaccine mandates, based on recent recommendations from the Advisory Committee on Immunization Practices (ACIP), a CDC advisory panel.

Some package inserts for the trivalent inactivated vaccine no longer list hypersensitivity as a contraindication, although severe allergic reaction, such as anaphylaxis, remains a contraindication, says Lisa Grohskopf, MD, medical officer with CDC's influenza division.

"We are recommending in these guidelines that essentially only individuals who have hives, specifically only hives, as a symptom as their allergy, [can] go ahead and receive vaccine without some further risk stratification," she says. "It's possible for a health-care worker to be stratified for the risk."

People who experience only hives following exposure to egg should be monitored for at least 30 minutes for signs of reaction. Other people with more severe reactions should be referred to a physician "with expertise in management of allergic reactions," the guidelines state. The vaccine should be administered in a setting where there can be rapid recognition and treatment of anaphylaxis, CDC says.

If someone has previously had a severe reaction to any component of the influenza vaccine, they should not receive the vaccine, the guidelines state.


1. Centers for Disease Control and Prevention. Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2011. MMWR 2011; 60(33);1128-1132

2. Hakim H, et al. Motivating factors for high rates of influenza vaccination among healthcare workers. Vaccine 2011; 29:5963-5969.