Public reporting is raising the stakes for flu vaccination. For the first time, potential patients can compare health care worker influenza immunization rates as part of the online hospital quality data provided by the Centers for Medicare & Medicaid Services (CMS) on

While that may not have been a blockbuster story for the broader news media, hospital leaders have taken notice and are placing more emphasis on achieving high vaccination rates. It is now common for hospitals to require employees to receive the flu vaccine or to wear a mask during the flu season.

Of the 3,676 acute-care hospitals reporting their rates for the 2013-2014 flu season, 58 reported 100% coverage. Almost 200 hospitals reported a flu vaccination rate of 99% and another 200 reported a rate of 98%. In fact, more than a third (37%) of all hospitals reported a rate of 90% or above — the Healthy People 2020 goal that has been promoted by The Joint Commission and the U.S. Department of Health and Human Services.

The influenza immunization rates reported by CMS include all employees, licensed independent practitioners (contracted physicians and advanced practice nurses), students, volunteers, and trainees who worked in the facility for even one day during the flu season, from Oct. 1, 2013 to March 31, 2014. Unknown status or even medical contraindications would lower the rate.

“[Hospitals] clearly don’t want to be outliers when it comes to this change in practice across the country as more and more institutions move to a variety of mandated programs,” says William Schaffner, MD, professor of preventive medicine at Vanderbilt University in Nashville, TN, and past president of the National Foundation for Infectious Diseases.

“Many of them now record immunization rates above 90%. Having your institution stuck at 72% begins to look inappropriate and no longer the norm. That motivates CEOs to say, ‘We have to do better and we’re going to do whatever it takes.’”

Tighter requirements = higher vaccination rates

Schaffner’s own institution recently shifted from a voluntary, education-based approach to a stricter requirement.

Employees who decline vaccination must have either a medical contraindication or a strongly held religious or philosophical belief against vaccination. (They can’t simply say they don’t want the vaccine.) The decision was made by senior managers, including the CEO and chief medical officer, he says. “There are certain things you just have to oblige people to do,” he says.

Vaccination rates immediately jumped to about 90%, even though the policy didn’t include disciplinary action that would be taken against employees who failed to get the vaccine.

Even adding new requirements to a voluntary program can boost rates. At Allegheny Health Network, a multihospital system in western Pennsylvania, employees who decline the vaccine must complete online education about influenza vaccination.

That step alone raised rates from about 50% to 72%, says MaryAnn Gruden, MSN, CRNP, NP-C, COHN-S/CM, manager of employee health services. “We wanted to educate people and let them know why they need to get [the vaccine], the ethical issues of protecting themselves as well as patients, and the facts about the vaccine,” she says.

At Virginia Mason Medical Center in Seattle, the first hospital system in the nation to require flu vaccination of employees as a condition of employment, the mandate has become routine. Nurses can decline the vaccine — but they must wear a mask during flu season if they are unvaccinated. Fewer than 10 nurses declined the vaccine this year, says employee health supervisor Beverly Hagar, BSN, COHN-S, and Virginia Mason reported a 99% immunization rate.

CMS measure presents tracking challenges

The CMS reporting has brought new attention to obstacles in flu vaccination and reporting. Tracking influenza vaccination can be challenging, especially among contracted physicians who work in multiple hospitals and employees and others who received their vaccine elsewhere.

Since “unknowns” lead to a lower rate, hospitals must methodically document vaccination status, which can be a labor-intensive process, says Gruden, who is a community liaison for the Association of Occupational Health Professionals in Healthcare (AOHP).

“If you are a big medical center or a multihospital system, it’s extremely difficult to get a handle on everybody who’s come through the door,” she says. “You have to work with other hospital departments [to gather the information].”

At Broward Health in Fort Lauderdale, FL, the employees in the four-hospital system are culturally diverse, and many have pre-conceptions about the flu vaccine, says John Berges, MD, CHCQM, medical director of Corporate Employee Health. Required annual education on influenza and vaccination hasn’t budged those attitudes. In the CMS reporting, the influenza vaccination rates at Broward Health hospitals ranged from 21% to 52%.

Also, the health system’s billing, call center and information technology employees work in a five-story building completely separate from the hospitals. “Most of them don’t feel motivated to receive the vaccination, and yet they’re counted,” Berges says. “It’s very challenging.”

The CMS reporting and the Healthy People 2020 goal of 90% vaccination have gotten the attention of the health system’s leadership. This season, for the first time, employees must receive the vaccination or sign a declination statement. Vaccination rates have risen, and a task force that includes the chief medical officer and chief human resources officer is looking at other steps to improve compliance, he says.

“This past year, we’ve had tremendous buy-in from the CEOs of the hospitals and administration in general,” says Berges. “Now they comprehend that we need to be at the 90% mark. The numbers have tremendously increased since we’ve gotten the CEOs involved.”

Looking beyond vaccine effectiveness

Hospitals underscore that vaccination is the best available method to prevent the spread of influenza — but that message was somewhat undercut this season with a vaccine that proved to be a poor match with the prevailing strain of the virus.

For employee health professionals, that meant promoting other important measures, including respiratory hygiene and the use of antiviral medications.

For example, Vanderbilt has “cough and sneeze stations” with tissues and hand sanitizer for both visitors and employees. Hospitals also have provided Tamiflu as a prophylaxis for employees who had an unprotected exposure to influenza.

CDC reported that 70% of the circulating influenza A H3N2 viruses had “drifted” from the strain used in the vaccine, which resulted in an overall vaccine effectiveness of just 23%. Among adults ages 18 to 49, the vaccine effectiveness was 12%, and among adults 50 and older it was 14%.

Still, CDC continued to emphasize the benefits even of an imperfect vaccine. “Even when vaccine effectiveness is reduced, vaccination still prevents some illness and serious influenza-related complications, including thousands of hospitalizations and deaths,” CDC epidemiologists said in a Morbidity and Mortality Weekly Report.1

Hospitals need to take a longer view of influenza immunization as they hone their programs, says Schaffner.

“A lot of institutions are taking responsibility and getting their workers immunized, even though the vaccine, as we know, is imperfect,” he says. “Now these institutions have to maintain that year in and year out. They can’t be discouraged just because the flu strain drifted.”


  1. Flannery B, Clippard J, Zimmerman RK, et al. Early estimates of seasonal influenza vaccine effectiveness — United States, January 2015. MMWR 2015; 64:9-15.