Whether it is due to apathy or ignorance, many workers in long-term settings have historically avoided seasonal flu shots, even though the residents under their care may be at high risk of experiencing complications of influenza infection.

“Often times in nursing homes, there are more tech nursing assistants, a less professional staff. They’re often young and healthy people who don’t realize that the real value of vaccination is to keep themselves well [so they do not] transmit disease to their elderly patients,” says Linda Greene, RN, MPS, CIC, senior advisor to the regulatory review committee for the Association for Professionals in Infection Control and Epidemiology (APIC).

Educate nursing home staff about how elderly patients have weaker immune systems, which makes them more susceptible to illness, Greene adds.

“If we’re going to make a dent in the vaccination rate, then we have to shore up what we do across the whole continuum of care, and APIC has been a leader in that area,” Greene says. “That’s been a goal of ours for a long time.”

Of course, the residents certainly should be immunized unless they have contraindications, but the elderly are unlikely to mount a strong immune response despite being vaccinated.

Concurring with Greene, a researcher who recently published a study on the issue says long-term care workers must be educated about the vaccine’s lower effectiveness among elderly residents.

“About three-quarters of older people in nursing homes get the vaccine,” says Jill Daugherty, MPH, PhD, lead author of the study and formerly a graduate research assistant at the Rollins School of Public Health at Emory University. “There are some who do not get it because maybe they have cancer or are immunocompromised.”

But even those who are vaccinated have a greater probability of being infected with influenza than younger, healthier people, she adds.

“For all of those reasons, if you are working among a group for whom getting the flu could be really detrimental and deadly, it’s important you do everything you can to prevent the spread of the virus,” Daugherty says. “We recommend that facilities that are struggling with their staff vaccination rates do more to educate their employees about the importance of vaccines and offer incentives to prop up those numbers as well.”


Healthcare workers in general have provided a variety of reasons for avoiding vaccination, and one could certainly argue that the flu shot is only marginally effective in seasons such as 2014-2015 when there is a mismatch between the vaccine and the predominantly circulating strains.

In looking at long-term care workers, Daugherty and colleagues found reluctance to receive a vaccine tied to the myths and misinformation that have been circulating for years.

The study examined flu vaccination rates among 1,965 workers at 37 nursing homes in Georgia, Florida, and Wisconsin.1

“We found that approximately half got the flu vaccine in the previous season,” Daugherty says. “This ranged widely, with Wisconsin having the overall highest rate of 97% in some facilities, and Florida having the overall lowest rate of 15% at certain sites.”

Healthcare workers in Wisconsin were more likely to believe the vaccine would be effective, she notes.

“There were more inaccurate beliefs among healthcare workers in Florida, and that corresponds with whether someone gets the vaccine,” Daugherty says.


One of the inaccurate beliefs was that the vaccine contained a live virus that could cause influenza in the immunized.

“We found that if a person believes the vaccine does not cause the flu then they were more likely to receive it,” Daugherty says.

In addition, some workers thought they would not spread the flu to residents even if infected. Others rationalize that since they never get the flu, they won’t this season.

“If workers believed they were likely to get the flu or that they could spread it to the people they worked with they were more likely to get the vaccine,” Daugherty says.

Broad demographics seemed to initially predict who would be vaccinated and who would decline.

“Black respondents were much more unlikely to get the flu vaccine than white respondents,” she says. “But once we controlled for their beliefs about the vaccine, that association went away, so their beliefs about the vaccine were the driving factor.”

The survey was conducted after the 2009 H1Nl pandemic and also covered the flu seasons of 2010-2011 and 2011-2012.

“The flu was in the news a lot around then, and there certainly was more of an emphasis to get vaccinated in those years,” Daugherty says.

All of the nursing homes made vaccination convenient and free with onsite shots during daytime hours at several different times during the flu season. Some nursing homes offered incentives to employees to get vaccinated. The most common incentive was they could have their name put in a raffle for a $100 gift card, she says.

None of the facilities studied mandate vaccination.


  1. Daugherty JD, et al. Influenza vaccination rates and beliefs about vaccination among nursing home employees. Am J Infect Control 2015;43:100-106.