By Gary Evans, Medical Writer

Employee health professionals stepping up to protect workers and patients during a severe flu season can become part of the outbreak they are trying to prevent.

“I even got the flu, and of course I had received the flu vaccine,” says Linda Good, PhD, RN, COHN-S, manager of Employee Occupational Health Services at Scripps Health in San Diego.

Although the vaccine is a mismatch this year, Good’s prior immunization afforded her enough protection to bounce back quickly with antiviral administration.

“I immediately got on the antiviral, and within about a day and a half I was back on my feet, functioning,” she says. “My feeling is even though we know that this year’s match isn’t perfect, it still gave enough protection that it was very worthwhile getting. That, along with the antiviral, was effective.”

The CDC recently released an interim vaccine efficacy estimate that found the current shot was 25% effective against the predominant circulating H3N2 influenza A strain.1 The vaccine has a 67% efficacy against H1N1 A and is 42% effective against influenza B viruses, the CDC reported. While these higher efficacy measures have helped, the overall flu season has been severe because 69% of the cases are due to H3N2. With the poor vaccine match and the tendency of H3N2 to cause severe infections, flu numbers have rivaled the 2009 pandemic and the CDC has projected a death toll in the 50,000 range.

“I am always amazed at how blasé people are about influenza,” Good says. “If any other infectious disease took as many lives or impacted productivity at work as much, the public would be in a panic. But for some reason, we still hear the same excuses against immunization: ‘I don’t want to put substances in my body,’ or ‘The shot makes me sick.’ I’m surprised by that.”

‘One of the Worst We’ve Seen’

Some hospitals in San Diego were inundated with flu patients.

“Our ERs were all very full, and one of our hospitals ran out of beds and they were putting people in chairs in the hallways,” Good says. “We were pretty hard hit — quite a few deaths and serious cases.”

Similar stories were being told in other regions, as the CDC at one point reported the unusual phenomenon of widespread flu activity nationwide.

“It’s one of the worst flu seasons we’ve seen in our hospital, and some people getting the flu are a little sicker,” says JoAnn Shea, RN, director of employee health and wellness at Tampa (FL) General Hospital. “With the flu shot they may not have a fever, but we have had some people out for a week, they feel so bad.”

When Hospital Employee Health spoke to Shea in mid-February, flu cases among employees had nearly doubled from the same time the previous year.

“Last year we had 78 cases, and this year we have probably 145,” Shea says. “One of my nurse practitioners just went home today with influenza B. Of those 145, just in the first two weeks of February we have had about 30 cases. There were 87 in January.”

Shea uses the nasopharyngeal polymerase chain reaction (PCR) test to confirm influenza infection in ill workers.

“We actually diagnose them,” she says. “So 94% of our employees received the flu shot. Only about 10% of the people who got the flu did not have the flu shot.”

Though there have been some severe infections, Shea says many of the vaccinated did not suffer prolonged fever and responded quickly to antivirals.

“As soon as they come in to our clinic and are diagnosed, we give them Tamiflu,” she says. “We can get our test results within an hour. We may send them home with the antivirals, and say hold on to them [pending test results] because if they are really sick we don’t want them hanging around the hospital.”

Criteria for return to work includes being afebrile for 24 hours without taking fever-reducing medicine. Flu vaccination for most employees was performed in November, well before it was clear how bad of a season was about to unfold.

“We had some people coming in to get flu shots in January that usually don’t get them,” she says. “They are supposed to get them by Nov. 30, but they read about the bad cases around the country.”

Perhaps the greatest incentive for immunization is the hospital policy that unvaccinated healthcare workers must wear a mask when on duty.

“They have to wear a mask even if they are not in patient care,” Shea says. “The only time they do not have to wear a mask is if they are eating or walking in the hallways, but if they are in patient care areas or at their work station they have to wear a mask. We found [this policy] has made our vaccination rates go higher — it’s hard to get over 90%. But a lot of people don’t want to wear a mask, so they get the flu shot.”

The San Diego health department has a similar requirement for unvaccinated workers, and Good says it has driven immunization rates up at her facility as well.

“We have about a 94% immunization rate, and the other 6% who decline have to wear a mask throughout the season when they are in any of our healthcare facilities,” Good says. “That number has been pretty consistent over the last few years, regardless of how the season has gone.”

Indeed, although healthcare workers were probably glad to be immunized as the severity of the season became clear, the shot-or-mask requirement has been the greatest factor in increasing the vaccination level, she says.

“I think people have accepted the idea,” she says. “I don’t think anyone is happy to have to wear a mask, but we put it in place a couple of years ago and I haven’t gotten a lot of pushback about it.”

NY Law Requires Shot or Mask

In New York, the shot-or-mask policy is a state law and clinicians are reporting similar results with increased immunization rates. One reason is that it allows workers to make a choice about immunization rather than simply having it mandated as a condition of employment, explains Lisa Saiman, MD, MPH, hospital epidemiologist at New York-Presbyterian Hospital in New York City.

Saiman and colleagues outline the circuitous route to success in a recent study,2 as the immunization rate of workers at the hospital varied widely over the last decade through a series of policies and flu events.

The 2006-07 and 2007-08 flu seasons saw worker vaccination rates just under 50% with a voluntary immunization policy. The addition of a signed declination policy for the 2008-09 flu season raised the healthcare worker immunization rate to 66%. With the emergence of pandemic influenza H1N1 A in the 2009-10 season, New York state mandated vaccine for healthcare workers.

“We got up to 90%, but that was a complete outlier year because of the pandemic,” she says.

With the mandate lifted after the pandemic, vaccination reverted to a 62% level with signed declination policies. With the addition of education that included dispelling common myths about the flu vaccine, worker immunization rose to 86% in the 2012-13 season.

The state law requiring healthcare workers who declined vaccination to wear a mask became effective for the 2013-14 season, and the results were dramatic. The vaccination rate was 92% and then went beyond that as the mask option became ingrained as the standard policy.

“It is not a mandatory vaccination policy, but if you decline you have to wear a mask in all areas in which patients might be present,” Saiman says. “It is very cumbersome to wear a mask all day, but people feel this gives them a choice. We got our rates up as high as 96% in 2015-16, and I can tell you anecdotally that has been sustained in the subsequent years.”

While some have argued that such mask policies change behavior through stigma, Saiman says healthcare worker unions in New York like the idea.

“The unions feel that their membership is given the choice to be vaccinated or not,” she says. “We are still healthcare professionals, and we are obligated to take care of our patients and our co-workers. So, if you make the decision for your own health not to [be immunized], you are at markedly increased risk of getting influenza and then making your patients and co-workers ill.”

A “mask-on” date is set every year by the New York governor’s office based on flu activity, she adds. While most healthcare workers have been immunized prior to that date, there typically is a number that come forward for shots when wearing a mask becomes required.

Better Than Mandate

“I think it has had a very beneficial effect,” Saiman says. “If you had asked me to bet, I always thought personally that a mandate for vaccine would be more powerful and influential. But that turned out not to be, so somebody knew a lot more about human behavior than I did. I think it is a great message for other states — that you can actually improve vaccination rates with a mandatory mask policy.”

The severity of some of the flu infections this year is being widely reported, and hopefully this severe season will have a positive effect on vaccine uptake in the future. Similarly, the 2009 pandemic showed how influenza virus could emerge and spread globally after an antigenic shift.

“I think the pandemic really gave healthcare personnel a markedly enhanced understanding of how severe influenza can be,” she says. “I also think that the messaging that has come out of the CDC, the New York state and city health departments, and our own workforce health and safety, is very aligned and consistent. I think healthcare personnel are really getting the message.”

That message, in part, is that vaccination helps a variety of stakeholders, from the workers’ own health to the protection of patients and co-workers.

“You’re protecting your patients and you are protecting your family,” she says. “All of those things together really are quite synergistic.”

The hospital uses PCR testing to diagnose and confirm flu infection in workers, and it can also pick other respiratory viruses that may threaten patients, she adds.

“We try really hard to support healthcare workers, diagnose any viruses, and tell them to go home if they are sick,” Saiman says. “That’s a big challenge, but healthcare workers really need to go home to not expose patients and co-workers, and for their own health. [We tell them] go home, get some chicken soup, put your feet up, get some good sleep, and take care of yourself.”


1. CDC. Interim Estimates of 2017–18 Seasonal Influenza Vaccine Effectiveness — United States, February 2018. MMWR 2018;67(6);180–185.

2. Batabyal RA, Zhou JJ, Howell J, et al. Impact of New York State Influenza Mandate on Influenza-Like Illness, Acute Respiratory Illness, and Confirmed Influenza in Healthcare Personnel. Infect Control Hosp Epidemiol 2017;38:1361-1363.