Employee health professionals were probably not surprised that workers in long-term care had the lowest flu immunization rates among healthcare workers in a recent report by the CDC. That is a longstanding problem and was reflected in the 2017-2018 survey: Only 67% of long-term care workers were immunized.1

The damning detail is that 90% of the record 80,000 deaths were in people over age 65, with most of the elderly deaths likely exposed in the community. It was a glaring contrast that was highlighted by the Surgeon General at a recent flu press conference at the National Foundation for Infectious Diseases (NFID) in Washington, DC.

“While three out of four healthcare workers [overall] are getting vaccinated, I’m embarrassed to say that coverage is still lowest among some subsets of our healthcare workers — long-term care workers — who often work with patients who we know are at the highest risk for the complications of flu,” Surgeon General Jerome Adams, MD, said at the NFID press conference. Adams called on “employers to take action to protect their staff from flu, to reduce absences, and to reduce the chances of their employees spreading the flu to others.”

Currently, 24 states have some form of flu shot provision for long-term care workers, with varying levels of requirements and exemptions, the CDC reports.2 While individual outbreaks of flu in long-term care facilities are sometimes reported in the news or medical literature, there really is no active surveillance system for these infections, certainly not one linking them to unvaccinated healthcare workers. Many facilities do not actively push seasonal flu shots if their state has no such requirement.

A Fatal Combination

One will find no greater proponent of vaccination — influenza or otherwise — than William Schaffner, MD, professor of preventive medicine at Vanderbilt University. However, the epidemiology of the 2017-2018 flu season indicates the deaths in the elderly were driven by forces beyond long-term care facilities, he explains.

“First, we had a really fierce dominant influenza strain — H3N2,” he says. “These H3N2 strains are notorious for having lots of complications in older persons. Also, the population in the U.S. that is older than age 65 is growing every day, so the denominator for the H3N2 virus was larger than it ever had been.”

The other critical factor was that the H3N2 strain in the vaccine was only about 25% effective overall and certainly less so in the specific elderly population. That said, public health agencies and medical associations have been pushing flu shots in long-term care for years and will continue to do so.

“The data indicate it is people who work in long-term care, along with visitors, who introduce the influenza virus into the facility,” Schaffner said. “We ought to be trying to vaccinate them on an annual basis, and I would love to see that as a requirement.” Mandatory flu vaccination policies are effective but primarily have been established in hospitals. Facilities with such requirements immunized 95% of workers last season, but immunization fell off dramatically in settings where requirements were not in place, the CDC reported.

The 80,000-death toll in the 2017-2018 flu season is the highest since the CDC began reporting flu deaths in the mid-1970s. The previous record was 56,000 deaths in the 2012-2013 season, while the lowest estimate is 12,000 deaths in 2011-2012.

“It was a significantly bad year,” Daniel Jernigan, MD, a medical epidemiologist at the CDC, said at the NFID meeting. “The same problem happened ... the season prior in the Southern Hemisphere.”

While flu in the Southern Hemisphere is used to roughly predict the severity of the subsequent U.S. season, influenza is infamous for its unpredictability. This year, the Southern Hemisphere is coming off a milder flu season dominated by an H1N1 strain that is covered by the vaccine, Jernigan said.

“We’re seeing a little of H1 now, but boy, I just would not take my chances,” he said. “I think I would get the vaccine now, and you don’t have to worry about whether it’s a mild or severe season.”

Beware of Complacency

Concerned about complacency, Adams emphasized that speculating on the severity of the 2018-2019 flu season is the “wrong question to be asking. Because at the end of the day, by the time we figure out if it’s a bad flu season or not, then a lot of the damage has been done.”

The emphasis this year is to promote widespread vaccination and administer antivirals as needed to those infected. Those who claim to never get the flu or cite other rationales for forgoing the annual shot were reminded of their civic duty.

“Getting the flu shot isn’t just about keeping you safe and healthy,” Adams said. “Getting the flu shot is about community. It’s about everyone else around you. Those 80,000 people who died last year from the flu — guess what? They got the flu from someone. Someone passed it along to them.”

While the deaths primarily hit the elderly, a record 180 children died of flu in the U.S. last season. Wendy Sue Swanson, MD, a pediatrician at Seattle Children’s Hospital, framed this finding in stark terms at the NFID meeting.

“I care deeply about children and the suffering that comes from influenza, the thousands of children who were hospitalized last year,” she said. “And think of it — 180 families put a child in a grave last year because of a vaccine-preventable infection.”

Adams also interjected a personal note, saying that as a father he was struck by the pediatric flu deaths.

“This really just hit me hard as a father of three young children myself — 180 kids died last year from the flu, and most of them were unvaccinated,” he said.

Eighty percent of the children who died of flu had not been immunized.


  1. CDC. Influenza Vaccination Coverage Among Health Care Personnel — United States, 2017–18 Influenza Season. MMWR 2018;67(38);1050– 1054.
  2. CDC. Menu of State Long-Term Care Facility Influenza Vaccination Laws. Feb. 28, 2018. Available at: https://bit.ly/2yce41h.