Improving healthcare worker flu vaccination in long-term care settings remains a challenge, but there are signs of improvement as more facilities are seeking “honor roll” status aimed at reaching higher immunization rates, says Amy Behrman, MD, FACP, FACOEM.

“There has been a leap forward in terms of the number of [long-term care] institutions providing proof that they belong on the honor roll,” explains Behrman, co-chair of the Influenza Working Group (IWG) of the National Adult Immunization and Influenza Summit (NAIIS), and director of occupational medicine at the Hospital of the University of Pennsylvania. “I have every confidence that we are going to see the number improved enormously over the next few weeks.”

The IWG partnered with the Immunization Action Coalition (IAC) to encourage joining the immunization honor roll for healthcare facilities and flu vaccine. “To be included in this honor roll, your organization’s mandate must require influenza vaccination for employees and must include serious measures to prevent transmission of influenza from unvaccinated workers to patients,” according to the IAC.1 “Such measures might include a mask requirement, reassignment to non-patient care duties, or dismissal of the employee.”

While other healthcare sectors have made progress on flu immunizations, workers in long-term care reported only a 67% vaccination rate in a CDC survey.2

“Long-term facilities lag far behind the vaccination rates in healthcare personnel in all other settings, despite the fact that their patients are at highest risk of complications and death,” Behrman says. “In my opinion, the evidence supporting vaccinating healthcare personnel to protect patients is actually the strongest in long-term care.”

Long-term care residents are vulnerable to flu outbreaks, as they may attain only marginal immunity if vaccinated. The virus spreads easily in communal settings. “They tend to have a much higher staff turnover. In general, their staff have much more physical contact on an ongoing basis as they help residents and patients with activities of daily living,” she says. “It is a vulnerable and challenging workplace.”

Behrman cites 2017-2018 flu season data in making her case for employee immunization. In one example, Kentucky reported 124 confirmed flu outbreaks in long-term care facilities that season.3

The lagging immunization rates reflect, in part, high staff turnover in these settings, as well as an education gap on the safety of the vaccine that has been largely closed in acute care. For example, a 2015 study revealed that 40% of long-term care staff disagreed with the statement: “Vaccine does not cause influenza.”4

The evidence is fairly compelling if ignorance and fear can be overcome. Influenza outbreaks in long-term care have been associated with low vaccination rates among staff.5 Conversely, studies have demonstrated decreases in all-cause mortality in facilities where many staffers are vaccinated.6

Overall, 24 states offer some form of flu shot provision for long-term care workers, with varying levels of requirements and exemptions, the CDC reports.7 The NAIIS is comprised of multiple public and private organizations, including the CDC, the IAC, and the National Vaccine Program Office. Behrman’s IWG committee is pursuing a 2018-2019 goal to improve staff flu vaccination coverage in long-term care.

“We have tried to create tools and promote an incentive that is relatively user friendly,” says Behrman, who also updated the effort recently in Baltimore at the annual meeting of the Association of Occupational Health Professionals in Healthcare.

As part of this initiative, the IWG developed a guidance document for long-term care administrators who are considering requiring staff flu vaccination. “Implementation of a mandatory influenza vaccination policy for healthcare personnel is not required by the federal government,” the IWG document states. “However, there is compelling evidence that healthcare organizations that implement influenza vaccination requirements successfully increase vaccination coverage of their healthcare personnel, and that such increases are associated with reduced staff and patient morbidity and mortality.”8

The guidelines also cite a recommendation by the Society for Post-Acute and Long-Term Care Medicine, which recommends mandatory flu vaccination policies and masking of those who are not immunized.

“We feel that there is a lot of room to bring the insight, guidance, and tools in acute care to long-term care settings,” says Behrman. “That is acknowledging that the leadership and staff of long-term care facilities have many challenges that are easier to deal with in acute care.”

Large healthcare systems in acute care and other settings are “basically making this a norm,” she says. Can employee flu vaccination culture change be achieved in long-term care settings?

“I think the answer to that is definitely yes,” she says. “We would like them to achieve the Healthy People 2020 goal of 90% vaccination, which will be difficult.”


  1. Immunization Action Coalition. Influenza Vaccination Honor Roll. Available at: Accessed Sept. 26, 2019.
  2. Centers for Disease Control and Prevention. Influenza Vaccination Coverage Among Health Care Personnel — United States, 2017-18 Influenza Season. MMWR Morb Mortal Wkly Rep 2018;67:1050-1054.
  3. Kentucky Department for Public Health. Weekly Influenza Surveillance Report. May 19, 2018. Available at: Accessed Sept. 26, 2019.
  4. Daugherty JD, Blake SC, Grosholz JM, et al. Influenza vaccination rates and beliefs about vaccination among nursing home employees. Am J Infect Control 2015;43:100-106.
  5. Saito R, Suzuki H, Oshitani H, et al. The effectiveness of influenza vaccine against influenza a (H3N2) virus infections in nursing homes in Niigata, Japan, during the 1998-1999 and 1999-2000 seasons. Infect Control Hosp Epidemiol 2002;23:82-86.
  6. Lemaitre M, Meret T, Rothan-Tondeur M, et al. Effect of influenza vaccination of nursing home staff on mortality of residents: A cluster-randomized trial. J Am Geriatr Soc 2009;57:1580-1586.
  7. Centers for Disease Control and Prevention. Menu of State Long-Term Care Facility Influenza Vaccination Laws. Feb. 28, 2018. Available at: Accessed Sept. 26, 2019.
  8. National Adult and Influenza Immunization Summit Influenza Working Group. Guidance for Leaders/Administrators in Post-Acute and Long-Term Care Facilities Who Plan to Improve Staff Influenza Vaccination Compliance through Vaccination Requirement Policies. March 2019 (Version 3). Available at: Accessed Sept. 26, 2019.