SHEA: Time to mandate flu shots for HCWs

'The evidence is irrefutable'

Influenza vaccination of healthcare personnel is a professional and ethical responsibility and non-compliance with healthcare facility policies regarding vaccination should not be tolerated, argues the Society for Healthcare Epidemiology of America (SHEA).

While the issue touches on a complex intersection of individual rights and public safety, all evidence and ethics point to a moral imperative. Protect frail patients by immunizing yourself against a common seasonal infection, says Neil Fishman, MD, president of SHEA. The SHEA panel included a bioethicist, he adds.1

"To me personally, and to a lot of the people involved on the task force, it really came down to ethics," Fishman says. "We believe that when people make the decision to enter the health care profession, that carries a professional and ethical responsibility to prevent the spread of infections to patients. It is an ethical responsibility to make certain that your patients don't get influenza. The ethics of our profession override all of our issues."

Thus, the paper goes beyond the current recommendations by the Centers for Disease Control and Prevention (CDC), which call for the use of voluntary strategies that include having workers who turn down vaccine sign off on declination statements. Such strategies, which include making the vaccine free and convenient to receive, have reached a point of diminishing returns at many facilities.

"The overall experience has seen very modest improvements in vaccination rates," Fishman says. "There are some institutions — some scattered examples that have had a greater success — but the overall national vaccination rates of health care personnel still hover in the 40% range."

Mounting evidence

The SHEA position paper comes as healthcare personnel and facilities prepare for the upcoming 2010 flu season, and on the heels of the pandemic of H1N1 influenza A. "To be honest, that was not the reason for coming out with this now," he says. "The impetus for producing this position paper was that we felt the level of evidence supporting mandatory vaccination was adequate to lead to the statement."

Indeed, the SHEA paper cites several studies since its last flu statement in 2005.2-4

"The evidence itself is irrefutable," Fishman says. "Influenza immunization should be mandatory for health care personnel."

The paper was endorsed by the Infectious Diseases Society of America (IDSA), which agreed that influenza vaccination of healthcare personnel is a core patient safety practice that should be a condition of both initial and continued employment in healthcare facilities.

"The scientific evidence shows significant reductions in the risk of influenza in both acute and long-term care settings as a result of strong immunization policies and programs," says Richard Whitley, MD, president of IDSA. "Vaccination of healthcare personnel saves patients' lives and reduces illness. It also protects the individual worker from falling ill during influenza outbreaks and from missing work, which further impacts patient care."

According to SHEA, the recommendations apply to all healthcare professionals in all healthcare settings, regardless of whether the worker has direct patient contact or whether he or she is directly employed by the facility. The policy also applies to students, volunteers, and contract workers. The only exemptions, say the epidemiologists and infectious disease physicians, should be in cases of medical contraindications.

There is a considerable gap between that ideal and current reality. According to a 2009 RAND Corporation survey, 39% of healthcare professionals stated they had no intention of getting vaccinated despite the heightened concern surrounding influenza with the H1N1 pandemic.

Unions may fight mandates

Mandates certainly increase the number of health care workers vaccinated, but critics say the tactic is unnecessarily punitive. Unions have successfully overturned mandates in some hospitals or health systems because they were not implemented through the collective bargaining process.

The American College of Occupational and Environmental Medicine (ACOEM) also has opposed mandatory influenza vaccination of health care workers, particularly since the effectiveness of the vaccine varies significantly as the prevailing strains change from year to year.

"Current evidence regarding the benefit of influenza vaccination in health care workers as a tool to protect patients is inadequate to override the worker's autonomy to refuse vaccination," ACOEM said in its position statement.

To Bill Borwegen, MPH, health and safety director of the Service Employees International Union (SEIU), the recent push for mandatory vaccination policies represents skewed priorities. The CDC recently proposed revised guidelines that recommend the use of face masks rather than N95 respirators for health care workers caring for patients with H1N1 influenza.

"The imbalance of protection is really startling," he says. "We won't give a health care worker a 50-cent, fitted N95 respirator when they go into a room with a coughing patient with suspected or confirmed H1N1."

Yet the CDC has stated that the H1N1 vaccine was just 62% effective, he notes. "If the vaccine was effective, we could maybe make the argument that this [mandatory policy] made sense," he says. "To fire people for not getting a vaccine that's not all that effective, it's just massive overreach."

Meanwhile federal health authorities are taking the first tentative steps toward considering a recommendation on mandatory influenza immunization of health care workers. Assistant Secretary of Health Howard Koh has asked the National Vaccine Advisory Committee (NVAC), an advisory panel of public health experts, to look into the issue. Current federal vaccine guidelines don't address vaccination mandates. Such requirements, even for school children, are typically set at the state or local level.

The SHEA position paper is available at:


  1. Talbot TR, Babcock H, Caplan AL, et al. Revised SHEA Position Paper: Influenza Vaccination of Healthcare Personnel. Infect Control Hosp Epidemiol 2010;31:987–995.
  2. Hayward AC, Harling R, Wetten S, et al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial. BMJ 2006; 333(7581):1241.
  3. 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(9):1580–1586.
  4. Thomas RE, Jefferson T, Lasserson TJ. Influenza vaccination for healthcare workers who work with the elderly. Cochrane Database Syst Rev 2010;2:CD005187.