CDC emphasizes need for HCWs to get flu shots

Advice given for increasing compliance

Improving compliance rates with influenza immunizations is an annual struggle for most hospital employee health professionals, but the U.S. Centers for Disease Control and Prevention (CDC) continues to emphasize the importance of vaccinating health care workers, especially those who attend high-risk patients.

The CDC’s updated HCW recommendations list influenza as a disease for which immunization is strongly urged. Guidelines call for health care facilities to offer vaccines before influenza season to all workers who have contact with high-risk patients, especially personnel who work in adult and neonatal intensive care units and medical and surgical units.1 (See Hospital Employee Health, October 1997, pp. 113-115.)

Despite that advice, an unpublished 1993 agency survey found that only 17% of hospitals contacted were vaccinating 50% or more of the employees they targeted, "which is lousy," says Raymond A. Strikas, MD, a medical epidemiologist in the CDC’s national immunizations program. "It suggests more needs to be done."

While some experts have proposed improving immunization rates by making vaccination a condition of employment (see HEH, October 1996, pp. 112-115), Strikas says he vacillates about imposing requirements. Instead, he suggests several other approaches based on understanding the possible reasons why HCWs avoid flu immunizations. (See how one hospital increased compliance rates in related story, p. 139.)

Education programs that inform employees of the risk to patients (as well as themselves) if they refuse to be vaccinated are an important factor. "If employees get vaccinated, they pose less risk as a group to patients," Strikas points out.

A 1997 study in long-term-care hospitals confirmed that. It showed that when more than 60% of staff were vaccinated, total patient mortality related to influenza was significantly reduced, while high vaccination rates of patients were not associated with significant effects on mortality.2

Nevertheless, "altruism only goes so far," Strikas adds. HCWs sometimes fail to realize that influenza can be a serious disease for themselves, as well, accompanied by several days of fever and a cough that could persist for two or three weeks. Education programs should explain those facts.

In addition, as many as one-third of doctors and nurses worry about adverse events from flu shots, Strikas says. "They don’t appreciate that the risk of adverse events, besides a sore arm, is minimal. That concern needs to be assuaged with data as best we can," he points out.

Fear of adverse reactions stems from having heard about or experienced reactions to past vaccines, especially the 1976 "swine flu" vaccine. Today’s vaccines are derived from subunits of chemically killed viruses that cannot cause influenza disease. However, many HCWs still cling to their fears, prompting one employee health department to launch an in-house study to determine what reactions are associated with current flu vaccine. Results showed that the occurrence rate of systemic symptoms among vaccinated workers was not greater than the rate among those who were not vaccinated. (See HEH, October 1997, pp. 117-119.)

In another study of staff physicians and nurses at a Veterans Affairs medical center, vaccine nonrecipients indicated that the main reason they refused to be immunized was concern about side effects. Researchers concluded that strategies to improve immunization rates should address concerns about vaccine safety.3

A CDC study of employees at a chronic care psychiatric facility showed that previous influenza vaccination and knowledge that vaccine does not cause influenza were the factors most predictive of current influenza vaccination.4

False convictions regarding vaccine safety also were identified in a study of low compliance rates among staffs of neonatal intensive care units.5

Besides directly addressing misconceptions about vaccine safety, Strikas recommends making vaccination convenient for employees by bringing it to their work and meeting sites via a mobile cart.

"Many people don’t take the time to go to the employee health office. If staff won’t come to the vaccination, bring vaccination to the staff," he suggests.

Employee health practitioners can take the cart to large staff meetings in hospitals and vaccinate attendees as they enter or leave. The mobile cart concept has improved compliance rates by being available both at work sites6 and at meetings or conferences.7

Another suggestion for increasing compliance, says Strikas, is to "make a competition of it between nursing staff units or departments," with a "modest reward" to the group that has the highest number of employees vaccinated in a given time period.


1. Centers for Disease Control and Prevention. Immunization of health care workers: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR 1997; 46(RR-18):1-42.

2. Potter J, Stott DJ, Roberts MA, et al. Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients. J Infect Dis 1997; 175:1-6.

3. Nichol KL, Hauge M. Influenza vaccination of health care workers. Infect Control Hosp Epidemiol 1997; 18:189-194.

4. Heimberger T, Chang HG, Shaikh M, et al. Knowledge and attitudes of health care workers about influenza: Why are they not getting vaccinated? Infect Control Hosp Epidemiol 1995; 16:412-415.

5. Eisenfeld L, Perl L, Burke G, et al. Lack of compliance with influenza immunization for caretakers of neonatal intensive care unit patients. Am J Infect Control 1994; 22:307-311.

6. Harbarth S, Siegrist CA, Schira JC, et al. Influenza immunization: Improving compliance of health care workers. Infect Control Hosp Epidemiol 1998; 19:337-342.

7. Ohrt CK, McKinney WP. Achieving compliance with influenza immunization of medical house staff and students: A randomized controlled trial. JAMA 1992; 267:1,377-1,380.