One in three hospitals now mandating flu shots

Governor vetoes California bill

Health department rules are broadening the scope of mandatory influenza vaccination policies, even as critics assail the policies as punitive and not science-based.

Almost one in three (31%) of hospital-based health care workers now report that their employers require influenza vaccination.1 Rhode Island, Colorado, and several local health departments in California require health care workers at hospitals, long-term care facilities, and ambulatory surgery centers to receive the influenza vaccine or wear a surgical mask during the flu season.

“The intention behind it is [to address] the documented low immunization rate for health care workers,” says Sherri Willis, public information officer for the Alameda County Public Health Department. “In other words, health care workers are not getting the flu shot and we want to assure their protection and that they are not transmitting the virus to patients.”

Facilities that attain a vaccination rate of at least 90% are exempt from the masking policy in Alameda County. Colorado has adopted that same exception, allowing facilities that reach a rate of 75% by December 2013 and 90% in 2014 and beyond to continue voluntary programs.

In Rhode Island, the masking policy only applies in direct patient care when the state director of health declares that flu is widespread.

Masking has become a major component of mandates. The California Medical Association sponsored a bill to require masking of health care workers who decline the flu vaccine. There isn’t any scientific evidence that masks reduce the nosocomial transmission of influenza, concedes Ryan Spencer, associate director of government relations for the CMA. “The mask was never regarded as being a substitute for the vaccine,” he says.

But it’s clear that health care workers don’t want to wear a mask. Masking policies increase compliance with vaccination, he says.

Politics of flu vaccine

The California bill illustrates some of the delicate political realities of an influenza vaccination mandate. Unions opposed the masking requirement as punitive, but when it was removed from the bill, the California Hospital Association withdrew its support.

The final bill required facilities to reach a 90% flu vaccination rate by 2015, but simply said that health care workers who don’t receive the vaccine “shall agree, in writing, to adhere to the most effective measures determined by the health facility in preventing health care workers from contracting and transmitting the influenza virus.”

Gov. Jerry Brown vetoed the bill, although he said he supports the Healthy People 2020 goal of reaching a 90% vaccination rate for health care workers. “This bill would move the date up to 2015 and make compliance mandatory, which are requirements I do not believe are reasonable,” he said in his veto statement. “I have confidence that local governments and health facilities are well equipped to make these decisions on their own.”

To combat the vaccine-or-mask mandates, unions took their message on the road in Pennsylvania. The union will work with hospitals to promote voluntary influenza vaccination, says Bill Borwegen, MPH, safety and health director of the Service Employees International Union (SEIU).

“We’re going to give a positive approach rather than an adversarial, coercive approach a try,” he says.

Masks can impair communication between patients and providers, Borwegen says. And because health care workers touch their face to adjust or reuse the masks, they may actually increase the risk of transmitting influenza, he says.

In unionized hospitals, the union is also prepared to file grievances and legal challenges to stop mandates, he says.

Is evidence over-sold?

While vaccine-or-mask becomes a common policy, a critical article in an Australian journal added to the controversy.

Influenza vaccination of health care workers is an example of guidelines that use evidence that is of “inadequate quality or may be misused to underpin particular advocacy positions,” the authors state.2

They note a “paucity of evidence” that health care worker vaccination reduces nosocomial transmission in hospitals. The randomized controlled studies commonly cited occurred in long-term care facilities and might not be applicable to an acute-care setting, says the article by Jackie M. Street of the University of Adelaide and Toni N. Delany of Flinders University, both in South Australia.

“Despite the lack of evidence, guidelines in the countries examined are often underpinned by claims that such evidence exists,” they wrote.

Guidelines on health care worker flu vaccination also selectively use only research findings that bolster their recommendations, oversimplify issues and include “dead-end” citations that don’t actually contain relevant evidence, the authors said.

The paper supports the contentions of labor unions and other opponents of mandatory policies.

Although the Mayo Clinic in Rochester, MN, has reached a 90% vaccination rate through a voluntary program, Bill Buchta, MD, MPH, medical director of the Occupational Health Service, questions the rationale for the 90% rate. One commonly cited study showed elimination of nosocomial cases with a vaccination rate of 60%, he notes.

Mandatory vaccination has “taken on a life of its own. It’s become a political issue, a public policy issue,” he says. “It doesn’t matter anymore if there’s a scientific basis.”

Tom Talbot, MD, MPH, chief hospital epidemiologist at Vanderbilt University Medical Center in Nashville, counters that attaining the highest quality evidence on the impact of health care worker vaccination isn’t really possible. Talbot says he identified about 50 published reports of outbreaks in health care facilities related to nosocomial transmission of influenza in the past four decades.

“You can’t ethically take a cohort of health care workers and not vaccinate them. We can’t do that study,” says Talbot, who is chair of the Task Force for Healthcare Personnel Influenza Vaccination of the Society for Healthcare Epidemiologists of America. “If you need that study, then you’re never going to support a mandatory policy.”


  1. Centers for Disease Control and Prevention. Influenza vaccination coverage among health-care personnel — 2011–12 influenza season, United States. MMWR 2012; 61:753-757.
  2. Street JM and Delany TN. Guidelines in disrepute: a case study of influenza vaccination of healthcare workers. Australian and New Zealand Journal of Public Health 2012; 36:357-363.