Hospitals should move to declination statements

HCWs need to sign if refusing influenza vaccine

Asking health care workers to sign a declination statement if they don’t receive their annual influenza vaccine soon may become the standard of care.

The Advisory Committee on Immunization Practices (ACIP), an advisory panel of the Centers for Disease Control and Prevention (CDC) in Atlanta, voted overwhelmingly to recommend the use of declination statements, along with other measures, to improve health care worker vaccination rates. They did not specify the wording of declinations.

The Joint Commission on Accreditation of Healthcare Organizations will consider the patient safety implications of the recommendations and whether new elements of performance within a standard should be drafted, says Robert Wise, MD, vice president of the division of standards and survey methods.

Declination statements have been viewed by some as a heavy-handed way to pressure health care workers into getting the vaccine. Although health care workers are among the top priority groups for influenza vaccination, their annual rates are less than 40%.

Yet advocates say it places the burden primarily on hospitals, which vary greatly in the effort they expend on influenza vaccination.

"If it’s done the way the ACIP intended it, every institution will have to reach out and touch every single health care worker," says William Schaffner, MD, chair of the department of preventive medicine at Vanderbilt University in Nashville, TN. "That means promoting it and bringing it literally to the arm of every single health care worker."

The recommendation for declination statements is embedded in a set of recommendations that promote education and strategies to encourage vaccination. The recommendations also were approved by another federal advisory panel, the Healthcare Infection Control Practices Advisory Committee.

But the American College of Occupational and Environmental Medicine (ACOEM) opposes the use of declination statements. ACOEM was expected to approve a position statement in late July, which stated, "A coercive program has the potential to harm the employer-employee relationship."

The draft statement further said, "There is no evidence to suggest that such programs will increase compliance, and the burden of requiring compliance from those who have already chosen not to participate would tax employee occupational health resources that could otherwise be devoted to positive reinforcement for compliance."

"It diverts resources from encouraging people to get the vaccine to becoming policemen and tracking people down to get letters signed by people who aren’t going to get the vaccine anyway," explains William Buchta, MD, MPH, medical director of the Employee Occupational Health Service at the Mayo Clinic in Rochester, MN, and an author of the ACOEM position statement.

Instead, federal agencies should focus on the need for comprehensive, interactive education of health care workers on influenza and vaccination, says Bill Borwegen, MPH, health and safety director of the Service Employees International Union. "It’s just such a negative way to approach this issue. They’re missing the most important parts of the program, which are the education and the free availability of the vaccine. . . . I’m a firm believer that through a good education program, you can dramatically increase vaccination rates."

As a monitoring tool, the declination statement can help hospitals determine true vaccination rates and compare rates by unit or department. For example, some health care workers may receive the vaccine from their private providers or other venues, which would not normally be counted by the hospital’s vaccination program.

The declination statement also can ask health care workers to state their reason for refusing to accept vaccination. Studies have shown that health care workers often have misperceptions about the vaccine; they believe it is not effective or can cause the flu. As healthy young adults, they may believe they are in a low-risk group and may not realize that they need the vaccine to protect vulnerable patients.1

"I think the declination is a matter of record keeping," says Jane Siegel, MD, professor of pediatrics and infectious disease specialist at the University of Texas Southwestern Medical Center in Dallas. "I think it’s important from a quality-improvement standpoint to have some record keeping and to know who’s getting the vaccine."

Wake Forest University Baptist Medical Center in Winston-Salem, NC, implemented a policy of declination statements last year and still is evaluating their impact.

"We wanted to make clear that they were not only putting themselves and their families at jeopardy of getting influenza, but they were putting their patients at risk," says Jon Abramson, MD, chair of ACIP and chair of the department of pediatrics at Wake Forest.

The declinations are patterned after similar statements that parents sign when they refuse to allow their children to be vaccinated, he says.

For years, the hospital has included check boxes on the flu vaccine consent form for employees who didn’t want the vaccine — with options to explain why, says Scott J. Spillmann, MD, MPH, director of medical center employee and occupational health services at the Wake Forest University Baptist Medical Center.

"I don’t think the fact that we had additional wording in the declination turned people off," he says. "We have been asking for input for several years now in order to refine and improve our campaign."

The hospital has about 100 "campaign coordinators" who work in units throughout the hospital to provide vaccination for 12,000 employees, students, and volunteers. Typically, the hospital has a vaccination rate of about 68%. (Last year, with restricted vaccine supply, the vaccination rate was about 60%, according to Spillmann.)

Signatures are collected on the forms, but the hospital doesn’t try to track down employees who haven’t had the vaccine or signed a form, he says.

Spillmann has noted some common reasons for refusing the vaccine, including fear of needles and fear of vaccine side effects.

"Despite our education attempts, there still are people who fear getting influenza from the vaccine." The hospital tries to address those issues in its educational campaign, which includes posters, mass emails, and educational presentations, he adds.

Nationally, the spotlight on influenza vaccination has been heightened by concern about the potential for pandemic influenza. Increasing vaccination rates of both health care workers and the broader community means better manufacturing capacity, ACIP members said.

Although the current vaccines would not be effective against avian influenza such as H5N1, infection control experts say vaccination could help reduce the risk of cross-transmission of the disease with regularly circulating viruses.

In other recommendations to improve health care worker vaccination rates, ACIP agreed hospitals should:

  • Vaccinate all eligible health care workers, including students, against influenza annually to protect their patients, themselves, their families, and their communities, and to reduce health care worker absenteeism.
  • Use strategies that have been shown to increase influenza vaccine acceptance, including mass vaccination clinics, mobile carts, flu deputies (i.e., peer vaccinators), vaccination access during all work shifts, role modeling, and support by institutional leaders.
  • Use health care worker influenza vaccination rates as one measure of patient safety and quality. 


1. National Foundation for Infectious Diseases. Improving Influenza Vaccination Rates in Health Care Workers: Strategies to Increase Protection for Workers and Patients. Bethesda, MD; 2004. Web site: