Hospitals go forward with mandatory flu vaccine

Shortage delays enforcement, but goal remains 

Boosting health care worker flu vaccination has been tough during a vaccine shortage. But commitment to this goal hasn’t waned for two hospitals that are launching mandatory vaccination programs.

This fall, Virginia Mason Medical Center in Seattle became the first hospital in the country to make flu vaccination an employee "fitness for duty" requirement. The hospital was forced to postpone its policy when vaccine supply was limited.

Meanwhile, the Mayo Clinic in Rochester, MN, delayed its Enhanced Flu Vaccine Program, which requires employees in high-risk units to receive the vaccine or sign a declination.

"We felt that this was something that would save lives and promote patient safety," says Robert Rakita, MD, chief of the infectious diseases section at Virginia Mason. "We try to put the patients first."

Greg Poland, MD, director of the Vaccine Research Group at the Mayo Clinic, is an outspoken advocate of mandatory influenza vaccination of health care workers.

"I cannot think of a single vaccine in any age group, for any disease . . . where a voluntary program works on a sustained manner," he says. "I think we have to acknowledge that and get over that. This is not about personal preference. This is about the privilege and ethics of society trusting us with their care."

Rakita and Poland note that health care workers also face mandatory vaccination requirements related to other diseases. They must receive an annual tuberculin skin test, and they must sign a declination if they don’t receive the hepatitis B vaccine (and they’re at risk of bloodborne pathogen exposure). Some hospitals require varicella vaccination or furlough health care workers if they contract chicken pox.

Some states require influenza vaccination for long-term care workers. For example, New York, Maryland, and North Carolina require long-term care staff to receive the influenza vaccine but allow for medical, religious, or philosophical exemptions.1 In Pennsylvania, health care workers must sign a declination if they choose not to receive the influenza vaccine.

Yet requiring annual influenza vaccination remains a controversial issue. Virginia Mason plans to provide an exemption for employees with a documented egg allergy, but not for those who object to vaccination. Those who don’t receive the vaccine because of medical reasons might be required to take prophylactic antiviral medication, says Rakita.

The Washington State Nurses Association in Seattle opposed the punitive nature of the policy and filed a petition in federal court, asking for an injunction. That court action has became moot with the vaccine shortage.

But the nurses’ union still hopes to discuss the vaccination issue in arbitration, says Anne Piazza, spokeswoman.

"We’d rather work with the hospital to help educate our nurses so they understand the importance of the vaccination," she says. "We oppose a mandatory policy in the absence of a declared public health emergency. We believe that threatening to fire nurses who don’t comply is simply bad policy on the hospital’s part."

Voluntary programs come up short

Both hospitals had tried vigorous voluntary programs. By national standards, they had done well with their vaccinations.

Last year, Virginia Mason launched an intensive promotion and vaccinated 55% of its 5,500 employees. The Mayo Clinic vaccinated 75% of its 33,000 employees. Nationally, only about 36% of health care workers receive the influenza vaccine, according to the National Health Interview Survey.

Yet at both hospitals, hundreds of employees with patient contact remained unvaccinated. "It’s more than just [a matter of] education," Poland says. "It’s just sort of laziness. Not getting around to it. As soon as it’s harder to decline than to just get the vaccine, people seem to comply."

Shortages raised the value of the vaccine; suddenly, health care workers asked to be vaccinated. But in general, influenza still is viewed as a commonplace disease — in part because health care workers confuse other respiratory ailments with the flu.

"People don’t realize that influenza is really deadly. They think it’s just too routine," says Rakita.

In fact, myths persist about the influenza vaccine, says influenza expert says William Schaffner, MD, chair of the department of preventive medicine at Vanderbilt University in Nashville, TN. "[Nurses] are very skeptical of influenza vaccine generically. The main reason is that they are worried about the vaccine making them ill in some fashion," he says.

Nurses also think of the vaccine in terms of their personal risk for influenza infection and don’t think of the potential impact on their patients, Schaffner adds.

How often do health care workers transmit influenza to patients? That isn’t clear. One recent study at Emory Healthcare in Atlanta involved "aggressive hospitalwide surveillance for nosocomial influenza." The effort identified six inpatients who met the definition for nosocomial- acquired influenza, including one who subsequently died with influenza pneumonia as a possible cause of death. Three of the patients were on the bone-marrow transplant unit, and one was in surgical intensive care. Awareness of the outbreak did not lead to higher rates of influenza vaccination among employees, the authors noted.2

In many cases, influenza isn’t noted as the specific cause of death, making it difficult to track the mortality related to complications from the disease, notes Rakita. The CDC estimates 25,000 people die of complications from influenza in a typical flu season.

Just based on those numbers, Rakita says, "I would think every single large institution in the country has likely transmission of influenza from staff members to patients and mortality resulting from that."

The problem is exacerbated by health care workers who come to work sick, notes Poland.

"If we had a health care worker who was infected with avian influenza or SARS [severe acute respiratory syndrome], would we let them step into the hospital and care for patients?" he asks. "If we had a vaccine for avian influenza or SARS, would we let them come to work without the vaccine?"

At least at two hospitals, the answer to those questions is no.


1. National Conference of State Legislatures. States with Laws Involving Immunizations and Long-Term Care Centers. June 2004. Web site:

2. Ribner BS, Cooper J. Nosocomial influenza A viral infections occurring in an acute care hospital during a community outbreak. Presented at the annual meeting of the Infectious Diseases Society of America. Boston; Oct. 3, 2004.