Hospitals making it harder for HCWs to 'just say no' to influenza vaccine

But will declinations really make a difference?

Just saying "no" to the flu shot isn't so simple anymore. Thanks to new state mandates and employer requirements, health care workers who don't want the vaccine are increasingly asked to acknowledge the risks for patients, themselves, and their family members.

Yet the debate persists about how effective those declination statements are — and how they should be used to improve influenza vaccination rates.

For some employee health professionals, a declination statement offers a golden opportunity for one-on-one education about influenza and the vaccine. Others view it as a heavy-handed effort to strong-arm health care workers into accepting a vaccine that is only partially effective.

One thing is clear: The impact of declination statements will vary widely depending on how they're used. There is a direct relationship between the burden and the benefit.

"The declination statement, at the end of the day, is no panacea and is undoubtedly a great encumbrance," acknowledges William Schaffner, MD, chairman of the Department of Preventive Medicine and professor of infectious diseases at the Vanderbilt University School of Medicine in Nashville and vice president of the National Foundation for Infectious Diseases Board of Directors.

Schaffner is a strong proponent of declination statements as one strategy to improve influenza vaccination rates of health care workers. But he says the statements themselves are worthless if they simply involve health care workers checking a box electronically, or even on paper, without follow-up.

"You have to have a face-to-face meeting with every health care worker who says 'no.' That's the educational moment," he says. "Only after they listen to you, and then they say, 'No,' do you let them out."

For large or multi-campus facilities, tracking the declinations and providing the "educational moments" can be overwhelming. In fact, at Vanderbilt, employees must complete a mandatory flu training module, but they can signal their declination of the flu vaccine electronically. That complies with new Tennessee Department of Health rule that requires health care facilities to provide flu education to all "direct care" employees and maintain a record of signed declination statements from those who refuse vaccination.

"We've already given 10,000 flu shots this season," says Melanie Swift, MD, medical director of the Vanderbilt Occupational Health Clinic. "There's just no way to lasso people and get them to sign a piece of paper."

Tennessee is just one state to adopt a regulation on declination statements. California and Rhode Island require health care facilities to collect declination statements. For example, the California Health and Safety Code requires employees of health care facilities who do not want the vaccine "to declare in writing that he or she has declined the vaccination." Minnesota has set a goal for 90% of all health care facilities to use an annual "declination" program by 2010.

Do declinations have a punitive tone?

The Joint Commission requirement to track health care worker influenza vaccination rates has clearly triggered a greater use of declination statements. But while hospitals have struggled with the logistics, others ask a basic question: If you want to change behavior, is it better to use a carrot or a stick?

Nancy Rudner Lugo, DrPH, NP, health care consultant and associate professor at the University of Central Florida College of Nursing, analyzed studies related to influenza vaccination of health care workers, and concluded that there is "limited evidence of the effectiveness of declinations" and that education and immunization campaigns can make the vaccinations "as routine and is wearing gloves."1 Hospitals too often implement declination statements without first probing the reasons for low vaccination rates and ways to encourage and educate employees, she says.

For example, an employee survey can determine why some employees avoid the vaccine. While declination forms often ask employees why they are declining, they also often include a statement acknowledging "I am putting my patients and co-workers at risk."

"There's a punitive tone to a declination," says Lugo. "There's a sense of liability. If I sign that I'm refusing it, what's going to happen?"

Research needs to establish stronger scientific evidence that health care workers are the vectors of influenza to patients and that declination statements are the answer to better vaccination compliance, says Swift.

A greater risk may be posed by visitors who come to the hospital and give patients a hug or a kiss, notes Swift. And health care workers can effectively prevent transmission through hand hygiene and respiratory hygiene, including wearing a mask if they have a cough, she notes.

Meanwhile, Swift wonders, "If you vaccinate the health care workers, does that really help the patients?" Studies of flu vaccination programs often compare mortality rates from influenza in facilities with no flu vaccine program and those that have a voluntary program, she notes. There is little data on the impact of declination statements.

"I'm willing to take a strong stance and make things mandatory if I'm convinced it's good for the health of the worker," says Swift. "I don't think flu vaccine for healthy people rises to that level now. I don't think the evidence of the protection of the patients is strong enough to start mandatory or coercive programs."

Asking for declination statements can be intimidating for employees, she says. "Employees are a vulnerable group," she says. "We need to advocate for the workers because they are susceptible to this power differential between them and their employer. Before we take any medical intervention and mandate or enforce it, we need to have some strong data behind it. We should not mandate that employees take any medication just because we have control over them and we can."

Will HCWs accept responsibility for shots?

Some hospitals that use declination statements have taken measures to take some of the negativity out of the process.

At Erickson Retirement Communities in Silver Spring, MD, national medical director Craig D. Thorne, MD, MPH, created a single flu vaccine consent form that emphasizes education, rather than usinga separate declination statement. The form stresses the importance of the flu vaccine to protect them, their family, co-workers and the patients or residents they care for.

Employees may then check a box either stating "I will accept the influenza vaccine, as it is my responsibility" or "whether for personal or medical reasons, I choose not to accept the vaccine at this time." They also may indicate that they received the flu vaccine elsewhere; those numbers are counted in the overall vaccination rate. (See sample form.)

Thorne also implemented a program to bring flu vaccine to employees on the floors. "Just by introducing that influenza form and encouraging mobile vaccine campaigns, we're already seeing a 78% increase in rates compared to last year, and we're still vaccinating," he said in early December.

Are flu shots a matter of employee health?

OSHA fact sheet warns of occupational risk

Here's a new spin on the campaign to convince health care workers to get the influenza vaccination: Do it for your own health.

The U.S. Occupational Safety and Health Administration has released a fact sheet on seasonal influenza vaccination that emphasizes the worker-safety aspect. OSHA states: "Employers have a duty to create a safe work environment. Encouraging influenza vaccination for their healthcare employees is one method of doing this. The current rate of influenza vaccination among healthcare workers is disappointing, and increasing this rate could significantly enhance health care worker safety and increase their productivity."

OSHA also notes that The Joint Commission, an Oakbrook Terrace, IL-based accrediting body, has made health care worker vaccination a priority, and that "employees increase their risk of contractingthe flu if they decide to decline vaccination."

"We consider it a form of personal protection for health care workers to receive the vaccine," says Patricia Bray, MD, MPH, acting director of OSHA's Office of Occupational Medicine. "Influenza is the most common cause of death from a vaccine preventable disease in the United States."

Although healthy adults are usually not at high risk of complications from influenza, she notes that the vaccine has been shown to reduce rates of illness and complications of illness in the 18- to 63-year-old age group.

Hospital-based outbreaks also affect health care workers, Bray notes, although there are no data showing that health care workers have a higher risk of contracting influenza than the general population. "It just makes sense that a group that has a high exposure rate has a higher likelihood of contracting the illness," she says.

OSHA did not mention the issue of declination statements. (Editor's note: The OSHA influenza vaccination fact sheet is available at

"In my experience, employee health programs that are positive in nature produce favorable results," says Thorne, a clinical assistant professor of medicine at the University of Maryland School of Medicine and adjunct assistant professor in the Department of Environmental Health Sciences at the Johns Hopkins University Bloomberg School of Public Health.

Erickson has 20 sites around the country with some 11,000 employees and many provide assisted living and nursing care as well as independent retirement living. Signing the declination form isn't mandatory, and Thorne isn't tracking which employees signed.

Individual sites may require employees to sign the forms. For example, at Riverwood Village in Silver Spring those directly providing healthcare services for residents must complete the form — but they also receive a $5 voucher to the cafeteria when they sign the form.

The bottom line, says Thorne: You have to balance the rights of the employee with the needs of the workplace, but education and convenience encourages workers to accept flu vaccines.


1. Lugo NR. Will carrots or sticks raise influenza rates of health care personnel? AJIC 2006; 35:1-6.