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Mandatory Vaccination Against Influenza: Strategies for Compliance


By Kelly M. Pyrek

Experts say that vaccination of healthcare workers against influenza is one of the key ways to protect patients and boost occupational health, yet annually, infection preventionists engage in a battle of persuasion and politics to get better compliance rates at their institutions. One of the challenges is ensuring that healthcare workers are not working while being infected with the influenza virus; during outbreaks in healthcare settings, laboratory-confirmed influenza attack rates have been documented to be as high as 51 percent. Studies have demonstrated that influenza vaccination of healthcare personnel has decrease infection rates, and a growing body of evidence has shown that vaccination can improve patient outcomes in healthcare settings.

While many facilities are requiring vaccination as a condition of employment, others are finding creative ways to get healthcare workers to do what's right while protecting the individual's right to choose. We look at three different approaches recently undertaken and described in the literature.

Lisa Esolen, MD, systems director of infection control at Geisinger Health System in Danville, Pa., and her colleagues detailed their health system's requirement that unvaccinated workers wear a face mask in the presence of patients if they choose not to get vaccinated, in a study in the journal Infection Control and Healthcare Epidemiology. Esolen, et al. (2011) report that Geisinger, a major teaching hospital, achieved 95 percent compliance in 2009, and subsequently reached 90 percent and 92 percent compliance for two years.

"We had tried a variety of initiatives just as other health systems had but only reached a compliance rate of about 60 percent," Esolen says. "We felt that to exceed 90 percent compliance we needed a stronger approach."

As Esolen, et al. (2011) explain further, "After studying our options and the diversity within our 31-county employee population, Geisinger Health System (GHS) decided to transparently operationalize a face-masking requirement as the cornerstone of our 2009-2010 vaccination campaign. In so doing, we preserved a degree of healthcare worker (HCW) choice, protected patients, and achieved our goal in a very short time frame."

With the required-masking policy being pivotal to Geisinger's influenza campaign, Esolen, et al. (2011) say the policy needed to be enforceable, transparent, clearly defined and required accountability. An electronic template listing department employees was designed; adjacent to the employee name was the date of their vaccination, while non-vaccination resulted in a blank box. A star sticker was placed on the employee badge when vaccinated, thus ensuring general awareness of who received the vaccine and who therefore did or did not need to don a mask. Unvaccinated employees were instructed to place a mask around their neck at the start of every shift and lift it over their face when within 6 feet of a patient. A new mask was needed each shift or whenever it became moistened, soiled or torn. Geisinger managers were held accountable for enforcement and persistently non-compliant employees were disciplined. The program ran from Nov. 1 through March 31.

After defining the masking policy Esolen and her colleagues established a highly convenient vaccination process by increasing vaccination hours, placing vaccination stations at employee entrances and outside the cafeteria, and by decentralizing vaccine supplies with the recruitment of about 150 "flu team captains." These clinical department captains received flu kits that contained the vaccine, supplies, consent forms and stickers. Because of the pandemic situation at the time, employees were also required to receive the H1N1 vaccine to be exempted from the masking policy; this was acknowledged by a second star sticker on the employee identification badge.

As Esolen, et al. (2011) note, "Once the logistical issues regarding the masking policy were established and handled, the vaccination process itself was swift and smooth. This method achieved 90 percent to 92 percent vaccination compliance for two consecutive years. Furthermore, 92 percent of all vaccine dispensed in 2009 was given in a span of only four weeks, making 2009-2010 by far the most efficient vaccination year in the history of our health system. The 2010 season has duplicated this timeline with even higher compliance numbers. Though the 2009 compliance with nH1N1 vaccination was slightly lower, this mirrored the national trend while still being much higher than prior seasonal vaccine years. Like other facilities, GHS experienced unreliable and erratic nH1N1 supplies as well as employee concerns about vaccine safety."

The mask mandate could be construed as a stringent approach that would be unpopular with employees, and as Esolen, et al. (2011) acknowledge, "Some have questioned whether a masking policy unfairly stigmatizes those who have a medical contraindication to vaccination. With our program, these individuals were not singled out since there were others who chose to mask rather than be vaccinated. Also, as we did not consider this a punishment but a protection, the reason for being unvaccinated was irrelevant."

"There were a variety of reactions to our program, but they were mostly positive," Esolen says. "The unvaccinated folks who wore masks were not happy about this requirement but they were more content to wear a mask than get vaccinated and were glad to have that option. Having some degree of choice here made a huge difference." Esolen adds, "I think our approach was a happy medium. We wanted high compliance but also did not want employees to have a perception that leadership was aloof to the concerns or did not care if they stayed in their current job or left. We wanted our success to be one that the employees actively participated in and could be proud of."

Whether it was the desire to protect their patients or a desire to avoid mask usage that may have fueled personnel’s participation, Esolen remains philosophical about the end result. "I think it was many things. Certainly the fact that senior leadership chose this issue to focus on increased the awareness and importance of this initiative for the safety of our patients as well as our employees. Others were motivated to be vaccinated so as to avoid wearing a mask for nearly six months. In either case we achieved our goal which was patient and employee protection."

While Geisinger is a substantial health system, Esolen says she believes similar vaccination compliance results could be achieved in a smaller setting. "I think this system may work even better in a smaller system where peer pressure can be significant and employees who are tempted to not wear a mask when required may be more obvious. The critical factor here is that the masking policy have real teeth -- it must be clear who needs to don the mask and it much be enforced without hesitation. Supervisors have to know that they can be subjected to disciplinary action if they have variable compliance on their unit."

And as Geisinger's program is closely watched by other facilities hoping to boost their vaccination compliance rates, Esolen reports that she and her colleagues have received interesting feedback since their study was published. "I have since given a talk to several hospitals in the central Pennsylvania area at the request of our state department of health encouraging other health systems to adopt stricter programs. Most of the feedback has been supportive. Most other hospitals are attracted to giving some degree of an option to employees and not risking lengthy legal battles."

Esolen, et al. (2011) note, "Despite the clear result of achieving our goal in a short time frame, there may be other downstream advantages to this approach. Changing our healthcare culture to one of safety is a major focus when discussing quality care. But is culture best changed by a mandate? A process that requires the final acquiescence of our healthcare workers, that still inspires abounding team spirit and peer pressure, and that acknowledges all employees in the accomplishment could have unique value. Achieving high vaccination compliance by mandate may be a necessary approach. Achieving it in this multifaceted way may create a more enduring commitment on an individual level."


Elizabeth L. Daugherty, MD, MPH, of the Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine in Baltimore, and colleagues, say that success of a stringent healthcare vaccination program hinges upon healthcare workers' understanding of it, as evidenced by the results of their recent survey of 928 hospital staff during the 2008-2009 influenza season. Although 91 percent of survey respondents with regular patient contact reported being vaccinated for influenza in the 2008-2009 season, just 60 percent reported consistent annual vaccination. Daugherty, et al. (2011) explain that, "Misinformation regarding hospital policies is widespread. Improvements in vaccination rates will likely require multifaceted, targeted efforts focused on specific influences on less adherent groups. The identified variability in influences on the decision to be vaccinated suggests possible targets for future interventions."

During the influenza season in early 2009, a voluntary, anonymous survey was distributed to staff; the 20-item survey assessed clinicians’ knowledge, attitudes, and beliefs related to both influenza vaccination in general and our hospital’s specific vaccination policy in particular.

Daugherty, et al. (2011) report that of those surveyed, 75 percent completed the survey; 623 respondents reported regular patient contact, and 91 percent of those reported vaccination in the current influenza season. However, only 60 percent reported consistently receiving the vaccine every year. Of those who were vaccinated, 8 percent reported being vaccinated for the first time during that influenza season. Forty-two percent of respondents were unaware of the major change in hospital policy regarding vaccination. Influences on the decision to be vaccinated varied significantly between those who are regularly vaccinated and those with inconsistent vaccination habits. Attitudes toward hospital policy varied significantly by race and clinical role.

In the past, Johns Hopkins had offered the seasonal influenza vaccine to all employees free of charge for more than 15 years, but vaccination had never been required before. In an effort to improve vaccination rates, a policy of active declination was instituted in 2006. At the beginning of the 2008-2009 influenza season, the vaccine policy was changed to require that surgical masks be worn by those who declined vaccination when their responsibilities required them to be in close contact with patients at a distance of less than 6 feet). Also during the 2008-2009 flu season, a colored ID badge clip was distributed to each staff member who was vaccinated. The lack of a badge clip was intended to prompt supervisors to remind unvaccinated staff about the mask requirement, but no specific discipline was delineated for those who failed either to receive vaccine or to wear the recommended mask. The hospital communicated details about the changes in hospital policy through a variety of methods, including formal and informal meetings with nursing and physician leaders on departmental and, for nurses, unit-based levels.

The researchers found that a number of staff were unaware of the policy changes; most believed incorrectly that vaccination or wearing of a surgical mask was required regardless of whether the employee had contact with patients. A small percentage of staff members were unaware of the prominently advertised ID tags distributed to those who had been vaccinated so that they would be easily identifiable to their supervisors. More than one-quarter of staff were unaware that the hospital had an active declination policy.

Daugherty, et al. (2011) report that they found significant variability in factors influencing the decision to be vaccinated, based on whether the respondent received vaccine consistently each season or was inconsistent in his or her vaccine uptake. Of note, those who reported receiving vaccine every season were more likely than inconsistent vaccinees to believe that the vaccine protected them against flu and prevented the spread of flu to their patients or their families. Those who were inconsistent in their uptake were more likely to report that external factors such as the mask requirement or supervisor expectations were strong influences on their vaccination decision. Perception of supervisor and institutional expectations were found to be significantly more important among those with inconsistent vaccine practice. Furthermore, the significance of workplace expectations were found to vary by sex, race and professional role. When it comes to opinions about the vaccination policy, the researchers found that those with inconsistent vaccination practice were less likely to believe that the policy had an impact on influenza prevention and more likely to feel that the policy is unfair. Nurses were more likely than physicians and nonclinical staff to feel that the policy was unfair and put too much pressure on staff.

The researchers say that "despite aggressive, targeted publicity and notifications, we found that effective communication regarding hospital policy appeared to be lacking, potentially engendering confusion and furthering misperceptions and mistrust. This is exemplified by the significant proportion of healthcare workers who were unaware of policy changes and the fact that greater than 50 percent reported incorrectly that the policy applied to staff without patient contact. Such broad misconceptions of the policy further call into question whether institutions have been as effective as they may have hoped in communicating the rationale and importance of vaccination to staff." They add, "We also found that those who are consistently vaccinated tended to make their decisions on the basis of the belief that vaccination is effective at keeping them, their patients, and their families healthy. Although those who are inconsistent in their vaccine practice do report that vaccine effectiveness is important, they are more likely than those who are vaccinated regularly to be driven in their decision making by external requirements, such as mask wearing and supervisor or institutional expectations. Such findings suggest that although external inducements may impact behavior intermittently, as expected, they are less likely to have the ability to change behavior over the long term. Furthermore, the group that is inconsistently vaccinated is also more likely to believe that the policy is unfair and puts too much pressure on staff to participate. The combination, then, of a group that is less likely to think that the policy is effective and more likely to think that it is unfair may be a group at risk for increasing institutional mistrust and discontent."

There is still work to be done in assessing attitudes toward influenza vaccination. As Daugherty, et al. (2011) summarize, "Our findings suggest a need for more investigation of factors influencing healthcare worker beliefs about vaccine effectiveness in order to tailor policies and programs to address not just adherence but the drivers behind it. Although we agree that mandatory vaccination will likely significantly improve adherence, the perception of unfairness and excessive pressure on the part of the institution is not a trivial concern. Policies that foster trust, rather than mistrust and resentment, are likely to be far more effective in the long run. Further investigation is warranted to assist in the development of such policies."


The following success story is significant not only because of the exceedingly high vaccination compliance rate among healthcare workers, but also because of the high rate of cooperation from affiliated physicians. Lynne V. Karanfil, RN, MA, CIC, of MedStar Health in Columbia, Md. and colleagues describe a mandatory program at MedStar Health, a regional healthcare organization that includes nine hospitals with approximately 25,000 healthcare workers and approximately 4,000 affiliated physicians.

As Karanfil, et al. (2011) explain, "With previous vaccination rates parallel to reported national rates of 54 percent among HCP, MedStar Health introduced a mandatory seasonal influenza vaccination program promulgated during the 2009-2010 influenza season. HCP and affiliated physicians were given an opportunity to apply for medical or religious exemptions. Non-compliant HCP were terminated. Non-compliant physicians had their privileges administratively suspended for the influenza season."

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