Increasing Influenza Immunizations Rates for Healthcare Workers

Nurses, as well as other healthcare workers (HCWs), have close interactions and contact with all types of chronically ill patients that are immunosuppressed, fresh surgeries, elderly or very young. Influenza, a vaccine-preventable disease, is a serious threat to the hospital population and healthcare environments are very conducive to the rapid transmission of influenza.1 According to the literature, about 36,000 deaths per year can be attributed to influenza and over 110,000 hospitalizations occur each year in the United States as a result of influenza infections.2 Currently, the Centers for Disease Control and Prevention (CDC) reports the HCW influenza vaccination rate is about 42 percent.3 Studies have found that when HCWs receive annual influenza vaccination, deaths were decreased among nursing home patients4 and illness, as well as absenteeism due to illness was reduced among healthcare workers.5 Although the exact number of influenza deaths associated with healthcare-acquired transmission is not known, healthcare-acquired influenza has long been accepted as a factor in influenza mortality.6 It is for this reason that it is imperative HCWs receive an annual influenza immunization as recommended by the Advisory Council on Immunization Practices (ACIP) and the Healthcare Infection Control Practices Advisory Council (HICPAC) unless medically contraindicated. This paper will focus on multi-factorial interventions to increase influenza immunization rates among HCWs.7

As indicated in the 2004 Association for Professionals in Infection Control and Prevention (APIC) position paper, the importance of improving influenza immunization rates among HCWs is a very necessary component of ensuring “patient safety and protection” (p. 123). In addition, immunization provides an extra level of personal protection for the HCW. Transmission of the influenza virus can spread rapidly from HCWs to patients and patients to HCWs, creating a vicious cycle. An institutional influenza outbreak can exacerbate staff shortages in clinical areas, not only by creating additional patient risk factors but also by further stressing hospital resources and increasing patient morbidity and mortality.2

One neonatal intensive care unit (NICU) reported an outbreak of influenza among 19 neonates with one outbreak related death that occurred. The source case was suspected to be an employee, although that could not be confirmed. The facility reported a 15 percent influenza immunization compliance rate for the staff that year. In the same article, a second influenza outbreak in a 12-bed transplant unit with all private rooms was discussed. During this outbreak there were four cases of health-care acquired influenza identified and in three of the four cases there had not been any outside visitors from time of admission to the onset of illness. According to the 2006 CDC guidelines, a healthcare-acquired infection is one in which the patient must have been in the hospital for more than 48 hours with no symptoms on admission. Again, the most likely source of spread in this outbreak was believed to have been a HCW since there had not been any outside contacts for three of four patients.2

The effects of influenza immunization of HCWs on mortality in 20 long-term care facilities were studied over a six-month winter period in 1996-97. This randomized controlled trial found that when HCWs were immunized there was a reduction in mortality among the patients; however, “virological surveillance showed no associated decrease in non-fatal influenza infection in patients.”4

APIC recommends the following:

1. That facilities have a written policy stressing the importance of annual employee influenza immunizations that must be shared with all employees regardless of institution size or type

2. The program must be designed and implemented annually to include the following: education of the HCW regarding the need to be immunized, the relatively low risk of adverse outcomes from receiving the vaccine, reducing barriers and providing access to immunizations for staff

3. Facilities must monitor immunization rates annually with feedback to the staff through patient safety and infection control

4. Monitor and track healthcare-acquired flu

5. Track community-acquired incidence through the public health system.2

The 2009 Joint Commission Standards of Care for Infection Prevention and Control, IC.02.04.01 states “the hospital offers vaccination against influenza to licensed independent practitioners and staff.” The Joint Commission elements of performance for the infection prevention standard clearly follow the APIC recommendations for influenza vaccinations.8

One study suggested that a survey be developed and administered to facility HCWs to identify barriers that prevented them from receiving the vaccine. The study concluded that those who declined the influenza immunization did so because they lacked sufficient knowledge of the vaccines effectiveness, safety or necessity, thereby; prompting the suggestion that emphasis is placed on vaccine efficacy and safety as a campaign strategy to increase immunization rates.9 Additional barriers or reasons found in the literature as to the low vaccination rates for HCWs include: inconvenience, belief that the flu shot can give you the flu, adverse reactions to the vaccine, fear of needles, cost and ignorance.10

At my 500-plus bed pediatric acute-care facility with an average of 5,600 employees, immunization rates have continued to increase slightly over the past three years following many interventions to increase compliance rates. Employees are required to view informational influenza videos prior to the flu season that are aired regularly on the hospital learning channel or can be viewed on the hospital intranet. Beginning in late September or early October, depending on vaccine availability, employee health nurses (EHN) staff the traveling immunization carts throughout the hospital, clinics, and other employee congregating areas, including the lobby area of the parking garage. Vaccinations are offered at varying times of the day and night for several weeks, making the vaccine available to all staff, volunteers, students, and physicians. After that time, vaccinations continue to be available through Employee Health. At the same time, the EHNs provide one-on-one education about the safety and efficacy of the vaccine and administer the vaccine or have the employee sign a declination, with the understanding that in the event they change their mind, the immunizations are available to them. Each year interventions to increase compliance at our facility are identified following assessment of the prior years’ immunization rates and employee surveys. 

Annual influenza immunization with informed declination for all HCWs is supported by many professional organizations, including the American Medical Association, the U.S. Department of Defense, the Society of Hospital Epidemiologists, the Infectious Diseases Society of America and the American College of Physicians, in addition to the groups identified earlier in this paper.11

Although a systematic review of the literature concludes there is no high level of evidence to support that immunizing HCWs for influenza will reduce the incidence of influenza in hospitalized patients, it is the right thing to do. Therefore, should a fragile, premature infant be cared for by a HCW who made an informed decision to decline an influenza immunization and came to work ill?

Kathy Ware, RN, CIC, has served as a nurse for the last 35 years and has worked in infection control for the past 11 years, certified for nine years. She is one of three infection prevention coordinators at Texas Children’s Hospital (TCH) in Houston, Texas. She is active in the APIC Houston Chapter 006, currently serving as past-president. She is enrolled at UTMB in Galveston and will complete the RN-BSN program in August 2009.


1. Goldstein A, Kincade J, Gamble G and Bearman R. Policies and practices for improving influenza immunization rates among healthcare workers. Infect Control Hosp Epidem. 25(11),908-911. 2004.

2. Dash G, Fauerbach L, Pfeiffer J, Soule B, Bartley J, Barnard B, Lundstrom T and Andrus M. APIC position paper: improving healthcare worker influenza immunization rates. Am J Infect Control. 32(3), 123-125. 2004.

3. CDC, 2006.

4. Carman W, Elder A, Wallace L, McAulay K, Walker A, Murray G and Stott D. (2000). Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomized trial. The Lancet. 35, 93-97. 2000. Retrieved Feb. 2, 2009 from PubMed.

5. Ablah E, Konda K, Tinius A, Long R, Vernie G and Burbach C. Influenza vaccine coverage and presenteeism in Sedgwick County, Kansas. Am J Infect Control. 36(8), 588-591. 2008.

6. Bridges C , Kuehnert M and Hall C. Transmission of influenza: implications for control in healthcare settings. Healthcare Epidem. 37, 1094-1101. 2003.

7. Pearson M, Bridges C and Harper S. Healthcare Infection Control Practices Advisory Committee and the Advisory Committee on Immunization Practices. Influenza vaccination of healthcare personnel. MMWR. 55(RR02), 1-16. 2006.

8. Joint Commission Resources. Meeting the Joint Commission’s infection prevention and control requirements (2nd ed.), Oak Brook, Ill. 2009.

9. Jadin S, Kloth G, Ehlert S and Qutaishat S. Barriers to receiving the influenza vaccine by healthcare workers in a rehabilitation facility. Am J Infect Control. 35(5), E166-E167. 2007.

10. Norwalk M, Lin C, Zimmerman R, Fox D, Raymund M, Tanis M, Harper J and Willis B. Self-reporting influenza vaccination rates among healthcare workers in a large health system. Am J Infect Control. 36(8), 574-581. 2008.

11. Tucker S, Poland G and Jacobson R. Requiring influenza vaccination for healthcare workers. Am J Nurs. 108(2), 32-34. 2008. Retrieved Feb. 5, 2009 from PubMed.

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