Mandatory Flu Vaccination of Healthcare Workers: A Patient Safety Imperative

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Despite knowing that vaccination is a patient-safety imperative, many healthcare professionals are not immunized against influenza. Healthcare institutions are trying to change that by mandating vaccination for its workers, and one of the biggest success stories has been unfolding for the last five years at Virginia Mason Medical Center (VMMC), a tertiary-care, multi-specialty medical center in Seattle with 5,000 employees.

By Kelly M. Pyrek

Despite knowing that vaccination is a patient-safety imperative, many healthcare professionals are not immunized against influenza. Healthcare institutions are trying to change that by mandating vaccination for its workers, and one of the biggest success stories has been unfolding for the last five years at Virginia Mason Medical Center (VMMC), a tertiary-care, multi-specialty medical center in Seattle with 5,000 employees.

Virginia Mason achieved and sustained influenza vaccination of more than 98 percent of its healthcare workers, a feat written up in the September issue of the journal Infection Control and Hospital Epidemiology by Robert Rakita, MD; Beverly Hagar, BSN, COHNS; Patricia Crome, MN; and Joyce Lammert, MD, PhD. Rakita, et al. (2010) report on their five year study (from 2005 to 2010) at VMMC, in which all healthcare workers were required to receive influenza vaccination; those who were accommodated for medical or religious reasons were required to wear a mask at work during influenza season.

In the first year of the program, 4,588 of 4,703 healthcare workers (97.6 percent) were vaccinated, and influenza vaccination rates of more than 98 percent were sustained over the subsequent four years of the study. Not only were all employees of the medical center required to receive the influenza vaccine, in addition, other individuals such as students, vendors, volunteers, contractors and outside physicians, were also required to be vaccinated. Less than 0.7 percent of healthcare workers were granted the aforementioned accommodation and less than 0.2 percent refused vaccination and left the medical center.

Although this vaccination rate seems extraordinary, Lammert, chief of medicine and also the main physician sponsor of the VMMCs vaccination program, says nothing less would have sufficed. Once we decided that we were going to require mandatory vaccination, we werent aiming for anything other than as close to 100 percent as possible, Lammert emphasizes.

The impetus for the vaccination mandate evolved from conversations during a workshop that was held to increase influenza vaccination rates at VMMC. One of our healthcare workers had been reading the literature and said she didnt understand why we dont require immunization for influenza, Lammert says. As we started to think about it, we said, We dont understand it either. So we brought the issue before our community board, comprised of non-medical members of the community and they were surprised that the national immunization rates were so low. They supported mandatory vaccination from the beginning because they felt it was the right thing to do to protect our patients. Strong support of the mandatory vaccination program also came from the medical centers senior leadership, and so a  multi-disciplinary task force including representatives from infection prevention and control -- was assembled to lead the influenza vaccination campaign during the first year of implementation.


Understanding barriers to vaccination and then addressing them in an educational, non-threatening way was critical to the success of VMMCs program. As Rakita, et al. (2010) point out, Multiple reasons exist for healthcare worker resistance to influenza vaccination, including cost, inconvenience, and fear of needles. Some of the more common bits of misinformation associated with influenza vaccine include a belief that one can get influenza from the vaccine, an assumption that flu is a mild illness, and a fear of adverse effects associated with the vaccine. Educational effortswhich explain that the injectable vaccine contains a killed virus and therefore cannot cause influenza, that illness due to influenza may be severe and even fatal, and that adverse effects due to the vaccine are typically mild and (other than a sore arm) are no different than those seen with placebo are useful but still have not led to a dramatic increase in vaccination rates.

The researchers say that VMMC managers and staff collected data on these barriers, educational deficits and preferences in receiving information about vaccination, and then in the spring of 2005, a comprehensive educational program was rolled out, including an informational Web site with links to outside sources of information (such as from the CDC), an online learning module, as well as meetings with staff and leadership who functioned as  champions of influenza vaccination, including VMMCs president and CEO. To boost the fun quotient of the immunization program, the researchers report that flu quizzes offered the chance to win prizes; other activities included a vaccination kickoff party with food, games, and members of the local professional football team attending; and an influenza video created by staff members with personal stories. In subsequent years, during the annual fall kickoff party, approximately 20 percent of employees were vaccinated.

The researchers say that creative approaches, such as a mobile flu cart and a drive through vaccination station, were successful in achieving program goals. It was important for us to work with the staff to better understand what their fears and concerns were, Lammert says. We spent a lot of time conducting staff forums and helping them understand why we thought vaccination was important and connecting the dots between our immunization efforts and patient safety mandates. Lammert adds, Its certainly important to think outside of the box to understand what the barriers are and to address them in any way possible. The drive-through immunization effort was helpful, as were the different types of partnerships we created the one with the Seattle Seahawks worked particularly well -- they actually require their players to get immunized. Creative partnerships, engaging the staff, and finding new ways of administering the vaccine definitely contributed to the vaccination compliance rates we achieved.

The difference before and after the start of the mandatory vaccination program are significant, other than a hiccup during the 2005-2006 flu season when vaccination rates dropped to 29.5 percent due to a national vaccine shortage. Rakita, et al. (2010) report that during the 2003-2004 influenza season, 54 percent of employees at VMMC were vaccinated with influenza vaccine; following the 2005-2006 season, the influenza vaccination rate increased to 97.6 percent. The vaccination rate increased slightly during the subsequent influenza seasons, up to 98.9 percent for the 2009-2010 season. As the program unfolded, the researchers report a more efficient vaccination program; for example, at the 2008 kickoff party, 1,010 employees were vaccinated during a three hour period.

Healthcare institutions, keeping in mind that the average healthcare vaccination rate is about 40 percent to 45 percent, are watching the move toward mandatory immunization very closely. Last year, the state of New York was the first to attempt mandatory influenza vaccination for healthcare workers but later rescinded this mandate due to a vaccine shortage triggered by the H1N1 influenza pandemic. The New York law was also challenged by unions, a situation familiar to VMMC when its policy was challenged by the Washington State Nurses Association (WSNA). The WSNA filed a grievance on behalf of the centers unionized nurses and an arbitrator agreed that the vaccination mandate should have been negotiated as part of the union's bargaining agreement with Virginia Mason; that decision was upheld on appeal.

Despite this legal decision, Rakita, et al. (2010) report that 515 (85.9 percent) of the 599 unionized inpatient nurses elected to be vaccinated in 2005-2006, increasing to 595 (95.8 percent) of 621 unionized inpatient nurses in 2009-2010. A handful of healthcare workers refused to be vaccinated; five left the medical center voluntarily while two were terminated during the 2005-2006 influenza season. Since then, the researchers report, just two more healthcare workers have left as a result of the vaccination mandate.

The WSNA had also asserted that the requirement for non-vaccinated healthcare workers to wear masks during the influenza season constituted an unfair labor practice; the researchers report that an administrative law judge ruled that it was permissible to require unionized healthcare workers to wear a mask as part of an infection control policy. This ruling is currently pending appeal at the National Labor Relations Board.

A discussion about the rights of the individual versus the rights of the patient was something Virginia Mason Medical Center welcomed the WSNA to have, and Lammert says it becomes a very simple issue when everyone at a healthcare institution understands why they are there and to whom they have an obligation. If you consider that we are here for our patients and that patient safety is paramount, it makes the discussion a lot easier, and it makes the right thing to do much clearer, she says. Its important to note that the WSNAs objection was not that their nurses shouldnt be immunized but that it should be something that was negotiated through their contract. The nurses in general believe they should get immunized and the first year 86 percent did, and last year 96 percent did. We are hoping that blocking implementation by unions is not going to be inevitable.

Absent union negotiations and legal challenges, healthcare institutions also could be challenged by resources and funding in their quest to replicate VMMCs success.  As Rakita, et al. (2010) note, A significant amount of human and financial resources are required for this effort, including employee time and cost of vaccine and supplies. The researchers report that the vaccination program required more than 500 hours of nursing and medical assistant time alone, and that the facility spent approximately $70,000 for the approximately 6,000 doses of influenza vaccine needed.

Its an undertaking that Lammert says she wishes all facilities will attempt. We really hope that the work we have done will help inspire other people to see that it is possible to drive compliance rates upward and that it is something they can do too, Lammert says. Most healthcare institutions already have some sort of immunization program, and I think almost any size facility can raise their vaccination rates because they are already going through the motions of administering vaccinations. The bottom line is, dare to do it. The first year there were some challenges and barriers but the second year was much easier and now its just something that everyone in our organization assumes we will be doing each fall. Last year we did both seasonal and H1N1 immunization so it was double the work and it was amazingly smooth.

Lammert continues, The No. 1 thing is having the support of institutional leadership in our organization we began at the top with our CEO saying, This is really important for our patients, and turning it upside down its not about the staff, its about the patients. When you change the conversation to placing focus on the patients I think that makes a significant difference. When you talk about safety you develop a mindset, a culture that safety is a benefit both to patients and to staff, as the two groups are absolutely connected.

Among those lauding VMMC for its efforts are Thomas Talbot, MD, MPH, and William Schaffner, MD, from the Departments of Medicine and Preventive Medicine at Vanderbilt University School of Medicine in Nashville, Tenn., who write in an editorial, This forthright and novel decision by VMMC leaders and vaccination program champions to emphatically emphasize the importance of influenza vaccination of healthcare workers has opened the door to a new approach to increasing patient safety as well as healthcare worker protection. Talbot and Schaffner (2010) add, With the growing interest in implementing similar programs, the healthcare worker influenza vaccination program, after years of extensive efforts that resulted in only a modest increase in coverage, now may follow the effective course taken by childhood vaccination programs and school entry requirements. Low healthcare worker influenza vaccination rates can no longer be tolerated, because our patients and our coworkers are at risk. Combining a mandatory healthcare worker influenza vaccination policy with a multifaceted infection control program -- which includes early identification of infected patients, source control, use of isolation precautions and personal protective equipment, restriction of ill healthcare workers and visitors, and other environmental controls -- can reduce transmission of influenza in healthcare settings and represents a new model of influenza infection control. For effectively implementing a mandatory healthcare worker influenza vaccination program, we can applaud the role that VMMC has played in pioneering another important infection control first.

As Talbot and Schaffner (2010) allude in their editorial, numerous healthcare systems healthcare institutions in the United States have followed VMMCs lead, and that Arguably, many of these organizations would not have taken this step if they had not had the successful example of VMMC to emulate.

As the Vanderbilt folks pointed out, several large organizations have followed our lead and in fact 203 institutions required flu immunization last year, Lammert says. I am hoping it will be much higher this year. Even in a mild flu year, 36,000 people in the U.S. die from influenza, and globally half a million people die, so in a non-pandemic year it is still a huge public health problem. Its so important to continue to raise peoples awareness about flu mortality.

Professional societies pushing for mandatory vaccination of healthcare workers include the Society for Healthcare Epidemiology of America (SHEA), which provided comment to the Department of Health and Human Services (HHS) on its Updated Guidance: Prevention Strategies for Seasonal Influenza in Healthcare Settings. In a letter to the HHS, SHEA wrote, Regardless of precautions applied in the prevention of influenza transmission, the best preventive measure is use of a safe and effective influenza vaccine. The importance of annual vaccination is stated, but only in terms of achieving high rates and improved levels of coverage. Now would be an appropriate time for a direct and unequivocal statement that every healthcare professional without a valid medical contraindication to receiving influenza vaccine should receive an annual vaccination; if not as a mandate, then as a professional obligation not dissimilar to the responsibility to apply hand hygiene and the other standard measures recommended in this guidance to prevent influenza. The letter adds, SHEA views influenza vaccination of healthcare professionals as a core patient and healthcare professional safety practice with which non-compliance should not be tolerated. The Society believes that it is the professional and ethical responsibility of healthcare professionals and the institutions within which they work to prevent the spread of infectious pathogens to their patients through evidence-based infection prevention practices including influenza vaccination. SHEA endorses a policy in which annual influenza vaccination is a condition of both initial and continued healthcare professional employment and/or professional privileges for the safety of both patients and healthcare professionals.


Rakita RM, Hagar BA, Crome P and Lammert JK. Mandatory influenza vaccination of healthcare workers: A 5 year study. Infect Control Hosp Epidemiol. 2010;31:881-888.

Talbot TR, Schaffner W. On being first: Virginia Mason Medical Center and mandatory influenza vaccination of healthcare workers. Infect Control Hosp Epidemiol. 2010 Sep;31(9).