Toolkit for Healthcare Administrators
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Healthcare workers are at risk for exposure to serious, and sometimes deadly, diseases. They can also be a key cause of outbreaks in a variety of settings including hospitals, medical practice offices, long-term care facilities, rehabilitation offices, and home-care. The CDC estimates that in the United States, each year on average 5% to 20% of the population contracts the flu, and more than 200,000 people are hospitalized from seasonal flu-related complications. Over a period of 30 years, between 1976 and 2006, estimates of flu-associated deaths in the United States range from a low of about 3,000 to a high of about 49,000 people.
According to the CDC the overall healthcare worker influenza vaccination coverage estimate for the 2014-2015 season was 77.3%, an increase of 13.8 percentage points compared with the 2010-2011 season estimate, but similar to the 75.2% coverage estimate reported in 2013-2014. Coverage in 2014-2015 was higher among healthcare personnel whose employers required vaccination (96.0%), compared to those whose employer did not have a policy or recommendation regarding flu vaccination (44.0%).
Healthcare personnel have frequent contacts with high-risk patients, and they can serve as a vehicle to transmit influenza even when they do not have symptoms. Up to 25% of healthcare workers with the flu may have minimal or no symptoms, yet can still transmit infection. Those with influenza-like symptoms work an average of 2.5 days while ill, and those infected with influenza can transmit the virus to others even before their symptoms begin.
Additionally, their absenteeism can stress a healthcare facility or system. Research shows that influenza vaccination of healthcare personnel decreases patient mortality by 40% to 50%, risk of nosocomial infection by 43% and absenteeism by 20% to 30% while limiting the risk of bringing illness acquired at work home to family members.
All staff members working directly with patients or handling material that could spread infection should get appropriate vaccines to reduce the chance they will spread disease.
When influenza infects patients, the illness can be severe, and even deadly. However, many healthcare workers still do not get the flu vaccine. While rates have improved, they remain below the national Healthy People 2020 target of 90%.
The average rates of influenza immunization in New Jersey hospitals are among the lowest in the nation. For the 2013–2014 season that ended March 31, 2014, only 59% of eligible healthcare workers in New Jersey hospitals were vaccinated.
In a CDC Internet survey of healthcare workers who said they would not be vaccinated in November 2014, 20.8% said the vaccine doesn’t work, 16.6% said they didn’t need it, 13.3% said they might get sick from it, and 6.5% thought the ingredients “are not good for you. “
The Joint Commission points to the wide variety of reasons identified by medical literature why healthcare personnel accept or decline influenza vaccinations. Among them are the following:
Reasons Healthcare Personnel Accept the Influenza Vaccination Reasons Healthcare Personnel Decline the Influenza Vaccination Desire for self-protection Fear of getting influenza/influenza-like illness Desire to protect patients Fear of vaccine side effects Desire to protect family members Perceived ineffectiveness of the vaccine Previous receipt of influenza vaccine Perceived low or no likelihood of developing influenza Perceived effectiveness of the vaccine Fear of needles Desire to avoid missing work Insufficient time, inconvenience, or forgetting to get the vaccination Peer recommendation Reliance on homeopathic medications Personal physician recommendation Belief that their own host defenses would prevent influenza Strong worksite recommendation Belief that other preventative measures would minimize or eliminate influenza risk Had influenza previously Lack of physician recommendation Belief that receiving the vaccine is a professional responsibility Belief that influenza is not a severe disease Access to the vaccination/convenience Lack of free vaccinations Vaccination provided free of charge Younger age Belief that benefit of the vaccination outweighs the risk of side effects
Source: Joint Commission on Accreditation of Healthcare Organizations. Providing a Safer Environment for Health Care Personnel and Patients Through Influenza Vaccination
The U.S. Department of Health and Human Resources’ Healthy People 2020 initiative aims to have a 90% vaccination rate of all healthcare workers by 2020. The Centers for Medicare and Medicaid Services will be deducting 2% of Medicare and Medicaid reimbursements to hospitals whose employee flu vaccination rates do not meet this goal.
Healthcare employers should adopt policies to provide a framework for influenza prevention strategies to protect employees and patients. These programs need buy-in from leadership, with particular emphasis on offering vaccinations at convenient times and at no cost for healthcare personnel, in tandem with educational resources and plans to alleviate language and cultural barriers
Influenza prevention should not be a stand-alone activity. It needs to be viewed as part of an overall infection control plan, and should include environmental and infection prevention measures as outlined in CDC’s Prevention Strategies for Seasonal Influenza in Health care Settings. An influenza infection prevention plan is the most effective method to protect healthcare personnel and their patients from influenza infection.
In addition to the information found in the CDC link above, the Department of Health and Human Services’ National Vaccine Advisory Committee has published a report Recommendations on Strategies to Achieve the Healthy People 2020 Annual Influenza Vaccine Coverage Goal for Health Care Personnel which highlights four main actions healthcare institutions can implement to achieve a 90% vaccination rate. Please see the full report for more detailed information.
- Education and Campaigns – Basic knowledge about influenza and influenza vaccination has been associated with vaccine receipt. Participation in structured in-service education or conferences has been associated with improved vaccination rates.
- Role Models – Vaccination of senior medical staff or opinion leaders has been associated with higher vaccination acceptance among staff.
- Improved Access – Removing administrative barriers and providing vaccine in locations and at times easily accessible by HCP can substantially improve vaccine acceptance.
- Measurement and Feedback – Posting of vaccination coverage levels in different areas of the hospital is a component of successful vaccination programs
Additional resources to help healthcare facilities reach a 90% vaccination rate:
- National Foundation for Infectious Diseases: Influenza Immunization of Healthcare Workers
- CDC MMWR Recommendations and Reports: Influenza Vaccination of Healthcare Personnel
- CDC Guidelines and Recommendations: Prevention Strategies for Seasonal Influenza in Healthcare Settings
- Healthleaders Media: 4 Tips for Raising Vaccination Rates Among Healthcare Workers
Preventing influenza spread between healthcare workers and patients should be an essential goal in the healthcare system. Attaining this goal will result in significant cost benefits as well. In a report published by the Center for Prevention and Health Services, there are a number action steps healthcare leaders can take that will improve their bottom line:
- Encourage Employees to get vaccinated
Getting employees vaccinated against the flu makes good business sense. Research shows it can lower direct and indirect employer costs.
- Offer opportunities to get vaccinated on-site
Workplace vaccination efforts are cost-saving for employers
- Audit health plans for consistent coverage for flu vaccine
Getting employees vaccinated against the flu should be a corporate health priority. Employers know what vaccination strategy works well for their organization.
In recent years, various forms of mandatory or semi-mandatory enforcement policies have been implemented in healthcare facilities to increase influenza immunization of healthcare workers, with varying degrees of success.
According to the Immunization Action Coalition, there are currently 588 institutions throughout the U.S. who have mandated influenza vaccination policies. There are six New Jersey hospitals and healthcare systems included in this group.
In a survey conducted by the CDC to collect information regarding the 2013-2014 flu season, about 75% of all healthcare workers surveyed in the country were estimated to have been vaccinated. However, in facilities where the policy was voluntary, vaccination rates in some places were below 50%.
According to Nursing World, successful voluntary programs that target staff vaccination have been implemented by various healthcare organizations. With improved education and vaccine accessibility, staff vaccination rates at the Mayo Clinic across four flu seasons (1999-2004) increased from a baseline of 53.6% to 75%, while the Minneapolis Veterans Affairs Medical Center improved their rates from a baseline of 25% in 1985 to 65% during the 2003-2004 flu season. Other institutions, too, have increased their HCW vaccination rates using a variety of strategies.
In New Jersey, a growing number of healthcare facilities require vaccinations of healthcare workers, but most still do not. The state and national hospital associations, as well as the American College of Physicians support flu vaccines for workers.
In addition to putting their patients at risk, many point to the harm that unvaccinated workers put themselves in. According to the American Public Health Association, up to 25% of unvaccinated health workers may be infected by influenza each year. Health workers themselves (and their family members) frequently have medical conditions that raise their risk for influenza morbidity and mortality. In addition, the aging of the healthcare workforce places an increasingly greater number and proportion of health workers in a higher-risk category.
Wearing a Mask:
For those who will not, or cannot get vaccinated for religious or medical reasons, many facilities require their healthcare personnel to wear a mask while in contact with patients or working in patient care areas during the annual influenza season.
New England Journal of Medicine
Mandatory Vaccination of Health Care Workers, Perspective
Clinical Infectious Diseases
Mandatory Influenza Vaccination of Health Care Workers: Translating Policy to Practice
American Hospital Association
AHA Endorses Patient Safety Policies Requiring Influenza Vaccination of Health Care Workers
American Public Health Association
Policy Statement: Annual Influenza Vaccination Requirements for Health Workers
Society for Healthcare Epidemiology of America (SHEA)
Position Paper: Influenza Vaccination of Healthcare Personnel
Mono County Health Department, CA
Mandatory Influenza Vaccine for Health Care Workers – Health Officer Order
Johns Hopkins Medicine
2015-2016 Mandatory Flu Vaccination Policy
- The ethics of mandatory vaccination against influenza for health care workers
- Vaccinating Health Care Workers Against Influenza: The Ethical and Legal Rationale for a Mandate
- The Ethics of Mandatory Vaccination Against Influenza for Health Care Workers
- The Evidence, Ethics and Politics of Mandatory Health Care Worker Vaccination
- An Ethical Analysis of Mandatory Influenza Vaccination of Health Care Personnel: Implementing Fairly and Balancing Benefits and Burdens
- State of Rhode Island
- MedStar (Baltimore and elsewhere)
- 38 of the 46 hospitals in Maryland (four more are adopting policies for 2013-2014)
- Virginia Mason, Seattle WA
- University of Pennsylvania, Philadelphia
- Barnes Jewish Christian Hospital-Washington University of St. Louis, MO
- Baptist Hospital-Wake Forest University, Winston Salem, NC
- Emory University-Atlanta, GA
- Creighton University, NE
- University of Iowa Hospital and Clinics
- Loyola University Hospital, Chicago
- Multiple HCA hospitals
- Most hospitals in Michigan, including University of Michigan and Michigan State
The CDC recommends the following healthcare workers should be vaccinated:
Physicians, nurses, emergency medical personnel, dental professionals and students, medical and nursing students, laboratory technicians, pharmacists, hospital volunteers, and administrative staff.
- Hepatitis B
- Influenza (Flu)
- MMR (Measels, Mumps & Rubella)
- Varicella (Chickenpox)
- Td or Tdap vaccine (tetanus, diphtheria, pertussis) – every ten years
- American Academy of Family Physicians
- American Academy of Pediatrics
- American College of Physicians
- American Hospital Association
- American Medical Directors Association
- American Pharmacists Association
- American Public Health Association
- Association for Professionals in Infection Control and Epidemiology
- Infectious Diseases Society of America
- National Foundation for Infectious Diseases
- National Patient Safety Foundation
- Society for Healthcare Epidemiology of America
First Do No Harm: Mandatory Influenza Vaccination Policies for Healthcare Personnel Help Protect Patients
Statements from leading healthcare organizations and related influenza resources to help you implement a mandatory influenza vaccination policy at your institution
Immunization of Healthcare Personnel: Recommendations of the ACIP
These recommendations can assist hospital administrators, infection-control practitioners, employee health clinicians, and HCP in optimizing infection prevention and control programs.
Influenza Vaccination of Healthcare Personnel: Recommendations of the HICPAC and ACIP
These recommendations are targeted at health-care facility administrators, infection-control professionals, and occupational health professionals responsible for influenza vaccination programs and influenza infection-control programs in their institutions.
General Recommendations on Immunizations: Recommendations of the ACIP
This report provides information for clinicians and other health-care providers about concerns that commonly arise when vaccinating persons of various ages.
ACIP Vaccine Recommendations
List of vaccine-specific recommendations.
Centers for Disease Control and Prevention (CDC): Flu Vaccination Pledge
Use this tool to have healthcare workers “take the pledge” to be vaccinated this season.
Declination of Influenza Vaccination
Use this form from the Immunization Action Coalition to document healthcare worker refusal to receive vaccination for reasons other than a medical contraindication.
Providing a Safer Environment for Health Care Personnel and Patients Through Influenza Vaccination
This publication by the Joint Commission helps health care organizations of all types improve seasonal influenza vaccination rates in health care personnel.
Seasonal Influenza Resources for Health Care Professionals
Published by the Centers for Medicare & Medicaid Services, this MLN Matters publication gives health care professionals info to order, refer or provide seasonal flu vaccines and vaccine administration to Medicare beneficiaries.
Poster – I Won’t Spread Flu to My Patients or My Family
Instruct your IT staff to place this button on your website, and copy the code displayed, so your healthcare workers can immediately connect to the CDC’s vaccination information.
Vaccine-Preventable Diseases – Roll Up Your Sleeves
CDC Expert Commentary by William Schaffner, MD
ACIP 2015 Adult Immunization Schedule
Dr. Sandra Fryhofer discusses the 2015 Advisory Committee on Immunization Practices (ACIP) adult immunization schedule