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Universal Flu Vaccination of Healthcare Personnel: A Patient Safety Issue

By Amesh A. Adalja, MD, October 22, 2010

Despite the well established risk from nosocomial transmission of influenza virus, only 37% of healthcare personnel (HCP) received the 2009 H1N1 influenza vaccine—a percentage that is much lower than is typical for seasonal flu vaccine (62%) and much lower than HHS goals for hospitals.1

The problem of nosocomial influenza transmission and HCP vaccination has been given high priority, as evidenced by the support of SHEA and IDSA—2 of the nation’s premier societies for infectious disease and infection control practitioners—as well as the American Academy of Pediatrics and the National Patient Safety Foundation.2,3,4

Action Plan to Improve Compliance Among HCPs

HCP failure to get vaccinated has been attributed to a host of factors, including the following:1

  • Underestimation of the risk of influenza

  • Underestimation of the effectiveness of the vaccine

  • Inconvenient administration times

  • Overestimation of vaccine side effects

To address this issue, the U.S. Department of Health and Human Services (HHS) developed an action plan to prevent healthcare-associated infections, HHS Action Plan to Prevent Healthcare-Associated Infections: Influenza Vaccination of Healthcare Personnel and assembled a multiagency work group that will focus on the following 3 tasks:

  1. Develop, synthesize and/or enhance evidence and tools for improving influenza vaccination of HCP.
  2. Enroll stakeholders in the initiative.
  3. Enhance and/or develop quality standards for influenza vaccination of HCP

Center for Biosecurity Recommendations

The Center for Biosecurity supports the important and achievable goal of 100% vaccination of HCP. The low rate of influenza vaccination is a serious problem, especially since, as the HHS work group notes, many influenza infections may be subclinical but still contagious. We offered several suggestions regarding the first 2 work group tasks noted above.  

1. Apply lessons learned from managing other HCP-related infectious diseases to develop, synthesize, and/or enhance evidence and tools for improving influenza vaccination of HCP.

It has been well established that HCPs do not consider influenza infection dangerous, particularly in comparison with pathogens such as hepatitis B, for which vaccination is required by OSHA. The perceived absence of personal danger may decrease compliance. However, it has also been well established that unvaccinated HCPs pose a danger to patients and to other HCPs. Since compliance has been shown to be increased when professional responsibility is emphasized, the following approaches should be considered:  

  • Educational efforts specifically targeted to increase HCP awareness of the risks of nosocomial infection, the effectiveness of influenza vaccine in preventing illness, and the professional responsibility to prevent HCP influenza infections
  • Assessment of policies and procedures that have proven to be effective in reducing nosocomial spread of other pathogens—eg, furlough of HCPs who are colonized/infected with methicillin-resistant Staphylococcus aureus (MRSA)—to determine their applicability in efforts to increase influenza vaccination
  • Tracking and reporting compliance with influenza vaccination in a manner similar to that employed for TB testing—eg, employee health administration of TB testing—and reporting noncompliance to department heads
  • Required use of surgical masks during flu season, especially for nonvaccinated HCPs

2. Patient safety advocates should be included among stakeholders engaged in HCP influenza vaccination initiatives, and they should be empowered to inquire about HCP vaccination status.

Task B involves engaging such stakeholders as medical and nursing societies in influenza vaccination efforts. Patient ombudsmen should be considered stakeholders as well. Their presence would emphasize the patient safety aspect of HCP influenza vaccination. It would provide further encouragement for HCPs to get vaccinated to avoid placing patients at risk of nosocomial infection. 

3. Adopt campaigns similar to those used to encourage hand washing.

When hospitals conduct hand-washing campaigns, they encourage patients to ask HCPs attending to them if they have washed their hands. During influenza season, patients could also be encouraged to ask HCPs if they’ve had their flu shots. Such a strategy would, again, reinforce the patient safety aspect of vaccination and emphasize professional responsibility to protect patients through vaccination.

HCP Vaccination Rates Must Be Improved

The efforts of HHS, in conjunction with the statements of SHEA, IDSA, AAP, and NPSF, will hopefully provide an impetus for HCP to become vaccinated and identify any shortcomings in vaccination strategies that warrant rectification. Full vaccination of the healthcare workforce is essential for patient safety and workforce resilience.


  1. U.S. Department of Health and Human Services. HHS Action Plan to Prevent Healthcare-Associated Infections: Influenza Vaccination of Healthcare Personnel. Accessed October 19, 2010.

  2. Talbot TR, Babcock H, Caplan AL, et al. Revised SHEA Position Paper: Influenza Vaccination of Healthcare Personnel. Infect Control Hosp Epidemiol. 2010;31:987–995. Accessed October 19, 2010.

  3. American Academy of Pediatrics. Policy Statement—Recommendation for Mandatory Influenza Immunization of All Health Care Personnel. Pediatrics 2010. Accessed October 19, 2010.

  4. National Patient Safety Foundation. National Patient Safety Foundation Supports Mandatory Flu Vaccinations for Healthcare Workers. Accessed October 19, 2010.