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Seasonal influenza affects 5% to 15% of the world’s population annually, with severe illness occurring in 3-5 million people, resulting in death for 250,000-500,000 annually (WHO, 2010). Reluctance among healthcare workers (HCWs) toward receiving the influenza vaccination continues to hamper efforts to ensure that HCWs are vaccinated annually as a patient safety measure. According to the Centers for Disease Control and Prevention (CDC), rates of annual HCW influenza vaccination coverage in the US reached only 44% and 49% during the 2006-07 and 2007-08 flu seasons respectively (CDC, 2010). In Europe, the coverage rate has been even lower at less than 25% (Burls, 2006). Slow progression in achieving adequate voluntary vaccination coverage rates, has resulted in a movement toward mandating annual influenza vaccination of HCWs in the US.

This article presents rationale both in favor and in caution of mandating annual HCW influenza vaccination. Literature findings are presented relative to HCW attitudes and behaviors toward receiving the annual influenza vaccine in North America and in Europe. The author’s position on the topic follows. For the purpose of this article HCWs are defined as formally trained persons who provide direct patient care in hospital, long-term care, home health, or clinic settings.

History and the future: Influenza epidemics

Increasingly, the impact of seasonal and novel, (for example, H1N1) influenza commands the attention of ministries and departments of health spanning the globe. The most widely publicized pandemics of the 20th century are referred to in terms of their alleged locations of origin: the Spanish flu of 1918, Asian flu of 1957, and Hong Kong flu 1968 (Kilbourne, 2006). Progressive globalization may set the stage for more frequent and severe future epidemics and pandemics. Birn, Pillay, and Holtz, 2009, note that the progression of globalization has evolved more rapidly over recent decades than ever before. Technology and neo-liberalism have opened lines of commerce between countries, progressing at greater speed than ever before imaginable, much less possible. Geography, national boundaries, time and distance no longer inhibit the movement of goods, services and people (Birn et al., 2009, p. 418). However what is lauded by supporters of globalization and neo-liberal philosophy as progress in the state of world trade is not achieved without consequence. Rapid and constant movement of goods, services, and people translates to rapid and constant movement of pathogenic organisms within and between countries, including, but not limited to, the influenza viruses.

The issue relative to global health

Should individual HCWs in the US and other nations be mandated to receive annual influenza vaccinations as a condition of employment in the interest of patient safety? There are two operational categories of mandate: 1) mandate for healthcare facilities to provide educational programs and access to influenza vaccinations for employees and 2) mandate for individual HCWs (without a medical contraindication), to receive the influenza vaccination as a condition of employment. The issue presented in this article relates to the latter definition.

A growing number of organizations support mandating influenza vaccination of HCWs in the US including: The Immunization Action Coalition, American Association of Pediatrics, American College of Physicians, Infectious Diseases Society of America, National Foundation for Infectious Diseases, National Patient Safety Foundation, Society for Healthcare Epidemiology of America, plus over 80 healthcare organizations in the US which currently mandate annual employee influenza vaccination (Immunization Action Coalition, 2010). The American Nurses Association’s position suggests a framework for mandatory vaccination policies, including that they be made at the state level, are part of comprehensive influenza infection control programs, contain suitable exemptions, and are non-discriminatory (American Nurses Association, 2010).

Literature findings did not indicate that Canada or European countries currently mandate individual HCWs to receive the influenza vaccination. For example, although frequent use of the word “should” pertaining to HCW influenza vaccination is noted in the Guide to Control of Respiratory Outbreaks in Long Term Care Homes published by the Ministry of Health, Ontario, Canada (2004), there is no actual mandate specified in the language of the document. In Germany, influenza vaccination is not mandated; less than 1/3 of HCW choose to be vaccinated (Wicker et al., 2009).

Residual considerations linked to a behavioral mandate include respect for autonomy and rights of individuals to refuse this repeated annual treatment. The American College of Occupational and Environmental Medicine (ACOEM), The Joint Commission, and the CDC advocate for mandating institutional programs rather than individual HCW annual vaccination (Sullivan, 2010 and Hill, 2006). Looijman-van den Akker (2009) surveyed 185 Dutch nursing home (NH) administrators to elicit their views on mandating annual influenza vaccination as a condition of employment for all NH HCWs. Although the influenza vaccination rate among NH HCWs averaged just 18.8% (in contrast to 91.6% of Dutch NH residents), only 24.3% of the NH administrators supported mandating the vaccination if voluntary acceptance did not reach acceptable levels. Exploration of the literature to discover what motivates and de-motivates HCWs to receive annual influenza vaccinations revealed a number of trends as well as some differences. Table 1 (please click the PDF icon above to view) summarizes findings of nine studies and literature reviews in North America and Europe.

Vaccination uptake is suboptimal in all world regions examined. Fear of side effects, perceived lack of personal risk, belief that influenza is not serious and doubts of vaccine efficacy were noted to be prominent de-motivators (Hoffman et al., 2006; Canning et al., 2005; Fernandez, 2009; Dedoukou et al., 2010; Smedley et al., 2007; Wicker et al., 2009; Toy et al., 2005). Self-protection and social identity with a professional group are motivators. Differences were noted between influenza vaccination behavior of nurses and that of physician. Physicians were more likely to receive annual influenza vaccination (Hoffman et al, 2006; Fernandez et al, 2009). Knowledge retention following influenza vaccination campaign education was often noted to be sub-optimal, translating to less likelihood of HCWs recommending and offering vaccination to patients (Toy et al., 2005 and Fernandez et al., 2009).

Rationale to support and refute mandatory influenza vaccination of HCWs

The aura of intensifying urgency to improve HCW influenza vaccination uptake stems not solely from the known impact of past epidemics and pandemics, but is due also to awareness of how rampantly the influenza virus can spread in the current global environment, uninhibited by humanly defined national borders. Herd immunity principles support the importance of annual HCW influenza immunization in the interest of patient safety (Crislip 2009, American Academy of Pediatrics, 2010). The director of the Center for Bioethics at the University of Pennsylvania has declared that with close to 100% of HCW influenza vaccination coverage, flu-related patient death rates can be reduced by 40% (Immunization Action Coalition, 2010). From these perspectives, in light of consistent suboptimal voluntary HCW vaccination uptake, one might argue in favor of mandating annual influenza vaccination as the most logical remaining option to achieve appropriate coverage.

In contrast, authors of a Cochrane analysis concluded that there is not sufficient evidence to support that vaccination of HCWs offers significant protection to the elderly patients they care for in long-term care facilities (Thomas, Jefferson & Lasserson, 2010). Similarly, the ACOEM position statement notes discrepancies in studies of patient benefits from HCW influenza vaccination (ACOEM, 2010). Some US healthcare facilities (and one state) have mandated annual influenza vaccination as a condition of employment with varying degrees of success. The Virginia Mason Medical Center in Seattle WA and the Mayo Clinic in Rochester, MN have achieved sustained relative success in their approaches (Hagar, 2010 and Talbot, 2008), whereas in 2009, efforts of the New York State Department of Health met with robust opposition followed by a coincidental abrupt halt to the mandate (Chan & Hartocollis, 2009).

Those in opposition to a vaccination mandate may argue that requiring vaccination as a condition of employment in the current “rights-awareness” environment may induce deleterious carry-over effects that work against alleviating the underlying drivers of HCW vaccination-avoidance behavior. Mandating vaccinations can unintentionally promulgate negative attitudes, resistance, and dissatisfaction among HCW who may perceive they are being coerced into choosing between receiving the annual vaccination and losing their livelihood.

Attitudes of HCWs toward influenza vaccination requirements influence their practice (Fernandez, et al., 2009 and Maurer, et al., 2009). A HCW who harbors resentment about having received a mandated annual influenza vaccination, may not be as motivated to prioritize education and vaccination of patients. Healthcare workers are generally trusted by those they care for. The 2010 Gallup Poll revealed that since 1999 nurses have topped the list for honesty and ethics in America annually except in 2001 when firefighters topped the list (Jones, 2010). Worldwide, nurses engage in the most frequent direct contact with patients. The attitudes, beliefs and personal health care choices of nurses can influence their patient education practices and clinical prioritization relative to the immunization of patients (Fernandez et al., 2009). As trusted professionals, nurses and other health disciplines influence the perceptions, behaviors and choices of patients relative to receiving annual influenza vaccinations (Maurer et al., 2009).

Recommendations

Although mandating annual influenza vaccinations for HCWs may be viewed as a necessary and effective means to bridge an urgent patient safety gap, a theory-based composite approach seems more logical for success in the long term. The literature indicates that many HCWs who decide to be vaccinated against influenza do so mainly for self-protection, rather than patient protection, even when they express an understanding of how immunity benefits patients (Smedley et al, 2007; Dedoukou et al., 2010). Despite a common thread of self-preservation as a motivating factor, persistent sub-optimal levels of annual influenza vaccination coverage among HCWs suggest there may be a critical explanatory link missing from the chain.

There may yet be untapped potential to effectively address this issue by engaging a perspective of inspiring HCWs through effectively designed, theory-based influenza vaccination programs targeting specific identified learning needs and learning audience cultures. The success attained by certain healthcare systems in the improvement of annual influenza vaccination coverage rates indicates that HCW populations can and do respond favorably to customized approaches.

A decision to mandate annual influenza vaccinations for HCWs as a condition of employment (otherwise and typically a free personal choice) calls for a heightened sensitivity on the front end, to the potential ramifications. Unintended negative consequences may emerge, stemming from evoked attitudinal reactions among HCWs who openly or covertly harbor feelings of resentment and resistance (Falomir-Pichastor, 2009). This in turn may carry over to practice, impacting patients who should be educated and offered annual influenza vaccination. Ironically, what appears to be success may inadvertently hinder patient vaccination coverage. A chain of events of this nature is less effectively remedied than prevented.

Deeper exploration of behavioral research theory and knowledge, leading to evidence-based, non-traditional annual influenza vaccination programs, may serve as the hinge to vaccination coverage improvement and deliverance from the perceived necessity to mandate annual HCW vaccinations. Retention of accurate imparted knowledge is a critical link to assimilation, translating to behavior change. In a survey of RNs (N = 500) employed in a large hospital who indicated they had received influenza-related education, fewer than 10% were able to respond correctly to basic influenza fact-recall survey questions (Talbot, 2008).

Comprehensive patient-safety-oriented influenza vaccination promotion programs, creatively designed with scientific and theoretical foundations to address specific concerns and learning needs of distinct HCW target audiences of all disciplines, presented in a captivating manner that fully engages learners in cognitive, affective and psychomotor domains, has potential to generate voluntary intent with follow through vaccination acceptance behavior. Employee satisfaction relative to fulfilling a professional duty to keep patients safe as opposed to complying with a mandate may be a rewarding after-effect of this behavioral outcome.

Literature findings summarized in Table 1 reflect failure to retain, assimilate and translate influenza vaccination education into practice. The design and delivery platform chosen for vaccination programs and campaigns is paramount to success. Incorporating effective, unique elements of design into annual required educational activities rather than mandating the vaccination itself, is logically more amenable to
HCWs who are accustomed to ongoing requirements for education and training. Continuing education (CE) credit offered for completion of the learning activity can be an added benefit for HCWs whose licensure renewal requires it. With regard to the ultimate impact on patient outcomes, it also seems logical to appreciate how the achievement of voluntary willingness among HCWs to receive annual influenza vaccinations (vs. a mandate), corresponds with an attitude and mindset congruent with improved patient education practices and consequently fewer missed opportunities to vaccinate patients.

Maurer et al., 2009 examined the reasons why opportunities for patients to be vaccinated in hospitals were missed. Based on extrapolation of responses from patients studied who would not have opposed being vaccinated had they been educated and offered the vaccine while in the hospital, it was estimated that a 14.4 % increase in adult influenza vaccination could be attained based on improved rates of healthcare provider recommendation.

Toward improvement

Some suggestions for intervention development include:

• Continue research aimed to reveal influencing factors underlying influenza vaccination avoidance behavior among HCWs.
• Engage a theory-based approach toward understanding the predisposing antecedents to intentions and behavior in order to develop the most appropriate interventions targeting specific causal factors. For example, the Theory of Behavioral Prediction (Fishbein & Ajzen, 2010), also recognized as the Reasoned Action Approach, offers practical guidance to predict and explain HCW intent and behavior.
• Draw from exemplars of healthcare facilities with high influenza vaccination coverage rates to develop effective agenda, presentations, and roll outs for annual vaccination programs considering discipline, gender and generation-specific needs when developing strategies.
• Explore avenues of education presentation which although perhaps non-traditional in healthcare settings, may be more effective in reaching into the culture of today’s healthcare workforce in ways that facilitate knowledge retention and assimilation.

Implications and conclusion

The scope of implications relative to enhancing patient safety through mass vaccination of HCWs globally, reach beyond annual influenza vaccinations. Globalization ushered in over the 20th century, like a virtual petri dish, facilitates the emergence and re-emergence of many communicable diseases including but certainly not limited to influenza. For instance, even as this article was written, a pertussis outbreak in certain regions of the US has instigated a push for broad pertussis vaccination coverage among all age groups (especially HCWs) in order to contain it (Reinberg, 2010). Policy decisions addressing the influenza vaccination situation may serve as precedential points of reference by which HCWs gauge and form opinions about how future similar situations will affect them as individuals and employees.

Effective approaches to the containment and most importantly prevention of communicable disease outbreaks, epidemics and pandemics, require the cooperation of HCWs including the informed (and preferably voluntary) decision to be vaccinated as a professional duty. Well-designed patient safety programs built with audience-sensitive, meaningful, educational content, guided by a theoretical framework and presented via an attractive, interest-sustaining, interactive platform require time and resources on the front end. In light of the failure to achieve adequate vaccination rates over prior decades of attempts, this approach holds promising potential for a return on investment that will multiply back in the form of applicability to global public health threats above and beyond the current issue of inadequate HCW influenza vaccination coverage rates.

Carol Ann Tuttas is the director for standards and certification at Cross Country Staffing in Boca Raton, Florida. She is a full time PhD student in nursing science at the University of Miami, Coral Gables, Florida.

Selected references

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