If children are required by law to receive a number of vaccinations before they may enter school, to control the spread of infections, shouldn’t healthcare workers be required to receive annual influenza immunizations, to prevent their passing the flu along to patients?

The federal Centers for Disease Control and Prevention (CDC) called attention to that question February 9, when the CDC’s Advisory Committees on Immunization Practices and Healthcare Infection Control Practices joined to urge flu shots for all healthcare workers. The advisory committees stopped short of recommending compulsory vaccination, but they cautioned that with fewer than half of healthcare workers currently receiving flu shots, the scene is set for influenza outbreaks in hospitals and other sites in which providers come into contact with patients.

A few months earlier, the Society for Healthcare Epidemiology cited the same figures in a position paper, saying that despite repeated recommendations by the CDC since 1984, “the percent of healthcare workers vaccinated annually remains unacceptably low.”

The disease that vaccination may help to prevent is no small matter, the position paper points out. “Influenza infection causes an average of 36,000 excess deaths and nearly 226,000 excess hospitalizations annually in the United States alone.” The paper also notes that healthcare transmission of influenza has been documented in many different patient populations and clinical settings, including neonatal intensive care units, pediatric wards, infectious disease units, general medical wards, oncology units, and emergency departments, as well as outpatient facilities such as clinics and doctors’ offices.

There are ways to reduce the risk of healthcare-associated influenza—including adherence to universal respiratory hygiene/cough etiquette, use of rapid diagnostic tests for patients, prompt treatment, and antiviral medication–but “the cornerstone of efforts and the most effective measure to prevent healthcare-associated transmission of influenza is healthcare worker vaccination with an effective influenza vaccine.” In a list of 100 references, the position paper cites evidence that flu vaccination “reduces morbidity, antibiotic use, and absenteeism in healthy adults” and mortality in vulnerable populations such as the elderly.

So, if the Advisory Committee for Immunization Practices has been recommending annual flu vaccination since 1984, why are so many healthcare workers not immunized? The authors point out that studies have shown healthcare workers have varied concerns about flu shots, including the possibility of adverse effects (“shots give you the flu”), fear of injections, perceived lack of vaccine efficacy, busy schedules, inconvenience, failure of employers to cover the cost of vaccine, and opposition to vaccination in general. In addition, a surprising number of healthcare workers “do not recognize their role in the transmission of influenza to their patients.”

“They don’t realize that you can pass the infection for 24 hours before you develop symptoms and for four or five days afterward,” says Dr. William Schaffner, chairman of the department of preventive medicine at Vanderbilt University. And healthcare workers may not realize how easily flu is transmitted. Large infectious droplets can spead two or three feet with every cough, and the smallest droplets even further, and the virus can live on a doorknob for hours.

There is also the persistent belief that you can get the flu from a flu shot, which Schaffner calls “a myth.” “The injected vaccine is not a live virus. It can’t and won’t give you the flu.” He speculates that the misconception may persist because so many respiratory illnesses are around during every flu season, and many people may come down with some other bug just at the time they receive a flu shot, leading them to incorrectly see a connection between the vaccine and their illness.

What to Do

The Society for Healthcare Epidemiology says it is convinced that vaccination is effective in reducing influenza, and that it has been shown that vaccinating healthcare workers “can have a dramatic effect on the safety of the workers and their patients.” The society therefore strongly recommends “active efforts to improve HCW vaccination rates,” including providing targeted information, increasing vaccine access, and emphasizing the ethical responsibility healthcare workers have to protect themselves and their patients. “These recommendations apply to all types of healthcare facilities, including acute care hospitals, long-term care facilities, and ambulatory settings, including free-standing clinics, outpatient surgery and dialysis centers, physicians’ offices, and homecare agencies.”

The society also recommends that healthcare workers who decline to receive vaccination after receiving an educational program be asked to sign a declination each year. A suggested form for “Declination of Annual Influenza Vaccination” is available online at the society’s website, www.SHEA.online.org.

Corresponding author of the position paper, “Influenza Vaccination and Healthcare Workers,” which was published in the November2005 issue of the journal Infection Control and Hospital Epidemiology, is Dr. Thomas Talbot. He can be reached at tom.talbot@vanderbilt.edu.