Document Type


Publication Date

Spring 2011


Since 1981, the Centers for Disease Control and Prevention (CDC) has recommended that all health care workers (HCWs) receive an annual influenza vaccination. The Healthy People objectives aimed for 60% coverage of HCW influenza vaccination by 2010 and 90% coverage by 2020. Although influenza vaccine uptake among HCWs has trended upward over the past several years, the percentage of immunized HCWs has remained approximately 40% between 2004 and 2008.

In order to complete the literature review, researchers identified and analyzed peer reviewed literature, news articles, professional organization position statements, and institutional policies published between 1991 and 2011. In the absence of evidence from the United States experience, materials relevant to Canada, France and the United Kingdom were reviewed.

Defining Health Care Workers and Settings: The healthcare workforce could be individuals who have direct exposure or have the potential for indirect exposure to patients or infectious materials including: body substances, contaminated medical supplies and equipment, environmental surfaces or air. They may be paid or unpaid, an employee, contractor, volunteer, visitor, or student. Health care workers work in a broad range of institutional and community settings.

Health Care Workers Impact Patient Safety: HCWs who have direct contact with patients are the primary source of infectious disease outbreaks in health-care facilities. During an average season, 23% of HCWs are infected with the virus, show mild symptoms, and continue to work despite being infectious. Over the past 30 years, nosocomial influenza outbreaks have been documented throughout the United States and abroad.

Strategies to Encourage Voluntary Vaccination Among HCWs: Healthcare facilities, and government and professional organizations have developed and supported various strategies to encourage voluntary influenza vaccination among HCWs, including: 1) educational and promotional campaigns, 2) increased access to the seasonal influenza vaccine, 3) declination statements, and 4) health programs that incorporate several strategies.

State–Mandated School Immunization and Exemption Policies: State laws that require vaccination as a condition for school attendance translate national recommendations into immunization practice. These laws have proven to be the most effective mechanism to protect children and their families from the effects of vaccine-preventable disease. Historical and modern examination of school vaccination laws provides a context for understanding the benefits of compulsory vaccination policy when applied to the health workforce.

All jurisdictions include "opt-out" or exemption provisions that permit parents to refuse immunizations for their children for one of three reasons: 1) medical contraindication, 2) religious beliefs, or 3) personal, moral, or philosophical beliefs. Two jurisdictions employ declination statements as a fourth option to allow refusal. 1 Mandatory Influenza Vaccination Policies in Healthcare Facilities: Beginning in 2004, healthcare facilities and local health departments began to require influenza vaccination as a condition of employment. Currently, 87 facilities in 30 states and the District of Columbia have implemented HCW mandatory influenza vaccination programs. Professional and Government Organizations Position Statements Related to Health Care Worker Influenza Vaccination: Several professional, government, non-profit organizations have indicated their support of mandatory influenza vaccination of HCWs as the most effective strategy to protect patients. However, the largest health care union, representing several categories of the health care workforce, opposes mandatory influenza vaccination. Health Care Workers’ Attitudes and Beliefs Related to Influenza Vaccination: The workforce continues to present several common arguments against influenza vaccination, including: 1) fear, 2) a belief in popular myths and misinformation, and 3) inconvenience. However, others accept the vaccination as an effective method to protect themselves, their families, and their patients.


This publication was supported by Contract Number HHSP23320095633WC funded by AHRQ, CDC, NVPO and OHQ on behalf of the Federal Increasing Influenza Vaccination Coverage Among Healthcare Workers Working Group.

Open Access




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