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Imagine this scenario: A lethal new virus attacks the United States, with devastating effects on vulnerable populations: the elderly, young children, the immunocompromised, and pregnant women. Intense publicity follows in the media, and nationwide anxiety ensues as do widespread calls for an immediate cure or, lacking that, a quick and highly effective prevention strategy.

The story sounds vaguely like the 2007 avian flu scare, if the feared widespread transmission of that virus to humans had, indeed, occurred. It does not sound like seasonal influenza, but in the absence of effective vaccine, a seasonal influenza epidemic would play out as described virtually every year. Fortunately, we have a highly effective prevention strategy: seasonal influenza vaccination.

There is a growing trend among hospitals and health care systems to require annual seasonal influenza vaccination of employees. While this is an operational decision by management, the implications of a mandatory vaccination policy are broad enough that trustees should be aware of the trend and the issues involved in making and executing such a policy.

Voluntary Programs Don't Work

The Centers for Disease Control and Prevention report that influenza is the most prevalent cause of deaths that can be prevented by vaccination in the United States. The Institute of Medicine's 1999 report, "To Err is Human: Building a Safer Health System," cites hospital-acquired infection as a significant safety issue and, following fire prevention, lists infection prevention as the primary safety activity of health care organizations. Hospitalized patients, the elderly (particularly those in nursing facilities), the immunocompromised, young children and pregnant women are among the most vulnerable to influenza and are most likely to account for nearly 300,000 influenza-related hospitalizations and 36,000 deaths that occur on average each year.

The Office of Disease Prevention and Health Promotion has suggested that by 2010, the United States should have been vaccinating 60 percent of the health care workforce; this modest goal has remained unmet. In 2010, the CDC reported that since statistics were first collected in 1989, the national rate of vaccination for health care workers never has been more than 49 percent. This statistic is particularly discouraging because studies show that a high level of vaccinated health care workers can reduce the mortality risk of elderly patients in long-term care facilities.

In response to the difficulty of achieving high rates of voluntary influenza vaccination among health care workers, several hospitals and systems have reported the results of mandatory vaccination programs. In 2005, with the approval of its trustees, Virginia Mason Medical Center, Seattle, was the first acute care institution to require mandatory vaccination, and it achieved a 98 percent vaccination rate. The first health care system to initiate a mandatory vaccine, BJC HealthCare, Saint Louis, reported a 98 percent vaccination rate in 2008. Finally, in 2010, MedStar Health, Columbia, Md., a nine-hospital nonprofit system, achieved a 98 percent vaccination rate among staff, hospital vendors and independent and employed physicians through its mandatory influenza policy.

Mandatory policies for influenza vaccination of health care workers have been endorsed by the Association for Professionals in Infection Control and Epidemiology, the American Academy of Pediatrics, the Infectious Diseases Society of America, the National Patient Safety Foundation, and the Society for Healthcare Epidemiology of America. And in April 2011, the American Hospital Association Board of Trustees approved a policy that required either influenza vaccination or the wearing of masks in the presence of patients across health care settings during the influenza season.

What's the Rationale?

Medical literature contains several arguments supporting mandatory influenza vaccinations for health care workers. They include:

  1. Vaccination of health care personnel is essentially a patient safety issue.
  2. Influenza infection acquired in the health care setting can be a cause of mortality and significant morbidity. Workers should take all available steps to prevent infecting the patients entrusted to their care.
  3. Immunization rates less than 80 percent are not sufficient to protect patients.
  4. Voluntary vaccination efforts that fall short of a specific mandate do not achieve the necessary rate of compliance.
  5. Vaccinations reduce health care worker absenteeism and presenteeism (that is, being present at work with impaired functioning).

In evaluating the question of a mandatory vaccination policy, trustees should consider four aspects of the policy: its science, ethics, legal implications and cost.

The science is clear. The administration of influenza vaccination is highly effective in preventing the illness in the general population. It is less effective in preventing illness in the most vulnerable populations — the elderly and those patients with compromised immune systems. Those patients are most frequently encountered in the inpatient or long-term care settings, and they are best protected by not being exposed to the virus in the first place. The most efficient way to preclude these patients' exposure is by vaccinating health care workers. Vaccination programs have shown mortality reduction in elderly patients in long-term care settings.

The ethics involve analyzing the balance between health care workers' duties and rights. The duty of nonmaleficence (the duty to do no harm) requires that workers do not place their patients in harm's way. It suggests that workers have a responsibility to be vaccinated against influenza. The duty of beneficence requires that workers act in the best interest of their patients, which calls for both the provision of appropriate medical interventions, but also the application of processes (such as influenza vaccination) to secure the best possible outcomes. These overarching duties and the fact that influenza vaccination is a low-risk procedure support the argument that vaccination of health care workers is an ethically proper requirement.

When taken into consideration, a worker's right to autonomy argues against compulsory programs. However, the rights of autonomy and freedom of choice with respect to medical care are not unlimited in the United States. Some employers, for example, require evidence of immunity to hepatitis B and rubella, and school districts mandate the full spectrum of childhood vaccinations. Mandatory vaccination programs are not unprecedented.

The legal implications of mandatory vaccinations center on workers' personal autonomy, contractual issues in collective bargaining and freedom of religion. The rights of workers in these circumstances generally are limited by the responsibilities that they have to their patients.

The costs associated with a mandatory vaccination program are relatively small when compared with the operating budget of most health care institutions. The question has not been studied rigorously in the health care setting, but available evidence suggests that influenza vaccination reduces absenteeism and is cost-effective — returning $2.58 for every dollar expended in one industrial setting.

Boards should view influenza prevention in the institutional setting as a patient safety issue. It is the responsibility of each institution to provide the safest possible environment for its patients, and the most effective preventive effort is to reduce the risk of exposure by vaccinating those who provide the care. Unfortunately, health care workers are lax in voluntary immunization, and the rates of immunization under voluntary policies consistently fail to reach levels required to establish a general immunity to influenza. Mandatory vaccination is scientifically based, ethical, legal and most likely cost-effective. Some organizations already have instituted the policy, and its effectiveness is evident.

Protect the Most Vulnerable

To return to the initial scenario, a new, potentially lethal virus predictably attacks the United States every year, and its effects are most serious among our most vulnerable patients. It is fortuitous that effective prevention is possible with a low-risk and inexpensive vaccine. We need to be sure that those providing care to our vulnerable patients are not a source of danger to them.

William J. Oetgen, M.D., M.B.A., F.A.C.P. (, is a cardiologist and clinical professor of medicine at Georgetown University, Washington, D.C., a member of AHA's Regional Policy Board 3, and a member of the board of directors of MedStar Health Inc., Columbia, Md. William L. Thomas, M.D., F.A.C.P. (william.l.thomas@, is an internist and executive vice president for medical affairs and chief medical officer of MedStar Health Inc.