Skip to main content Accessibility help

Mandatory Influenza Vaccination of Healthcare Workers: A 5-Year Study

  • Robert M. Rakita (a1), Beverly A. Hagar (a2), Patricia Crome (a3) and Joyce K. Lammert (a4)



The rate of influenza vaccination among healthcare workers (HCWs) is low, despite a good rationale and strong recommendations for vaccination from many health organizations.


To increase influenza vaccination rates by instituting the first mandatory influenza vaccination program for HCWs.

Design and Setting.

A 5-year study (from 2005 to 2010) at Virginia Mason Medical Center, a tertiary care, multispecialty medical center in Seattle, Washington, with approximately 5,000 employees.


All HCWs of the medical center were required to receive influenza vaccination. HCWs who were granted an accommodation for medical or religious reasons were required to wear a mask at work during influenza season. The main outcome measure was rate of influenza vaccination among HCWs.


In the first year of the program, there were a total of 4,703 HCWs, of whom 4,588 (97.6%) were vaccinated, and influenza vaccination rates of more than 98% were sustained over the subsequent 4 years of our study. Less than 0.7% of HCWs were granted an accommodation for medical or religious reasons and were required to wear a mask at work during influenza season, and less than 0.2% of HCWs refused vaccination and left Virginia Mason Medical Center.


A mandatory influenza vaccination program for HCWs is feasible, results in extremely high vaccination rates, and can be sustained over the course of several years.


Corresponding author

Section of Asthma, Allergy, and Immunology, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA 98111 (


Hide All

Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington

Rona Consulting Group, Seattle, Washington



Hide All
1. Thompson, WW, Shay, DK, Weintraub, E, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA 2003;289(2):179186.
2. Thompson, WW, Shay, DK, Weintraub, E, et al. Influenza-associated hospitalizations in the United States. JAMA 2004;292(11):13331340.
3. Poland, GA, Tosh, P, Jacobson, RM. Requiring influenza vaccination for health care workers: seven truths we must accept. Vacane 2005;23(17-18):22512255.
4. American Cancer Society. What are the key statistics about breast cancer? Last medical review: September 18, 2009. Last revised: July 9, 2010. Accessed July 19, 2010.
5. Nichol, KL, Lind, A, Margolis, KL, et al. The effectiveness of vaccination against influenza in healthy, working adults. N Engl J Med 1995;333(14):889893.
6. Bridges, CB, Thompson, WW, Meitzer, MI, et al. Effectiveness and cost-benefit of influenza vaccination of healthy working adults: a randomized controlled trial. JAMA 2000;284(13):16551663.
7. Nichol, KL, D'Heilly, SJ, Greenberg, ME, Ehlinger, E. Burden of influenza-like illness and effectiveness of influenza vaccination among working adults aged 50-64 years. Clin Infect Du 2009;48(3):292298.
8. Fiore, AE, Shay, DK, Broder, K, et al; Centers for Disease Control and Prevention. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009 [published correction appears in MMWR Recomm Rep 2009;58(32):896-897]. MMWR Recomm Rep 2009;58(RR-8):152.
9. Govaert, TME, Thijs, CTMCN, Masurel, N, Sprenger, MJW, Dinant, GJ, Knottnerus, JA. The efficacy of influenza vaccination in elderly individuals: a randomized double-blind placebo-controlled trial. JAMA 1994;272(21):16611665.
10. Gooskens, J, Jonges, M, Claas, ECJ, Meijer, A, van den Broek, PJ, Kroes, ACM. Morbidity and mortality associated with nosocomial transmission of oseltamivir-resistant influenza A (H1N1) virus. JAMA 2009;301(10):10421046.
11. Voirin, N, Barret, B, Metzger, MH, Vanhems, P. Hospital-acquired influenza: a synthesis using the outbreak reports and intervention studies of nosocomial infection (ORION) statement. J Hosp Infect 2009;71(1):114.
12. Pearson, ML, Bridges, CB, Harper, SA; Healthcare Infection Control Practices Advisory Committee (HICPAC); Advisory Committee on Immunization Practices (ACIP). Influenza vaccination of health-care personnel: recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP) [published correction appears in MMWR Recomm Rep 2006;55(9):252]. MMWR Recomm Rep 2006;55(RR-2):116.
13. Talbot, TR, Bradley, SF, Cosgrove, SE, Ruef, C, Siegel, JD, Weber, DJ. Influenza vaccination of healthcare workers and vaccine allocation for healthcare workers during vaccine shortages. Infect Control Hosp Epidemiol 2005;26(U):882890.
14. American College of Physicians (ACP). ACP Policy on Influenza Vaccination of Health Care Workers, Accessed November 17, 2009.
15. Bryant, KA, Stover, B, Cain, L, Levine, GL, Siegel, J, Jarvis, WR. Improving influenza immunization rates among healthcare workers caring for high-risk pediatric patients. Infect Control Hosp Epidemiol 2004;25(11):912917.
16. Weingarten, S, Friedlander, M, Rascon, D, Ault, M, Morgan, M, Meyer, RD. Influenza surveillance in an acute-care hospital. Arch Intern Med 1988;148(1):113116.
17. Schepetiuk, S, Papanaoum, K, Qiao, M. Spread of influenza A virus infection in hospitalised patients with cancer. Aust N Z J Med 1998;28(4):475476.
18. Weinstock, DM, Eagan, J, Malak, SA, et al. Control of influenza A on a bone marrow transplant unit. Infect Control Hosp Epidemiol 2000;21(11):730732.
19. Malavaud, S, Malavaud, B, Sandres, K, et al. Nosocomial outbreak of influenza virus A (H3N2) infection in a solid organ transplant department. Transplantation 2001;72(3):535537.
20. Potter, J, Stott, DJ, Roberts, MA, et al. Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients. J Infect Dis 1997;175(1):16.
21. Carman, WF, Elder, AG, Wallace, LA, et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial. Lancet 2000;355 (9198):9397.
22. Saigado, CD, Giannetta, ET, Hayden, FG, Farr, BM. Preventing nosocomial influenza by improving the vaccine acceptance rate of clinicians. Infect Control Hosp Epidemiol 2004;25(11):923928.
23. Hayward, AC, Harling, R, Wetten, S, et al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial. BMJ 2006;333(7581):12411246.
24. Lemaitre, M, Meret, T, Rothan-Tondeur, M, et al. Effect of influenza vaccination of nursing home staff on mortality of residents: a cluster-randomized trial. J Am Geriatr Soc 2009;57(9):15801586.
25. Hampton, T. H1N1 vaccine urged for health workers, but some resist getting on board. JAMA 2009;302(17):18481849.
26. Immunization Action Coalition. Vaccination information for healthcare professionals. Honor roll for patient safety, Accessed March 4, 2010.
27. Babcock, HM, Gemeinhart, N, Jones, M, Dunagan, WC, Woeltje, KF. Mandatory influenza vaccination of health care workers: translating policy to practice. Clin Infect Dis 2010;50(4):459464.
28. Stewart, AM. Mandatory vaccination of health care workers. N Engl J Med 2009;361(21):20152017.
29. James, JM, Zeiger, RS, Lester, MR, et al. Safe administration of influenza vaccine to patients with egg allergy. J Pediatr 1998;133(5):624628.
30. Kelso, JM, Li, JT, Nicklas, RA, et al; Joint Task Force on Practice Parameters; Joint Task Forcee on Practice Parameters for Allergy & Immunology. Adverse reactions to vaccines. Ann Allergy Asthma Immunol 2009;103(4 suppl 2):S1S14.
31. Berwick, DM, Calkins, DR, McCannon, CJ, Hackbarth, AD. The 100,000 lives campaign: setting a goal and a deadline for improving health care quality. JAMA 2006;295(3):324327.
32. Weingarten, S, Riedinger, M, Bolton, LB, Miles, P, Ault, M. Barriers to influenza vaccine acceptance: a survey of physicians and nurses. Am J Infect Control 1989;17(4):202207.
33. Margolis, KL, Nichol, KL, Poland, GA, Pluhar, RE. Frequency of adverse reactions to influenza vaccine in the elderly: a randomized, placebo-controlled trial. JAMA 1990;264(9) :11391141.
34. Nichol, KL, Margolis, KL, Lind, A, et al. Side effects associated with influenza vaccination in healthy working adults: a randomized, placebo-controlled trial. Arch Intern Med 1996;156(14):15461550.
35. Ofstead, CL, Tucker, SJ, Beebe, TJ, Poland, GA. Influenza vaccination among registered nurses: information receipt, knowledge, and decisionmaking at an institution with a multifaceted educational program. Infect Control Hosp Epidemiol 2008;29(2):99106.
36. Sartor, C, Tissot-Dupont, H, Zandotti, C, Martine, F, Roques, P, Drancourt, M. Use of a mobile cart influenza program for vaccination of hospital employees. Infect Control Hosp Epidemiol 2004;25(11):918922.
37. Saigado, CD, Farr, BM, Hall, KK, Hayden, FG. Influenza in the acute hospital setting. Lancet Infect Dis 2002;2(3):145155.
38. Centers for Disease Control and Prevention (CDC). Interventions to increase influenza vaccination of health-care workers—California and Minnesota. MMWR Morb Mortal Wkly Rep 2005;54(8):196199.
39. Polgreen, PM, Polgreen, LA, Evans, T, Helms, C. A statewide system for improving influenza vaccination rates in hospital employees. Infect Control Hosp Epidemiol 2009;30 (5):474478.
40. Talbot, TR. Do declination statements increase health care worker influenza vaccination rates? Clin Infect Dis 2009;49(5):773779.
41. Polgreen, PM, Septimus, EJ, Parry, MF, et al. Relationship of influenza vaccination declination statements and influenza vaccination rates for healthcare workers in 22 US hospitals. Infect Control Hosp Epidemiol 2008;29(7):675677.
42. Palmore, TN, Vandersluis, JP, Morris, J, et al. A successful mandatory influenza vaccination campaign using an innovative electronic tracking system. Infect Control Hosp Epidemiol 2009;30(12):11371142.
43. Finch, M. Point: mandatory influenza vaccination for all health care workers? Seven reasons to say “No.” Clin Infect Dis 2006;42(8):11411143.
44. Lugo, NR. Will carrots or sticks raise influenza immunization rates of health care personnel? Am J Infect Control 2007;35(1):16.
45. Jensen, PA, Lambert, LA, Iademarco, MF, Ridzon, R; Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep 2005;54(RR-17):1141.
46. Wilde, JA, McMillan, JA, Serwint, J, Butta, J, O'Riordan, MA, Steinhoff, MC. Effectiveness of influenza vaccine in health care professionals: a randomized trial. JAMA 1999;281(10):908913.
47. Lester, RT, McGeer, A, Tomlinson, G, Detsky, AS. Use of, effectiveness of, and attitudes regarding influenza vaccine among house staff. Infect Control Hosp Epidemiol 2003;24(11):839844.
48. Bridges, CB, Kuehnert, MJ, Hall, CB. Transmission of influenza: implications for control in health care settings. Clin Infect Dis 2003;37(8):10941101.
49. Foy, HM, Cooney, MK, Allan, ID, Albrecht, JK. Influenza B in households: virus shedding without symptoms or antibody response. Am J Epidemiol 1987;126(3):506515.
50. Rea, E, Upshur, R. Semmelweis revisited: the ethics of infection prevention among health care workers. CMAJ 2001;164(10):14471448.
51. McLennan, S, Gillett, G, Celi, LA. Healer, heal thyself: health care workers and the influenza vaccination. Am J Infect Control 2008(1);36:14.
52. Tilburt, JC, Mueller, PS, Ottenberg, AL, Poland, GA, Koenig, BA. Facing the challenges of influenza in healthcare settings: the ethical rationale for mandatory seasonal influenza vaccination and its implications for future pandemics. Vaccine 2008;26(suppl 4):D27D30.
53. Stowe, J, Andrews, N, Wise, L, Miller, E. Investigation of the temporal association of Guillain-Barre syndrome with influenza vaccine and influenzalike illness using the United Kingdom general practice research database. Am J Epidemiol 2009;169(3):382388.
54. Sivadon-Tardy, V, Orlikowski, D, Porcher, R, et al. Guillain-Barre syndrome and influenza virus infection. Clin Infect Dis 2009;48(1):4856.
55. Tang, JW, Settles, G. Images in clinical medicine: coughing and masks. N Engl J Med 2009;361(26):e62.
56. Aiello, AE, Murray, G, Coulborn, R, Noone, A, Monto, AS. Mask use reduces seasonal influenza-like illness in the community setting. In: Programs and abstracts of the 48th Annual ICAAC/IDSA 46th Annual Meeting. American Society for Microbiology: Washington, DC, 2008. Abstract V-924.
57. Aiello, AE, Murray, GF, Perez, V, et al. Mask use, hand hygiene, and seasonal influenza-like illness among young adults: a randomized intervention trial. J Infect Dis 2010;201(4):491498.
58. Cowling, BJ, Chan, KH, Fang, VJ, et al. Facemasks and hand hygiene to prevent influenza transmission in households: a cluster randomized trial. Ann Intern Med 2009;151(7):437446.
59. Loeb, M, Dafoe, N, Mahony, J, et al. Surgical mask vs N95 respirator for preventing influenza among health care workers: a randomized trial. JAMA 2009;302(17):18651871.
60. Jefferson, T, Del Mar, C, Dooley, L, et al. Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review. BMJ 2009;339:b3675.
61. Srinivasan, A, Perl, TM. Respiratory protection against influenza. JAMA 2009;302(17):19031904.
62. Shine, KI, Rogers, B, Goldfrank, LR. Novel H1N1 influenza and respiratory protection for health care workers. N Engl J Med 2009;361(19):18231825.
63. Lee, PY, Matchar, DB, Clements, DA, Huber, J, Hamilton, JD, Peterson, ED. Economic analysis of influenza vaccination and antiviral treatment for healthy working adults. Ann Intern Med 2002;137(4):225231.
64. Burls, A, Jordan, R, Barton, P, et al. Vaccinating healthcare workers against influenza to protect the vulnerable—is it a good use of healthcare resources? A systematic review of the evidence and an economic evaluation. Vacane 2006;24(19):42124221.
65. Hartocollis, A, Chan, S. Albany judge blocks vaccination rule. New York Times. October 17, 2009 A17.
66. Gorman, S. Medical workers balk at mandatory flu vaccines. Reuters. Accessed March 4, 2010.
67. Saxen, H, Virtanen, M. Randomized, placebo-controlled double blind study on the efficacy of influenza immunization on absenteeism of health care workers. Pediatr Infect Dis J 1999;18(9):779783.


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed