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H E A LT H C A R E E P I D E M I O L O G YI N V I T E D A R T I C L E
Robert A. Weinstein, Section Editor
Do Declination Statements Increase Health Care Worker
Influenza Vaccination Rates?
Thomas R. Talbot
Departments of Medicine and Preventive Medicine, Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee
In response to health care worker influenza vaccination rates that are below desired targets, strategies designed to stimulate
vaccination have been proposed, including the use of declination statements for those refusing vaccination. The impact of
these statements has not been thoroughly investigated and may be affected by their specific language and context. This review
examines the available data on the use and impact of declination statements to increase health care worker vaccination rates
and notes some potential pitfalls and issues that may arise with their use.
Because health care workers (HCWs) play an important role
in the transmission of influenza to patients, influenza vacci-
nation of HCWs has been recommended for several decades
. Often serving as the nidus for health care–associated in-
fluenza outbreaks, healthy HCWs can shed influenza virus with
little or no symptoms and may work while ill . Vaccination
of HCWs against influenza reduces themorbidityandmortality
rates of patients in long-term care facilities [3–5], and vacci-
nation of target populations reduces medically attended acute
respiratory infections in their close contacts . Unfortunately,
influenza vaccine coverage of HCWs in the United States has
languished at ∼40% , leading many groups to call for new
measures to improve vaccination rates of HCWs [2, 8–12].
Numerous tools have been used to enhance HCW influenza
vaccination coverage, including provision of vaccine free of
charge, off-hours vaccination, mobile vaccination carts, ad-
ministrative emphasis and support, enhanced education, and
incentives [1, 2, 7, 11]. Despite these techniques, few institu-
tions have achieved vaccination rates of 180%.
A common component of the HCW hepatitis B vaccination
programs , the use of a signed informed declination state-
ment for those refusing vaccination, has recently been rec-
ommended as a tool to improve HCW influenza vaccination
rates [2, 7, 9, 14]. The intent of a declination statement is to
Received 9 April 2009; accepted 25 May 2009; electronically published 21 July 2009.
Reprints or correspondence: Dr Thomas R. Talbot, A-2200 Medical Center North, 1161 21st
Ave S, Vanderbilt University Medical Center, Nashville, TN 37232 (firstname.lastname@example.org).
Clinical Infectious Diseases2009;49:773–9
? 2009 by the Infectious Diseases Society of America. All rights reserved.
ensure that HCWs are appropriately informed of the rationale
for influenza vaccination, to promote the message of patient
safety, and to dispel commonly held misconceptions regarding
influenza and influenza vaccination. This review examines the
use and impact of declination statements on vaccination rates
to illuminate the current debate surrounding the use of such
statements as a part of HCW influenza vaccination programs.
HCW HEPATITIS B VACCINATION AND THE USE
OF DECLINATION STATEMENTS
Signed declinations have been used as a tool to increase HCW
hepatitis B vaccination rates for several decades. In 1991, the
Occupational Safety and Health Administration enacted the
Federal Bloodborne Pathogens Standard  in response to
increasing concerns regarding the occupational risk of blood-
borne pathogen transmission. This standard requires the pro-
vision of personal protective equipment, proper waste disposal,
postexposure follow-up plans, and work practice controls. In
addition, employers must offer the hepatitis B vaccine to em-
ployees with the potential for blood and body fluid exposure.
Those who refuse vaccination must sign a declination form
indicating that they understand the rationale for offering the
vaccine and the risks involved with refusal .
It is difficult to determine the precise impact of the use of
declination statements on hepatitis B vaccination rates from
that due to other vaccination program components. Although
prestandard vaccination coverage was not recorded, a survey
in 1994 of 138 hospitals found that 66.5% of eligible HCWs
had received 3 doses of hepatitis B vaccine. Vaccination cov-
erage was higher among hospitals who notified supervisors or
imposed sanctions for HCWs who refused vaccination and
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