Mandatory Influenza Vaccination • CID 2010:50 (15 February) • 459
M A J O R A R T I C L E
Mandatory Influenza Vaccination of Health Care
Workers: Translating Policy to Practice
Hilary M. Babcock,1Nancy Gemeinhart,2Marilyn Jones,2W. Claiborne Dunagan,1,2and Keith F. Woeltje1
1Washington University School of Medicine and
2BJC HealthCare, St Louis, Missouri
(See the editorial commentary by Pavia, on pages 465–7.)
Influenza vaccination of health care workers has been recommended since 1984. Multiple strat-
egies to enhance vaccination rates have been suggested, but national rates have remained low.
BJC HealthCare is a large Midwestern health care organization with ∼26,000 employees. Because
organizational vaccination rates remained below target levels, influenza vaccination was made a condition of
employment for all employees in 2008. Medical or religious exemptions could be requested. Predetermined medical
contraindications include hypersensitivity to eggs, prior hypersensitivity reaction to influenza vaccine, and history
of Guillan-Barre ´ syndrome. Medical exemption requests were reviewed by occupational health nurses and their
medical directors. Employees who were neither vaccinated nor exempted by 15 December 2008 were not scheduled
for work. Employees still not vaccinated or exempt by 15 January 2009 were terminated.
Overall, 25,561 (98.4%) of 25,980 active employees were vaccinated. Ninety employees(0.3%)received
religious exemptions, and 321 (1.2%) received medical exemptions. Eight employees (0.03%) were not vaccinated
or exempted. Reasons for medical exemption included allergy to eggs (107 [33%]), prior allergic reaction or allergy
to other vaccine component (83 [26%]), history of Guillan-Barre ´ syndrome (15 [5%]), and other (116 [36%]),
including 14 because of pregnancy. Many requests reflected misinformation about the vaccine.
A mandatory influenza vaccination campaign successfully increased vaccination rates. Fewer
employees sought medical or religious exemptions than had signed declination statements during the previous
year. A standardized medical exemption request form would simplify the request and review process for employees,
their physicians, and occupational health and will be used next year.
Influenza infection is associated with 36,000 excess
deaths and 1200,000 hospitalizations in the United
States annually [1, 2]. It is the leading cause of vaccine-
preventable death in the United States every year .
The risk of complications associated with influenza is
higher among older persons, young children, and pa-
tients with underlying medical conditions [2, 4]. In-
fected people may shed virus before symptoms develop
[5–8], and health care workers often work while sick.
Outbreaks of influenza in hospitals have been well de-
scribed [3, 4, 9–12].
Influenza vaccination of health care workers reduces
Received 20 October 2009; accepted 9 December 2009; electronically published 11
Reprints or correspondence: Dr Hilary M. Babcock, Washington University School
of Medicine, Campus Box 8051, 660 S Euclid Ave, St Louis, MO 63110 (hbabcock@
Clinical Infectious Diseases2010;50:459–64
? 2010 by the Infectious Diseases Society of America. All rights reserved.
employee illness and absenteeism[4, 13–15].Innursing
home settings, vaccination of health care workers has
been shown to decreasemorbidityandmortalityamong
nursing home residents [16–18]. The impact of vac-
cination of workers in acute care settings is more dif-
ficult to study because of the short duration of most
hospitalizations. Other evidence for the importance of
herd immunity on influenza rates comes from a Jap-
anese study in which the vaccination of school children
against influenza resulted in decreased mortality asso-
ciated with pneumonia or influenza in the general pop-
Annual influenza vaccination wasfirstrecommended
for health care workers by the Advisory Committee on
Immunization Practices in 1984 [3, 20, 21]. The Society
for Healthcare Epidemiology , the Association for
Professionals in Infection Control , and the Infec-
tious Disease Society of America  also strongly en-
dorse health care worker vaccination. The US National
Health objectives for 2010 include a health care worker
influenza vaccination rate of 60%. Recommendedprac-
by guest on November 14, 2015
464 • CID 2010:50 (15 February) • Babcock et al
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