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Feature Article

Why do some health care workers decline flu vaccination?

Influenza (commonly known as flu) is a contagious respiratory illness caused by influenza viruses. Flu can cause mild to severe illness, and can even lead to death, especially in older adults. The best way to prevent the flu is by getting vaccinated each year.

The Centers for Disease Control recommends all people aged six months or older should get a flu shot to reduce their risk of getting sick. The Veterans Health Administration (VHA) recommends that all its Veteran patients be vaccinated annually. Vaccination is the single most effective approach to blocking transmission between health care personnel and patients, which may occur in both directions. VHA actively encourages its employees and volunteers to get flu shots as well.

In 2005, 45 percent of VHA's health care workers were vaccinated against seasonal influenza. The administration committed itself to increasing that percentage to 80 percent by 2011, and VHA has served as a model across the United States for vaccine acceptance. Vaccination rates, however, actually decreased among VHA employees, just as it did elsewhere in the United States, during the 2010-2011 influenza season from the season before—and a study published in the September 2012 issue of the journal Infection Control and Hospital Epidemiology explored why. i

"Most importantly, we wanted to better understand the reasons employees refused the vaccine despite our sustained, widespread efforts to increase acceptance" explains Tamara M. Schult, MPH, of VHA's Office of Public Health in Washington, D.C. "We also wanted to determine whether vaccine acceptance varied by hospital location, and to find any measures facilities had taken that explained the variability of acceptance levels among them."

Using the results of a national health promotion survey that was conducted in a sample of VHA's 245,000 employees in January and February 2010 (30.4 percent of whom responded), the team found that those VHA employees who were not vaccinated declined for the same reasons most Americans decide not to be vaccinated.

Using a technique called factor analysis, the team recognized four important clusters of reasons for declining vaccination, conveniently labeled as: 1) "don't care," 2) "don't want," 3) "don't believe," and 4) "don't know."

Reasons people in the "don't care" group declined included not being able to find a place that had the vaccine; cost of the vaccine; forgetting to be vaccinated; the inconvenience of being vaccinated; and purported allergy to influenza vaccine. Those in the "don't want" group said they don't like vaccinations; were concerned about possible side effects; or don't like needles. Those who "don't believe" either don't agree with national recommendations to be vaccinated or believe the vaccines are not effective; and those who "don't know" said they weren't in a high priority group for the vaccination, or don't have contact with high risk patients.

The clustering of reasons suggests a new strategy to increase vaccine acceptance: Vaccine education programs could recognize these groupings of reasons and focus on those broader issues rather than on a single reason.

Among those vaccinated, the two most important reasons given for taking the vaccine were to protect their family or members of their household from becoming ill, and to protect themselves from illness. Clinical staff (those who provide care directly to patients) also cited protecting their patients as a very important reason for being vaccinated, while others cited convenience.

Younger people, especially those in the 20-29 age group, tended to decline vaccination more frequently than their older counterparts; African Americans in all professions declined vaccination more frequently than all other racial or ethnic groups (including non-Hispanic whites, Hispanic whites, Asians, and others); and non-clinical staff and licensed practical nurses and nursing assistants were less likely to be vaccinated than those in other health care job categories.

At the facility level, the researchers found the most important predictor of how many employees were vaccinated was the vaccination rate in the previous year. "This likely reflects sustained management support of the program from one year to the next," Schult explained. "When management commitment falters, vaccination rates decrease."

At least 10 of VA's 152 medical centers saw a decrease of 20 percent from one year to the next, which the authors ascribe to a failure to assign adequate resources to the annual vaccination campaign.

"It is evident from our analysis that a single message regarding influenza vaccination for health care workers will no longer be sufficient, given the differences that exist according to job category, age, and race or ethnicity," concludes Schult. "Occupation-specific and culturally appropriate messaging will be essential for continued success in future campaigns."

According to the paper, VHA is weighing the pros and cons of implementing a mandatory policy for influenza vaccination of its health care employees, in order to meet the Department of Health and Human Service's Healthy People 2020 goal of having 90 percent of all health care employees vaccinated annually by 2020.

However, VHA is 10 times larger than any organization that has implemented mandatory vaccination to date; it may be difficult to deliver such large quantities of vaccine; there may be union issues related to such a policy; and there is only limited data to indicate that a mandatory vaccination policy either decreases absenteeism among workers, or reduces influenza-related illness in patients.

Veterans enrolled in VA health care and VA staff may get a flu shot at their nearest VA health care facility. VHA does not vaccinate family members, either of Veterans or of VA staff. Both Veterans and VA staff members should get flu shots as soon as they become available in the fall, so that they are protected all winter. They need a new flu shot every year to protect themselves from the viruses circulating that season.

According to VA's Office of Public Health, flu shots are both safe and effective. Most people have no serious side effects or allergic reactions. A very small number of people may get minor body aches, headache, or a low-grade fever that lasts a day or two. You cannot get the flu from a flu shot, because it only contains strains of non-living flu viruses.

Other things people can do to slow the spread of flu include avoiding people who are sick; washing their hands often; keeping their hands away from their face; covering coughs and sneezes; and staying home when they are sick.


i TM Schult, ER Awosika, MJ Hodgson, PR Hirsch, KL Nichol, SR Dyrenforth, SC Moore, "Innovative Approaches for Understanding Seasonal Influenza Vaccine Declination in Healthcare Personnel Support Development of New Campaign Strategies," Infection Control and Hospital Epidemiology, Vol. 33, No. 9 (September 2012), pp. 924-931.

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