Success and unintended consequences of compulsory participation in a health care personnel influenza immunization program

Background: Since 2008, the National Institutes of Health Clinical Center, a research hospital serving an immunosuppressed patient population, has required staff with patient contact to undergo annual influenza immunization or file a formal declination. Over the past four influenza seasons, acceptable reasons for declination were progressively narrowed to improve immunization rates. These changes were associated with noteworthy trends in declination choices.

Methods: A database of personnel with patient contact is updated annually and used for notification and tracking. From 2008 to 2011, staff could decline without documentation on the basis of medical contraindications (egg allergy, Guillain-Barre syndrome, or severe allergic reaction) or immunization at outside locations, or select from a menu of other reasons for declining immunization. In 2011, we required physician documentation of medical contraindications or outside immunization, and eliminated all but one declination option. Staff could still request religious exemption but were asked to provide a written request. There were no penalties for noncompliance, but those who did not comply in a timely manner were notified in reminder calls and emails that they would be invited to explain noncompliance to the medical board.

Results: From 2008 through 2011, overall immunization rates remained between 82.7% and 88.7%. With implementation of the stricter declination requirements in 2011-12, the immunization rate climbed to 96% (p<0.0001). Medical contraindications were claimed by 1.3-2.3% each year. The proportion of staff requesting religious exemption was stable at 0.25% to 0.47% from 2008-11, then more than tripled in 2011-12 to 1.7% (p<0.0001) when that was the only declination option not requiring physician documentation.

Conclusion: Implementing stricter rules for vaccine declination substantially increased provider immunization rates without either jeopardizing employment or imposing disciplinary penalties. An unintended consequence of the escalated requirements was a tripling in the proportion of staff claiming religious exemption. Our experience demonstrates that the vast majority of health care personnel can be persuaded to undergo influenza immunization but that a small proportion will find creative ways to avoid it.