Use of a Mandatory Declination Form in a Program for Influenza Vaccination of Healthcare Workers
Objective. To evaluate the utility and impact of using a declination form in the context of an influenza immunization program for healthcare workers.
Methods. A combined form for documentation of vaccination consent, medical contraindication(s) for vaccination, or vaccination declination was used during the 2006‐2007 influenza season in a healthcare system employing approximately 9,200 nonphysician employees in 3 hospitals; a skilled nursing care facility; a large, multisite, faculty‐practice plan; and an administrative building. Responses were entered into a database that contained files from human resources departments, which allowed correlation with job category and work location.
Results. The overall levels of influenza vaccination coverage of employees increased from 43% (3,892 of 9,050) during the 2005‐2006 season to 66.5% (6,123 of 9,214) during the 2006‐2007 season. Of 9,214 employees, 1,898 (20.6%) signed the declination statement. Among the occupation groups, nurses had the lowest rate of declining vaccination (13.2% [393 of 2,970]; P < .0001), followed by pharmacy personnel (18.1% [40 of 221]), ancillary personnel with frequent patient contact (21.9% [169 of 771), and all others (24.7% [1,296 of 5,252]). Among the employees who declined vaccination, nurses were the least likely to select the reasons “afraid of needles” (3.8% [15 of 393], vs. 9.1% [137 of 1,505] for all other groups; P < .001) and “fear of getting influenza from the vaccine” (13.5% [53 of 393], vs. 20.5% [309 of 1,505]; P = .002). Seven pregnant nurses had been advised by their obstetricians to avoid vaccination. When declination of influenza vaccination was analyzed by age, 16% of personnel (797 of 4,980) 50 years of age and older declined to be vaccinated, compared with 26% of personnel (1,101 of 4,234) younger than 50 years of age (P < .0001).
Conclusions. Implementing use of the declination form during the 2006‐2007 influenza season was one of several measures that led to a 55% increase in the acceptance of influenza vaccination by healthcare workers in our healthcare system. Although we cannot determine to what degree use of the declination form contributed to the increased rate of vaccination, use of this form helped the vaccination program assess the reasons for declination and will help to focus future vaccination campaigns.
Received September 25, 2007; accepted January 4, 2008; electronically published February 28, 2008.
The annual vaccination of healthcare workers against influenza virus infection has been identified as an important goal for healthcare organizations. A growing body of data has demonstrated that such vaccination reduces the transmission of influenza virus in healthcare settings,1,2 decreases influenza morbidity and mortality among patients,1,2 and reduces absenteeism among healthcare workers.3,4 Multiple agencies and organizations, including the Centers for Disease Control and Prevention (CDC),5 the Joint Commission,6 the Association for Professionals in Infection Control and Epidemiology,7 and the Society for Healthcare Epidemiology of America,8 have strongly endorsed the goal of increasing the rate of influenza vaccination of healthcare workers. Despite these efforts, the national rate of influenza vaccination of healthcare workers has remained approximately 40%.5,9,10 Recent efforts to increase this rate have included obtainment of the support of top management, education of healthcare workers about the benefits of influenza vaccination, offers of the vaccine to all healthcare workers at no cost and at convenient locations, monitoring of vaccination and declination of vaccination among healthcare workers, providing feedback of vaccination rates to healthcare workers and their supervisors, use of the level of influenza vaccination coverage among healthcare workers as a quality indicator measure for patient safety, and obtainment of signed declination statements from healthcare workers who decline vaccination for reasons other than medical contraindications.5,11‐15 This last recommendation, to obtain signed statements of declination, has been somewhat controversial. In 1991, the Occupational Safety and Health Administration, in their final rule on exposure to bloodborne pathogens,16 included the use of a declination form for healthcare workers who declined to receive hepatitis B vaccination. In part, the inclusion of use of a declination form was intended to “encourage greater participation in the vaccination program”16(p64156) by healthcare workers. There are limited data to suggest that the use of declination forms for healthcare workers who declined hepatitis B vaccination achieved the goal of increasing the rate of vaccination of healthcare workers.17 Similarly, there is a paucity of data to demonstrate that the use of declination statements for influenza vaccination will improve vaccination coverage levels among healthcare employees.5,18
A potential advantage of the use of a declination statement is that obtaining such statements from healthcare workers who decline vaccination for reasons other than medical contraindications can assist facilities in identifying the personnel who might require targeted education or other interventions to overcome barriers to vaccine acceptance. In addition, collection of such information will allow healthcare facilities to determine what proportion of their staff are reached by a vaccination program and are offered vaccine.5 The disadvantages of the use of a declination statement include the problem that the “burden of requiring compliance from those who have already chosen not to participate might tax employee occupational health resources that could otherwise be devoted to positive reinforcement for compliance.”18 In addition, some people think that creative programs that employ the “carrot” approach rather than the “stick” approach while still respecting the rights of both patients and employees may be more successful in increasing the rate of vaccination.18
For facilities that elect to employ a declination statement, there are few published examples to choose from and only 1 report that evaluates the use of such a statement in the context of a program to increase influenza vaccination coverage levels among healthcare workers.19 As part of an influenza vaccination program during the 2006‐2007 influenza season, our healthcare system elected to implement use of a declination statement for healthcare workers. This article reviews our experience with that declination form for tracking employee participation in the influenza vaccination program and identifying employee groups and negative attitudes among employees for targeted intervention.
Methods
Setting and Participants
The influenza vaccination program was conducted in a healthcare system that consists of 2 adult, tertiary care, urban hospitals with a total of 1,084 licensed beds; a 100‐bed geriatric specialty inpatient facility; a 250‐bed skilled nursing care facility; a large, multisite, faculty practice plan that has approximately 2 million outpatient visits per year; and a large administrative office building located several miles from the clinical facilities and in which no patient care occurs. For purposes of analysis, employees who worked in the geriatric inpatient facility were grouped with the employees in the skilled nursing facility. The healthcare system employed approximately 9,200 nonphysician employees during the study period.
The Influenza Vaccination Program
Before the 2006‐2007 season, employees were encouraged to receive influenza vaccination, through the use of posters and articles in various employee communications. Although employee participation was tracked, this occurred in a retrospective fashion, and vaccination rates were calculated and published periodically. All employees were eligible for free vaccinations, either by presenting to the Employee Health Office during normal business hours or by using the rolling carts that visited all areas once or twice during the season. The carts were scheduled to visit inpatient areas during all 3 work shifts and on weekends as well as weekdays. On a few days, vaccination tables were set up outside the areas frequented by employees, such as an entryway from the employee parking garage. During the 2005‐2006 influenza season, the system achieved an overall influenza vaccination coverage level of 43% (3,892 of 9,050).
Starting in the spring of 2006, institutional leadership announced that a major safety goal for the healthcare system would be to achieve a rate of influenza vaccination among employees of 65%. A task force was appointed to coordinate a program to meet this goal. Top management took a much more public stance in support of the program, supervisors were given weekly feedback on the participation of employees in their sections, and a very popular T‐shirt was given to employees who received vaccinations. In addition to these new measures used to increase vaccination rates above those of the previous season, it was decided that use of a declination form would be implemented.
Although no employee was required to receive influenza vaccination, employees were officially required to sign a form that served as either a vaccination consent form, a form to document medical contraindication(s) for vaccination, or a vaccination declination form (Figure). In addition to a short statement that summarized the advantages of employee vaccination, the declination section of the form allowed employees to mark the reason(s) for declination of influenza vaccination. A blank space was available for employees to write in any reason(s) not preprinted on the form. All data from the forms were entered into an institutional database on a weekly basis. Supervisors were given a weekly list of all employees in their section who had not completed one of the sections of the form. Although supervisors could strongly encourage the employees in their area to participate in the program, no formal disciplinary action was specified for failure to participate. Physicians were not included in the program, because there was no unified database to track them. However, physicians were strongly encouraged to receive influenza vaccination. In addition to the introduction of the declination form, the weekly tracking of employees, and the distribution of T‐shirts, the campaign differed from the program in the previous year in that vaccination carts made an additional 1 or more visits to each employee work area during the season than the number of visits made during the previous season, with a focus on visits during evening, night, and weekend shifts.
Figure. The form used for consent to, waiver of, or declination of influenza vaccination.
All vaccinations consisted of a unit dose of inactivated vaccine. No live, attenuated influenza vaccine was used because, in previous years, no employees chose to receive that preparation.
Employees
For the purposes of analysis, healthcare workers were divided into 4 occupational groups: nurses, ancillary personnel with frequent patient contact (nursing technicians, physical therapists, occupational therapists, respiratory therapists, radiology technicians, and environmental management personnel), pharmacists, and all others. Assignment to these categories was based on the employee’s classification in the human‐resources database. The ages of healthcare workers were determined on the basis of data contained in the human‐resources database.
Statistical Analysis
All differences between variables were calculated using a χ2 test with a 
table. Statistically significant differences were considered to be present for P values less than .05.
Results
Overall Vaccination Coverage Level
During the 2006‐2007 influenza season, 66.5% of all healthcare system employees (6,123 of 9,214) received influenza vaccination (Table 1). This was greater than the rate of 43% vaccinated during the previous influenza season (
). Of 9,214 employees, 141 (1.5%) reported medical contraindications, and 1,898 (20.6%) signed the declination statement. In addition, 1,052 (11.4%) of the 9,214 employees did not participate in the program by completing any sections of the form. When analyzed by geographic entity, there was no statistically significant difference between vaccination coverage levels at the 2 hospitals and the multisite faculty practice (hospital 1, 65.1% [1.662 of 2,553]; hospital 2, 68.5% [2,285 of 3,334]; multisite faculty practice, 68.9% [1,583 of 2,298]; 
for all comparisons). However, both of the hospitals and the multisite faculty practice had statistically significantly higher rates of vaccination than the 61.3% rate (407 of 664) for the geriatric inpatient facility combined with the skilled nursing facility (for hospital 1, 65.1% vs. 61.3%, 
; for hospital 2, 68.5% vs. 61.3%, 
; for the multisite faculty practice, 68.9% vs. 61.3%, 
). Employees at the administrative building several miles from the medical center had a vaccination rate of 51% (186 of 365), which was significantly lower than the rate at any of the clinical sites (for hospital 1, 51% vs. 65.1%, 
; for hospital 2, 51% vs. 68.5%, 
; for the multisite faculty practice, 51% vs. 68.9%; 
; for the geriatric and nursing facilities combined, 51% vs. 61.3%, 
). When analyzed by occupational group, nurses were more likely to accept vaccination than were the 2 groups pharmacy personnel and all others combined (79.8% [2,370 of 2,970], vs. 58.3% [3,189 of 5,473]; 
), as were ancillary personnel with frequent patient contact (73.1% [564 of 771], vs. 58.3%; 
) (Table 2).
Declination Forms
Analysis of the data by occupational group revealed that nurses had the lowest rate of declination of vaccination (13.2% [393 of 2,970]; 
for comparison with the rate of all other occupational groups combined and with the rate for each other occupational group), followed by pharmacy personnel (18.1% [40 of 221]), ancillary personnel with frequent patient contact (21.9% [169 of 771]), and all others (24.7% [1,296 of 5,252]) (Table 2). Only nurses had a rate of declination that was significantly different from that of any other occupational group. Among personnel who declined to be vaccinated, nurses were the least likely to express a fear of needles (3.8% [15 of 393], vs. 9.1% [137 of 1,505] for other groups combined; 
) and the least likely to express a fear of acquiring influenza from the vaccination (13.5% [53 of 393], vs. 20.5% [309 of 1,505] for other groups combined; 
) (Table 3). There were no statistically significant differences between occupational groups with regard to other reasons chosen for declination of vaccination. Of the 1,898 employees who declined vaccination, 362 (19.1%) expressed a fear of acquiring influenza infection from the vaccination. Nurses were more likely than members of other groups to write in a reason for declination of influenza vaccination that was not listed on the form (188 [47.8%] of 393 nurses). Because the answers were handwritten text, it was not possible to statistically analyze these responses. However, the majority of nurses who wrote in an alternate reason focused primarily on their objection to being “pressured” or “coerced” into being vaccinated. Seven nurses noted that they were pregnant and had been advised by their obstetricians to avoid vaccination. When declination of influenza vaccination was analyzed by age, 16% of personnel (797 of 4,980) 50 years of age and older declined to be vaccinated, compared with 26% of personnel (1,101 of 4,234) younger than 50 years of age (
).
Discussion
The vaccination of healthcare workers against influenza infection has been targeted by many national agencies and medical organizations as an important goal for the promotion of patient safety. Despite this emerging consensus, the national rate of influenza vaccination among healthcare workers has remained approximately 40%.5,9,10 In an effort to increase the rate of vaccination among healthcare workers, several measures have been suggested, such as obtainment of the support of top management, education of healthcare workers about the benefits of influenza vaccination, offers of vaccination to all healthcare workers at no cost and at convenient locations, monitoring of healthcare worker vaccination and declination, providing feedback of vaccination rates to healthcare workers and their supervisors, and use of the level of influenza vaccination coverage of healthcare workers as a quality indicator measure for patient safety.5,11‐15 Unfortunately, hospitals that have implemented these measures have not always found that they raised rates of employee vaccination.20 Most recently, a CDC advisory committee recommended that signed declination forms be obtained from healthcare workers who decline to be vaccinated for reasons other than medical contraindications.5 However, there are few published examples of this approach and none that have data to document that use of declination forms increases the rate of employee vaccination. One national health organization has opposed the use of declination statements for influenza vaccination in favor of more‐innovative, positive reinforcements.18 A similar declination form was recommended in 1991 by the Occupational Safety and Health Administration,16 but, to date, there are limited data to suggest that the use of this declination form has increased the rate of hepatitis B vaccination among healthcare workers.17 However, in a survey of 150 hospitals conducted in 1992, 15 (10%) reported that the requirement of a declination statement influenced employees to be vaccinated for hepatitis B.21
As part of our influenza vaccination program during the 2006‐2007 influenza season, our healthcare system elected to implement use of a declination form for healthcare workers. Overall, 20.6% of all employees signed the declination statement. When analyzed by occupational group, nurses had the lowest rate of declination of vaccination (13.2%). Pharmacy personnel (18.1%), ancillary personnel with frequent patient contact (21.9%), and all others (24.7%) had similar rates of declination. The reasons for declination of influenza vaccination also varied by occupation—nurses were least likely to select the reason “afraid of needles” or “fear of getting influenza from the vaccine” and were more likely to write in objections to being coerced or pressured into vaccination than were all other groups. Of all employees who declined influenza vaccination, 19.1% expressed a fear of acquiring influenza infection from the vaccine, despite the fact that only inactivated vaccine was used in our campaign.
Employees younger than 50 years of age were more likely to decline to be vaccinated than were employees 50 years of age or older. These results are similar to those reported by King et al.10 in an analysis of rates of influenza vaccination among healthcare workers through the 2000 National Health Interview Survey.
Although declination statements have been advocated as a potential method of increasing rates of vaccination among healthcare workers, we are unable to say what role, if any, implementing use of the declination form had in the increase in our vaccination rate from 43% to 66.5%. As often happens in such circumstances, the new use of the declination statement was not the only change made in our program during the 2006‐2007 influenza season. Top management took a much more public stance in support of the program, supervisors were given weekly feedback on the participation of employees in their sections, a very popular T‐shirt was given to employees who received vaccinations, and mobile vaccination carts were used more extensively. All these changes are likely to have had a positive impact on the vaccination program.
The declination form did assist us in identifying personnel who might require targeted education or other interventions to overcome barriers to vaccination acceptance. This was most clear among nursing personnel, a high percentage of whom identified the “coercive” nature of the program as one of their major objections. We were also interested to learn that, despite an aggressive educational campaign, 19.1% of all employees expressed a fear of acquiring influenza infection from the inactivated vaccine. As we entered the subsequent vaccination season, public relations was approached and was asked to assist in devising strategies to give the vaccination program a more positive image. It is also clear that more emphasis must be placed on addressing the side effects of the vaccine and on helping employees appreciate that the benefits of influenza vaccination extend to patients and family members, even if the employees themselves do not exhibit substantial symptoms of infection.
It was also of concern that 7 pregnant nurses identified their obstetricians as sources of advice to avoid influenza vaccination. This occurred despite the fact that pregnant women are one of the populations targeted by the CDC as being at increased risk for severe complications from influenza infection.5 We plan to address this in the upcoming season by instituting educational programs aimed at healthcare providers who care for high‐risk patients, such as pregnant women.
Implementing use of a declination statement during the 2006‐2007 influenza season was one of several measures that were introduced and that led to a 55% increase in the rate of acceptance of influenza vaccination by employees in our healthcare system. It also helped to identify areas for which additional education will be required to approach universal acceptance of vaccination. Although it is possible that the use of the declination form contributed to the perception that employees were being coerced into accepting vaccination, our overall conclusion was that the form made a positive contribution to the vaccination program.
The use of a declination form can be viewed as a compromise between voluntary and mandatory vaccination—or as a transitional phase between voluntary and mandatory vaccination. Given our success in increasing rates of vaccination and our desire to provide a safe environment for patients, we anticipate a transition to mandatory influenza vaccination. Future campaigns will also involve physician participation.
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