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Mandatory Shots: Should Hospitals Force Health Care Workers to Get the Flu Vaccine?

The views expressed are those of the author and are not necessarily those of Scientific American.

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A growing number of U.S. hospitals now compel health care workers to get vaccinated against the flu and other infectious diseases to protect patients from communicable diseases. In the case of the flu, the need is obvious: hospitalized patients who become infected have an elevated risk of developing complications or dying.

Yet the vaccination requirement is not universal across all hospitals, and some health care worker unions object to such demands. A range of findings, however, suggest that the benefits of compulsory vaccination outweigh the downsides.

In my first investigation of disease outbreak, when I worked at the Centers for Disease Control, five newborns contracted whooping cough in a neonatal intensive care unit (NICU) where coughing health care workers who had not been vaccinated against the disease had exposed 40 babies to the illness. The study could not prove that the health workers caused the disorder in the babies—visitors or others could have been the vector. But a link seemed highly likely.

Other disease outbreaks have been traced more firmly to unvaccinated health care workers, particularly in the case of influenza. In 1998, two patients died and 25 were sickened with flu at Memorial Sloan-Kettering Cancer Center in New York. The deaths occurred in the hospital’s bone marrow unit. Only 12 percent of health care workers in the unit at the time had been vaccinated against the flu. In another fatal flu outbreak, one baby died and 19 were sickened in a Canadian neonatal intensive care unit. Only 15 percent of health care workers were vaccinated.

These unvaccinated health care workers weren’t breaking any laws. Indeed, many states have no laws requiring hospital employees, even those working in a NICU, to be vaccinated against whooping cough or other infectious diseases. Ten states require hospital employees to get the vaccine that protects against measles, mumps and rubella. Only three states mandate flu shots for hospital workers.

The CDC has recommended since 1984 that health care workers receive the flu vaccine, but less than three quarters of healthcare workers got a flu shot in 2011. Now more hospitals are taking the matter into their own hands and establishing mandatory flu vaccination policies. That approach may be the more effective way to go. A recent study shows that hospital policy mandating vaccination gets better results than state policy does. Researchers at the University of Pittsburgh found hospital mandates were associated with a 3–12 percent increase in health care worker vaccinations whereas state laws did not result in a significant increase.

The Children’s Hospital of Philadelphia mandated the flu vaccine for its employees in 2009. They saw health care worker vaccination coverage rise from 90 percent to nearly 100 percent. The hospital administration feared a mass exodus of staffers and was reassured to see very few leave.

“We’re a big institution,” says Susan Coffin, associated director at the center for pediatric clinical effectiveness who helped devise the policy. “We employ around 10,000 people and in the first year nine people declined the vaccine.”

Loyola University Medical Center in Illinois was also an early adopter of mandatory flu vaccinations. When it implemented the policy in 2009, one employee out of nearly 8,000 declined the vaccine and left the hospital. Loyola has boasted employee flu vaccination rates of 99 percent ever since.

Johns Hopkins Health System in Maryland employs around 25,000 people. Less than one percent declined the flu vaccine after they implemented a policy mandating the flu vaccine last year. Many medical centers in Baltimore have followed their example.

“When we looked at the literature there was evidence that with the type of work we were doing and the type of patients we’re looking after, it was our ethical duty to do this,” says Trish Perl, senior epidemiologist at Johns Hopkins Health System. Some hospitals have seen patient mortality decrease by up to 40 percent following the mandatory vaccination of health care workers.

Still, some health care worker unions are taking legal action to block such policies.

The National Union of Nurses and Hospital Employees stalled a University of New Mexico mandatory vaccine policy last month. The complaint prevents the university from firing employees who refuse the vaccine.

When New York State mandated flu vaccinations for health care workers in 2009, unions obtained a court injunction that stopped the mandate. This year, New York responded by requiring unvaccinated health care workers to wear masks during flu season.

The New York State Nurses Association opposed the 2009 mandate and disagrees with the mask rule. It argues that nurses who choose not to be vaccinated should instead receive paid sick leave when they are ill.

“The best way to protect patients and stop the spread of flu is to let nurses stay home when we are sick,” said Carol Lynn Esposito, director of Nursing Practice, in an emailed statement.

But some studies show that viral shedding can occur before a person develops flu symptoms. A report by the Children’s Hospital of Philadelphia (pdf) states that a person can transmit the influenza virus 24 hours before they feel ill.

For now, patients will have to rely on contacting hospitals directly to learn about specific health care worker vaccination policies. The CDC and Health Resources and Services Administration have yet to collect these data.

Until that information is available, “Have you been vaccinated against measles, mumps, rubella, influenza and whooping cough?” should be every patient’s first question.

Seema Yasmin About the Author: Dr. Seema Yasmin is a professor of public health at the University of Texas at Dallas and a staff writer at The Dallas Morning News.

The views expressed are those of the author and are not necessarily those of Scientific American.

Comments 29 Comments

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  1. 1. David Cummings 12:11 pm 12/23/2013

    Interesting (and sad) that Carol Lynn Esposito, director of Nursing Practice, is so abysmally ignorant on the subject of how diseases are spread.

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  2. 2. Uncle.Al 1:39 pm 12/23/2013

    Embrace halcyon ephemerides of administrative omniscience. OBEY

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  3. 3. Vence1953 5:30 pm 12/23/2013

    My last pay check was $9500 working 12 hours a week online. My sisters friend has been averaging 15k for months now and she works about 20 hours a week. I can’t believe how easy it was once I tried it out. This is what I do,,,,,,Rush64.COM

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  4. 4. larkalt 5:45 pm 12/23/2013

    It seems incredible to me that there would even have to be a conflict about vaccinations for health care workers.
    If they don’t want to get vaccinated they should be in another line of work. Unless possibly if they have a medical reason why they can’t get vaccinated – but few people do.
    Hospitals have a reputation for being dangerous. But the patients don’t have a choice about being there and sick people are more endangered by infections than healthy people. A doctor who makes a patient sick by coughing near them, is doing a bad job as a doctor.

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  5. 5. msprivatematters 8:53 pm 12/23/2013

    As a healthcare worker I AM NOT YOUR DROID. You do not get to tell me how to handle my body. You have no knowledge of the condition of my immune system. If you feel the Oraellian right to do so then you must ban cigarettes and alcohol, put governors on all engines, wrap your children in bubble wrap and take them away from parents since the are not qualified to raise them, punish people for obesity – are you getting the drift yet? If you start by treating me like an object, where will it stop? You have crossed a dangerous line of freedom here. I suggest you take an ideological step back.

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  6. 6. msprivatematters 9:05 pm 12/23/2013

    Do any of you know what is in a vaccine? Contents of that vial? Side effects? Are you “hoping” it’s not an attenuated virus? Most flu shots are an “educated guess” for the next year – is that what you put your faith and child’s health into? What about the heavy metals that used to be in them? What’s in them now? Shame on you for your blind faith and your children’s lives. I work with infection control people every day and have caught them out in more than one occasion for incorrect data, on one occasion during H1N1, that could have had disastrous effects on the staff. No one is infallible. Everyone needs to ask questions. Ask yourself this, does not disease die out in a natural death with or without interference from the medical profession? Do a little research on that…

    And as for a healthcare worker “making” someone sick, what about that old man coughing and hacking everywhere in the ER without covering his mouth or using a tissue. I am not the only vector possible. Check out your grocery cart next time you’re at the store. Take some swabs with you and see what grows – you know – swab the place where the customer plops her kid with the dirty diaper and then next you get to put your purse there. Or old man from above goes to get a jug of milk with that cart – and hasn’t washed his hands. How many old women with runny noses and soggy tissues are handling those apples before you buy them? Be careful where you point fingers.

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  7. 7. Alchemyguy 11:31 pm 12/23/2013

    Health care workers here (Alberta) are not compelled to get the flu shot, but if they refuse it and call in sick they do not get to use their sick time. No shot, no sick pay.

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  8. 8. Soccerdad 12:08 am 12/24/2013

    So it seems msprivatematters knows her immune system well enough to know that she doesn’t need certain vaccines. And yet she seems to have an unfounded fear of vaccines which will not only protect her, but more importantly the patients who trust her to care for them. No vaccine – no job caring for patients.

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  9. 9. larkalt 4:44 am 12/24/2013

    @msprivatematters We are talking about protecting people in hospitals. There must already be a “no smoking” policy in hospitals, at least for the employees. Also employees are not supposed to show up for work, drunk or high.
    The rest of your suggestions do not apply to protecting people in hospitals.
    Yes, hospitals are dangerous places for other reasons than healthcare workers not getting vaccinated. But the article did say,
    “Some hospitals have seen patient mortality decrease by up to 40 percent following the mandatory vaccination of health care workers”
    Do you think that it’s OK that an unvaccinated health care worker causes an increased chance of death in sick patients?

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  10. 10. David Cummings 8:57 am 12/24/2013

    What? You’re going to make me wash my hands after I go to the bathroom? How dare you! As a health-care union member, I have rights! No one else knows the condition of my skin! No one can force me to use soap! Soap is stress!

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  11. 11. Peter65 1:26 pm 12/24/2013

    @msprivatematters I think that I am entirely justified in not wanting unvaccinated healthcare workers attending me in hospital. As far as your alleged health work is concerned your body is just another piece of equipment and you need to do what you can to prevent it spreading infections to people. From your ignorant ill informed and irrelevant ranting I doubt that you are a health care worker, if I am wrong then some one with your level of ignorance about vaccination and epidemiology is not fit to work in a hospital.

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  12. 12. bigtruck797 3:56 pm 12/24/2013

    I don’t want anyone too stupid to get a flu shot taking care of me in the hospital!

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  13. 13. hartson 5:50 pm 12/24/2013

    Last time I got a flu shot, I got the flu.

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  14. 14. jmanderson78 1:46 am 12/25/2013

    I’m a little surprised at the amount of faith people seem to have in the flu vaccine. As @msprivatematters mentioned, it’s just an “educated guess” since the virus constantly mutates and there is no way of knowing for sure what strain will emerge for the coming flu season. The hospital where I work has a mandatory flu vaccination policy, but unfortunately that doesn’t mean either healthcare workers or patients are safe from the current flu virus.

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  15. 15. larkalt 4:52 am 12/25/2013

    Vaccines in general aren’t 100% effective, but they are still recommended.
    It’s like driving with your seatbelt on – you still might get killed in a car accident, but it’s less likely, so it’s still a good idea.
    The flu vaccine takes several weeks to prevent flu, and you might get the flu anyway but it will be less severe.
    As msprivatematters said, you could still die from an infection in a hospital even if all the workers there are vaccinated. But it would be less likely, which is a good thing.

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  16. 16. jonhuie 1:40 pm 12/25/2013

    It is shocking that this is even a question. It is obvious that hospital workers must receive all vaccines that protect the patients – and also that protect the workers. There is no place here for personal choice – other than the choice to work in a place other than a hospital, health care environment, restaurant, or anywhere else with contact to food or people.

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  17. 17. David Cummings 1:47 pm 12/26/2013

    Saying that hospital workers don’t need to get vaccinated since someone else in the waiting room might sneeze on you is so incredibly stupid that it should be grounds for permanent disqualification as a healthcare worker.

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  18. 18. hkraznodar 4:36 pm 12/26/2013

    @Uncle.Al – Please die and make the world a better place. Your sociopathic comments add nothing to the discussions and are frequently quite offensive to pretty much everyone.

    @vence1953 – I hope SciAm tracks you down and bills you for advertising your illegal scammer site on a discussion forum they run.

    @msprivatematters – Fine by me but then if you are unvaccinated and even 1 person at your facility dies, you have to get your blood tested and if you carry the disease or its antibodies you clearly are the source of the death and are thus guilty of first degree murder. In my state that carries the death penalty.

    @hartson – Yeh, me too. Thing is it was pretty mild. Just to be clear, the flu does not impact your digestive system in any way. It only affects breathing. If you had any non-respiratory related symptoms then it wasn’t flu. (fever and muscle pain can be respiratory symptoms)

    @jmanderson78 – Better an educated guess than sitting around doing nothing. If you lived in an area with a high incidence of drive by shootings, would you prefer bullet proof windows or regular windows? Sure a bullet could come through the wall but the ones that hit the window wouldn’t come through and there wouldn’t be flying glass either. Some of us actually understand statistical probability.

    @jonhuie – Most restaurants require their sick employees to work anyway. The higher the price of the food the less likely it is but I have yet to find a fast food place that pays sick employees to stay home.

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  19. 19. befreekillyourtv99 11:14 pm 12/26/2013

    @msprivatematters: thank you for speaking the truth. Most people are too brainwashed to even acknowledge the possibility that influenza vaccination could be pointless and actually dangerous. I was unfortunate to let myself be swayed by peer pressure at my workplace (hospital) a few years ago and suffered a horrible anaphylactic reaction…Never again will I subject my body to such an invasion of toxins! After doing some research I found that there are plenty of scientists and doctors that don’t agree with all influenza vaccine propaganda that we are bombarded with…in fact, there are studies that show that flu shots do more harm than good but of course these are rejected and never discussed. Could it be these mandatory vaccination policies are actually influenced by financial interests? No of course not, the pharmaceutical companies would never stoop that low…right?

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  20. 20. RemmegC 5:31 pm 12/27/2013

    @msprivatematters — you should just be fired from your healthcare position. You are clueless when it comes to disease control and your red herring argument was so idiotic; I laughed until my mascara ran. It was a good chortle. What I would suggest is a script for some anti-psychotics for your paranoia.

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  21. 21. RemmegC 5:37 pm 12/27/2013

    @befreekillyourself I think you are one of those doomsday preppers. You most likely didn’t read the informed consent and had an allergy. Too bad you got treated in time for you anaphylaxis. The world would be a better place without you as well. You are the type that spreads ignorance.

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  22. 22. larkalt 8:10 am 12/29/2013

    Is your anger actually at the anti-vaxxer, or something else?
    The anti-vaxxers are unlikely to show up to read responses, especially when the responses may contain verbal violence.
    If you are really angry at something else, it might be important for you to discover what that is.
    Also, why do you associate “doomsday preppers” with anti-vaxxers?
    Do you consider it crazy for someone to think society might collapse?

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  23. 23. ceres 7:05 am 12/30/2013

    I think that so-called doomsday preppers are MORE likely to be get recommended vaccines for themselves and their families than the anti-vaccination types. Society won’t collapse because of good infectious disease control. It could collapse due to epidemics of highly contagious conditions like measles or polio though! Anti-vaccination people are the ones to be afraid of.

    Those nurses in the union in New York State should be ashamed of themselves. I was just reading last week about the brave polio vaccination workers in Pakistan. The government must assign armed escorts to protect them because of Taliban attacks. The nurses in New York State, and @msrivatematters too,, should go live with the Taliban, as the Taliban is against vaccination.

    Vaccination compliance is better in poorer areas of the U.S.A. than the coastal cities. Prevalence of unvaccinated children is highest, and rising, in ultra wealthy enclaves e.g. in Los Angeles, maybe New York City. Measles outbreaks are also on the rise.

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  24. 24. RemmegC 11:03 am 12/30/2013

    @Ceres, finally a voice of reason. You are correct, society will collapse when the public health infrastructure is compromised. Which is why, for all those “anti-vaxxers” out there, working inside a hospital where you are dealing with a society that is immunocompromised – it is your duty to be vaccinated to protect your patients.

    @larkalt, it is the similar attitude that anti-vaxxers and doomsday preppers that I find sensationally stupid. They are uninformed and spread wrong information. I am not angry I am just telling the truth. The collosal ignorance of befree and msprivatematters is what I find appauling. Especially, as supposed “healthcare professionals.” They are spreading very poor and inaccurate information.

    There are public health workers who put their lives on the line (polio vaccination workers in Pakistan) everyday doing surveillance on your food and water resources and watching for outbreaks so that you and your families can live in a healthy environment. Who do you think are the first responders when a terrible outbreak hits? Another imperative point to bring up; why do you think childhood diseases are back on the rise again? Ceres, makes an excellent point. Things like the black plague, swine flu, polio, small pox, measles, pertussis and tetanus are just a few diseases our society no longer suffers from because of vaccines. The day I see the raw data (which doesn’t lie) that vaccines are not effective and it is published in a peer reviewed journal and adopted as a clinical practice, only then will any of you “anti-vaxxers” will have a leg to stand on. Until then, I think it’s time for all of you to get informed and stop living with your heads up your ass.

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  25. 25. larkalt 10:29 am 12/31/2013

    I’m not an anti-vaxxer. I asked the questions I did, because of the verbal violence in your initial posting.
    If you are not angry, you should know that verbal violence will only harden anti-vaxxers in their position. Really – studies have shown that vicious or violent comments online harden people in whatever attitude they initially had.
    When people change their minds, they do so when they feel safe. It allows contemplation.
    Also, your verbal violence makes people who are in favor of vaccination look bad.
    Sciam apparently leaves it up to bloggers to moderate the comments on their posts. But this blogger isn’t doing this, which is too bad.

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  26. 26. SYasmin 9:32 pm 01/3/2014

    Clearly there are very strong beliefs on both sides of the vaccinate/don’t-vaccinate fence. Verbal violence will not convince folks on any side of the debate. I ask that we respect each other’s opinions in the hopes of engaging in a useful conversation that we can all learn from.

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  27. 27. 7Valleys 9:31 pm 01/10/2014

    “Health Care Worker” simply means employed by a hospital. Researchers miles away from the hospital they work for, who never set foot in the Hospital let alone see a patient, are “health care workers.” IT people who work in the data center across town are “health care workers.” It’s an extremely broad category.

    In general health care workers who have contact with patients are vaccinated, it’s those that work a job that has nothing to do with patients that are the real issue. Is it really necessary to force someone who sits in a non-descript office building coding websites to get a flu vaccine?

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  28. 28. 7Valleys 9:37 pm 01/10/2014


    Two comments, one, the vaccination program in Pakistan was a coverup for a CIA operation to catch Bin Laden, so probably not a good argument for anything. And Two, the end of the Black Death came centuries before vaccination, and it’s ending is really an example of the effectiveness of genetic adaption not vaccination.

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  29. 29. rogerwaxjr 12:38 pm 01/27/2014

    After losing my cousin this week to H1N1, me and my entire family have been doing a lot of research on how to keep our family safe from contracting anything to do with influenza or the flu!! You always see it on the news, but when it hits home… wow! you never expect it.We have been trying the standard things like washing our hands, but also wanted to find a way to make sure that that our houses are clean and germ free as well. We did some research and just purchased this cleaning product called Saniguard from Has anyone ever used this product? Everything we have read so far has been great, but we can’t find any testimonials. Any feed back would be great! Thanks and best wishes to everyone and God bless Love you cuzz

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