As we are nearing 2020, it’s a fair question to check in on how close the nation is to reaching the targets set by Healthy People 2020. Perhaps the more important question is how these goals may be creating a discriminatory class system separating the vaccinated versus the unvaccinated in the workplace.

National Crusade for Mandatory Workplace Vaccination

Many consider the workplace mandate for annual influenza vaccinations the most disturbing piece of the Healthy People 2020 agenda. The objective calls for mandatory flu shots as a condition of employment among 90% of health care workers.

In 2012, monumental federal actions prompted some movement toward that goal. The Centers for Medicare and Medicaid Services implemented a final rule requiring hospitals to report vaccination rates, tying these rates to Medicare reimbursement.1 Additionally, the U.S. Department of Health and Human Services’ National Vaccine Advisory Committee approved recommendations urging health care facilities to consider mandatory flu vaccination policies as a condition of employment.2

Despite federal actions, many high-profile groups representing health care workers continue to be divided on flu vaccine mandates. The National Nurses Union, the largest nurses union in the country, for example, publicly oppose mandatory vaccinations for health care workers,3 while the American Nurses Association regularly speaks out in support.4

But the division does not stop the bullying and humiliation tactics used nationwide to discriminate against health care workers declining to get influenza vaccine, a vaccine that for the past three flu seasons federal health officials admit has had an effectiveness rate of at best 47% to 62%.5 In addition, influenza vaccine-related injuries and deaths are the number one most compensated vaccine injury claim for adults in the federal vaccine injury compensation program (VICP).6

Just Shy of a Full-Scale National Flu Vaccine Mandate

What started as small steps has evolved into a full-on war on autonomy, personal and religious freedoms and protection of bodily integrity.

Overall, 13 states require or recommend an annual flu shot for workers in hospital and other medical settings. California was the first state to require hospitals to offer free flu vaccines to all employees and require those who decline to sign a form stating their refusal.7 In 2013, Rhode Island became the first state to implement one of the tougher mandatory flu vaccines for health care personnel. During periods deemed as “widespread flu outbreak,” individuals must receive a flu vaccine or face citations of “unprofessional conduct” against their license and a $100 fine.8

The heavy-handed approach from federal agencies and states has trickled down to individual policies in the medical settings. In 2005, only a few hospitals mandated flu vaccines across the country. The number grew to more than 400 in 2011.9

During the 2014-15 influenza season, 40.1% of health care personnel reported a requirement from their employer to receive the flu vaccine, according to a nonrandom Internet survey including 1,914 individuals. The requirement was most common in the hospital setting (64.8%) and least common in the long-term care setting (26%). Conversely, during the 2011-12 flu season, only 20.9% of health care professionals reported such a mandate from their employer.10

Hundreds of workers have been fired nationwide for opting out of the flu vaccination when their employer required inoculation. In 2012, TriHealth, the largest employer in Cincinnati, Ohio, terminated 150 employees who did not comply with their flu vaccine mandate.11

Christiana Care Health System, the largest private employer in Delaware, pins workers with “I’m vaccinated” badges to outcast unvaccinated workers. Vaccinated workers also receive credit toward an annual bonus, while those who opt out of vaccination must wear face masks during any patient interaction.12

Kaiser Permanente incorporated a flu vaccination policy into its three-year agreement with the Coalition of Kaiser Permanente Unions. The agreement, which went into effect October 1, 2015, mandates free seasonal flu vaccination for the 105,000 Kaiser Permanente workers in seven states and the District of Columbia represented by the hospital unions. Unvaccinated workers must sign a refusal form and are required to wear a surgical face mask during flu season while working in patient care areas.13

Workers Left Without a Choice

It is very apparent these strong-arm tactics have gone a long way to bully many health care workers into getting annual flu shots.

The CDC has reported an increase the rate of flu vaccination among health care personnel year after year. According to their 2015 online survey, 77.3% reported receiving the influenza vaccine during the 2014-15 season.14 In comparison, vaccination rates among health care workers more than a decade earlier were as low as 35.8% according to 2000 National Health Interview Survey data on 1,651 health care workers.15

The problem with this—besides the fact that people are being stripped of their most basic informed consent rights—is that there may be no impact from the mandates because there comes a point when there is no real return on preventing influenza in the workplace by requiring flu shots for all employees.

Limited Effect of Vaccination on Influenza Incidence Rates

A September 2015 retrospective study revealed that once health care worker vaccination rates plateau and reach 50% in the workplace, there is no further drop in influenza rates. The study assessed the nosocomial influenza rate during five flu seasons at the University of New Mexico Health Sciences Center in relation to vaccination rates among the center’s health care personnel. Researchers reviewed rates of influenza (defined as infections diagnosed at least 48 hours after hospital admission for influenza-like illness) from 2010 to 2015. Overall, there were 523 admissions with a confirmed influenza diagnosis.

Also during this time period, rates of vaccination increased from 47% to 96%. However, analysis revealed that despite an initial decrease in influenza rates from 9% to 4.9% during the first year, subsequent seasons showed no additional decrease in infections (4.3%, 5.2% and 5.1%, respectively). Overall, the decrease in influenza rates from the first to the final season was deemed non-significant.16

“It’s not that we should stop vaccinating,” study researcher Brandon Dionne told Medscape, “but we should be focusing on other interventions … like hand-washing.” He added, “At a certain point, you don’t have a real return on vaccination for reducing nosocomial flu.”17


  1. Federal Register. Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2012. Final Rule by Centers for Medicare & Medicaid Services Nov. 4, 2011.
  2. Wrangham T. Labor Unions Oppose Mandatory Flu Shots as AMA Cherry-Picks Ethics to Endorse Vaccine Mandates. NVIC Newsletter Aug. 21, 2012.
  3. National Nurses Union. Largest National Nurses Union Opposes Mandatory Flu Vaccination as Condition of Employment. Press Release Feb. 8, 2012.
  4. American Nurses Association. American Nurses Association Makes New Recommendation That All Nurses Should Be Immunized Against Vaccine-Preventable Diseases. Press Release Aug. 20, 2015.
  5. CDC. Seasonal Influenza: Past Flu Seasons (2006-2014). Aug. 26, 2014.
  6. HRSA. Vaccine Injury Compensation Program Data & Statistics.
  7. Buck C. Mandatory flu shots for Kaiser hospital employees in new 3-year contract.The Sacramento Bee Oct. 1, 2015.
  8. Devine DJ. Vaccines & Viruses: Nurses who refuse flu shots must wear masks. World Mag Sept. 29, 2015.
  9. Tanner L. Hospitals crack down on workers who refuse flu shots. Associated Press Jan. 13, 2013.
  10. Black CL, Yue X, Ball SW, et al. Influenza Vaccination Coverage Among Health Care Personnel—2014-15 Influenza Season. MMWR Sept. 18, 2015.
  11. WLWT15. TriHealth fires 150 employees for not getting flu shots. Nov. 27, 2012.
  12. Fox M and Derenowski J. Hospital Beats Flu Vaccine Procrastinators With In-Your-Face Effort. NBC News Oct. 18, 2015.
  13. Kaiser Permanente. Kaiser Permanente and Coalition Unions Join Forces to Protect Patients and Workers From the Flu. Press Release Sept. 30, 2015.
  14. See Footnote 8.
  15. King WD, Woolhandler SJ, Brown AF, et al. Brief report: Influenza vaccination and health care workers in the United States. Journal of General Internal Medicine 2006;21:181-4.
  16. Dionne B, Brett M, Culbreath K, et al. Limited Effect of Healthcare Worker Influenza Vaccination Rates on the Incidence of Nosocomial Influenza Infections. Interscience Conference of Antimicrobial Agents and Chemotherapy (ICAAC) 2015. Abstract I-296 Sept. 18, 2015.
  17. Johnson K. Benefit of Healthcare Worker Flu Shots Questioned. Medscape Sept. 22, 2015.