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Figure.  Changes in Health Care Personnel Influenza Vaccination Mandate by VA Status
Changes in Health Care Personnel Influenza Vaccination Mandate by VA Status

VA indicates Veterans Affairs.

Table 1.  Hospital Characteristics by VA Status and Survey Year
Hospital Characteristics by VA Status and Survey Year
Table 2.  Non–Veterans Affairs Hospitals Health Care Personnel Influenza Vaccination Mandate by Survey Year and Hospital Characteristic
Non–Veterans Affairs Hospitals Health Care Personnel Influenza Vaccination Mandate by Survey Year and Hospital Characteristic
Table 3.  Aspects of Hospital Health Care Personnel Annual Influenza Vaccination Policies in 2017
Aspects of Hospital Health Care Personnel Annual Influenza Vaccination Policies in 2017
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Infectious Diseases Society of America; Society for Healthcare Epidemiology of America; Pediatric Infectious Diseases Society. IDSA, SHEA, and PIDS joint policy statement on mandatory immunization of health care personnel according to the ACIP-recommended vaccine schedule. http://www.idsociety.org/uploadedFiles/IDSA/Policy_and_Advocacy/Current_Topics_and_Issues/Immunizations_and_Vaccines/Health_Care_Worker_Immunization/Statements/IDSA_SHEA_PIDS%20Policy%20on%20Mandatory%20Immunization%20of%20HCP.pdf. Published December 2013. Accessed March 26, 2018.
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US Department of Veterans Affairs. VHA directive 1192: seasonal influenza prevention program for VHA health care personnel. https://www.publichealth.va.gov/docs/flu/VHA_Directive_1192_Sep2017.pdf. Published September 26, 2017. Accessed March 26, 2018.
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De Serres  G, Skowronski  DM, Ward  BJ,  et al.  Influenza vaccination of healthcare workers: critical analysis of the evidence for patient benefit underpinning policies of enforcement.  PLoS One. 2017;12(1):e0163586.PubMedGoogle ScholarCrossref
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Amodio  E, Restivo  V, Firenze  A, Mammina  C, Tramuto  F, Vitale  F.  Can influenza vaccination coverage among healthcare workers influence the risk of nosocomial influenza-like illness in hospitalized patients?  J Hosp Infect. 2014;86(3):182-187.PubMedGoogle ScholarCrossref
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Carman  WF, Elder  AG, Wallace  LA,  et al.  Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial.  Lancet. 2000;355(9198):93-97.PubMedGoogle ScholarCrossref
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Hayward  AC, Harling  R, Wetten  S,  et al.  Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial.  BMJ. 2006;333(7581):1241.PubMedGoogle ScholarCrossref
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Lemaitre  M, Meret  T, Rothan-Tondeur  M,  et al.  Effect of influenza vaccination of nursing home staff on mortality of residents: a cluster-randomized trial.  J Am Geriatr Soc. 2009;57(9):1580-1586.PubMedGoogle ScholarCrossref
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Potter  J, Stott  DJ, Roberts  MA,  et al.  Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients.  J Infect Dis. 1997;175(1):1-6.PubMedGoogle ScholarCrossref
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Ahmed  F, Lindley  MC, Allred  N, Weinbaum  CM, Grohskopf  L.  Effect of influenza vaccination of healthcare personnel on morbidity and mortality among patients: systematic review and grading of evidence.  Clin Infect Dis. 2014;58(1):50-57.PubMedGoogle ScholarCrossref
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Thomas  RE, Jefferson  T, Lasserson  TJ.  Influenza vaccination for healthcare workers who care for people aged 60 or older living in long-term care institutions.  Cochrane Database Syst Rev. 2013;(7):CD005187.PubMedGoogle Scholar
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Wang  TL, Jing  L, Bocchini  JA  Jr.  Mandatory influenza vaccination for all healthcare personnel: a review on justification, implementation and effectiveness.  Curr Opin Pediatr. 2017;29(5):606-615.PubMedGoogle ScholarCrossref
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Talbot  TR.  Update on immunizations for healthcare personnel in the United States.  Vaccine. 2014;32(38):4869-4875.PubMedGoogle ScholarCrossref
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Dubov  A, Phung  C.  Nudges or mandates? the ethics of mandatory flu vaccination.  Vaccine. 2015;33(22):2530-2535.PubMedGoogle ScholarCrossref
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Black  CL, Yue  X, Ball  SW,  et al; Centers for Disease Control and Prevention (CDC).  Influenza vaccination coverage among health care personnel—United States, 2013-14 influenza season.  MMWR Morb Mortal Wkly Rep. 2014;63(37):805-811.PubMedGoogle Scholar
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Black  CL, Yue  X, Ball  SW,  et al.  Influenza vaccination coverage among health care personnel—United States, 2014-15 influenza season.  MMWR Morb Mortal Wkly Rep. 2015;64(36):993-999.PubMedGoogle ScholarCrossref
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Polgreen  PM, Chen  Y, Beekmann  S,  et al; Infectious Diseases Society of America’s Emerging Infections Network.  Elements of influenza vaccination programs that predict higher vaccination rates: results of an emerging infections network survey.  Clin Infect Dis. 2008;46(1):14-19.PubMedGoogle ScholarCrossref
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Simeonsson  K, Summers-Bean  C, Connolly  A.  Influenza vaccination of healthcare workers: institutional strategies for improving rates.  N C Med J. 2004;65(6):323-329.PubMedGoogle Scholar
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Talbot  TR, Dellit  TH, Hebden  J, Sama  D, Cuny  J.  Factors associated with increased healthcare worker influenza vaccination rates: results from a national survey of university hospitals and medical centers.  Infect Control Hosp Epidemiol. 2010;31(5):456-462.PubMedGoogle ScholarCrossref
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Centers for Medicare & Medicaid Services.  Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and FY 2012 rates; hospitals’ FTE resident caps for graduate medical education payment, 42 CFR parts 412, 413, and 476. Vol 76. Washington, DC: Department of Health and Human Services; 2011. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2012-IPPS-Final-Rule-Home-Page-Items/CMS1250103.html.
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Lindley  MC, Bridges  CB, Strikas  RA,  et al; Centers for Disease Control and Prevention.  Influenza vaccination performance measurement among acute care hospital-based health care personnel—United States, 2013-14 influenza season.  MMWR Morb Mortal Wkly Rep. 2014;63(37):812-815.PubMedGoogle Scholar
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Centers for Disease Control and Prevention.  Interventions to increase influenza vaccination of health care workers—California and Minnesota.  MMWR Morb Mortal Wkly Rep. 2005;54(8):196-199.PubMedGoogle Scholar
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    2 Comments for this article
    EXPAND ALL
    Why Not More of an Increase?
    Frederick Rivara | University of Washington, Seattle
    While the increase in vaccination requirements is heartening, I am surprised that it is not much closer to 100%, both to protect the health care workforce during the busy respiratory season as well as to protect patients.
    CONFLICT OF INTEREST: Editor, JAMA Network Open
    Response to "Why not more of an increase?"
    Todd Greene, PhD, MPH | Veterans Affairs Ann Arbor Healthcare System and Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI.
    Thanks for the question! Although there has been a significant increase in vaccination mandates, particularly in non-VA hospitals, mandates are likely not 100% for a number of reasons. First, as noted in the article and invited commentary, some ambiguity surrounding what constitutes a "mandate" may have led to underreporting. Second, the data regarding both influenza vaccine effectiveness and transmission of influenza between health care personnel (HCP) and patients is not as robust as we would like. Interestingly, a recent paper by Frederick et al. (Infect Control Hosp Epidemiol 2018;39:452–461) showed mandatory HCP vaccination facilities had higher vaccination coverage and lower symptomatic HCP absenteeism. Finally, other voluntary approaches have been shown to be effective at ensuring that HCP receive the annual vaccination.
    CONFLICT OF INTEREST: Lead author
    READ MORE
    Original Investigation
    Infectious Diseases
    June 1, 2018

    Changes in Influenza Vaccination Requirements for Health Care Personnel in US Hospitals

    Author Affiliations
    • 1Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
    • 2Patient Safety Enhancement Program, Veterans Affairs Ann Arbor Healthcare System/University of Michigan, Ann Arbor
    • 3Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
    JAMA Netw Open. 2018;1(2):e180143. doi:10.1001/jamanetworkopen.2018.0143
    Key Points español 中文 (chinese)

    Question  How has the proportion of US hospitals requiring receipt of annual influenza vaccination among health care personnel changed in recent years?

    Findings  In this national survey study, which included responses from 1062 infection preventionists at both Veterans Affairs and non–Veterans Affairs hospitals between the 2013 and 2017 calendar years, required influenza vaccinations among health care personnel increased from 37.1% to 61.4%; this change was driven by increases in non–Veterans Affairs hospitals.

    Meaning  Influenza vaccination mandates for health care personnel have increased in recent years, coinciding with concurrent increases in vaccination coverage among health care personnel.

    Abstract

    Importance  Annual influenza vaccinations are currently recommended for all health care personnel (HCP) to limit the spread of influenza to those at high risk of developing serious complications from the virus. Vaccination coverage has been shown to be significantly greater among employers requiring and encouraging HCP to receive the annual influenza vaccination.

    Objectives  To compare the proportion of respondent hospitals requiring HCP to receive annual influenza vaccination between 2013 and 2017 and to assess the degree to which these proportions differed between Veterans Affairs (VA) and non-VA hospitals.

    Design, Setting, and Participants  This national survey study included responses from 1062 infection preventionists between 2013 and 2017 from nationally representative samples of all VA and non-VA hospitals in the United States. Data analysis was conducted from November 17, 2017, to March 26, 2018.

    Main Outcomes and Measures  Survey response indicating hospital requirement for annual influenza vaccination of HCP.

    Results  The overall response rate for the 2013 survey was 69.3% (non-VA, 70.6% [403 of 571]; VA, 63.5% [80 of 126]) and in 2017 was 59.1% (non-VA, 59.1% [530 of 897]; VA, 58.9% [73 of 124]). Among all responding hospitals, mandatory influenza vaccination requirements for HCP increased from 37.1% in 2013 to 61.4% in 2017 (difference, 24.3%; 95% CI, 18.4%-30.2%; P < .001). This change was driven by non-VA hospitals, as requirement policies increased from 44.3% (171 of 386) in 2013 to 69.4% (365 of 526) in 2017 (difference, 25.1%; 95% CI, 18.8%-31.4%; P < .001). Conversely, there was no significant change during this period in the proportion of VA hospitals that required influenza vaccinations for HCP (1.3% [1 of 77] to 4.1% [3 of 73]; difference, 2.8%; 95% CI, −2.4% to 8.0%; P = .29).

    Conclusions and Relevance  Despite a substantial increase in mandates among non-VA hospitals, we found that many non-VA hospitals and nearly all VA hospitals are still not currently mandating influenza vaccinations for HCP. In addition to implementing other well-described strategies to increase vaccination rates, health care organizations should consider mandating influenza vaccinations while appropriately weighing and managing the moral, ethical, and legal implications.

    Introduction

    Annually, influenza accounts for significant morbidity, mortality, and cost burden.1 Since the 2010 to 2011 influenza season, estimates indicate that seasonal influenza-related illnesses ranged from 9.2 million to 35.6 million, with up to 710 000 hospitalizations leading to as many as 16.7 million medical visits and up to 20 000 pneumonia- and influenza-related deaths.2 Similar clinical and economic burdens were reported within the Veterans Affairs (VA) hospital setting.3,4 During the 2014 to 2015 influenza season, more than 11 500 confirmed cases and a hospitalization rate of 74.2 per 100 000 VA users were observed.4 Recent estimates of health care–associated influenza range between 1% and 5%.5,6 The Centers for Disease Control and Prevention Advisory Committee on Immunization Practices continues to recommend that all health care personnel (HCP) be vaccinated annually against influenza.7 Additionally, the US Department of Health and Human Services wants 90% of HCP vaccinated by 2020.8 During the 2016 to 2017 influenza season, an estimated 78.6% of all HCP received the annual influenza vaccination, with the highest coverage rates found among HCP required by their employer to be vaccinated (96.7%).9

    Although multiple national recommendations urge influenza vaccination for all HCP,10 not all health care facilities mandate its receipt. As part of the national surveys of infection preventionists (experts on practical methods of preventing and controlling the spread of infectious diseases) conducted in 2013 and 2017,11,12 we assessed the degree to which hospitals require HCP to receive annual influenza vaccination. As we were interested in determining how influenza vaccination requirements for HCP have changed in recent years, we compared the proportion of respondent hospitals requiring HCP to receive annual influenza vaccination, based on survey responses from 2013 and 2017. We also assessed the degree to which these proportions differed between VA and non-VA hospitals.

    Methods
    Survey Procedures

    This study was part of an ongoing panel survey in which we ask infection preventionists across the United States every 4 years what practices their hospitals are using to prevent common health care–associated infections.11 The study follows the American Association for Public Opinion Research (AAPOR) reporting guideline. For the first wave in 2005, the national random sample was selected by identifying all nonfederal, general medical, and surgical hospitals with an intensive care unit and at least 50 hospital beds using the 2003 American Hospital Association (AHA) database. Hospitals were then stratified in to 2 bed size groups (50-250 beds and ≥251 beds), and a random sample of 300 hospitals from each group was selected. For the second (2009) and third (2013) waves of the ongoing study, the survey was sent to the same hospitals sampled in 2005 with a few exceptions owing to closures or mergers between the longitudinal survey points. Because data from the 2003 AHA database may no longer reflect the current distribution of US hospitals, for the fourth (2017) wave we resampled based on AHA fiscal year 2013 data. In the fourth wave, we randomly sampled 900 general medical and surgical hospitals with an intensive care unit. Hospitals of all bed sizes were included in the 2017 sample. For each survey wave, we sent surveys to all VA hospitals across the United States. This study obtained institutional review board exemption from the University of Michigan and approval from the VA Ann Arbor Healthcare System. The VA survey was anonymous and was conducted with a waiver of signed informed consent.

    The study surveys were mailed to the hospital infection preventionist. At hospitals that employ more than 1 infection preventionist, we asked that the lead infection preventionist serve as the primary respondent, although we encouraged consulting with others as needed to complete the questionnaire. The survey process followed a modified Dillman approach,13 which included a first mailing of the survey, a reminder letter or postcard after approximately 2 weeks, and additional survey mailings at 4, 7, and 16 weeks to infection preventionists who had not yet responded.

    The survey instrument included questions about facility characteristics, the infection control program, infection preventionists, and frequency of use of practices related to the prevention of health care–associated infections. The third wave, distributed in May 2013, also included the question, “Are health care workers at your hospital who provide patient care required to receive influenza vaccination?” Respondents answering no to this question were asked to specify the reason HCP were not required to receive the influenza vaccination. The fourth wave, distributed in May 2017, included the question, “Does your hospital mandate health care workers to receive annual influenza vaccination?” along with questions regarding declination and requirements for wearing masks.

    Statistical Analysis

    As only the third and fourth waves of the survey included questions regarding influenza vaccination requirements for HCP, the current analysis compares responses from these waves. Descriptive statistics were generated for select general hospital characteristics obtained from the 2013 AHA survey and for the respective proportions of hospitals requiring annual influenza vaccination for HCP. Confidence intervals were calculated using Proc Freq (SAS Institute Inc) with the RISKDIFF statement, which gives the 95% Wald confidence interval based on asymptotic standard errors. To determine differences in proportions, we used the χ2 test. All tests were 2-sided with a P value less than .05 considered statistically significant. All analyses were conducted using SAS software version 9.4 (SAS Institute Inc).

    Results

    The overall response rate for the 2013 survey was 69.3% (non-VA, 70.6% [403 of 571]; VA, 63.5% [80 of 126]) and in 2017 was 59.1% (non-VA, 59.1% [530 of 897]; VA, 58.9% [73 of 124]). A comparison of respondent and nonrespondent characteristics for both waves of the survey is provided in the eTable in the Supplement.

    A total of 1062 hospitals (463 in 2013 and 599 in 2017) were included in this analysis; 24 hospitals (20 from 2013 and 4 from 2017) did not answer the influenza vaccination questions and were removed. Select hospital characteristics by VA status and survey year are shown in Table 1. Approximately 60% of VA hospitals that participated in this study were in rural locations (2013: 19 of 31 [61%]; 2017: 18 of 30 [60%]) and 80% were teaching hospitals (2013: 65 of 79 [82.3%]; 2017: 56 of 72 [77.8%]). There were some differences seen in the participating non-VA hospital demographic characteristics between 2013 and 2017. In 2017, there were fewer urban hospitals (2013: 300 of 358 [83.8%]; 2017: 413 of 528 [78.2%]; difference, −5.6%; 95% CI, −10.8% to −0.4%; P = .04) and teaching hospitals (2013: 161 of 400 [40.3%]; 2017: 170 of 528 [32.2%]; difference, −8.1%; 95% CI, −14.3% to −1.8%; P = .01). In 2017, non-VA hospitals also had a lower average number of hospital beds (mean [SD], 2013: 273.0 [214.3] beds; 2017: 202.6 [189.5] beds; difference, −70.3%; 95% CI, −96.8 to −43.8%; P < .001). Overall, the percentage of hospitals reporting mandatory influenza vaccinations for HCP increased from 37.1% in 2013 to 61.4% in 2017 (difference, 24.3%; 95% CI, 18.4%-30.2%; P < .001) (non-VA: 44.3% [171 of 386] in 2013 to 69.4% [365 of 526] in 2017; difference, 25.1%; 95% CI, 18.8%-31.4%; P < .001; VA: 1.3% [1 of 77] in 2013 to 4.1% [3 of 73] in 2017; difference, 2.8%; 95% CI, −2.4% to 8.0%; P = .29) (Figure).

    Table 2 shows differences in mandate presence by survey year and hospital characteristics among non-VA hospitals. Because too few VA hospitals mandated vaccinations, we were unable to stratify results among VA hospitals based on hospital characteristics. Differences in the reported presence of mandates by hospital characteristics were not observed among 2013 respondents from non-VA hospitals. In 2017, mandates for HCP influenza vaccinations were reported by a higher percentage of nonprofit hospitals compared with their for-profit counterparts (difference, 25.5%; 95% CI, 12.3%-38.8%; P < .001).

    Aspects of hospital influenza vaccination policies by mandate status for 2017 are shown in Table 3. All 368 hospitals mandating influenza vaccinations had allowable declinations. Of note, 94 of 366 hospitals (25.7%) with vaccination mandates in place did not impose penalties for noncompliance with the hospital policy on influenza vaccination. Among the 231 hospitals that reported not having a specific influenza vaccination mandate, 158 hospitals (68.4%) had policies for declination (non-VA: 75.2% [121 of 161]; VA: 52.9% [37 of 70]) and 94 hospitals (40.9%) had requirements for wearing masks (non-VA: 57.8% [93 of 161]; VA: 1.4% [1 of 69]).

    Discussion

    Several important findings emerged from our national survey study. First, compared with 2013, when less than half of hospitals mandated influenza vaccinations,12 there was a significant increase in hospitals mandating HCP receive vaccinations in 2017 among non-VA hospitals. Second, despite an increase in the proportion of non-VA hospitals mandating vaccinations, penalties for noncompliance with the hospital policy on influenza vaccination were not universal among hospitals with mandates. Third, few VA hospitals mandated receipt of HCP influenza vaccination, and we did not observe a significant change between 2013 and 2017. While the VA did not specifically mandate receiving influenza vaccinations at the time of the 2013 and 2017 surveys, a VA directive was subsequently released in September 201714 articulating that all HCP were expected to receive the annual influenza vaccination and were required to wear masks throughout the influenza season if unable or unwilling to get vaccinated.

    Mandating influenza vaccination remains a controversial topic, with uncertainty of the effectiveness of HCP influenza vaccination in reducing patient morbidity and mortality,6,15-20 different conclusions regarding the grading of the evidence,21,22 and numerous legal and ethical precedents to be carefully considered.23-26 Still, over the past several years, HCP influenza vaccination coverage rates have continuously been greater than 95% among HCP required by their employer to be vaccinated.9,27,28

    Although mandating influenza vaccinations intuitively leads to increased vaccination coverage of HCP, other strategies have proven to be successful. Strategies to promote influenza vaccinations, including influenza education for HCP, free and easily accessible vaccinations, annual influenza campaigns, incentives, signed declination policies, and using HCP vaccination rates as an organizational quality measure, have been well described.29-32 Starting January 2013, acute care hospitals participating in the Centers for Medicare & Medicaid Hospital Inpatient Quality Reporting Program were required to report HCP influenza vaccination data through the Centers for Disease Control and Prevention National Healthcare Safety Network program.33 Public reporting of vaccination data has been shown to increase vaccination coverage,34 and it is plausible that the increase in vaccination mandates observed in this study stems, at least in part, from the contemporaneous implementation of the Centers for Medicare & Medicaid public reporting ruling.

    We found that few VA hospitals explicitly mandated that HCP receive annual influenza vaccination. As outlined in the goals of the 2017 to 2018 VA influenza vaccination program,35 since the beginning of fiscal year 2013 VA facilities have been expected to gradually work toward the 2020 Healthy People goal of 90% influenza vaccination rate for HCP. Several VA hospitals have previously shown success in improving HCP vaccination rates in the absence of a national mandate. For example, the Minneapolis VA Health Care System in Minneapolis, Minnesota, improved vaccination rates from less than 25% to greater than 65% by implementing the use of mobile carts to facilitate the delivery of vaccinations.36 The Lebanon VA Medical Center in Lebanon, Pennsylvania, increased vaccination rates from approximately 50% to greater than 75% by offering time-off incentives to vaccine recipients.29 Regardless of whether an organization has an official mandate for vaccinations, establishing a written policy that states the organizational commitment to increasing vaccination rates is among the recommended strategies for improving vaccination coverage among HCP.29

    Limitations

    Our study had limitations. First, the survey response rates were 69% in 2013 and 59% in 2017, and our results may not be generalizable to all hospitals. Second, the updated 2017 responses were obtained from a different sample of hospitals than in previous waves, with a statistically significantly higher proportion of rural, nonteaching hospitals with smaller total bed sizes. Still, this updated sample is nationally representative, and we did not detect differences in the presence of vaccination mandates by these hospital characteristics. Third, it is possible that the observed increase in the proportion of non-VA hospitals mandating vaccinations between surveys could have partially stemmed from the slight difference in question wording. Of note, the 2013 survey question explicitly focused on HCP providing patient care, potentially leading to an underestimation of the vaccination requirement among all HCP. This may have been represented more in 2017 responses to the reworded question, which lacked explicit mention of patient care provision. In the 2017 survey, although the provision of patient care was not specified directly in our key question of interest, it was included in the question regarding the requirement for wearing a mask for HCP not receiving the influenza vaccination. As such, these details may have helped prompt the respondent to think of HCP providing direct patient care. Fourth, it is possible that our study of the proportion of hospitals having a mandate in place for HCP vaccination is underreported, as the presence of declination policies or requirement for wearing a mask could be considered mandates. However, this potential underreporting likely applied equivalently in both 2013 and 2017 survey years. Fifth, we did not collect influenza infection rate data for the surveyed hospitals. As such, we were not able to demonstrate whether influenza rates differed by mandatory vaccination status.

    Conclusions

    This 2017 US national survey found that more than two-thirds of non-VA hospitals mandate HCP influenza vaccination, which is a significant increase from 4 years prior. While HCP influenza vaccination in VA hospitals is strongly encouraged, as of summer 2017, less than 5% of VA hospitals mandated influenza vaccination for HCP providing care for veterans.

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    Article Information

    Accepted for Publication: April 12, 2018.

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Greene MT et al. JAMA Network Open.

    Corresponding Author: M. Todd Greene, PhD, MPH, Patient Safety Enhancement Program, Veterans Affairs Ann Arbor Healthcare System/University of Michigan, 2800 Plymouth Rd, North Campus Research Complex Bldg 16, Room 470C, Ann Arbor, MI 48109 (mtgreene@med.umich.edu).

    Author Contributions: Dr Greene and Mr Ratz had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Greene, Fowler, Saint.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Greene, Ratz.

    Critical revision of the manuscript for important intellectual content: Greene, Fowler, Krein, Bradley, Saint.

    Statistical analysis: Greene, Fowler, Ratz.

    Obtained funding: Krein, Saint.

    Administrative, technical, or material support: Fowler.

    Supervision: Greene, Saint.

    Conflict of Interest Disclosures: Dr Greene reported receiving grants from Blue Cross Blue Shield of Michigan Foundation and the US Department of Veterans Affairs Patient Safety Center of Inquiry during the conduct of the study. Ms Fowler reported receiving grants from the US Department of Veterans Affairs National Center for Patient Safety and Blue Cross Blue Shield of Michigan Foundation during the conduct of the study. Mr Ratz reported receiving grants from Blue Cross Blue Shield of Michigan Foundation during the conduct of the study. Dr Krein reported receiving grants from Blue Cross Blue Shield of Michigan Foundation and US Department of Veterans Affairs during the conduct of the study. Dr Saint reported receiving grants from Blue Cross Blue Shield of Michigan Foundation and US Department of Veterans Affairs during the conduct of the study as well as personal fees from Jvion and from Doximity outside the submitted work. No other disclosures were reported.

    Funding/Support: This study was supported by grant 2413.II from the Blue Cross Blue Shield of Michigan Foundation, grants from the US Department of Veterans Affairs (Dr Saint) and the Veterans Affairs National Center for Patient Safety–Funded Patient Safety Center of Inquiry (Drs Krein and Saint), and Veterans Affairs Research Career Scientist Award 11-222 (Dr Krein).

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Additional Contributions: Jason Engle, BS, Patient Safety Enhancement Program, assisted with conducting the survey mailing. He received no compensation.

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