1. Witt, Catherine L. MS, NNP-BC

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We are on the tail end of a particularly virulent flu season in the United States. Although this season may have been worse than others, the Centers for Disease Control and Prevention (CDC) estimates that each year more than 200,000 people are hospitalized with influenza and as many as 49,000 die, depending on the severity of the strain in a particular year.1 Yet despite this, vaccination rates remain low. According to the CDC, the flu vaccination rate in 2011 was highest among pharmacists (88.7%), and physicians (83.8%), with nurses at 81.5% and nurse practitioners/physician assistants at 73.3%.2

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Evidence has shown that one of the best ways to avoid spreading influenza is through vaccination in conjunction with other protective measures such as hand washing, staying home when ill, and avoiding contact with sick people.1-3 However, the influenza virus can be spread by an infected person before showing any symptoms of disease. This means that healthcare workers can be passing the virus to patients or coworkers even before they know they are infected. Patients, including the elderly and newborns, who are immune compromised are at particular risk of serious complications from influenza, including death.


It is not just the flu vaccine we should be worried about. This issue includes a case study of an infant with pertussis, a disease that has increased significantly over the last few years.4 The rise in pertussis is thought to be partly because of the waning immunity among those who have had the vaccine. Unfortunately, it can also be attributed to an increase in the number of parents who are choosing not to have their children vaccinated or are not following the recommended schedule for vaccines. Lack of familiarity with previously common communicable diseases leads consumers to focus on possible adverse effects, rather than on the benefits.5 Misinformation and myths abound, and the emotional power of a "story," however unsubstantiated, can outweigh statistical and scientific information.


Nurses are uniquely positioned to make a difference in education and example when it comes to vaccinations, including the influenza vaccine. Many misconceptions exist regarding vaccines, including beliefs that vaccines cause autism or other developmental problems, a theory that has been repeatedly disproven. Some parents believe that natural immunity is preferable, disregarding the real risks of complications from diseases such as measles, chicken pox, or pertussis. Others believe that a healthy lifestyle will protect them from diseases such as pertussis or the flu. A few are convinced that vaccine companies or the government is promoting vaccines as a way to profit financially.5


Unfortunately, healthcare workers sometimes subscribe to these beliefs as well. Despite yearly education campaigns and free access to the flu vaccine, without mandatory vaccination requirements fewer than 50% of healthcare workers nationally were vaccinated for influenza in 2008.3 Reasons that healthcare workers (including nurses) gave for not getting the flu vaccine included that they did not want to get vaccinated, they did not think that vaccinations worked against the flu, they were allergic to the vaccine, they were afraid of the adverse effects or afraid of getting sick from the vaccine, or they did not think that the vaccine was needed.2,3 This year, reports of nurses refusing the vaccine and losing their job have appeared in the media, raising the question of what an employer can require an employee to put into his or her body.


Certainly there are some people with medical conditions, including allergies that prevent them from getting the vaccine. Religious beliefs may also mean that some individuals should be exempt from vaccination. These are legitimate reasons. However, many of those who refused did not do so because of medical or religious reasons. Even among registered nurses, there were a surprising number that believed getting a flu shot would give them the flu, and many others who thought that the vaccine was not effective.3 A study in Switzerland had similar findings, noting that a 5-year education campaign for influenza vaccines resulted in a significant increase in flu vaccines among physicians but not among nurses.6 Nurses cited the same reasons that were noted in other studies in the United States: fear of side effects, uncertainty about effectiveness or need for the vaccine, and employer influence.6


It is distressing that nurses and nurse practitioners, who have the most direct contact with patients, have lower rates of flu vaccination than physicians or pharmacists. Nurses have an ethical responsibility to be informed. Keeping abreast of evidence is vital for patient care and public safety. The American Nurses Association Code of Ethics for Nurses speaks to the duty to maintain competence, maintain and improve healthcare environments, and promote community, national, and international health needs.7 This means looking carefully at the scientific evidence and making informed personal decisions. It means educating patients about the evidence. As nurses, we should know how to evaluate scholarly, peer-reviewed evidence and know the difference between evidence and opinion or anecdotal reports. A decision to refuse personal vaccinations, unless for medical or religious reasons, should be based on evidence. Educating our patients should be based on the same.




1. Centers for Disease Control and Prevention. Published 2011. Accessed January 28, 2013. [Context Link]


2. Centers for Disease Control and Prevention. Published 2012. Accessed January 28, 2013. [Context Link]


3. Jeng Lin C, Nowalk MP, Zimmerman RK. Estimated costs associated with improving influenza vaccination for health care personnel in a multihospital health system. Jt Comm J Qual Patient Saf. 2012;38:67-72. [Context Link]


4. Snapp B, Fischetti D. Bordatella pertussis in infants: a re-emerging disease. Adv Neonatal Care. 2013;13. [Context Link]


5. Luthy KE, Beckstrand RL, Meyers CJH. Common perceptions of parents requesting personal exemption from vaccination [published online ahead of print July 25, 2012]. J School Nurs. 2012. DOI: 10.1177/1059840512455365. [Context Link]


6. Friedl A, Aegertr C, Saner E, Meier D, Beer JH. An intensive 5 year long influenza vaccination campaign is effective among doctors but not nurses. Infection. 2012;40:57-62. [Context Link]


7. American Nurses Association. Guide to the Code of Ethics for Nurses. Interpretation and Application. Silver Spring, MD: American Nurses Association; 2010. [Context Link]