390


a lesser extent, obtaining “Flu Stop Shop” space, equipment, adver- tising and educational materials, and prizes and gifts. We have demonstrated that a sustained improvement in HCW


influenza vaccination and declarationrates is possible without aman- datory policy. Although we had a moderate declination rate, overall we engaged >90% of staff who either had the vaccine or declined. Unwavering hospital board and executive support, a strong


communication strategy, and dedicated funding were crucial. Devolvement of responsibility to managers in ensuring that staff were vaccinated was facilitated by real-time feedback of vaccina- tion rates. Monitoring compliance with the vaccination program (vacci-


nation rates plus signed declaration forms) as a whole is suggested as a metric as well as monitoring actual vaccination rates where mandatory vaccination is not in place.1 Anecdotally, some staff were vaccinated elsewhere without informing us. To ensure higher rates, we would have to make vaccination mandatory, a step we are reluctant to take, given that there is no such directive in our state and because we have achieved very good staff engagement without. A study of Australian stakeholders demonstrated strong


support for voluntary but not mandatoryHCWinfluenza vaccina- tion.2 Another found that only 51% favored mandatory vaccina- tion.3 Anecdotal evidence suggests that our staff would not favor a mandatory policy. Some refused to sign the declaration form, believing this was an encroachment on their autonomy. This find- ing is similar to another Melbourne hospital, which reported that 5.4% of unvaccinated staff had not completed a declaration form because they “did not wish to.”4 In our opinion, the case formandatory vaccination does not out-


weigh the ethical arguments against.Vaccination is neither necessary nor sufficient to prevent influenza transmission in the healthcare set- ting.5 Many US professional bodies endorse mandatory influenza vaccine, while others oppose it. Vaccination rates of nearly 100% have been achieved in organizations with mandatory policies, with termination of staff who refuse.6,7 Others have achieved rates >90% without a mandate, although some used other incentives including financial rewards.8,9 We demonstrated sustained improvement in staff influenza


vaccination rates without a mandate or incentives. We do not believe a mandatory policy would be well accepted by our staff, and given that it will not prevent all healthcare-associated influ- enza, this is not something we plan to introduce. Our program


Caroline Marshall et al


was successful and sustainable, but it was also cost and labor intensive.


Author ORCIDs. Caroline Marshall, 0000-0001-5901-2004


Acknowledgments. We thank Barry Rosenberg and Chris Ott for providing data.


Financial support. No financial support was provided relevant to this article.


Conflicts of interest. C.M. reports that her spouse holds a small number of shares in CSL, which makes an influenza vaccine. All other authors report no conflicts of interest relevant to this article.


References


1. Wang D, Worth L, Bull A, Bennett N, Richards M. Influenza vaccination of Victorian healthcare workers: will a higher target increase vaccine uptake? Aust NZ J Public Health 2014;38:490.


2. Lim YC, Seale H. Examining the views of key stakeholders regarding the pro- vision of occupational influenza vaccination for healthcare workers in Australia. Vaccine 2014;32:606–610.


3. Leask J, Helms CM, Chow MY, Robbins SC, McIntyre PB. Making influenza vaccination mandatory for health care workers: the views of NSW Health administrators and clinical leaders. NSW Public Health Bull 2010;21: 243–247.


4. Heinrich-Morrison K, McLellan S, McGinnes U, et al. An effective strategy for influenza vaccination of healthcare workers in Australia: experience at a large health service without a mandatory policy. BMC Infect Dis 2015;15:42.


5. Cheng AC, Worth LJ. Mandatory influenza vaccination of healthcare work- ers: is it necessary or sufficient to protect patients? Healthcare Infect 2014; 19:114–115.


6. Babcock HM, Gemeinhart N, Jones M, Dunagan WC, Woeltje KF. Mandatory influenza vaccination of health care workers: translating policy to practice. Clin Infect Dis 2010;50:459–464.


7. Rakita RM, Hagar BA, Crome P, Lammert JK, Mandatory influenza vaccina- tion of healthcare workers: a 5-year study. Infect Control Hosp Epidemiol 2010;31:881–888.


8. Drees M, Wroten K, Smedley M, Mase T, Schwartz JS. Carrots and sticks: achieving high healthcare personnel influenza vaccination rates without a mandate. Infect Control Hosp Epidemiol 2015;36:717–724.


9. Honda H, Sato Y, Yamazaki A, Padival S, Kumagai A, Babcock H. Asuccess- ful strategy for increasing the influenza vaccination rate of healthcare workers without a mandatory policy outside of the United States: a multifaceted inter- vention in a Japanese tertiary care center. Infect Control Hosp Epidemiol 2013;34:1194–1200.


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