July 21, 2015
Board of Directors
Open Business Session
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CONSIDERATION OF AMERICAN NURSES ASSOCIATION
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POSITION STATEMENT ON IMMUNIZATION
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Nursing Practice and Work Environment
As of June 29, 2015
REPORT TYPE: ACTION
EXECUTIVE SUMMARY
 Historically, ANA has strongly supported immunizations to protect the health of the
public from highly communicable and deadly diseases such as measles, mumps,
diphtheria, pertussis and influenza, and has also supported mandatory vaccination policies
for registered nurses and healthcare workers under certain circumstances. However, in
light of a recent and significant measles outbreak in the United States, ANA has reviewed
current and past position statements for clarity and intent, and current best practices and
recommendations from the broader health care community. Based on that review and
discussion with the ANA Board of Directors at their March 19, 2015 meeting, a revised
position statement that clarifies ANA’s position and incorporates current best practices is
needed.

The position statement promotes and supports mandatory vaccination for all citizens
including health care personnel according to the best evidence and current guidelines
from the Centers for Disease Control and Prevention and the Advisory Committee on
Immunization Practices. Exemptions from vaccination include medical contraindication
or exemption based on religious belief. Exemptions should be granted only where
supporting documentation is provided from the appropriate authority.

Background information includes recommendations for both employers and registered
nurses related to implementation of mandatory vaccination programs.
RECOMMENDED MOTION
Moved, That the ANA Board of Directors approves the American Nurses Association Position
Statement on Immunization.
ALTERNATIVE MOTION
Moved, That the ANA Board of Directors does not approve the American Nurses Association
Position Statement on Immunization.
Attachment: American Nurses Association Position Statement on Immunization
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Position Statement
American Nurses Association Position Statement on Immunization
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Effective Date: Pending ANA Board of Director Review
Status: Revised Position Statement
Written By: Nursing Practice & Work Environment Department
Adopted By: ANA Board of Directors (pending)
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This position statement supersedes the following position statements:
Position Statement on Mercury in Vaccines, June 21, 2006.
I.
Purpose: Historically, ANA has strongly supported immunizations to protect
the health of the public from highly communicable and deadly diseases such
as measles, mumps, diphtheria, pertussis and influenza (ANA, 2014, ANA,
2006), and has supported mandatory vaccination policies for registered
nurses and healthcare workers under certain circumstances. However, in
light of a recent and significant measles outbreak in the United States, ANA
has reviewed current and past position statements for clarity and intent, and
current best practices and recommendations from the broader health care
community. Based on that review, it was determined that a revised position
statement clarifying ANAs position and incorporates current best practices is
needed.
II.
Statement of ANA Position: To protect the health of the public, all
individuals should be immunized against vaccine-preventable diseases
according to the best and current evidence outlined by the Centers for
Disease Control and Prevention (CDC) and the Advisory Committee on
Immunization Practices (ACIP). All health care personnel (HCP), including
registered nurses (RNs), should be vaccinated according to current
recommendations for immunization of HCP from the CDC and Association for
Professionals in Infection Control and Epidemiology (APIC)..
ANA only supports exemptions from immunization for the following reasons:
1. Exemption due to medical contradictions
2. Exemption based on religious beliefs
All requests for exemption from vaccination should be accompanied
by documentation from the appropriate authority to support the request.
Individuals who are exempted from vaccination may be required to adopt
measures or practices in the workplace to reduce the chance of disease
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transmission. Employers should ensure that reasonable accommodations are
made in all such circumstances.
III.
Background
The mandatory vaccination controversy surrounding the rights of the
individual vs. the protection of the public has been highlighted recently related
to a measles outbreak that affected both children and adults who were not
vaccinated against the disease. Over a six month period, five outbreaks and
173 confirmed cases of measles were reported to the CDC (2015). Reasons
for an individual’s decision not to vaccinate vary and include concerns about
the safety of vaccination, objections to vaccination based on religious
grounds, and lack of urgency or priority, explained in part by the supposition
that herd immunity will protect the unvaccinated from infection (LaVail &
Kennedy, 2012).
The Public
Current evidence and research support that immunizations are essential to
the primary prevention of disease from infancy through adulthood. In fact, the
impact of vaccines in reducing and eliminating vaccine-preventable diseases
has been one of the great public health achievements in the United States
(CDC, 2011). Effective vaccination programs of both children and adults
according to current recommendations from the CDC and ACIP are critical to
promote and maintain the health of the public. Vaccine-preventable diseases
include seasonal influenza for which annual immunization is recommended.
Between 1976 and 2007, the number of deaths annually from influenza
ranged from 3,000 to 49,000, with many more people hospitalized due to
severity of symptoms (CDC, 2013).
Registered Nurses
As stated in the Code of Ethics for Nurses (ANA, 2015, p. 19), RNs have an
ethical responsibility to “model the same health maintenance and health
promotion measures that they teach and research…” which includes
immunization against vaccine-preventable diseases.
Vaccine Prevention Programs
Most states do not have a law requiring vaccination of HCP. Therefore, the
onus has been left to hospitals or health care facilities to develop their own
policies. While evidence of vaccination against highly communicable
diseases such as mumps, measles and rubella are often a pre-requisite of
employment in health care facilities, this does not hold true for influenza
which requires annual immunization.
Voluntary influenza vaccine programs for HCP have been in place since the
CDC recommended in 1984 that all health care workers receive the influenza
vaccine. The documented success of voluntary programs has been seen
primarily with the influenza vaccine, but the overall vaccination rates have
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remained low at around 50% (Galanakis, 2013). In sharp contrast, facilities
that have adopted mandatory influenza vaccine policies and programs have
been highly successful. An early adopter of mandatory influenza vaccination
of HCP, Virginia Mason Medical Center in Seattle, Washington, increased
their annual immunization rate to 98% or better (Rakita et al, 2010). After
adoption of a mandatory influenza vaccination program, the Johns Hopkins
Medicine System in Baltimore, Children’s Hospital of Philadelphia, and Loyola
University Medical Center in Illinois all reported influenza vaccination rates of
99% (Galanakis, 2013, Yasmin, 2013). Such adoption rates emphasize the
need for mandatory immunization programs where voluntary programs fail in
order to promote and maintain the health of the public.
All individuals including HCP have the right to apply for an exemption to
vaccination based on medical contraindications or religious beliefs. To ensure
that appropriate standards are applied, such exemptions should be granted
only when supported by formal documentation from an appropriate authority,
such as a healthcare provider or religious leader, detailing the reason an
exemption is needed.
If an RN or other health care worker is exempted from vaccination, the health
care facility will have the discretion to determine what steps, of any,
unvaccinated RNs or health care workers must take to reduce the risk of
transmitting disease to patients. Consequences for refusal by RNs or other
health care workers to participate in a mandatory vaccination program, or, if
exempted from vaccination, to follow steps to reduce the risk of disease
transmission, may result in disciplinary action by the employer.
IV.
Responsibilities of Registered Nurses and Employers
Successful immunization policies and programs require open communication
and transparency between RNs and employers. RNs are responsible to
provide patients with evidence-based information to support and promote
optimal health and wellness, and to lead by example by participating in
health-oriented activities such as immunization to the greatest possible
extent. ‘Public trust will be damaged if [nurses] appear to suggest vaccines
for others but avoid them for themselves’ (Galanakis, 2013).
Employers of registered nurses are responsible for establishing a culture of
safety and implementing policies that improve the health of their workers. The
Infectious Diseases Society of America, the Society for Healthcare
Epidemiology of America and the Pediatric Infectious Diseases Society
recommend that immunizations should be provided in the work setting at no
cost to HCP to ensure access to vaccination, and that workplace
immunization programs should include appropriate education and training of
staff (IDSA, 2013).
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If registered nurses are represented by a union or collective bargaining unit,
the employer should work with the designated representative to clarify or
resolve any issues that may arise associated with implementation of a
mandatory vaccination policy or program.
V. Summary of Relevant ANA Publications and Initiatives
Code of Ethics for Nurses
The Code of Ethics for Nurses (the Code) makes explicit the primary goals,
values, and obligations of the profession. ANA believes that the Code is
nonnegotiable and that each nurse has an obligation to uphold and adhere to its
ethical precepts.
Five provisions within the Code speak to the obligation of registered nurses to
act in a manner that is consistent with maintaining patient and personal health:
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Provision 2: The nurse’s primary commitment is to the patient, whether an
individual, family, groups, community, or population.
Provision 3: The nurse promotes, advocates for, and protects the rights,
health, and safety of the patient.
Provision 4: The nurse has authority, accountability, and responsibility for
nursing practice; makes decisions; and takes action consistent with the
obligation to promote health and to provide optimal care.
Provision 5: The nurse owes the same duties to self as to others, including
the responsibility to promote health and safety, preserve wholeness of
character and integrity, maintain competence, and continue personal and
professional growth.
Provision 6: The nurse, through individual and collective effort, establishes,
maintains and improves the ethical environment of the work setting and
conditions or employment that are conducive to safe, quality health care.
ANA Immunize Website and ImmuNews Newsletter
The ANA Immunize website provides nurses and other health professionals with
research, education, tools, advocacy information and resources related to
immunizations. The site also includes information by workplace setting and for
special populations.
The ImmuNews E-Newsletter provides monthly articles, news and resources
from CDC, immunization organizations, ANA State Nurses Associations and
ANA Organization Affiliates.
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VI. References
American Nurses Association. (2015). Code of ethics for nurses with
interpretive statements. Silver Spring, MD: Nursesbooks.org
American Nurses Association. (2014). ANA Immunize: Bringing immunity to
every community. Retrieved from http://www.anaimmunize.org/
American Nurses Association. (2006). ANA Position statement on Mercury in
Vaccines.
Centers for Disease Control and Prevention. (2015). Measles cases and
outbreaks. Retrieved from http://www.cdc.gov/measles/cases-outbreaks.html
Centers for Disease Control and Prevention. (2013). Mortality and morbidity
weekly. Retrieved from
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6249a2.htm
Centers for Disease Control and Prevention. (2011). Ten great public health
achievements. Retrieved from
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6019a5.htm
LaVail, K. & Kennedy, A. (2012). The role of attitudes about vaccine safety,
efficacy, and value in explaining parents’ reported vaccination behavior. Health
Education and Behavior, 40(5), 544-551.
Galanakis, E., Jansen, A., Lopalco, P.L., Giesecke, J. (2013). Ethics of
mandatory vaccination for healthcare workers. Euro Surveill. 18(45), 20627.
IDSA, SHEA and PIDS. (2013).IDSA, SHEA and PIDS Joint policy statement on
mandatory immunization of health care personnel according to the ACIPrecommended vaccine schedule.
Rakita, R. M., Hagar, B. A., Crome, P., & Lammert, J. K. (2010). Mandatory
influenza vaccination of healthcare workers: A 5-year study. Infection Control,
31(09), 881-888.
Yasmin, S. (2013). Mandatory shots: should hospitals force health care workers
to get the flu vaccine [Scientific American Blog]. Retrieved from
http://blogs.scientificamerican.com/guest-blog/2013/12/23/mandatory-shotsshould-hospitals-force-care-workers-to-get-the-flu-vaccine/
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