One Flu Shot at a Time

November 27, 2017

UT MD Anderson's multi-pronged approach to flu vaccination raised their rates from 56% to 97% in less than a decade.

By Paromita Pain
Population Health Scholar
University of Texas System
Doctoral Student in Journalism
UT Austin Moody College of Communication

Dr. Elizabeth Frenzel (left), UT MD Anderson’s Director for Employee Health & Well-being.

Dr. Elizabeth Frenzel (left), UT MD Anderson’s Director for Employee Health & Well-being.

During the flu season of 2006-2007, only 56% of employees at The University of Texas MD Anderson Cancer Center got flu shots. That number represented a serious threat both to patients getting care at MD Anderson and to fellow staff. For Dr. Elizabeth Frenzel, an expert in employee health and infectious disease, it also represented an opportunity. If she and her colleagues in the Department of Employee Health and Well-being could improve vaccination rates, they could make the environment safer and healthier for everyone. They could demonstrate the value of well-considered and planned employee health initiatives. And they could save lives.

“That 56 percent average understated the problem, since the numbers were lower among healthcare workers who were caring for our immunocompromised, high-risk patients,” said Frenzel, who is now MD Anderson’s Director for Employee Health & Well-being. “Only 47 percent of employees working in high risk patient care areas were vaccinated. In the inpatient nursing units, it was only 41 percent. We needed to improve.”

Beginning the following year, Frenzel and her colleagues embarked on a multi-year program to increase vaccination rates, along with a parallel quality improvement project  to document and evaluate the effort. By 2015, vaccination rates were up to 97 percent. As these numbers went up, the number of flu cases acquired in the hospital by immunocompromised cancer patients went down. It was 6 percent in 2006-2007, and 2.3 percent in 2013-14. “Our research shows that as employee vaccination rates increased over an eight year period, we had a significant decrease in hospital-associated influenza infections in patients,” said Frenzel.

The key, said Frenzel, was to attack the problem on multiple fronts. Access was expanded and improved. The on-site vaccination clinics, which previously had been dispersed throughout the entire facility, were centralized in the main hospital complex.  The number of clinics, and the hours they were open, were increased. And the hours of the roaming clinics, which traveled to high-priority areas, were more than tripled.

On the communication front, Frenzel realized that while the hospital had long offered flu shots, there had rarely been much promotion surrounding it. She and her team began working with the internal communication department to ensure there was more concerted communication efforts and education surrounding the issue among staff. The benefits of vaccination were especially emphasized. In 2008, the “Be a Flu Fighter-Immunize to Save Lives” campaign was developed, as well as the 24-hour “Flu Marathon” to encourage more staff to get vaccinated.

“Often it is assumed that just because people work here in healthcare, they will understand the need for the shot, and take it upon themselves to get it,” she said. “We should never assume things. Gather the data, define the problem and then plan your program.”

In order to better document and track immunization efforts, Frenzel and her colleagues developed a mechanism for efficient on-site data entry into Employee Health’s electronic health record. They provided weekly updates of vaccination rates to supervisors and senior management encouraging vaccination, and scheduled follow-up roaming clinics to targeted areas with lower vaccination rates.

Perhaps the most significant shift was in the institution’s immunization policy. In 2009, MD Anderson implemented a mandatory participation program for all employees working in high-risk clinical areas and inpatient nursing sites. Healthcare workers in these areas either had to receive their immunization onsite, provide documentation of offsite immunization, or sign a declination that acknowledged the risk to patients of remaining unvaccinated. In 2010, the mandatory participation program was expanded to include all staff who worked in clinical operations; and in 2011, to all employees who had any contact with patients. In 2012, an institutional policy for  all healthcare workers at MD Anderson, including not just employees but contractors, trainees, and volunteers, boosted rates by 23% in 1 year.

Everyone covered by the policy is now required every year to either get the flu vaccine or to wear a surgical mask when caring for patients during the respiratory virus season. In 2015, over 19,000 MD Anderson employees were getting vaccinated, which represents 97% of its workforce.

The success of the flu vaccine effort, said Frenzel, has a number of lessons. Creating successful programs in occupational health and safety requires having a clear understanding of what the problem is, a mastery of the data and the science behind it, and a strategic vision for moving forward. It requires collaboration, integration, and the building and maintenance of relationships with the different groups involved. And it needs both leadership, on the front end, and buy-in on the back end.

“Getting a flu shot is the norm now,” said Frenzel.  “It’s been a paradigm shift in our patient safety culture.  Employees understand the importance of protecting our patients, and how well it aligns with our mission.” 


Frenzel E, Chemaly RF, Ariza-Heredia E, Jiang Y, Shah DP, Thomas G, Graviss L, Raad I. Association of increased influenza vaccination in health care workers with a reduction in nosocomial influenza infections in cancer patients. Am J Infect Control 44:1016-21, 9/2016. PMID: 27158088.