To mandate or not to mandate? Is that the Question?

Ebbs and flows in attention to influenza vaccination over the last 2 decades have followed a familiar pattern, spiking when vaccine supplies are down or a rising number of cases (or complications) catches news headlines, and then evaporating. But influenza and its complications account for the greatest number of vaccine-preventable deaths worldwide -- even without a major epidemic. Concern about the implications of the high level of susceptibility among health workers has been mounting with increasing calls for making annual influenza vaccination a requirement for healthcare workers. A growing number of providers have implemented requirements, and multiple professional associations, including APHA, urge making requirements standard practice. Divergent responses by some healthcare workers capture headlines. In debating requirements, however, the essential question can get overlooked: How to raise vaccination coverage to the level needed for herd immunity in the healthcare setting – i.e., > 90% vaccine uptake both within units and institution-wide? We suggest that the issues relevant to healthcare worker immunization against influenza are not so dichotomous. Moreover, dichotomizing can narrow thinking and limit problem-solving. While requiring health workers to be immunized can be a means to achieving the primary goal, which is to promote a safer environment in the healthcare setting, the question is: When are mandates needed – and how should they be implemented? Reframing with a more holistic view considers how health worker susceptibility fits into evolving initiatives promoting patient safety, emergency preparedness, and healthy communities.