By Cathryn Domrose
Flu season is fast approaching, and with it the flu vaccine. Dreaded by some, welcomed by others and a source of discussion for all involved in patient care, flu vaccinations raise many important questions for healthcare professionals. Do healthcare workers have an ethical obligation to get vaccinated? Should flu vaccination be mandatory for healthcare workers? Should those who aren’t vaccinated be required to wear masks or work away from patients?
For many clinicians, it’s not an issue. Some 80% of nurses were vaccinated for influenza by November 2012, according to a survey by the CDC. That is shy of the 90% recommended by the Healthy People 2020 objectives set up by the U.S. Department of Health and Human Services, but well above the 63% rate for all healthcare workers.
“I think we’re making good progress,” said Carolyn B. Bridges, MD, FACP, the CDC’s associate director for adult immunizations. “When you’re looking at coverage for nurses, there’s certainly an improvement. About 75% of nurses were vaccinated in 2011.”
Legally, individual states can require workers to get vaccines to protect public health, said Alexandra M. Stewart, JD, assistant professor at George Washington University School of Public Health and Health Services in Washington, D.C. Twenty-one states have some sort of law requiring healthcare workers to get flu vaccines, but the laws vary widely based on settings included, types of workers, exemption policies and enforcement methods, she said.
More than 275 hospitals, healthcare systems and long-term care facilities mandate the flu vaccine for employees, according to the Immunization Action Coalitions Honor Roll for Patient Safety. A 2011 CDC survey of 880 hospitals across the nation showed about half required workers to accept or decline vaccination on the record, and of those, fewer than half imposed consequences (such as requiring surgical masks) for refusal.
In a few well-publicized cases during the past flu season, some facilities fired nurses for refusing the vaccine without what their employers considered a valid reason. In Rhode Island, which mandated all healthcare workers to get vaccinated or wear a mask, SEIU Healthcare Employees Union 1199 filed a lawsuit (which was later dropped) arguing the law violates providers’ rights and that requiring masks for unvaccinated workers ignores scientific evidence, jeopardizes patient care and demonstrates a lack of respect for hard-working healthcare employees. A health department rule similar to Rhode Islands law went into effect in New York for the upcoming flu season.
A number of peer-reviewed studies show a statistically significant correlation between vaccinating healthcare workers and limiting the spread of influenza in hospitals and nursing homes, Bridges said. Some of these are cited in an article in the Nov. 25, 2011, issue of the CDC’s Morbidity and Mortality Weekly Report: Immunization of Health-Care Personnel, Recommendations of the Advisory Committee on Immunization Practices. Depending on how well the vaccine is matched to strains of seasonal flu, it can reduce chances of transmission by between 50% and 70% in working-age adults, she said.
Estimated deaths from flu-related complications varied between 3,000 and 49,000 annually between 1976 and 2006, according to CDC figures. Those most vulnerable include the elderly, children younger than 5, pregnant women and those with medical conditions.
Bridges said the most important goal is educating those who had the lowest rates of vaccination last year, aides (47%) and clerical staff (54%), particularly in long-term care facilities. LTC settings have lower vaccination rates than hospitals and medical offices, yet patients are among the most vulnerable to dangerous flu complications, such as pneumonia. Nurses have a real leadership role to play in being advocates and role models for getting vaccines, she said.
Those who work with patients have a clear ethical obligation to get the flu vaccine, said Lucia D. Wocial, RN, PhD, a nurse ethicist with Indiana University Health and the Charles Warren Fairbanks Center for Medical Ethics, and an adjunct assistant professor at the Indiana University School of Nursing in Indianapolis. IU Health required vaccines for the first time last year. Unless there is a valid reason - such as a history of severe allergic reactions to vaccines or strong religious beliefs against all vaccines - nurses should get vaccinated to help protect themselves, their patients and co-workers against the spread of the illness, she said. ”When you go into a profession like nursing, you have an obligation to do good for other people,” Wocial said. ”That’s what the public expects of this profession.”
The American Nurses Association supports state laws requiring all healthcare workers to be vaccinated, but stops short of supporting mandatory vaccination policies by individual institutions. ”It’s an area where we really have made some strides. Is the punitive method really the way we want to be doing that?” said Cheryl Peterson, RN, MSN, director of nursing practice and policy for the ANA.
Though studies, including a 2012 CDC report, show mandatory vaccination in institutions increases compliance rates to almost 100%, the CDC does not take a position on mandatory vaccination, Bridges said. Some hospitals have achieved high rates of vaccination using strong leadership and consensus-building among workers to create a culture where vaccination is an expected norm, she said.
Next year, the Centers for Medicare and Medicaid Services plans to collect and publish flu vaccination rates for healthcare workers in hospitals and ambulatory surgical centers as part of its list of quality measures to allow the public to compare facilities.
Management at IU Health, along with many other health centers in the U.S., decided to act after the 2009 H1N1 pandemic, which swamped EDs and forced providers to look at ways to avoid spreading the virus. Despite educational efforts, the vaccination rate for healthcare workers hovered around 65%, said Laurie Fish, RN, BSN, CIC, the facility’s executive program director for infection prevention. Last year, when vaccines were mandated, the rate rose to 98% in IU Health’s 18 hospitals. Alternatives, such as a nasal spray or preservative-free vaccines, were offered. About 950 of the 30,000 healthcare workers applied for exemptions for medical and religious reasons and about 630 were granted, she said. Fewer than 300 employees were fired, she said.
One of those who was dismissed, Ethel Hoover, RN, BSN, had worked at IU Health for more than 20 years. Hoover said she believed the flu vaccine was insufficiently researched and not proven effective. ”It should be an American adult’s choice what they consume or inject into [his or her]body, not some pharmaceutical or government promoting an unproven vaccine,” she said.
Some evidence, including a 2010 study in the Journal of Infectious Diseases, suggests surgical masks can help prevent influenza transmission. But Fish said her institution concluded the evidence that masks prevent flu transmission was not strong enough to allow them as an alternative to the vaccine.
Though studies show institutional mandates produce greater vaccination compliance rates, state laws are less likely to be successfully challenged by labor groups and others, Stewart said. ”This is not an abuse of rights,” she said. ”This is a public health matter.”
Cathryn Domrose is a staff writer.