A call for increased use of seasonal influenza vaccine in healthcare workers

As we are now in the midst of influenza season and there have been an impressive number of patients with influenza on our pulmonary service, I thought I would take a minute to discuss mandatory influenza vaccine for health care workers. According to the Immunization Action Coalition, the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Hospital Association, American Public Health Association, Association for Professionals in Infection Control and Epidemiology are just a few of the organizations that support annual influenza vaccination for all health care personnel. The CDC also recommends that all healthcare workers receive annual influenza vaccination. Despite the number of professional organizations calling for mandatory immunization, the CDC reports that the vaccination rate for health care workers was 75.2% in 2013-2014.

Although there remains some controversy over exactly how effective vaccination of health care workers against seasonal influenza is at protecting patients (variable rates of staff vaccination in the studies that have been done make interpretation more difficult), there clearly is a benefit to patients. Not only will vaccination of health care workers providing direct patient care decrease the risk of transmission of influenza, but it will help decrease staff sick days and promote better staffing levels.

There are two of the primary ethical considerations for mandating vaccinating health care workers against seasonal influenza: beneficence, doing good for patients and promoting their well-being; and non-maleficence, doing no harm to patients. By requiring influenza vaccination, the risk of transmission of influenza to patients is reduced, thus promoting well-being and doing no harm. The New York State Department of Health states this well when they say that there is a “reasonable expectation that patients and residents should not be exposed to influenza in their homes or in medical care facilities, by the personnel who they rely upon to care for them”.

As health care professionals, promoting patient welfare and avoiding harm to patients are the core of what we do. By this standard, influenza vaccination is a professional obligation.

[V]accination of health care workers meets criteria for being standard care—namely, that vaccination has clear evidence of benefit to patients and is not overly burdensome in safety, cost, pain, and suffering, or infringement of personal autonomy—and thus I argue that it is ethically obligatory as nonmaleficent care…Failure to vaccinate, given the minimal risk, inconvenience, and suffering involved, is unjustifiable on the part of the health care worker.(Cortes-Penfield)

I agree with this. Personally, I feel I have a professional obligation to protect my patients from preventable infectious diseases. More broadly, I feel I have a moral obligation to protect not only my patients, but others in my family and community as well. I feel that the only reason not to be vaccinated against influenza should be a medical contraindication to the vaccine.

Some argue that mandating influenza vaccine for health care workers violates their autonomy, that health care workers should have the right to decline vaccination if they feel concerned about the safety of the vaccine. However, vaccination is a situation where the interests of the public at large should outweigh personal autonomy. The risk of adverse reaction to or complications from the vaccine are very low, lower than the risk of complications from the disease itself. The potential benefit, especially for patients who may have a true medical reason for not being vaccinated themselves and who are under our care not by choice, but by necessity, far outweighs the risk to the individual healthcare worker. Galanakis et al, writing for EuroSurveillance, conclude:

Controlling the spread of infection is a top priority in public health. Hence, when the choice is to be made between safety and liberty, limits on liberty may be justified, as the right of the community to protection seem to outweigh the right of [health care workers] to free decisions. Even spending resources on unsuccessful voluntary vaccination campaigns seems not to be justified, as such resources could better be used elsewhere.

Immunization against seasonal influenza vaccination should be seen by health care workers not as a burden, but as much as a professional obligation as maintaining job related skills, washing hands before and after patient care, and ensuring patient safety through best practices such as confirming patient identity. These are not optional parts of the job, they are essential to the tasks we perform every day. Receiving vaccination against seasonal influenza (or, for that matter, any vaccine preventable infection) should be just as much a part of providing ethical care. Ottenburg reminds us that we have chosen our professions in health care and that choice comes with the obligation “…to do no harm, to do good, to respect patient autonomy, and to treat all patients fairly.”

Resources

Influenza Vaccination Honor Roll (n.d.) Immunization Action Coalition. Retrieved from http://www.immunize.org/honor-roll/influenza-mandates/
Influenza Vaccination Information for Health Care Workers. (n.d.) Centers for Disease Control and Prevention. Retrieved from: http://www.cdc.gov/flu/healthcareworkers.htm
Prevention of Influenza Transmission by Healthcare and Residential Facility and Agency Personnel (19 Nov 2014) New York State Department of Health. Retrieved from: http://www.health.ny.gov/regulations/recently_adopted/docs/2014-11-19_prevention_of_influenza_transmission.pdf
Cortes-Penfield, N(2014) Mandatory Influenza Vaccination for Health Care Workers as the New Standard of Care: A Matter of Patient Safety and Nonmalfiecient Practice. American Journal of Public Health. 104(11): 2060-2065. doi: 10.2105/AJPH.2013.301514. Epub 2013 Dec 12.
Galanakis, E. Janson, A. Lopalco, PL. Giesecke, J. (2013) Ethics of mandatory vaccination for healthcare workers. Euro Surveill. 2013;18(45):pii=20627.

Ottenberg, AL. Et al. (2011) Vaccinating Health Care Workers Against Influenza: The Ethical and Legal Rationale for a Mandate. American Journal of Public Health. 2011; 101(2): 212-216. doi: 10.2105/AJPH.2009.190751.

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