Mandatory Immunizations for Health Care Workers: The good, the bad and the ugly

June 14th, 2011

In the famous words, “an ounce of prevention is worth a pound of cure”, our founding father Benjamin Franklin demonstrates his knowledge of principles that would develop the infrastructure of public health preparedness centuries later. During the beginning of the 20th century, infectious diseases such as smallpox, diphtheria, pertussis, tetanus, polio, mumps, measles, rubella, and haemophilus influenzae were common and took a fatal toll on the world’s population. The development and administering of vaccines was critical to prevent and control the morbidity and mortality rates of nine preventable diseases and the complications of that time. Immunizations served as a critical form of intervention to effectively combat disease and keep populations healthy in a cost efficient manner.

Influenza or the “flu” has the reputation for being the most deadly disease of human kind, with the first pandemic dating back to 1508. There have been other known pandemics such as the Spanish Flu in 1918 that killed approximately 40 million, with 500 million people ill and most recently in 2009, with the H1N1 strain that killed almost 15,000 people. Because the flu virus spreads through exposure of contaminated air and surfaces, the impact is broad, making it a highly contagious. With no known cure, preventing influenza or the “flu” requires the same persistence and science that have been invested in the infectious diseases previously noted. According to the Center for Disease Control and Prevention (CDC), the use of vaccines to prevent the flu has been associated with reductions in influenza-related respiratory illness and physician visits among all age groups, hospitalization and death among persons at high risk, ear infections among children, and work absenteeism among adults.

The CDC has been recommending that all health care workers get yearly flu shots for 25 years. Despite this recommendation, only half of hospital employees voluntarily get flu shots. The medical and public health community recognize that the hospitals and health care systems need much higher vaccination rates, and have developed and implemented various programs in the country to increase rates. According to the Society for Healthcare Epidemiology of America, voluntary vaccination programs have been in place for decades with little evidence for an overall increase in vaccination rates among health care providers. The momentum of mandatory vaccinations for health care workers (HCWs) are continuing to increase as health care cost rises and our economy recovers. Today, several hospitals and health care systems require health care workers to be immunized against influenza as a condition of employment, with Virginia Mason Medical Center (Seattle, WA) leading the way as the first medical institution to implement such policies.

History has shown us the health benefits that vaccination offers. However such accomplishments have not gone without controversy. From Jacobson vs. Massachusetts , a case that upheld the right of states to enforce vaccinations laws to protect the health of the common welfare, to New York being the first state to establish a directive requiring all HCWs to be immunized against influenza, the emphasis is rightfully on the ethical responsibility and duty to act in the best interest of protecting the general public and to prevent infectious disease outbreaks. This blog article provides you a snapshot of the benefits of immunizing HCWs, the controversy behind mandatory vaccinations and what’s at stake if we don’t do anything.

The Good- Vaccinating Health care workers benefits everyone by:

• Increasing compliance and infection control: According to bioethicist Arthur Caplan, PhD, Director of the Center for Bioethics at the University of Pennsylvania in Philadelphia, “If you can get close to 100 percent vaccination rates [among healthcare workers]; you can cut patient death rates from flu by 40 percent.” In the 2009-2010 flu season, MedStar Health System, a nine hospital system in Maryland and the District of Columbia, achieved a 98 percent rate compliance after implementing a mandatory influenza immunizations to 26,000 employees and affiliated HCWs. Traditional voluntary vaccination programs typically have a 40-50% compliance rate according to the New York Times. Doubling the influenza vaccine compliance rates has positive health implications for its patients and workers.

• Preventing complications and hospitalizations. The CDC reports that vaccination is a cost-effective counter-measure to seasonal outbreaks of influenza. A study led by Dr. David K. Shay in February, 2008 reported that the flu vaccine was effective in keeping 3 out of 4 people out of the hospital for influenza related complications during the 2005-2006 and 2006-2007 flu seasons.

• Increasing population immunity: According to the Society for Healthcare Epidemiology of America, getting vaccinated against the flu creates a “herd immunity” by protecting those who are vaccinated and those who may be unable to receive vaccines (such as individuals who have allergic reactions to eggs) or those who have compromised immune systems.

• Saving money: Getting sick with the flu not only takes a toll on your body, but also on your pocket. Because you’re out sick, there is a direct impact to you due to lost of productivity (not working means no paycheck and fewer things accomplished) and the costs for medical care and medication to alleviate flu symptoms. To look at the cost savings of getting vaccinated, a study published in the Annals of Internal Medicine titled Effectiveness and Cost-Effectiveness of Vaccination Against Pandemic Influenza (H1N1) 2009 estimated the overall cost of vaccinating a city the size of Baltimore-Washington Metropolitan area (around 8.3 million people) is $110 million. According to this study, the short term savings for the city and its residents is equivalent to $686 million in influenza treatment cost. This means that cities and individuals can spend over 6 times less money to prevent the flu by getting vaccinated, versus paying for the treatment, medication and hospital visits to alleviate flu symptoms.

The Bad- Current issues around mandatory influenza vaccinations include:

• Breach of individual rights: According to the Society of Healthcare Epidemiology of America, a majority of health care workers accept the concept of mandatory influenza vaccination, with one study noting that 70% of respondents believed vaccinations should be mandatory for health care workers who do not have an allergy to the influenza vaccine. Those who oppose this stance believe that such policies are coercive and negatively impact the employee-employer relationship, although there are no available data that supports this statement. In fact, healthcare institutions already mandate multiple conditions that reduce the risk of infectious disease transmission require employees to be vaccinated against against varicella, measles, mumps and rubella. Adding influenza to the list of requirements would only continue to maintain the highest level of patient care and service in US medical institutions.

• Misconceptions about the efficacy and safety of vaccine: The misconception about the flu vaccine’s effectiveness and safety has also been used as a reason to not get vaccinated leaving HCWs and individuals vulnerable to infection. The reality is, influenza vaccinations saves lives, and has a 75% effectiveness in preventing hospitalizations from flu complications. To learn about common misconceptions and the facts, visit the CDC website at: In addition, the CDC also recognizes the safety track record of the seasonal influenza vaccine as well as the H1N1 vaccine. According to the CDC, hundreds of millions of Americans have received seasonal flu vaccines and millions of people have also safely received the 2009 H1N1 vaccine. The most common side effects following flu vaccinations are mild, such as soreness, redness, tenderness or swelling where the shot was given. The CDC and the Food and Drug Administration (FDA) monitor for any signs that the vaccine is causing unexpected adverse events and work with state and local health officials to investigate any unusual events.

The Ugly: What happens if we do nothing?

• Increased health complications: According to the CDC, complications of flu can include bacterial pneumonia, ear infections, sinus infections, dehydration, and worsening of chronic medical conditions, such as congestive heart failure, asthma, or diabetes. Influenza risk is not created equal. Unfortunately, specific groups are more vulnerable to the flu, including, children younger than 5, adults 65 years of age and older, pregnant women, and individuals who already have existing medical conditions.

• Increased mortality: The development of vaccines has been recognized as one of the top 10 achievements in public health during the 20th century. Without this innovation, the rate of infection would climb, and with the number of deaths inevitably following that trend. Unfortunately, influenza has no cure and at times, can be fatal, especially to higher risk groups such as the elderly, children under the age of five, pregnant women and individuals with certain medical conditions. Wikipedia notes that the influenza virus is associated with 36,000 deaths and 200,000 hospitalizations each year in the US. From a local perspective, 36,000 deaths amount to filling up all Maryland’s acute care beds three times over capacity or having over a third of all students in Baltimore county schools come down with the flu.

Influenza is still one of the top deadliest communicable diseases of our time. Our country can continue to have a top notch medical care system if we implement innovative solutions such as mandatory vaccination programs for HCWs. Just like the vitamin D that is added into our milk to supplement calcium absorption, the influenza vaccine provides added protection to our immune system to decrease our risk of contracting the highly infectious flu virus. There’s a lot at stake if we do nothing, and that is why we should commend the medical and public health institutions for continuing on the path of prevention and addressing the most important aspect of health care: patient safety and positive health outcomes.

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