Manda­tory flu vac­ci­na­tions for health­care work­ers miss the mark

Manda­tory vac­ci­na­tion for health­care work­ers—like flu shot—misses mark

Modern Healthcare - - NEWS - MER­RILL GOOZNER

The worse-than-nor­mal flu sea­son brings to the fore a trou­ble­some is­sue for ad­min­is­tra­tors at the na­tion’s hos­pi­tals and physi­cian of­fices: Should physi­cians, nurses and any­one else with di­rect ex­po­sure to pa­tients be forced to get the an­nual in­fluenza vac­cine? At first blush, the re­quire­ment seems like a no-brainer. If the first pre­cept in medicine is “never do harm to any­one,” then fa­cil­ity man­agers would seem per­fectly within their rights to in­sist that health­care work­ers not be al­lowed to ex­pose vul­ner­a­ble pa­tients to a po­ten­tially deadly virus. A 2011 sur­vey by the Cen­ters for Disease Con­trol and Preven­tion found at least 400 hos­pi­tals make the flu vac­cine a manda­tory con­di­tion of con­tin­ued em­ploy­ment. At least 29 have fired peo­ple who re­fused to com­ply for other than health or re­li­gious rea­sons. Other hos­pi­tals have in­sisted the un­vac­ci­nated wear masks at all times.

The manda­tory shot has drawn fire from unions, civil lib­er­tar­i­ans and some sci­en­tists. It is the sci­en­tific con­cerns that ought to give ad­min­is­tra­tors pause, since the ev­i­dence back­ing the ef­fi­cacy of the flu vac­cine is far weaker than ei­ther the government or most pub­lic health of­fi­cials like to ad­mit.

A report is­sued last fall by the Univer­sity of Min­nesota’s Cen­ter for In­fec­tious Disease Re­search & Pol­icy, whose ex­pert panel in­cluded a num­ber of lead­ing pub­lic health sci­en­tists and drug in­dus­try rep­re­sen­ta­tives, con­cluded that ex­ist­ing vac­cines are far from ad­e­quate in pro­vid­ing “herd im­mu­nity” for vul­ner­a­ble pop­u­la­tions. The CIDRAP report also found that calls for uni­ver­sal vac­ci­na­tion—the CDC now rec­om­mends an­nual vac­ci­na­tion for ev­ery­one over 6 months of age—“have not al­ways used state-of-the-art sci­en­tific data.”

The report cited at least 30 ex­am­ples of government agen­cies and med­i­cal so­ci­eties ex­ag­ger­at­ing the ben­e­fits of the vac­cine. Brochures claim that the vac­cine pro­tects against flu in 70% to 90% of adults who re­ceive it; of­fi­cial doc­u­ments state 50% of deaths among the el­derly could be pre­vented with uni­ver­sal vac­ci­na­tion. (The CDC es­ti­mates 89% of the 731,831 peo­ple who died from flu be­tween 1976 and 2007 were over 65.)

Yet that’s not what the ev­i­dence says. Most years, be­cause the pre­cise ge­netic makeup of the pre­dom­i­nant flu strain can­not be known when the vac­cine is devel­oped, in­oc­u­la­tion pro­vides im­mu­nity in slightly more than half the peo­ple who re­ceive the shot. This year, be­cause the match was pretty solid, the CDC es­ti­mates ef­fi­cacy at about 62%.

How much pro­tec­tion is af­forded pa­tients in a doc­tor’s of­fice or hospi­tal if nearly 4 out of ev­ery 10 work­ers, even if in­oc­u­lated, may be car­ry­ing the virus?

Last week, I spoke with Dr. Michael Oster­holm, one of the pri­mary au­thors of the CIDRAP report. He backs calls for uni­ver­sal vac­ci­na­tion. But he op­poses fir­ing peo­ple over the is­sue be­cause it ig­nores the fact that con­sis­tent pro­tec­tion re­mains elu­sive for the present gen­er­a­tion of vac­cines. “If I fix 9 of the 10 screen doors in my sub­ma­rine, it’s still go­ing to sink,” he told me.

There may even be risks as­so­ci­ated with mak­ing flu shots manda­tory. Health­care work­ers, who are prone to the same mis­con­cep­tions about the ef­fi­cacy of the vac­cine as the gen­eral pop­u­la­tion, may think they needn’t take other pre­cau­tions to pre­vent the spread of in­fec­tion within their fa­cil­i­ties if they have had a flu shot. They in­clude proven disease-preven­tion steps such as fre­quent hand­wash­ing, avoid­ing di­rect con­tact with pa­tients with flu symp­toms and lim­it­ing visi­ta­tion at hos­pi­tals.

In other words, a rea­son­able alternative to manda­tory vac­ci­na­tion is in­te­grat­ing vol­un­tary cam­paigns en­cour­ag­ing 100% com­pli­ance into a com­pre­hen­sive pro­gram aimed at elim­i­nat­ing all in­fec­tious disease trans­mis­sion—at least un­til a bet­ter vac­cine comes along.


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