Should flu shots for health professionals be required?
■ Whether mandating influenza immunizations is appropriate
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to firstname.lastname@example.org, or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted April 8, 2013.
Scenario: If all frontline health care workers received flu shots, patients and the public would be safer. But there are concerns that it isn't fair to make vaccinations a requirement for employment.
Reply: In an average year, influenza infects nearly one in 10 people, resulting in an estimated 200,000 hospitalizations and 24,000 deaths. The flu season this year was not average. It was the most severe since the novel H1N1 pandemic of 2009. Daily media reports showed overwhelmed emergency departments and pharmacies running out of vaccine. The Centers for Disease Control and Prevention in January reported higher-than-usual death rates among the elderly.
Vaccination is the most effective tool for preventing the spread of influenza and is currently recommended for all individuals older than 6 months. Still, vaccination rates have remained low even among priority groups like health care workers.
The CDC and its Advisory Committee on Immunization Practices have highlighted health care workers as priority recipients for influenza vaccination since 1981. The reason for this focus is clear: Health care workers are on the front lines in settings with a high-exposure risk. Influenza is highly contagious, and exposure frequently can result in infection if a worker is not protected. An infected worker then can expose patients and co-workers, even before symptoms begin. Health workers also frequently continue to come to work even when they are sick.
The risk of infecting others is especially consequential, because health professionals provide care to vulnerable groups such as infants or those who are immune-compromised and may be unable to produce an immune response to the vaccine. Not only does vaccination protect patients, but a healthy work force decreases absenteeism, which is critical during the busy respiratory infection season in winter. Yet flu vaccination rates of health workers remain well below the 90% level at which herd immunity benefits are seen.
Resistance to influenza vaccination is a singular phenomenon — many health workers accept other vaccines like hepatitis B but decline the influenza vaccine. Why? Studies reveal misperceptions about the flu vaccine, including fear of side effects and beliefs that the vaccine causes influenza or is not effective in preventing it. Many health workers have firsthand experience with the significant morbidity and mortality associated with influenza, yet feel they are at a low risk of infection themselves.
The likelihood that a given person will receive the vaccine also has been associated with convenient access to vaccine. Immunization programs have attempted to target these factors through strategies such as educational campaigns and incentives, providing easy access to free vaccine or recruiting vaccination “champions” to encourage colleagues. Some institutions have introduced declination forms on which a health worker who declines vaccination must document his or her refusal. But these interventions have not been able to increase vaccination beyond 70%, suggesting that programmatic interventions can only go so far as long as vaccination remains voluntary.
When workers must get vaccinated
Does this state of affairs provide justification for requiring vaccination for all health care workers? Mandatory influenza vaccination policies have proliferated since Virginia Mason Medical Center first instituted a mandate in 2004. Under that mandate, vaccination was considered a part of fitness for duty, and vaccine refusal resulted in termination of employment in the absence of a medical or religious exemption. Since then, hospitals and health care systems in 45 states have implemented some kind of institutional mandatory policy.
Mandatory policies vary in their demands and penalties. They range from the completion of a written declination form with a penalty such as wearing a mask during influenza season or receipt of a below-expectations report in a performance evaluation to vaccination as a condition of continued employment unless there is a valid, doctor-certified medical exemption.
Professional consensus as contained in the AMA Code of Medical Ethics holds that “physicians have an obligation to accept immunization in the absence of a recognized medical, religious, or philosophic reason not to be immunized” and, if they are not immunized, to accept the decision of a “health care institution, or other appropriate authority to adjust their practice activities.” Examples of “adjustments of practice activities” that the code gives are wearing masks or refraining from direct patient care.
Influenza vaccination as a condition of employment has received much attention. Are these policies justifiable? Several ethical principles and precedent suggest they are. Jacobson vs. Massachusetts, a landmark case in which the U.S. Supreme Court examined the constitutionality of that state's mandated actions during a smallpox epidemic, provides the legal framework for mandates, stating that compulsory vaccination is allowable for public benefit.
Health worker vaccination results in significant benefits for vulnerable patients, especially those who cannot be vaccinated themselves. Vaccinated workers prevent nosocomial influenza infection and are better able to take care of patients. Immunization also can be seen as a part of professional responsibility. Under the principle of “first do no harm,” health care workers have an obligation to protect patients, and putting patients' interests first is demanded by nearly all medical, nursing and dental codes of ethics. In other words, health workers are obligated to take actions that prevent harm to those dependent upon them.
Lastly, there is the matter of trust. Patients are dependent on health professionals to prevent or manage illness, and therefore trust that workers have taken steps to protect and promote their health. We have expectations of the people to whom we regularly entrust a certain service time. When we select a child care facility for our child, we trust that staff has passed the required background checks and completed cardiopulmonary resuscitation training. Staff may feel that a background check is an infringement on their liberty, but it is a part of their professional obligation. Many professions have requirements to ensure that their members are able to carry out their job responsibilities safely when those responsibilities involve protecting the well-being of another.
While mandatory policies are ethically justifiable, there are important caveats. People have a right to make choices about what happens to their bodies, although this comes with a responsibility to consider the consequences of those choices upon others. This is especially pronounced with vaccination — we receive vaccines to protect ourselves but also to protect our neighbors. When we decide not to be vaccinated, we put others at risk as well as ourselves.
Beyond the legal and ethical arguments, there are concerns that mandatory policies can affect morale negatively. Mandates are coercive, but that does not mean that buy-in cannot be achieved. While there are many reasons why health care workers do not get vaccinated, there are many reasons that they do, including a desire to protect patients and fulfill professional responsibility. These facilitators can be leveraged to build support for a mandatory program as a commitment to community responsibility for promoting patient safety and the workers' own well-being. A recent study on a mandatory policy in a large pediatric network found that, although the majority of staff felt that the mandate was coercive, the majority also agreed with the policy to protect patients and staff.
Mandatory influenza vaccination of health workers is now endorsed by many professional organizations as a public health and patient safety necessity. Current health worker vaccination rates — despite intensive, multicomponent voluntary intervention — also indicate that mandates are needed. Such policies must be accompanied by ongoing educational efforts to address misperceptions and concerns, gain strong collaborative leadership and enlist local champions. These efforts promote buy-in and sustainability, and ensure that programs are implemented equitably. Mandatory programs also send a message that influenza vaccination is important for everyone. We will continue to have severe influenza seasons, and vaccination will remain the best prevention tool.
— Kristen A. Feemster, MD, MPH, MSHP, assistant professor of pediatrics, Division of Infectious Diseases, the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania
— Arthur L. Caplan, PhD, Drs. William F. and Virginia Connolly Mitty Professor of Bioethics, director of Division of Medical Ethics, New York University Langone Medical Center
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to email@example.com, or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.