Mandatory Immunization of Health Workers - Literature review Example

Mandatory Immunization of Health Workers A rapid increase in the number of flu instances around the world has spurred plans for mass immunization around the globe. In the United States vaccination campaign is implemented on a voluntary basis. Voluntary immunization however, has not been able to ensure the desired immunization rate of 83% to 94%, which would ensure herd immunity (Anikeeva et al., 2009). Data from the National Health Interview Survey (NHIS) has shown that only 36% of health care workers are actually immunized each year. The remaining 64% is the key cause to influenza outbreaks in clinical setting (Centers for Disease Control, 2003). Failure of voluntary vaccination has spurred plans to make immunization mandatory for health care personnel (HCP). This proposal, despite its perceived efficiency, has met severe resistance; numerous law suits were filed to protect the decision autonomy of health care personnel. In October 2009 Justice Thomas J. McNamara has halted a decision on mandatory vaccination in New York State, which was the only state in the nation to mandate vaccinations to HCP (Chan & Hartocollis, 2009). A series of studies conducted prior to that decision have indicated that majority of HCPs themselves skipped their annual flu shots and vaccinations. Because of increased risk, associated with such refusals, hospitals have resorted to pressure, making nurses’ immunization a condition for continuous employment. In 2004 only 55% of nurses were inoculated against flu – all despite participating in respective educational programs. Nevertheless, the Washington State Nurses’ Association has responded with a law suit upholding nurses’ right for an autonomous decision unless CDC declares a public health emergency (Callahan, 2009). In 2006 the American College of Preventive Medicine submitted a resolution to the American Medical Association recommending mandatory flu shots for all healthcare professionals; the controversy however continues (Callahan, 2009). This is largely happening due to the fact that HCP do not receive proper education and training on advantages of immunization. Secondly, a great number of myths among HCP and lay people are preventing health providers from attaining desired vaccination rates. Vaccination is the principal measure for preventing influenza and reducing the impact of epidemics. Various types of vaccines are reported to be safe while being used for over 60 years. Among the elderly, vaccination reduces influenza-related morbidity by 60% and influenza-related mortality by 70-80%. Among healthy adults the vaccine is very effective (70-90%) in terms of reducing influenza morbidity, and vaccination has been shown to have substantial health-related and economic benefits in this age group (World Health Organization, 2009). Furthermore, influenza puts a considerable economic burden in the form of hospital and other health care costs and lost productivity. In the United States of America, for example, recent estimates put the cost of influenza epidemics to the economy at US$ 71-167 billion per year (WHO, 2009). Mass vaccination, therefore, is perceived as the most cost-effective way of preventing the adverse consequences of the possible epidemics. Research has shown that for every dollar invested into vaccination, the savings was $2.58 (Campbell & Rumley, 1997). Vaccination of HCP is generally believed to reduce the spread of the disease in health care settings. It contributes to reduction of staff absenteeism, and is beneficial to patient due to reduced risk of infection (Anikeeva, 2009). In addition, HCPs are frequently viewed as the source of influenza in clinical setting. One of the key reasons to vaccination is that health workers often continue to work while being infected. CDC states that the best way to reduce influenza transmission rate is though increased use of influenza vaccines (CDC, 2003). A randomized trial, conducted during three consecutive years (from 1992-1993 to 1994-1995) in two large Baltimore hospitals has proven that influenza vaccine was generally effective in preventing infection by influenza type A and B in health care professionals. Vaccinated employees were observed to have had a total 28.7 days per hundred subjects of reported febrile respiratory illness (compared to 40.6 days per 100 subjects in the non-vaccinated control group). It was also observed that vaccinees had a total 9.9 days of absence per 100 subjects as compared to 21.1 days per 100 subjects in the control group (Wilde, McMillan, Serwint, Butta, O'Riordan & Steinhoff, 1999). Results of this randomized trial speak in favor of the annual influenza vaccination of health care workers. Despite all the positive elements of mandating flu vaccination, this process has several considerable negative elements, which are causing low percentage of immunized health care personnel. One of the main negative aspects of mandatory vaccination is related to coercion in work environment. In her analysis of ethical considerations of mandatory vaccination, Anikeeva (2009) stated that medical workers needed to be immunized and that agencies were acting out of principles of nonmaleficence and beneficence. Contrary to this come the rights of HCP, where their autonomy, in regards to vaccination decisions, should be recognized and observed. The pressure associated with mandating vaccination could result in certain worker alienation or termination. Talbot (2008) stated that mandatory vaccination practice in Virginia Mason Medical Center led to termination of nearly 1% workers. Talbot also argued that high percentage of mass immunization of health workers could be attained via education, which medical care providers often failed to recognize as a continuing driving factor in immunization of HCP. This view was also supported by Anikeeva (2009). Finch (2006) cited an example of voluntary hepatitis B vaccination programs, where immunization rate reached 75% among HCP. Such high percentage was predominantly attained through targeted education, free vaccine and active declinations. Failure of health care providers to educate their staff on vaccine questions led to numerous myths related to immunization. Myths, associated with vaccination, were the main cause of high percentage of refusals to get immunized. Finch (2006) further argues that mandatory vaccination programs are likely to cause legal consequences in case of adverse consequences. In addition, mandatory vaccination can be viewed as violating one’s civil liberties. Other consequences of mandatory vaccination can include reduced focus of other intervention methods including hand hygiene and patient isolation, which thus create a false sense of security. Finch (2006) and Talbot (2008) state that because of the issues associated with mandatory vaccination, voluntary immunization is viewed as more preferable. Anikeeva (2009) states that reasons for vaccination of health care workers should be coming from duty-of-care considerations rather than coercion. Furthermore, positive working environment promotes stronger relationships between employers and employees. Finch (2006) suggests that voluntary immunization is viewed as more preferable, and methods including prizes, recognition or rewards for units or departments as well financial rewards will help to avoid the ethical pitfalls of coercion. In addition to positive incentives the question of mandatory flu vaccination makes creation of a respective task force on a community level well justified. As stated previously, according to National Health Interview Survey (NHIS), immunization percentage among health workers is far below the target rate (CDC, 2003). It would be necessary therefore to conduct mass surveys among the non-immunized workers with the purpose of establishing reasons for their active declination. Results of such surveys would serve as guidelines in a targeted education campaign. Scientific evidence (Anikeeva et al., 2009; Finch, 2006; Talbot, 2008) confirms that in most cases reasons of refusal are based on myths and overall immunization rate can be increased through education. Other research data indicates that vaccination of health workers is an effective means of preventing patient morbidity and mortality (Wilde, McMillan, Serwint, Butta, O'Riordan & Steinhoff, 1999). The second main function of the task force would be the educational one. Educational classes, distribution of reminders, notes etc. are seen as expedient in conveyance of information on vaccine, its safety and effectiveness. Ample evidence is available on efficiency of vaccine (Sullivan, 2010); it is very important that the task force can collect relevant research data and present it to health care workers on a consistent basis. It is worth noting that while emphasizing positive aspects, medical workers should be informed of the possible side effects. In this case, research data is also helpful in establishing probability of adverse consequences resulting from vaccination. The third role of the task force would be to participate in clinical trials which are aimed at establishing the influence of unvaccinated medical personnel onto patients, including patients from the risk group. It is worth mentioning that this function has a limited applicability, mainly because trials are difficult to conduct in small rural hospitals. If participation in a trial is hindered or impossible, rural hospitals can concentrate on educational and information gathering functions. Along with this emphasis on principles of nonmaleficence and beneficence should be placed. Summing up, despite the proven efficiency of mandatory vaccination in achieving high immunization rates, compulsory vaccination of HCP is not advisable. Mandating vaccine to health workers can cause a number of adverse consequences ranging from complications after immunization to deterioration of work relationships, including termination. In addition, mandatory immunization can have adverse legal consequences. While effectiveness of immunization of health workers has been proven, its implementation on a mandatory basis is discouraged. A more effective immunization plan for health workers should be based on positive incentives, including direct awards and rewards as well as certain restrictions for non-vaccinated personnel. Restrictions might incorporate denial of access to areas where immunized workers are allowed to work. The role of task force in immunization of health workers is also hard to overestimate. One of the functions that a task force can perform are research and educational. Education of HCP is viewed as the most efficient means of increasing overall immunization rate. References Anikeeva O., Braunack-Mayer A., & Rogers W. (2009). Requiring Influenza Vaccination for Health Care Workers. American Journal of Public Health, 99, 24–29. Callahan, J. (2009). Emerging biological threats. Santa-Barbara, CA: Heinemann Educational Books. Campbell, D.S. & Rumley, M.H. (1997). Cost-effectiveness of the Influenza Vaccine in a Healthy, Working-age Population. Journal of Occupational and Environmental Medicine, 39, 408–414. Centers for Disease Control and Prevention. (2003). Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR, 52(RR-8): 1-34. Chan, S., & Hartocollis, A. (2009, October 16). Judge Halts Mandatory Flu Vaccines for Health Care Workers. The New York Times. Retrieved from http://cityroom.blogs.nytimes.com/. Finch, M. (2006). Point: Mandatory Influenza Vaccination for all Heath Care Workers? Seven Reasons to Say “no.” Clinical Infectious Diseases, 42, 1141–1143. Sullivan, P., (2010). Influenza Vaccination in Healthcare Workers: Should it be Mandatory? The Online Journal of Issues in Nursing, 15. DOI: 10.3912/OJIN.Vol15No01PPT03 Talbot, T. R. (2008). Improving rates of Influenza Vaccination among Healthcare Workers: Educate; Motivate; Mandate? Infection Control and Hospital Epidemiology, 29, 107–110. World Health Organization. (2003). Factsheet #211: Influenza (Seasonal). Retrieved from http://www.who.int Wilde, J., McMillan, J., Serwint, J., Butta, J.; O'Riordan, M., A., Steinhoff, M., (1999). Effectiveness of Influenza Vaccine in Health Care Professionals: A Randomized Trial. JAMA, 281(10), 908-913. Read More