Elsevier

Vaccine

Volume 23, Issues 17–18, 18 March 2005, Pages 2251-2255
Vaccine

Requiring influenza vaccination for health care workers: seven truths we must accept

https://doi.org/10.1016/j.vaccine.2005.01.043Get rights and content

Abstract

In this paper we outline the seven primary truths supporting the call for requiring influenza immunization of all health care workers. We view this as a serious patient safety issue, given the clear and compelling data regarding the frequency and severity of influenza infection. In addition, clear-cut safety, efficacy, economic, legal, and ethical platforms support the use of influenza vaccine. Unfortunately health care workers have demonstrated, over almost 25 years that they are unwilling to comply with voluntary influenza immunization programs utilizing a variety of education and incentive programs, at rates sufficient to protect the patients in their care. We suggest that an annual influenza immunization should be required for every health care worker with direct patient contact, unless a medical contraindication or religious objection exists, or an informed declination is signed by the health care worker. High rates of health care worker immunization will benefit patients, health care workers, their families and employers, and the communities within which they work and live.

Introduction

Influenza causes worldwide yearly epidemics resulting in 250,000–500,000 deaths [1]. The most efficient method of preventing these annual outbreaks and resulting morbidity and mortality is by the use of pre-exposure immunization. Because those most vulnerable to the complications of influenza, including death, congregate around health care workers by virtue of attending clinics, hospitals, and offices, an important method to decrease exposure to those most vulnerable is to immunize health care workers. The Centers for Disease Control and Prevention (CDC) has recommended influenza vaccination for all health care workers since 1981. Since that time, health care organizations across the country have established voluntary programs to provide influenza vaccine to health care workers in order to protect the lives and health of their patients. The response thus far has been dismal, as only 36% of US health care workers received influenza vaccination in 2002 [2]. Even among health care centers utilizing highly organized and aggressive campaigns to promote immunization of health care workers, 30–50% remain unvaccinated. After more than two decades of voluntary trial and error programs, the time has come to take the next step in addressing this public health challenge by requiring influenza immunization of all health care workers. Here, we provide the data and rationale for such a requirement. We suggest that an annual influenza vaccine should be required for every health care worker with direct patient care activities, unless a medical contraindication to influenza immunization exists, a religious objection to immunization exists, or an informed declination is signed by the health care worker. This is identical to the highly successful method utilized in the hepatitis B immunization requirement for health care workers.

Since the initial Centers for Disease Control and Prevention (CDC) recommendation, the scientific understanding of influenza, the influenza vaccine, and the data on the efficacy of influenza immunization support the assertion that immunizing health care workers safely and effectively prevents a significant number of influenza infections, hospitalizations, and deaths among the patients they care for, as well as preventing workplace disruption and medical errors by workers absent from work due to illness, or present at work, but ill [3], [4], [5], [6], [7]. It is now undeniable that influenza vaccination of health care workers does result in improved patient safety, improved employee safety, and decreased health care expenditures [6], [7]. In this paper, we provide the data for these assertions and put forward the proposal that the medical community has a moral imperative to take appropriate action to protect the vulnerable patients for whom they care, their fellow health care workers, and the public at large. With voluntary health care worker vaccination programs failing to achieve acceptable immunization rates [8], the data lead us to conclude that requiring influenza immunization of health care workers is a moral imperative. If the medical community is unable to overcome the inertia of the current policy that endangers the public, the medical community may lose control of the ability to make this choice.

We suggest that the medical, legislative, and public views of this health threat would likely be different if we were discussing a more exotic virus having the same transmissibility and morbidity as influenza. If we had a safe and effective vaccine against a newly emerging infection such as SARS or avian influenza, would we allow health care workers to care for infected patients without having received the vaccine? Conversely, would we allow infected health care workers to care for uninfected patients? In fact, concerns about the ethics of such behavior would surface almost immediately. Yet, we allow precisely these situations to occur with a virus that kills 36,000 Americans every year—the equivalent of a September 11, 2001 World Trade Center disaster every month of every year [9]. This is a horrific carnage that pales, however, to the 250,000–500,000 persons lost to this virus every year worldwide. Although we recognize that there are differing opinions regarding the appropriate policy regarding the issue of health care workers and influenza vaccine, we must acknowledge seven truths emerge from decades of research. Together they form a platform on which we can firmly stand and contend that we should require influenza vaccines for all health care workers.

Section snippets

The first truth: influenza infection is a serious illness causing significant morbidity and mortality adversely affecting the public health on an annual basis

Influenza is the sixth leading cause of death among adults in the United States, killing an average of 36,000 Americans annually [9]. Influenza kills as many or more Americans each year than breast cancer (40,000), and three times as many as HIV/AIDS (14,000) [9], [10], [11]. Influenza is related to 1 out of every 20 deaths in the US among those older than 65 years of age. Overall, nearly 1 out of every 10,000 Americans will die of influenza and its complications this winter [2], [12]. In

The second truth: influenza-infected health care workers can transmit this deadly virus to their vulnerable patients

Complications of nosocomial influenza are particularly burdensome on the elderly, the immunocompromised, critically ill patients, and young children—the very populations congregated in hospitals and medical clinics [2], [9], [14], [15]. Influenza infection in these populations can often result in severe, prolonged, devastating illness, death, increased length of stay, and added costs [14], [16]. The virus can be transmitted to patients and other employees by both symptomatic and asymptomatic

The third truth: influenza vaccination of health care workers saves money for employees and employers and prevents workplace disruption

Nichol et al. [6] reported that healthy working adults who receive influenza vaccination have 25% fewer upper respiratory infections, 44% fewer doctor visits, and 43% fewer sick days off, saving an average of $47 per person annually. A previous study by Nichol et al. [23] revealed that among three different cohorts of 25,000 adults each studied over 3 years, influenza vaccination reduced pneumonia and influenza hospitalizations by 48–57%, all acute and chronic respiratory conditions by 27–39%,

The fourth truth: influenza vaccination of health care workers is already recommended by the CDC and is the standard of care

This recommendation has been in place by the Centers for Disease Control and Prevention since 1981. Since that time, hospitals, clinics, and health organizations have developed influenza immunization programs and have devoted resources to it. However, these programs are passive, voluntary systems that fail to recognize the current data and realities [24]. The result is a failed and incomplete system reaching an average of only 36% of US health employees annually [2]. Voluntary health care

The fifth truth: immunization requirements are effective and work in increasing vaccination rates

A requirement for vaccination is not unique to influenza. Childhood immunization rates vastly improved in the US, often exceeding 90–95%, once mandatory school-entry immunization requirements were put into place. In health care settings, mandating hepatitis B vaccination and rubella vaccination has also been successful in achieving nearly universal immunization of health employees against these pathogens. Similarly, health care worker requirements for measles, mumps, varicella, and annual

The sixth truth: health care workers and health care systems have an ethical and moral duty to protect vulnerable patients from transmissible diseases

The Occupational Safety and Health Agency and the Joint Commission on Accreditation of Healthcare Organizations have supported the idea of protecting health care workers and the patients they care for by pursuing vaccination initiatives as well as other measures to protect all involved. Beyond government interventions, the medical community has an ethical obligation to act with the safety of its patients as its foremost interest. It is now known that health care workers are vectors for the

The seventh truth: the health care system will either lead or be lambasted

Health organizations must take responsibility for curbing yearly epidemics that profoundly influence the health of our patients, our health care workers, our communities, and our global health. The US health care system has largely remained self-governing with regard to many health policies. With the recognition that voluntary health care worker immunization programs achieve only dismal vaccination rates among health care workers, the medical community should take decisive action. To make an

Acknowledgements

We wish to acknowledge the many professional colleagues with whom we have had many lively debates and discussions regarding the issue of requiring influenza immunization of health care workers.

Disclaimer: The views and opinions expressed herein are not necessarily the views and opinions of the Mayo Clinic, Department of Defense, The National Foundation for Infectious Diseases, The International Society for Vaccines, Center for Disease Control and Prevention, or any of the professional societies

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