Updates: H1N1 vaccine supply and NY health care worker mandates

There's more coverage of the H1N1 vaccination program than we or anyone else can digest. However, this story from yesterday's Washington Post, "Why such a shortage of swine flu vaccine?" does a very good job examining the most common topic of late, the recent shortfall in H1N1 vaccine supply compared to government and manufacturer predictions. (Whether this technically qualifies as a 'shortage' is up for debate.)

According to this Associated Press report late yesterday, the vaccine supply situation seems to be improving. Hopefully, interest in the vaccine will remain high until adequate vaccine doses become available. Otherwise, it's quite possible that later this winter, health officials will find themselves with the opposite problem -- millions more doses of H1N1 vaccine than citizens making an effort to receive it.

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In related news, we wrote several posts earlier this month on mandatory vaccination policies for health care workers, particularly the statewide program in New York. Citing inadequate supplies of both H1N1 and seasonal flu vaccines, Gov. David Paterson announced late last week a suspension of the requirement for the current flu season. Here is coverage from the New York Times.

Notwithstanding the New York decision, many health systems are proceeding with influenza vaccination requirements this fall. The Immunization Action Coalition has compiled an "Honor Roll" of health care facilities with vaccination requirements for health care workers.

Opposing views from ethicists on health care worker flu vaccine mandates

Two bioethicists have weighed in via op-eds on the debate over mandating seasonal and swine flu vaccination for health care workers.

On the 'pro' side, our colleague Art Caplan minces no words in his column, "Health Workers: Get Flu Shots or Get a New Job," on MSNBC.com this morning. He writes:

"Look, there are legitimate issues that ought to be debated whenever someone says you must do something to benefit others ranging from taxation to restrictions on driving under the influence. But health care workers' own code of ethics dictates that they put the interests of others — their patients — first. Getting a flu shot is the least those who claim to be bound by professional ethics ought to do."

Taking the other side is George Annas, professor of health law at Boston University and a strong critic of mandates in medicine and public health. In an op-ed published in Newsday, "Don't Force Medical Pros to Get H1N1 Vaccine," Annas writes:

"The ultimate measure of success or failure of a swine flu vaccination program will be in lives saved and lives lost. The most effective way to maximize the numbers of the public being vaccinated is to send the message that physicians and nurses believe this is the most reasonable approach to take to prevent wide-scale death and disease from the swine flu. Legal threats and mandates undercut that public health message and will backfire."

Annas makes a strong point about the potentially troublesome message sent to the public about the importance of flu vaccination, if even health care professionals have to be compelled to receive it. Why enthusiasm for vaccination among health care workers is so low continues to puzzle public health experts. In the meantime, requiring vaccination in this community may be a necessary evil to prevent avoidable disease and death among patients.

Looking at one hospital's health care worker flu vaccine mandate

Earlier this week we wrote about the opposition in some quarters to the growing number of health care workers being required to receive flu vaccinations. In the past few days, media coverage of this issue has continued to grow, much of it centered on the state-wide policy recently introduced in New York and a recent protest against it.

Far more common, however, are policies created by individual hospitals or health systems. Shortly after our last post on this topic, we learned that our own institution, the University of Pennsylvania, had recently announced an influenza vaccination requirement for all personnel working in one of Penn's hospitals or other patient care facilities. This includes physicians, students, staff, and volunteers, regardless of whether they have direct patient contact. The requirement is for both seasonal flu vaccination annually and (depending on availability) the H1N1 vaccine this fall.

The policy -- available here -- is a useful case study for how one of the nation's most prominent health systems is implementing and enforcing the annual requirement, described as "a condition of employment or access to Penn Medicine facilities." The vaccines will be administered at no cost to employees. Exemptions are available for medical or religious reasons, supported by a letter from an employee's physician or clergy, respectively. Exemptions will be evaluated on a case-by-case basis; those employees for whom exemptions are granted will be required to wear face masks at work for the duration of flu season.

After a warning, those failing to receive the vaccine or an approved exemption "will be subject to further disciplinary action up to termination of employment." More information is available in this Q&A document distributed with the new policy.

Policies will surely differ slightly among health care institutions, but the Penn policy provides a good example of the evidence and arguments cited by disease control specialists in support of health care worker flu vaccination requirements.

Again, it's worth repeating that this and every other flu vaccine mandate in the news lately involves only health care workers, part of an initiative launched long before the current H1N1 situation. Public health officials remain unequivocal that there are no plans to require H1N1 vaccination for the general public, a message at risk of getting lost amid coverage of this related, but distinct policy debate.

Hospitals facing resistance to health care worker flu vaccine mandate

A brief respite from all-things-H1N1 to mention a related topic in vaccine ethics and policy: the growing number of hospitals requiring employees to be vaccinated against seasonal influenza this fall and the resistance they are reportedly encountering.

As readers of this site know, public health and disease control experts have long been discouraged by the shockingly low rates of influenza vaccination among health care workers, despite the potential benefits to patients in reducing the likelihood of hospital-borne infections (not to mention the personal protection the vaccine provides). Strategies to boost vaccination rates among hospital staff -- educational campaigns, pleas to professional duty, monetary incentives like prize raffles -- have had only modest results.

Notably, health care workers who decline vaccination typically explain their decision by pointing to the same inaccuracies that vaccination proponents are continually trying to correct among the general public. (Included in this list: the possibility of getting the flu from the vaccine itself, something about one's personal constitution that means they "never get the flu," and unproven concerns about the vaccine's safety.)

In the past few years, a handful of hospitals and other health care facilities experimented with mandating seasonal flu vaccination as a condition of employment. This fall, the number of institutions implementing such a policy appears to have surged. Opponents of the requirements -- including many of the usual voices in the vaccine safety and policy debate joined here by labor organizations representing hospital workers -- are already lining up to voice their concerns, as stories in last week's Washington Post and New York Times report.

Left unclear in both of these stories is how H1N1 vaccination fits into programs that had been developed with the annual seasonal influenza vaccination in mind. The Post story implies that at least some of the hospitals mentioned are implementing requirements that include both types of flu vaccine, a difficult task given the uncertainties surrounding the timing of the H1N1 vaccine's arrival in large quantities.

That ambiguity underscores the confusion sure to surround the enforcement of health care worker seasonal flu vaccination mandates amid the tremendous attention surrounding H1N1 flu this fall. In fact, the nation's leading voice in public health, CDC director Thomas Frieden, suggested in the Times that waiting to introduce these mandates would have preferable. He says, "This is just not the right flu season to take this on."

It's hard to argue that vaccination of health care workers against flu doesn't protect patients, reduce hospital infections, and set a good example for the importance of annual vaccination. For health officials already confronting the overwhelming communication and logistical challenges related to H1N1 vaccination, introducing health care worker vaccine requirements (and responding to resistance and resulting media coverage) adds to the unprecedented challenges facing our public health infrastructure and leaders in the coming months.

Seasonal flu: Examining school-based vaccination; Debating health-care worker mandates

A few recent items related to seasonal influenza vaccination:

-- Lisa Schnirring at CIDRAP News published an interesting story last week examining the potential use of school-based flu vaccination efforts in order to increase coverage in the under-18 population for whom vaccination is now recommended by the ACIP. Optimism for these in-school vaccination programs seems to be in short supply given the various pressures -- funding, staffing, and performance -- faced by school districts around the country.

-- Each flu season, the amount of attention grows regarding the astonishingly-low influenza vaccination rates among health-care workers grows. Two recent papers join the discussion about the use of mandates to boost coverage in this group:

• "Requiring Influenza Vaccination for Health Care Workers" (American Journal of Public Health, online pre-publication -- subscription required); Reviews the ethical arguments for and against mandating vaccination, concluding that a program providing small incentives for compliance and requiring active refusal is ethically superior to mandated vaccination.
  

• "The Ethics of Mandatory Vaccination against Influenza for Health Care Workers" (Vaccine, Vol. 26, No. 44, 5562-5566 -- subscription required); Focuses primarily on the ethics of mandatory vaccination for those working in long-term care facilities, and concludes that mandates are only justifiable if voluntary programs fail to achieve 50% coverage among health-care workers.
  

Growing support for health care worker flu vaccine mandate

The Infectious Diseases Society of America released a report on Thursday calling for mandatory influenza vaccination of all health care workers. Here's the press release from the IDSA. An excerpt:

"'It’s our professional duty to first do no harm,' said Andrew T. Pavia, MD, chair of IDSA’s National and Global Public Health Committee. 'Voluntary systems haven’t brought immunization rates up far enough. For the sake of our patients, all health care workers must get a flu shot every year or they must be required to opt out in writing.'"

This position was part of a larger report looking at many aspects of seasonal and pandemic influenza planning and response. There's an important caveat, however. The IDSA recommendation allows for health care workers to decline vaccination, provided they do so in writing, a provision likely motivated by practical reasons rather than sound medical or public health reasoning.

CIDRAP News covered the announcement, quoting our own Art Caplan and David Curry's op-ed in the San Jose Mercury News, which he previously noted here.

Today's Boston Globe picked up on the IDSA position in an editorial today titled "The best shot at fighting the flu." They write:

"One step in getting all health providers at or close to 100 percent is the new policy of the Joint Commission on Accreditation of Healthcare Organizations to require that they at least offer flu shots to all workers. But full compliance will come only through action by Congress and Health and Human Services. A flu shot mandate is one of the most effective steps the nation could take to prepare for a pandemic and, at the same time, reduce the annual toll of the flu virus."

Op-ed on health care worker flu vaccination

Our colleagues Art Caplan and David Curry wrote an editorial in Tuesday's San Jose Mercury News on the disturbingly low influenza vaccination rates among physicians and other health care workers. Here's an excerpt from the piece, declaratively titled "Make sure your health care workers got flu shot":

"The roughly 40 percent rate of flu vaccination for health care workers means that two in three of the people caring for her are not vaccinated. Do you have the right to ask that health care workers who interact with your parent get the flu vaccine? Why not? You should ask those providing health care: 'Did you get your flu shot this season?' And don't forget the person who brings the food tray, changes the bedding or installs the cable TV. Asking may be embarrassing, but it will remind health care workers to do the right thing.

It is time to move public policy in the direction of mandatory flu vaccines for all appropriate health care employees. Choice is a key value for us all, but spreading infection among the sick is too high a price to pay for that choice. We should not have to wonder whether the person taking care of us, our newborn or our elderly parent has gotten a flu shot."