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Brandon Hostler’s arm is usually among the first extended for the annual flu shot at Ruby Memorial Hospital in Morgantown, W.Va. He is, after all, a registered nurse — he knows it can do some good.
But if that shot ever becomes mandatory, he will balk.
“I wouldn’t quit or switch jobs,” he said. “But we are health care professionals. We know the risks and the benefits, and to force us to do something like that and not have a say in it, I think it would be offensive and unwanted.”
In this moment of looming change and controversial mandates in American health care, the debate over whether flu shots should be mandatory for hospital employees has become a smaller but important battle between those who feel government should force its hand to improve the health care system and those who believe that critical civil liberties are being steamrolled.
In the thick of the fray is a problem of massive proportion: Influenza kills between 3,000 and 49,000 people each year and sends 200,000 to the hospital for respiratory illnesses and heart conditions. That’s according to a subcommittee of the federal government’s National Vaccine Advisory Committee, which will meet this week to discuss potential strategies for dramatically boosting immunization and inching closer to a Healthy People 2020 goal.
The U.S. government would like to see 90 percent of America’s health care personnel immunized annually against the flu by the end of the decade. But reaching that goal begs a major question: Should the government encourage organization-wide, state-based or even national mandates to get there?
In the 2010-11 flu season, 63.5 percent of health care personnel received a flu shot, according to the Centers for Disease Control and Prevention. In hospitals that required immunization, compliance was nearly universal.
“This should be mandated and it should have been done earlier,” said Helen Darling, president and CEO of the National Business Group on Health.
The nonprofit organization, which represents more than 300 large employers, including 68 of the Fortune 100 companies, threw its support behind a flu shot requirement for health care workers last week, and it did so in part due to three additional statistics, Darling said. The virus can be transmitted to patients by both symptomatic and asymptomatic health care providers. One in four health care workers shows evidence of having the flu each year. And 70 percent of them continue to work despite having flu-like symptoms.
“The idea that a pregnant woman can enter a hospital and deliver a baby in a place where employees aren’t required to take every step possible to guard against a preventable disease … I just think that many people would be stunned by that,” Darling said. “If hospital workers don’t want to get the shot, they don’t need to work in a hospital — they can go work in a library and spread their germs to people checking out books.”
Where’s the ‘Informed Consent?’
Needless to say, not everyone agrees. Barbara Loe Fisher, co-founder and president of the National Vaccine Information Center, says some of the studies supporting the effectiveness of the flu vaccine are “flawed” — at least enough that workers should be allowed to exercise “informed consent.” In a letter to the U.S. Department of Health and Human Services regarding the subcommittee’s recommendation, Fisher and her team also called into question the CDC’s estimate for annual flu-related deaths. All told, she said, the evidence is too shaky for any kind of government-imposed mandate.
Certainly, she said, the shots should be available for those that want them. “But there should be in America the right to make informed, voluntary choices about the preventive health care we use. Because when these hospital employees receive flu shots, they’re engaging in a medical intervention that carries a risk of great sickness and even death.”
Front Line Obligations
Those arguments don’t hold much weight with health officials in Colorado who want the vaccine administered to all hospital and nursing home employees — with no religious or personal exemptions allowed. A narrow set of individuals with documented medical conditions could apply for a waiver, but they would be required to wear a mask during flu season.
The Colorado Hospital Association supports the general idea, which will be taken up by the state board of health later this month.
“If we did face a serious epidemic, it serves no one’s interest to have our health care workers on the front line at home, sick,” said Steven Summer, the hospital association’s president and CEO. “They would be the first-responders, and having them home sick wouldn’t work so well. In the absence of a clear mandate, we can’t get where we need to be.”
On a more individual level, it’s an “ethical responsibility,” said Amy Garcia, chief nursing officer for the American Nurses Association.
“Part of nursing’s code of ethics is that the patient comes first. So we believe if there is a chance that a nurse could expose a patient, it is the ethical responsibility of the nurse to be protected by vaccinations,” Garcia said.
A strictly enforced policy is a little different, though, she said. Any formalized rule should always be accompanied by enough protections to ensure that “nurses are treated fairly.”
That includes suitable exemptions for those allergic to the vaccine, the ability to opt-out for personal reasons, and bans on discrimination or punitive measures for those who choose not to participate. The policy should also be part of a larger “comprehensive infection control program” that includes the use of masks, gloves and aprons in appropriate settings, Garcia said. And immunization clinics should be free and convenient for employees working all shifts.
Swine Flu Fever
Few of those protections were in place in 2009, when the nation panicked under the building threat of H1N1 and New York state officials issued an edict that medical professionals either receive seasonal and swine-flu vaccines or lose their jobs.
“There was mass outrage because it was put forward without any discussion, there were no personal exemptions, no religious exemptions,” said Renee Gecsedi, a registered nurse and director of education practice and research for the New York State Nurses Association. “There was a medical exemption but it was so narrow that people with egg sensitivities — which often flare up after the vaccination — weren’t included “
The uproar coupled with the vaccine shortage that year caused state officials to rescind the policy. But it served as a telling measurement of public opinion, Gecsedi said: “If these mandates go into effect, employees need to have options.”
Uncertain Steps Ahead
At the moment, the subgroup of the federal government’s National Vaccine Advisory Committee isn’t advocating a full-scale national mandate. In fact, its draft proposal only recommends that health care employers “strongly consider an employer requirement for influenza immunization” after a broader, multi-pronged approach fails to hit certain benchmarks in the build-up to the 90 percent goal for 2020.
Still, the federal government’s not ruling anything out, said Dr. Don Wright, deputy assistant secretary for health care quality at the Department of Health and Human Services.
“The National Vaccine Advisory Committee can accept, modify or reject the subcommittee’s proposal — or they can come up with something else,” he said. “I’m not sure where the committee will come out.”
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