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Most Health Care Professionals Dodge Influenza Vaccination for Themselves
In the United States, influenza immunization rates for health care professionals in surveyed health care institutions have been reported to range between only 15% and 40%, despite recommendation by the Centers for Disease Control and Prevention since 1984 that health care professionals receive influenza vaccinations annually. (1-3) A pattern of health care professional noncompliance with annual influenza vaccination is a worldwide phenomenon, even when programs exist to boost vaccination rates, say Australian public health (non-clinical) health policy researchers Olga Anikeeva, et al. For example, “a program in Australian Capital Territory elder-care facilities included the provision of reminders and information about the importance and benefits of influenza vaccination, but resulted in only 28% of staff obtaining vaccination. [4] Similarly in a tertiary Australian hospital in which an influenza vaccination promotion program had been in place since 2001, only 24% of staff reported being fully vaccinated despite 96% of staff indicating that they were willing to update their vaccination status. [5] A study conducted in neonatal intensive care units in the United States found that influenza immunization compliance rates among staff ranged between 15% and 20% and that 76% of staff continued to care for patients despite reporting flu-like symptoms. [6] In the United Kingdom [and in Europe, in general], less than 25% of health care workers are vaccinated against influenza each year despite being aware of the potential benefits of vaccination. [7]” A 2006 survey of a national sample of primary care physicians and subspecialists likely to see patients at high risk for complications from influenza (family physicians, internists, geriatricians and pulmonologists) showed that 87% of respondents reported receiving an influenza vaccine during the 2003-2004 influenza season, with no significant difference across specialty groups. The researchers were overjoyed at their findings. However, their survey response rate was only 38% and apparently no followup survey instrument was conducted to increase participation. (8) Why do most health care professionals tend to dodge influenza vaccinations for themselves? British researchers O’Reilly, Cran and Stevens researched this question among 203 nurses. (9) Of the 203 nurses, 76 (37%) were immunized and 127 (63%) declined. Vaccine recipients were more likely to be male, full-time and to previously have had influenza immunization. The commonest reason given to the researchers for declining the immunization was that there was no personal benefit as they were healthy (69%). The second commonest reason, given by 19%, was concern about side effects. In contrast to the findings of O’Reilly, et al., in the United Kingdom for declining influenza vaccine, the principal reasons for declining immunization in North American studies were 1) avoidance of medications and 2) fear of adverse reactions. (9) Guillain-Barre syndrome is one such severe reaction, and it struck a higher than expected number of recipients of swine influenza vaccine during the 1976-1977 influenza season in which the Centers for Disease Control strongly recommended vaccination of “every man, woman and child.” (10-11) This butchered vaccination event had a certain effect on the perception of risk among the general public and health care professionals. (12) Faced with the poor reception of influenza vaccine by health care professionals for decades, and only small increases in immunization rates achieved by a number of interventions, Anikeeva, et al, suggest mandatory influenza immunization. (1) Mandatory vaccination for children before they enroll in school has become widely accepted in the United States, point out the authors. Anikeeva, et al., lavishly present ethical arguments supporting compulsory vaccination of health care professionals. They argue, “[I]t is ethically required for health care workers to accept influenza vaccination to minimize the risk of harm to patients.” How do they justify this conclusion? In their own words, they say, “we need to turn to the widely accepted ethical principles of nonmaleficence and beneficence.” They continue, The duty to do no harm, or nonmaleficence, can be understood to mean that health care workers have a duty not to place patients at undue risk of harm. Applied to influenza vaccination, this principle suggests that health care workers have an obligation to their patients to take reasonable actions to prevent transmission of the virus. Thus, it may be argued that it is ethically required for health care workers to accept influenza vaccination to minimize the risk of harm to patients. The duty of beneficence requires health care workers to act in the best interest of their patients. Understood broadly the duty of beneficence includes not only the provision of specific medical interventions but also at least a prima facie duty to take reasonable steps to secure good outcomes for their patients. If we accept this broad definition, the duty of beneficence could be construed to require annual influenza vaccination, because this would give health care workers greater immunity and increase their capacity to provide care during outbreaks of influenza. Of course, duties of beneficence and nonmaleficence are not unlimited. We do not require health care workers to risk their lives or endanger their colleagues in the interests of their patients. When health care workers choose to endanger their own lives, we may describe their actions as “heroic,” which suggests that we consider them to have gone beyond what duty requires. The authors continue, “[O]n the basis of the arguments above, it seems that health care workers have an obligation to accept influenza vaccination, on the grounds of beneficence and nonmaleficence. The two exceptions to this general rule would be health care workers who are unable to accept the vaccine for medical reasons or who conscientiously object to vaccination.” To achieve high influenza vaccination rates among health care professionals, the authors suggest implementing a “program of incentives and sanctions.” “Incentives might include financial rewards, prizes, or public approbation for health care workers who choose to accept influenza immunization. For example, there could be honorable mentions or rewards for hospital units or wards whose staff vaccination rate reached a set percentage. Positive incentives would eliminate potential infringements of health care workers’ rights and would likely remain cost-effective for participating health care institutions…It is important to ensure that the financial incentives are not so large that they may be perceived as coercive for health care workers with relatively low incomes.” Modest rewards like a free frozen yogurt or a movies ticket or a health book seem to work well, the authors note. What about sanctions against the wily health care professionals who dodge the bullet? The authors suggest “suspension of minor privileges or limits on areas in which non-compliant staff may work.” (1) Breezily, the authors end their article remarking, “Of course, this kind of program must be accompanied by other measures to reduce barriers related to education, access, cost, and insurance, and accompanied by appropriate compensation for workers who experience vaccination-related adverse events. The number of adverse events is likely to be small, but financial benefits and health care for those adversely affected are important both on grounds of fairness and to encourage participation.” (1) Editorial Comment: Unpredictable catastrophic adverse reactions (such as Guillain Barre with swine flu vaccine and myocardial inflammation/infarction with recent smallpox vaccine) in healthy vaccinees are one of the reasons why widespread vaccination remains controversial. If a government body recommends or commands the injection or ingestion of foreign material into millions of healthy individuals, it better be sure that the foreign material does no harm. Compulsory vaccination programs have always and always will meet with a degree of resistance within the targeted populations. (13) Notes:
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