Effect Measure

In an earlier post I said I opposed mandatory vaccination for adults (but not for children), the one exception being for health care workers because they come in contact with people at high risk. My view then was that if you work in a health care institution and won’t get vaccinated against flu, then you shouldn’t come to work. Now I am re-evaluating my position as a result of some cogent and pragmatic comments from lawyer-bioethicist George Annas, professor of health law, bioethics and human rights at Boston University School of Public Health, and author of “The Rights of Patients.” I know Annas to be pro-vaccination and unambiguous about mandatory vaccination for children. His (and my attitudes) about adults is that there is a primacy to the principle of autonomy, as bioethicists frame it, and that no one who is competent to decide for themselves should be legally forced to be vaccinated. But we differed on the matter of health care workers because I felt that while they might be able to decide for themselves, they had no right to put their patients at risk. But Annas has argued — I think persuasively — that legally requiring vaccination for health care workers would backfire:

Surveys have noted an erosion in public trust of government officials, but continued confidence in physicians and nurses. In this context, persuasion based on science, ethics and prudence, not on legal threats, should be the mandatory course of action for public health officials.

Physicians and nurses, educated and licensed professionals, dedicated to their patients’ health and welfare, do have an ethical obligation to take all reasonable steps to protect their patients. During a threatened flu pandemic, like swine flu, this includes, I think, getting a swine flu vaccination.

So why not require vaccination if they refuse? There are at least four reasons.

The first is symbolic: The practice of medicine (and nursing) is a voluntary one based on informed choice – and will hopefully remain this way. Forcing physicians and nurses to become unconsenting patients – even for a flu shot – undermines the consensual nature of the health care relationship, and at least suggests that if health care professionals can be forced to take a vaccination for the good of others, perhaps everyone else can, too.

The second reason is pragmatic. We are likely to get more physicians and nurses vaccinated in a well-planned and executed voluntary program (including providing the vaccinations at staff meetings, for example), than in a forced program that will draw and energize opposition.

Third, if enough physicians and nurses refuse vaccination, the mandate will be unenforceable, since no responsible public health official would try to close a hospital for failure to comply with the mandate in the midst of a flu epidemic.

Fourth, the requirement that physicians and nurses be vaccinated as a condition of practicing medicine and nursing in health care settings will predictably confuse the public when clarity is critical.

The public will reasonably ask, if physicians and nurses won’t voluntarily take the swine flu vaccine, why should I? Do they know something I don’t? (George Annas, Opinion piece in Newsday [Long Island, New York])

I don’t think I’d put them in the same order, but all of them have some force. The most persuasive to me are the purely pragmatic concerns of reasons number two and three (but I’d reverse the order). In a setting of human resource shortage it’s an unenforceable requirement. I also agree that a health care worker who doesn’t get vaccinated is acting unethically and unprofessionally, like one that doesn’t wash his hands between patients. The question of confusion (reason 4) comes next and Annas’s symbolic concern is important but doesn’t top the list for me. My concerns are pragmatic and his arguments make sense to me.

Annas’s concern in this instance, as it has been throughout his long career, is that we shouldn’t be turning an ethical obligation of health care workers into an arbitrary and perhaps counterproductive legal one (he wonders why it is just necessary for swine flu and wasn’t necessary for seasonal flu, a good question, I have to admit). His view is that we will get a better result if we work with medical and nursing organizations (including licensing boards, if appropriate) to explain the reason and need for vaccination. If that doesn’t work, he fears that legal coercion will not improve matters but make it worse. [see also the excellent piece by Peter Sandman and Jody Lanard on this general topic].

I think he persuaded me, especially as his penultimate paragraphs show that his view and mine aren’t fundamentally different:

And to the extent that the [New York State Health] commissioner wants to protect health care workers themselves, the focus should not be entirely on vaccinations, but should include the health care institution environment, including hospital infection control procedures, adequate supplies of respiratory masks, and reasonable sick leave and worker compensation policies.

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.

Comments

  1. #1 j man
    October 5, 2009

    “I also agree that a health care worker who doesn’t get vaccinated is acting unethically and unprofessionally, like one that doesn’t wash his hands between patients.”

    This is not a good analogy. Washing your hands has no side effects. If you look at the insert for the h1n1 vaccine, the list of side effects and contraindications is quite long and scary. The vaccine also depresses the immune system which would make the health care workers more susceptible to infections such as MRSA. Ultimately the precedent set erodes the freedom of choice.

    Check out this article and see for yourself.

    FDA Approved H1N1 Vaccines Contain Ingredients Known to Cause Cancer and Death http://wp.me/pxS0O-4I

  2. #2 Jonathon Singleton
    October 5, 2009

    Excerpt from an email to the guy who wrote Avian Flu Talk — “What’s In CSL’s Panvax Vaccine?” By rickster58 (23 Sep 2009)

    Australia has always used an inactivated seasonal flu vaccine. I don’t know about Britain, but both the US and Canada use MedImmune’s seasonal FluMist vaccine. Now, that little LAIV-bugger’s technical safety is tres questionable in scientific circles (see Crof’s H5N1 Blog and NCBI links below)… Healthcare workers in Indiana and Tennessee will be among the first in the US to get LAIV-based swine flu vaccines today, Monday 5th Oct…

    Crof’s H5N1 Blog — Chan: H1N1 spreading at “unbelievable” rate (August 29, 2009)
    http://crofsblogs.typepad.com/h5n1/2009/08/chan-h1n1-spreading-at-unbelievable-rate.html

    Jonathon Singleton said August 31, 2009, in reply to Sandra…

    “Sandra, the serious public health problem at present are the effects and consequences of pumping many millions of people simultaneously with live, attenuated H1N1/2009 influenza vaccines (LAIVs).

    LAIV-based swine flu vaccines are weakened live viruses. But because of the technical nature of manufacture [identical to MedImmune's seasonal FluMist vaccine], this cold-adapted live vaccine has been found to be genetically unstable in warm body cells.

    Unlike the safer inactivated type, [MedImmune's Influenza A (H1N1) 2009 Monovalent Vaccine Live Intranasal] facilitates replication-cycle mutations of the virus in lung cells whilst inducing the protective mucosal immune response [and significant viral shedding]. These viral replication mutations can be transmitted to others, serving to seed future wave strains of transgenic flu.

    Yes, many people involved in science and healthcare are frightened about this improperly tested realtime science experiment becoming a “Dr. Crippen” (Emma Thompson’s role in the movie I Am Legend). The “cure” becoming the “cause” of a public health disaster…

    Strange, I always thought medicine was about not creating more harm than what would have transpired without intervention!?!”

    Background reading:

    Chen Z, Aspelund A, Kemble G, Jin H.Molecular studies of temperature-sensitive replication of the cold-adapted B/Ann Arbor/1/66, the master donor virus for live attenuated influenza FluMist vaccines. Virology 2008, 380(2), 354-62.

    Chan W, Zhou H, Kemble G, Jin H. The cold adapted and temperature sensitive influenza A/Ann Arbor/6/60 virus, the master donor virus for live attenuated influenza vaccines, has multiple defects in replication at the restrictive temperature. Virology 2008, 380(2), 304-11.

    Block SL, Yogev R, Hayden FG, Ambrose CS, Zeng W, Walker RE. Shedding and immunogenicity of live attenuated influenza vaccine virus in subjects 5-49 years of age. Vaccine. 2008, 26(38), 4940-6.

  3. #3 Noadi
    October 5, 2009

    I’m actually disappointed that hospitals don’t require this independently, and seasonal flu included. I wonder how many elderly patients are killed every year from flu they contract from a health care worker?

  4. #4 DemFromCT
    October 5, 2009

    I work at a hospital and am the designated persuader. I agree entirely with George Annas, and raised the NYS issue in comments here some time ago. It’s not just docs and nurses. Housekeepers and maintenance folks who work at a hospital are seen as community health experts (just accept it!) and if the gestalt at the hospital is an angry one, that spreads throughout the greater community.

  5. #5 DemFromCT
    October 5, 2009

    For clarity, even if it’s only HCW that are mandated, that resentment is infectious like a virus within a hospital community.

  6. #6 mem
    October 5, 2009

    I agree totally with this article. I am a avid believer in control over one’s body. As a nurse for 25 yrs. I have always put my patient’s needs above my own. Every year most of us voluntarily get our flu shots. I sat in a meeting of doctors, nurses and ancillary staff where our hospital infection control nurse informed us of this mandate. The meeting became hostile and a supervisor had to end the subject. This was followed by the mandate being written on our pay stubs. That was a pretty firm statement of the consequences. I probably would have gotten the shot anyway by nov 30th but I would have liked to have this choice. This mandate has only made me decide to retire as soon as I can from healthcare. What will be the next mandate? The constitution gave us free choice but obviously the government, the media and the powerful pharmacutical companies have alot to say over what I put into my body.

  7. #7 Clare
    October 5, 2009

    Having just read #6, is the problem a: that mandates force people to do things they wouldn’t otherwise do or b: that they indicate a lack of trust among the “higher ups” that health workers will do the right thing if allowed to make up their own minds about it. I can more readily understand the second objection than the first. As a patient, I’d be very curious to know how many of the people who care for me in a clinic, hospital etc. have taken rational and sensible precautions against making other people sick. Naively, I had imagined that being up to date with recommended immunizations was a basic requirement. If mandates are altogether too clumsy and coercive, perhaps getting everyone on board with a marketing campaign might work: “Come to us! n% participation among our staff in getting their vaccinations!” (I’m only being a bit tongue in cheek..)

  8. #8 DemFromCT
    October 5, 2009

    Clare, I am certain the motivating factor was a record of 50% of HCW getting vaccinated over the years contrasted with fear of overrun and short-staffed hospitals. Best intentions and all…

  9. #9 Colin
    October 5, 2009

    So the contentious issue is people want the choice. I respect that. So how about wearing your choice on your sleeve, literally.

    Don’t mandate vaccination but mandate a button “I chose not to get the flu shot” to be worn on the sleeve. If you *chose* not to get a flu shot then you should have no problem wearing that choice, yes?

    See how many high-risk patients refuse to get care from the people who chose not to get a flu shot.

    I’m sure someone will liken this to a scarlet letter or a yellow badge [that the Nazi's made the jewish wear], but of course neither of those were a “choice” like choosing to not get a flu vaccine. Do you object to wearing scrubs, a white coat, or a name tag?

    [/devil's advocate]

  10. #10 Orac
    October 5, 2009

    The vaccine also depresses the immune system which would make the health care workers more susceptible to infections such as MRSA.

    Got any evidence for that assertion or that the flu (or swine flu) vaccine “depresses the immune system” and makes those who receive it “more susceptible to infections such as MRSA”?

    I didn’t think so.

  11. #11 Orac
    October 5, 2009

    FDA Approved H1N1 Vaccines Contain Ingredients Known to Cause Cancer and Death http://wp.me/pxS0O-4I

    Heh. The ol’ “toxin” gambit:

    http://scienceblogs.com/insolence/2007/11/cries_the_antivaccinationist_why_are_we.php

    Really. I know who Dawn Crim is. She was an antivaccine commenter at my blog so loony that, after about a year or two, I couldn’t take her idiocy any more and banned her, making her only the second commenter in the history of my blog ever to be banned. Trust me, it takes a lot of abuse to achieve that.

  12. #12 Scicurious
    October 5, 2009

    It’s very interesting the psychological effect that the word “mandatory” has. My MRU recently made both the regular flu shot and the H1N1 when it comes out mandatory for all hospital employees, who will risk being fired if they don’t get it. And the resentment has been astronomical. Many of the people I know were planning on getting one or both shots, and now, they don’t want to. Because it’s mandatory. They don’t want to be forced. I personally think that, if they were going to get the shot in the first place, getting up in arms over whether it’s mandatory is silly, but I do also understand where they are coming from. A good persuasive voluntary program probably would have been much more effective.

  13. #13 Joe
    October 5, 2009

    It’s my understanding that health professionals will be among the first in line to receive the H1N1 vaccine. This would be the intranasal version. The insert advises the recipient to stay away from immune compromised people for three weeks..due to shedding.
    Correct me if I am wrong…but aren’t the immune compromised tended by health professionals? Does anyone see a potential problem here?

  14. #14 James Pannozzi
    October 5, 2009

    OUTSTANDING comments which should be read by every concerned citizen!

    There is one paragraph that I will quote which says it all perfectly:

    “The practice of medicine (and nursing) is a voluntary one based on informed choice – and will hopefully remain this way. Forcing physicians and nurses to become unconsenting patients – even for a flu shot – undermines the consensual nature of the health care relationship, and at least suggests that if health care professionals can be forced to take a vaccination for the good of others, perhaps everyone else can, too.”

    Well said!

    Thanks
    JP

  15. #15 concerned nurse
    October 5, 2009

    Why don’t we insist that Richard Daines publicly receive the H1N1 vaccine as a show of support for the health care workers. When asked if he will receive the vaccine he stated that he would not be the first in line for it. What better way to allay fears of safety issues than to publicly receive it himself. Why not Mr Daines?

  16. #16 M. Randolph Kruger
    October 5, 2009

    So folks, what about the rights of the individual? They were people before they became medical types. Hey, the Hong Kong workers are in revolt too with the majority just saying NO. Why is that?

    I a big supporter of vax for other things….Polio for one. On the other hand that is a long tested vaccine. This one has a previous history that it cant get away from and the fact that its live and not Memorex and there are universally and apparently a lot of problems. Most are mild but the ones that arent. You have to get the titers to get a protection and no one can even say with assurances that you even need to get this… 1.5% fatality rate around the world. That leaves you with a 98.5% chance of making it. Its not H5N1, its H1N1 and its under an EUA and that by admission indicates that they have no other guns in the arsenal.

    Mind, if this were H5N1 and those same numbers who were infected were now dead, young Randolph would be pushing his way to the front of the line to be vax’d as that has a current 63% CFR, but its not. Could it turn zoo and get worse? Sure, but everyone here has gotten it including me… I got a headache, the kids got it for 4 days and 23 days, mommy laid in the bed and complained for 5 days.
    Daddy (me) was the caregiver. So why take a flu shot? By the time they get this out there the herd will be protecting most everyone with a likely mutation in a month or two that might take a few.

    So it begs the question…Do we really need to inject ourselves with this stuff for protection or is it better to let it nail you and then proceed on with our lives? We have had several fatalities locally but the ones who passed were HIV, Cystic Fibrosis, and Multiple Sclerosis patients already…The underlying conditions seem to be the nail in the coffin so to speak.

    http://www.reuters.com/article/topNews/idUSTRE5940BH20091005

    We are fortunate that everyone is working hard here to take care of the hospitalized cases and understand that there are quite a few…Clearing of space for non-emergency cases is underway and there are machines going even as we speak but its not killing for the better part even those people. HCW’s also have families and dozens of them are down right now along with those families but they also havent gotten the seasonal flu shot this year either…. Now that would be for what reason?

    How do you convince people to take flu shots? You force the HCW’s to take them and then not publish how many got sick from it. The second way is to pass laws that ensure you get dead cops and national guardsmen that allow for forced vaccinations. I can assure you that if its tried it will go the way of the 1976 vax.

    Too many people were affected locally and we have very long memories in the South… Kind of like the years when we quit trusting our government.

  17. #17 DemFromCT
    October 5, 2009

    Joe, take the package insert to mean “severely immunocompromised”. Birth center employees can get it even if pregnant patients should not. Whether cancer ward employees should get it is a different issue.

    From a hospital perspective the bigger problem is many employees have asthma or are over 49 and not candidates for it (the nasal spray is primarlily for ages 2-49 with no underlying respiratory issues.)

  18. #18 R. Coleman PhD
    October 5, 2009

    When I reveal the following facts to people I must be careful since they usually just roll their eyes over or run screaming from the room like a child whom I have just told there is no Santa Claus. I wonder how you will react?
    If you go back to 1870 and come forward using the data and research of A. Bechamp, Estor, Enderlein, Rosenow, Reich, Rife, and now Nasennes in Canada spanning over 100 years you come to a revelation. Allopathic medicine and the germ theory of disease is a huge deceit.
    Bacteria are pleomorphic not monomorphic.
    Vaccines are not safe nor effective. Health and disease does not work as we have been indoctrinated and brainwashed to believe.
    Knowing all this, I cringe at all the misguided and false comments that I read about vaccines and their supposed immunity granting properties.

    DrCee
    You cannot secure nor restore health with pus or poisons.

  19. #19 DemFromCT
    October 5, 2009

    DrCee, have you met Orac? He perhaps has more patience for this nonsense than I do.

    The fact that pediatricians like myself no longer see life threatening cases of meningitis due to HiB and Prevnar vaccines (let alone polio) is one of the public health triumphs of the 20th century.

    How people can be so far out on some other planet and cut off from reality never ceases to amaze me. How do you explain the absence of polio and H flu meningitis? Or the absence of epiglottitis in young children? The right answer is vaccines. What’s your answer? Miasma? Leeches? Well, leeches are useful for anticoagulation…

    To put it differently, there are legitimate concerns about vaccines in general and this one in particular, but yours is not among them.

    Cheers!

  20. #20 Pete A
    October 5, 2009

    No right minded person can say that the threat level of the current pandemic influenza warrants enforced vaccination which is widely heralded as not thoroughly tested.
    Although obviously a nasty illness the CFR is still quite low and in general hospitals seem to be coping.
    Every one of us can be vectors during this pandemic and should all behave responsibly but if there has ever been a case for human rights being upheld this is it.
    Should all visitors to hospitals be vetted to ensure they have been vaccinated also not to mention porters, kitchen staff, orderlys, ambulance staff, community carers, GP’s the list goes on and on of people who have contact with clients with UHC’s.
    I could understand if the virulence were greater but while we appear to be fairing quite well why alienate a large percentage of essential healthcare professionals.
    Obviously this should be kept under review through the pandemic and enforced if necessary.

  21. #21 TOP Scheine
    October 5, 2009

    @DemFromCT: If you can handle a few facts about (swine) flu vaccines, your reality will never be the same…
    Allow me to recommend this news release:
    http://www.prlog.org/10364103-fear-and-loathing-in-swine-flu-land-top-10-facts-about-the-swine-flu-vaccine.html

  22. #22 NJ
    October 5, 2009

    From the link given @ 21:

    Evidence that shows there presently exists an international corporate criminal syndicate that, in violation of the RICO Act (18 USC sec 1961-1969), is intent upon embarking upon a cascading event of genocide within the United States, in the UK, and in other countries around the world, most likely in Autumn 2009 / Winter 2010, using as their weapon an enforced program of toxic vaccines after a deliberate release of a virus to spark a pandemic could immensely profit vaccine companies.

    Which can only be stopped by wearing tinfoil hats!!!!!111111!!!!

  23. #23 SusanC
    October 5, 2009

    Demfromct

    For clarity, even if it’s only HCW that are mandated, that resentment is infectious like a virus within a hospital community.

    That is exactly right. Policymakers need to beware of unintended consequences, some more far reaching than others. Trust is hard to gain, easy to lose. The downside of having a resentful workforce is really not worth it.

  24. #24 M. Randolph Kruger
    October 5, 2009

    I guess there are several questions that havent been answered yet

    -Benefit of vax to infection/recovery
    -Benefit of vax to prevent death
    -Possible side effects
    -Known side effects
    -Canadian study(s) Are they being withheld prevent alarm or lack of it. E.g. the seasonal flu somehow increases your chances of getting swine flu. If that is the case what does swine flu vax do to you except increase your titer levels against a virus from pushing on 8 months ago… Limited or high levels of titer? Do tell.

    -Distrust of government. Well bunkies, I didnt like government under the Republicans.. You cant begin to imagine my distrust of this one.

    -Government control of the media. How come we are not hearing more about the bad stuff? This isnt perfect vaccine by a stretch. There are UNIVERSAL reactions to it so far. Most are mild but hey, cant be telling people its going to necrose the skin or make it hard at the injection site.

    -Forced vaccinations. How many cops and guardsmen will go down trying to enforce that one? How many cops and guardsmen would refuse the order? Have to define acceptable losses and what anarchy and chaos would ensue. Down south they would both laugh at you along with the people they are supposed to vaccinate.

    -Mandatory vaccinations of HCW’s. No proof that they wouldn’t spread the virus to their families anyway. And whats this “stay away from immunocompromised” people stuff. If this is inactivated then its one thing, if it turns you into a shedder thats another

    -Constitutional Rights. Well they have been beating the hell out of that lately now haven’t they? Seems that Obama has a bit of credibility issue with this one and closing Gitmo. This is the same government (Obama’s) that handed out hundreds of billions of dollars to ensure the banks were able to lend…Try that and see what happens.

    But this last one is where the sticking point is. The very implication that this is in the public health interest is pretty lacking. Prove it folks. Maybe if this had been March and Minneapolis and people were dropping in the streets it would have been one thing. But it isnt. Indeed, there was no attempt to close the borders and prevent the spread…ITS MILD REMEMBER? And Obama made sure it was Napolitano that made the statement… He has his goat if she blows it.

    Okay, so really it is mild with a capital M unless you have it and the government has in its infinite wisdom still stated that it might implement this. Hospitals and their intimidations of HCW’s will simply result in a sick out. In fact the unions in CA have gone on record that they are NOT going to take the vaccine. Want to see a strike? Now excuse me, someone jump up here and tell me why so many educated people are not rolling up their sleeves? Vaccinations are not in any employment contract and the Supremes have held before that there has to be an overriding reason to conditionalize employment for something like this. Employers like me have covered themselves by simply making the statement to the employees, “Consult your Physician”. None around here are simply because its already out of the bag and starting to peak.

    Litigation-1.5% isnt enough I would say to take an EUA vaccine in the eyes of a state court in most places except in Massachusetts and the old Soviet Union as a condition of employment or the right to be an American. Am I drawing a parallel? You are damned skippy I am. In the US you have the right to life and liberty. If that government imposes upon that you get compensated right? Well folks it took Congress almost ten years to fund the pot that did that and compensated the injured from 1976. They also became uninsurables after that. Average payout was 1 million, average cost to each was over 385,000 bucks for those that lived. Weeks in iron lungs, permanent post vax paralysis and nerve attenuation. Medicaid afterwards.

    So, its day 1 of the new swine flu vax. I hold no position either way except to ask why we are taking it? It so far hasnt been tested by the users (US) and we are going to have to wait a bit to see if its going to do some whacking on our population. Beauty of it is that to me, maybe we should have sent it to Supari first and then let her take the heat from the Indonesian population if it was bad vax? We would have found out that it was bad, it would have gotten her out so we could find out about H5N1 and well Doctors, you did no harm…Sort of.

    Ah-But thats the Socialist Democrat Party in me.

    Get back to me on those points and paint them thick and liberally. It should really stir the pot on both sides of this debate. We will know in a month whether it did any good, or if it did any bad. If the vaccinated get sick and die from Swine then there is going to be Hell to pay in the Administration…

    Goats will be slain.

  25. #25 Phillip Huggan
    October 5, 2009

    I’d hope there wouldn’t be this debate if death toll is higher. At some CFR threshhold just fire anyone earning a salary spreading flu.

    Another actor working aganst stopping the spread may have be Russia. Still trying to figure out why they attempted to penetrate the North American media with their GMO potato ruse. Was it for good reasons or bad reasons. Yeah you tricked me and Canadian Press. Good luck fooling solid CBC and Reuters. Was the test really necessary to establish you can trick Tabloid sources?!

  26. #26 Don S
    October 5, 2009

    As a physician I am ethically obligated to not put my patients at risk needlessly. I must be vaccinated as an ethical obligation.

    Am I obligated as an employer of nurses to make sure that my staff is also not putting patients at needless risk?

    I think so, although I do not know if it extends (or not) to firing them if they do not comply with my strong request.

    Does a member of a healthcare team that is possibly going to be in great demand during an epidemic, (ICU nurses, respiratory care staff) have an obligation not only to not potentially expose high risk individuals, but reduce the risk that they will be unavailable to work during a time of great need?

    I think so.

    The answer, from an ethics POV, may not be to have the state require individuals be vaccinated, but to have the state require that hospitals require it as part of patient rights to saftey. It may seem like a bit of semantics but there is an ethical difference.

  27. #27 Gaythia
    October 5, 2009

    How does this position compare to standards for health care workers who may be exposed to other communicable diseases, TB for example?

  28. #28 Kathy
    October 5, 2009

    To make small talk at a recent appointment, I casually asked my doctor’s longtime nurse about getting the H1N1 shot. She told me with a straight face that no, she would refuse the shot, because being an African American she did not trust “the government” and was afraid “they” were conducting an experiment with the vaccine, a la the Tuskeegee Project. I honestly did not know what to say to that…

  29. #29 Wicked Lad
    October 5, 2009

    Colin at #9: “Don’t mandate vaccination but mandate a button ‘I chose not to get the flu shot’ to be worn on the sleeve. If you *chose* not to get a flu shot then you should have no problem wearing that choice, yes?”

    DonS at #26: “Am I obligated as an employer of nurses to make sure that my staff is also not putting patients at needless risk?”

    Bingo. I have a checkup with my GP in a few weeks. I’ve been thinking of calling to ask if all the medical personnel in the office have had both flu shots. If not, I may have to find another GP. I’m not in a high-priority group, so I won’t have had the pandemic H1N1 flu shot.

    The main reason for my concern, of course, is contagion. Secondarily, I want health care from people whose judgment I can respect.

    So I like Colin’s suggestion, and patients like Colin and me surely make DonS’s quandary just that much tougher.

  30. #30 Phila
    October 5, 2009

    Evidence that shows there presently exists an international corporate criminal syndicate that, in violation of the RICO Act (18 USC sec 1961-1969), is intent upon embarking upon a cascading event of genocide within the United States, in the UK, and in other countries around the world, most likely in Autumn 2009 / Winter 2010, using as their weapon an enforced program of toxic vaccines after a deliberate release of a virus to spark a pandemic could immensely profit vaccine companies.

    I’m sorry to say that this scenario is not quite accurate. What’s actually going on is that the Obama Regime is purposefully spreading disinformation about a looming genocidal plot using vaccines, so that everyone who believes in Freedom will refrain from getting the shots. Then, they’ll release an engineered virus that’ll kill everyone except the trusting statist sheeple who accepted the vaccine. At that point, there’ll be no truthseekers left to question where Obama was actually born, and he’ll be able to push his Enviro-Marxist Islamo-Nazi policies through without any opposition.

    I just made this up now. But you’ve gotta admit it sounds plausible.

  31. #31 BW
    October 5, 2009

    A couple of years ago, I spent two days in hospital. At one point, a nurse leaned across me to do something. I have a difficulty with that, having been trained to go around, not across but, worse, she was ill. Two days later, so was I — very.

  32. #32 isles
    October 5, 2009

    Maybe we should also leave it up to healthcare workers’ discretion to determine how much training they need before they can qualify for a license, or how much continuing education they need once in practice. Wouldn’t want to stir up resentment by imposing someone else’s ideas of what makes them safe to care for patients, right?

  33. #33 Dr Denise
    October 5, 2009

    These are very insightful comments. What recourse is there for those of us HCW who are allergic to the flu vaccine?

  34. #34 caia
    October 6, 2009

    I understand, and yet… as a patient, I would infinitely prefer that my HCWs be vaccinated. And if I had a family member who was immunocompromised in the hospital, I can imagine standing at their door and demanding to know from every RN, LPN, PA, TA, phlebotomist, doctor, social worker, and member of dining services if they’d been vaccinated.

    Not really. But I’d want to. To bad, contrary to Colin’s suggestion, that you can’t tell by looking.

  35. #35 k
    October 6, 2009

    Phila, The funny thing about all this Obama trashing is that he is almost identical to Bush in his policies and actions. Main difference is that he is far more eloquent so perhaps he sounds different but he is not different. So if you want to promote conspiracy theories please do it for the ruling elite, as it appears to make little difference whether the red faction or the blue faction is in power. Obama is not calling the shots any more than Bush was. There is the conspiracy to get your teeth into, just who is running the nation since they gunned down John. What president dare oppose, when they know that they can be gunned down in plain sight of a nation with even the people tasked to protect them pulled off to allow plenty of time for the snipers to get in a killing shot.
    http://www.youtube.com/watch?v=XY02Qkuc_f8

    At any rate blame Obama for being a more suave Bush if you want to blame him for anything. We are still at war and going in deeper. His health care plan will end up helping the drug companies. He continues the policies of bailing out banks started by Bush. ETC ETC ETC

  36. #36 Jonathon Singleton
    October 6, 2009

    Caia, have I misinterpreted your “guard dog” analogy!?! Cheers Then — Jonathon:*)

    Caia, “And if I had a family member who was immunocompromised [or pregnant] in the hospital, I can imagine standing at their door and demanding to know from every RN, LPN, PA, TA, phlebotomist, doctor, social worker, and member of [cleaning and dining services] if they’d been [recently vaccinated with MedImmune's LAIV-based swine flu vaccine -- the duration of transmission risk virus replication and shedding extends between 7-21 days].”

    Excerpt from FDA pdf re: MedImmune’s Influenza A (H1N1) 2009 Monovalent Vaccine Live, Intranasal: “[The swine flu and seasonal FluMist vaccines] are manufactured by the same process. Information in this section is based on studies conducted with FluMist”

    Primary Immune Tribune (E-newsletter of the Immune Deficiency Foundation), Dec 2006, Volume 1, Issue 3. http://www.imakenews.com/idf/e_article000704177.cfm?x=b11,0,w

    Excerpt: “Healthcare workers who receive FluMist [and/or LAIV-based swine flu vaccines] may also present a possible way for a person with a primary immune deficiency disease to become infected with the flu vaccine strains. Although there is no data about transmission of the live vaccine virus from vacinees to immune compromised contacts and subsequent development of disease, the Centers for Disease Control and Prevention have stated that the inactivated vaccine (flu shot) is preferred over live, intranasal influenza vaccine (FluMist) for physicians, nurses, family members, or anyone else coming in close contact with anyone with a weakened immune system…”

  37. #37 Dr Denise
    October 6, 2009

    What about hospital workers who are allergic?

    This legislation is New York is not well thought out if we cannot provide for this contingency. Should we all just quit?????

  38. #38 Lulu
    October 6, 2009

    I agree with you and Annas even though I have a young preemie and worry about her exposure. Why couldn’t the govt have come up with an incentive program–an extra paid day off, t-shirts, cash to reward those who get the shot? Spend the enforcement money on enticing or rewarding HCW for getting this somewhat controversial vax for the good of their patients?
    Slightly off topic–why haven’t I seen yet a good explaination for why, if you had swine flu already, you should get the vax anyway. Oh, the virus could mutate doesn;t make sense, b/c then the vax wouldn’t work either, right? wrong?

    thanks for this great site

  39. #39 albatross
    October 6, 2009

    Why are medical professionals not wanting to get either seasonal or swine flu vaccines? We’re talking about people who ought to have an informed opinion about the risks and rewards here, and also people who (if they have families) have a strong incentive to avoid bringing flu home to their kids. My first guess is that the medical professionals refusing these vaccines are making a more-or-less informed decision about the risks and rewards. (Surely more informed than my decision, taken with zero medical training and zero experience treating sick people!)

    Why is it more likely that the organization mandating the vaccine will make sensible tradeoffs than the medical professionals themselves? Is there some strong reason to suspect that the medical professionals are ignoring risks to their patients? Wouldn’t that also involve ignoring smaller risks to their families? (Almost any doctor or nurse must have a much higher risk than I do of bringing the flu home from work!)

    As an interested layman, when I see doctors and nurses having to be strong-armed into getting a vaccination, that makes me suspect that it’s not all that great an idea to get it myself. I am *way* less equipped to evaluate the risks than someone who went to medical school, or even nursing school.

  40. #40 Phila
    October 6, 2009

    At any rate blame Obama for being a more suave Bush if you want to blame him for anything. We are still at war and going in deeper. His health care plan will end up helping the drug companies. He continues the policies of bailing out banks started by Bush. ETC ETC ETC

    Posted by: k | October 6, 2009 4:47 AM[kill]‚Äč[hide comment]

    My comment was a joke. I know it’s hard to tell when people are serious these days, which is why I pointed out that I’d made the whole thing up.

    For the record, I didn’t expect much from Obama beyond better environmental policies, little or no censoring of scientists, and slightly less insane foreign policy. That’s what we got, by and large, so I’m happier than I was. Other than that, we basically agree that his policies are not exactly progressive….let alone “socialistic,” as I would prefer.

  41. #41 Colin
    October 6, 2009

    albatross and others, you do realize that hospitals, et al. employ more than doctors and nurses?

  42. #42 Marilyn Mann
    October 6, 2009

    Slightly OT, but there’s a good article on H1N1 and fears about vaccines in The New Yorker. Michael Specter, The Fear Factor. http://www.newyorker.com/talk/comment/2009/10/12/091012taco_talk_specter

  43. #43 albatross
    October 6, 2009

    Colin: Fair enough. Is there good data on what fraction of practicing doctors get the yearly flu shot? Or about what fraction of practicing doctors are planning to get the swine flu shot?

  44. #44 Emily
    October 11, 2009

    First let me say- Healthcare worker describes more than just doctors and nurses.It’s ok though.. I’m used to be forgotten. As a paramedic I am in peoples homes, trapped in an ambulance less than 3 feet away from their germs and disease. I am at the highest risk of anyone to get the swine flu.
    But here’s the reality- people need to just be smart about it! If you’re sick don’t come to work! Whether you’re a healthcare worker or not, it is irresponsible to drag yourself into work just to infect everyone else!
    Also, the swine flu is no more dangerous than any other flu. The difference- its a new strain of flu and people are freaking out. Each year the sick, elderly and even some children die from the regular flu. Why? because their immune systems are already being taxed and become overwhelmed.
    Why should I be forced to get vaccinated? Why do I lose my rights to choose whats right for my body because I help the sick and injured? If anything I am more informed, more pre-cautious and better prepared than the non health care worker. The swine flu is no more contagious than the regular flu. So if I take extra precaution and should I get sick I simply stay home like I would with the normal flu, why should my rights be squandered?
    It’s so simple.. people need to stop trying to force everyone else into doing what THEY think is right. Keeping people informed, making suggestions and letting them be the responsible adult is the right thing to do. And not forcing them to do something because someone else is scared.

  45. #45 revere
    October 11, 2009

    Emily: Since my daughter is a non-nurse non-doctor health care worker, I of course agree there are more HCWs than doctors and nurses and I hope I didn’t give that impression. And you and I agree on autonomy. But we disagree on other things. This is not the same as seasonal flu. Its epidemiology is quite different and that is important. And if it is irresponsible to come to work if you are sick, even if that means that you will lose wages to keep your family housed and fed, then why isn’t it irresponsible to not get vaccinated?

    People are “forced” (required to do things as a condition of employment) all the time. If you work in a cafeteria you have to wear a hair net. You have to wear a mask in surgery, etc. My concern about mandatory vaccination for HCWs is that it will backfire. It is mainly pragmatic. If you are irresponsible enough to work during a pandemic when a vaccine is available and you are close contact with people at high risk from serious complications if they get flu from you (even if you are fine) then in my view you shouldn’t be a HCW. There are a lot of other kinds of work. No one is forcing you to be a paramedic. It doesn’t even pay well. But we need you and you are essential to the community so if mandatory vaccination means that people like you can’t be prevented from working because you are essential, then the whole structure is unfair and crumbles and will back fire. So if you don’t get vaccinated then wear a mask or risk killing some kid.

  46. #46 Emily
    October 11, 2009

    Revere: I think that’s a little dramatic-” So if you don’t get vaccinated then wear a mask or risk killing some kid.” Clearly you’re afraid of being killed by the piggy flu.
    And you’re right I’m not being forced to be a paramedic but why should I be punished for my career choice. And your definitely right that I don’t get paid very much. But shouldn’t I be rewarded for what I do for the public? Not punished and spoken down to on a daily basis. I urge you to use your strong language to increase my pay. I would love to make more. But would you rather I do something I hate, than something I love just because it pays more. I have coworkers who act like that. They do this job because it pays just slightly more than flipping burgers. And I promise you you’d rather someone like me who enjoys her job than someone like that. But I digress….
    And don’t you think that as an educated medical professional I’m not thinking every day about contracting some other disease or virus? I gotta tell you the piggy flu is NOT my biggest concern. Hep A, B and C, TB, HIV,Cdiff and even MRSA threaten me every day. I don’t see the goverment bending over backwards to save me from those.
    And so I do my part. I take the best precautions that I can. I wash my hands like I have OCD. I change my clothes before going home to my family. I wear a mask and have my patient put on a mask if they are sick. And I stay home and use my sick time when I need to. Because I know that if I get sick and come to work, they get sick.
    I will say however that not everyone treats they’re job in the medical field with such care and concern. Just yesterday I watched a doctor sneeze on a patient. Didnt even bother to cover his face. He should lose his job for such disregard for the sick. But should I lose mine if I do everything that is suggested without getting a vaccine when there’s no garrauntee?
    And you’re definitely right in saying “But we need you and you are essential to the community”! I’m tired of being treated like an uneducated taxi driver. I am an educated medical professional and just like I said in my earlier statement, those who are responsible will take the appropriate precautions. Vaccination is not always the best precaution. Do you know that even when you get a flu vaccine you can still get the flu? Its not a guarantee. I’ve done the research and weighed the benefits and risks of this vaccine.
    I think your comparison of hair nets and face masks to vaccinations is ridiculous. Mandating someone to where something vs injecting something into their body is very different. This could affect my well being. I want to see the studies about the outcome of the vaccines… the indepth studies done over a length of time.. oh yeah thats right.. there arent any.
    And if you are a health care worker and not going to work will endanger your families well being then my suggestion would be to GET A NEW JOB! If you cannot afford to take sick days (which are typically paid days off) then you shouldn’t be putting you and your family at risk.
    Another thing.. if we are mandating health care workers to be vaccinated why not mandate everyone? What about the city bus driver? The lunch lady at your kids school? The cashier at the bank, money is one of the dirtiest things out there! What about the person making your whopper or big mac? Or your postoffice worker? And sure medical professionals are around the sick but these other people interact with many more than we do. They could be causing this pandemic. The people who dont think to wash their hands or cover their mouths when they cough.
    We could go back and forth forever about this. My feeling about the flu shot is that people need to be informed. They need to weigh the benefits and risks for themselves. To do without thinking makes you just another robot. If we all just did without thinking we’d all drive american made cars and still be eating spam everyday.

  47. #47 Racter
    October 11, 2009

    Emily,
    I can’t speak for the Reveres, but I damn sure am afraid of being killed by the “piggy flu”, and with very good reason.

    I don’t know if your education as a medical professional provides you with the ability to appreciate the significance of it, but I’ll share this: my FEV1 scores are below thirty percent on a good day. In addition to that, a few months ago I was an ambulance ride behind a spontaneous pneumothorax, and they tell me I’m looking at near even odds of having another. I am PAINFULLY aware that, like yourself, many (if not most) people dismiss “piggy flu” as “not their biggest concern” — because that attitude increases the risk for me considerably. My main strategy is to avoid such people as much as possible, but, as you must realize, there are a lot of people who can expect to log some hospital time nearly every winter (especially), and that’s not always subject to choice. I anticipate the spring head count at my pulmonary rehabilitation group being a pretty grim affair.

    I have been in a small exam room with a HCW who had visible signs of illness. I’m not the least bit bashful when it comes to asking questions about that sort of thing, and this particular HCW informed me that she wasn’t really feeling up to being at work, but had already used up her allottment of sick days. Evidently, that Primum non nocere thing is really more a guideline than a rule.

    Your slippery slope argument doesn’t wash with me. I can chose not to ride the bus, to do my banking online, to keep my kid home from school. I wouldn’t eat a Big Mac if you put a gun to my head anyway. I do NOT, however, always have a choice about whether to visit a hospital. The people who work there DO have choices, and what’s more, those people are responsible to others for some of the choices they make.

    Maybe we can cut a deal: more paid sick time for health care workers in exchange for a promise to accept the most proven method of preventing certain illnesses: vaccination.

  48. #48 revere
    October 11, 2009

    Emily: Despite the overheated rhtetoric on both sides, I don’t think we are far apart. Regarding the doctor you cite, he/she should be censured or punished for putting a patient at risk in that way. I’ll let others decide what the punishment should be but we both agree that what he/she did was irresponsible and reckless. I feel the same way about not getting vaccinated. We’ve reviewed here the studies of vaccine efficacy, and while you are right the vaccine doesn’t protect 100%, you are quite wrong in saying there are no studies of efficacy. See this post for a partial review and an entry into the literature.

    Regarding you pay, we have argued here for years that we need to strengthen the public health infrastructure — all of it. As a matter of record, emergency services have a higher profile and influence than public health, which, when it works, nothing happens, but the entire system needs to be strengthened. If people think they know what to do with their money better than the government, let them take the $300 they saved with a tax cut and buy some emergency services with it. So we agree there. But you do not seem to understand the public health implications and importance of influenza as a transmissible disease of populations. But if you are afraid of dying of MRSA (which you should be), know that a major risk factor is to get flu first. It is people your age who are dying of flu with secondary MRSA.

  49. #49 Emily
    October 11, 2009

    Revere:
    I think you’re right. That if most people knew what we really did and what we are compensated for it, they would be surprised. Most people go on from being a paramedic not because they don’t enjoy the job but they can make twice as much doing something else with less responsibility.
    Although I haven’t come out and said it quite yet I will now: I am already on the list to receive the vaccine. So you can feel some relief that although it may not be a guarantee- most likely I will not have the piggy flu this year and wont be spreading the chaos! As a person with severe asthma I get the flu shot every year. Mostly because of my asthma but because like most I don’t like being sick. And really its just self preservation but I do know that being vaccinated can affect my patients in a positive way. Because not that I don’t care about my patients but I have a family to go home too. Its the same reason I got the Heb B series because that is not manditory but advised. And being a smart health care provider I know that its in my best interest.
    I argue this “manditory vaccination” thing because honestly I believe its someones choice. And maybe another solution is to mandate checks every time someone comes into work. ” Do you have a fever?” you’re being sent home. ” Do you have cough or congestion?” you’re being sent home.
    Because just like Racter who posted a comment has experienced: I too have been witness to health care professionals being sick at work. Yet they’re never sent home?!
    I think that with better hand washing practices, awareness and education we will be more successful at preventing a flu outbreak than by vaccinating everyone under the sun. Because here’s the reality. They’re never going to make it mandatory. People will be too busy fighting about and forgetting to wash their hands and cover their mouths that the flu will already be killing people. Where are the national campaigns about healthy practice??? I saw a short bit on the Disney channel about washing your hands but am yet to see one before, after or during an adult show. For most, it really can be as simple as that.
    As for you Racter I hope that this winter goes easy on you. I hope that you don’t have to spend any more time than necessary in the hospital. But as you know, hospitals are a dirty place and are only worse when workers show up sick. So I applaud you for speaking up. Everyone should!! I spoke my mind just the other day when a coworkers showed up to work complaining that she had a fever. I was very insistent that she go home. Because what people don’t realize is that although a chest cold or a flu isn’t that bad for them, if I get it I can have serious complications with my asthma or even death. I just wish that people would use common sense.
    I think you will be hard pressed to mandate a vaccine especially with all the skeptics and critics out there. If we spent our money on educating the public better I think we could curb the amount of illness’ this winter, piggy flu or not.

  50. #50 rs mcnall
    October 12, 2009

    Why not start with just getting the information out there?

    HCWs are altruistic. Studies show that HCWs are most motivated by the factor that being vaccinated helps them not to harm the patients they are trying to help.

    HCWs are smart. Provide them with the studies that show that

    1. An infected person can shed flu virus for days with no symptoms;

    2. That hospitals with high rates of HCW vaccination have sharply lower rates of patient death;

    3. Also, that vaccinated HCWs miss less work by being out sick. And get fewer co-workers sick. It goes around.

    Instead of backlash, you get front-lash. In our office, with good information provided, our staff (who are not HCWs) have 78% vaccination.

  51. #51 rsm mcnall
    October 12, 2009

    To clarify my last post,

    We get 70%-80% voluntary flu-shot compliance every year. Voluntary.

    We have a free clinic every Fall where we provide flu shots, other shots, and (also free) chocolate chip cookies.

    As experts like the writers of this column know, vaccination is a good idea. But just because people are smart doesn’t mean they know everything. It just needs to be explained. If you show staff the scientific studies, they will read.

    We put out info on the personal, office, family, and societal advantages. We give newsy, detailed, accurate, verifiable information about flu prevention all year long — especially in the month or so before our free clinic.

    Our top management thinks staff ignorance about the actual advantages and disadvantages of vaccination is costly, and invests the resources to allow our staff to make *really* informed decisions.

    Result: we have a savvy staff that mostly gets vaccinated — voluntarily — every year.

    Our vaccinated staff don’t infect co-workers as much. Even the folks who don’t get vaccine know about it and get some protection from herd immunity.

    So we have fewer days of work are involuntarily missed. The workforce health probably pays back everything invested in education, vaccine, and cookies.

    The benefits go beyond money, and beyond our office. Our young and healthy staff don’t infect their friends or family, as much either.

    Overally, it’s a subtle morale raiser. It’s one way we look out for each other.

  52. #52 BiteTheDust
    October 16, 2009

    So the parents choose not to be vaccinated, but also decide the kids aren’t to be vaccinated. One of the children catches pertussis from a parent and dies.

    Who is to blame?

    Robbo

  53. #53 MedStudent13
    November 29, 2009

    I find this post especially interesting in the context of a month and half later when we are still experiencing a shortage of H1N1 vaccine, even for health care workers. Asking health care workers to logically examine the arguments for and against getting the vaccine raises a variety of ethical and scientific issues. It is, after all, the job of the health care workers to protect their patients and, “above all else, do no harm.” In the case of an infectious disease like influenza we have taken extraordinary measures to protect patients, especially those who are more susceptible for whatever reason, and to protect ourselves. It seems to me then that despite personal arguments for or against this particular vaccine, there ought to be other measures in place to protect patients and employees without legal enforcement. Setting in place a law requiring health care workers to get the H1N1 vaccine will increase the demand for an already limited supply forcing us to be more selective in deciding who receives the vaccine. A worker in the health care field is already more apt to take care of their health and protect against the spread of infectious disease by other means that the lay person may not. If we then deny said lay person who is not taking other measures to protect themselves or those around them the opportunity to be vaccinated, the repercussions will likely out weigh the extra effort put in by the unvaccinated health care worker to protect their patients. As a medical student, we have been “strongly encouraged” to get the vaccine, especially if working in the hospitals and physician offices. Unfortunately, however, each time these words of encouragement are offered, they are accompanied by a memo regarding the shortage of vaccine and the fact that, until further notice, it is unavailable through the institutions we are working in. Until a balance can be found between supply and demand and unequivocal evidence is presented to health care workers of the vaccine’s insurmountable efficacy, a mandate of this nature will never hold.

  54. #54 Mountainland Applied Tech
    September 28, 2010

    I’m still not sure what to think of the swine flu thing. There was never enough of the vaccination to go around, everyone was in a panic, schools were shutting down. However, I never saw anyone with it, or knew anyone that got it. Was it really that bad?

  55. #55 Mendel Potok
    September 29, 2010

    Why in the world would a law be required in the first place? If you have a health care professional who doesn’t believe in vaccination, he’s likely from the middle ages. Come on, can we really assume that these highly trained and educated people would choose to put themselves, their patients, and their livelihoods at risk? They don’t believe the same chain emails demonizing vaccinations like some of us do!

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