The H1N1 flu vaccine became available earlier this month, and for many health care workers getting the vaccine is mandated. New York has created a state-wide mandate that all health care workers who have direct patient contact get seasonal and H1N1 flu shots or face the possibility of losing their jobs. Many hospitals have also created mandates, including the Hospital Corporation of America, Emory hospital, the University of Pennsylvania hospital, the University of Maryland hospital, the Loyola University health system, and the Good Samaritan Hospital in San Jose.
Many health care workers are opposed to these mandates, as was demonstrated by health care workers protesting the New York mandate outside of the state capitol (video). The California Nurses Association and the National Nurses Organizing Committee have recommended that the vaccine be encouraged but “nurses should maintain their right to decline for personal reasons.” Some reasons the protesters give for objecting to the mandate (here, here, and video here) include: the vaccine is not as effective as other mandated vaccines; there are equally effective alternatives, for example, wearing face masks and washing their hands; the vaccine was not sufficiently tested and may be unsafe; and H1N1 flu is not sufficiently dangerous to warrant a mandate. A common thread throughout the protest coverage is that health care workers do not want to be told what they must put in their bodies. This morning a group of New York emergency room nurses announced that they would be filing a lawsuit to block the mandate later this week.
Art Caplan, professor of bioethics and the director of the Center for Bioethics at the University of Pennsylvania argues that these mandates are appropriate because they will save lives and getting vaccinated is part of the health care workers’ responsibility to patients and to each other. Professor Caplan writes that if health care workers are vaccinated, patient mortality would decrease and nurses and doctors would remain healthy and able to care for sick patients. He estimates that in the case of the annual flu vaccination, if 100% of health care workers were vaccinated, patient deaths from the flu would drop 40%. Since April, 76 children have died from H1N1. [Note: As of October 23, 2009, that number rose to 86.]
In many states, hospital workers are already required to be vaccinated against measles, mumps, and rubella as a condition of their employment, but flu shots are voluntary. In this case, however, Professor Caplan argues that mandating the H1N1 vaccine may be the only way to obtain the individual medical and public health benefits. He reports that neither voluntary vaccinations (only 50% of health care workers elect to receive the annual flu shot) nor alternative protections like face masks (20% of health care workers who wear face masks still catch the flu) are likely to achieve the same benefits as a mandatory vaccination.
Some who object to the mandate have voiced concerns about the vaccine’s safety and efficacy because they claim it was rushed through development. But the Center for Disease Control and Prevention director, Dr. Thomas R. Frieden, assures, “We have cut no corners. This flu vaccine is made as flu vaccine is made each year, by the same companies, in the same production facilities with the same procedures, with the same safety safeguards.” The vaccine is not safe for some individuals who have egg allergies or risk factors for a rare complication known as Guilliame-Barre syndrome, and they are exempt from the mandate. Some of the mandates, although not New York’s, also exempt people with religious objections to vaccination.
If a mandate requiring health care workers to receive the H1N1 vaccination is necessary, then the penalty for opting out should be both fair and effective. Currently, health care workers in New York who refuse the vaccine risk losing their jobs. Could New York still reach its pubic health goals and increase vaccination rates among health care workers with a less severe penalty? For example, could the same purpose be served by notifying patients and other doctors that an individual has refused the vaccine, which would allow patients to choose to receive care from practitioners who are vaccinated?
Some health care workers and their advocates would prefer a program whereby adults did not have to choose between their job and taking a vaccine they have concerns about. Individuals’ choices about their own health care should be respected, and health care professionals are likely to make informed choices. On the other hand, health care professionals’ vaccination decisions will also affect the patients they see who are especially vulnerable to the H1N1 complications. And requiring vaccinations might be necessary to protect those patients.
– Kelly Lowenberg