The Controversy: Mandatory Flu Vaccines

Many hospitals are moving towards creating mandatory influenza vaccination policies as a condition of employment. Such mandates are causing surefire responses on both sides of the fence. What is the push behind the movement, and what is causing the pushback?

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First, let me just go over some of the symptoms of the flu, and then we will get down to business on the controversy surrounding the push to create mandatory flu vaccines for healthcare workers:

  • Sudden onset fever
  • Headache
  • Chills
  • Myalgia
  • Dry cough
  • Sore throat
  • Stuffy nose
  • Loss of appetite
  • Limb or joint pain
  • Difficulty sleeping
  • Diarrhea or upset stomach

I can't think of anyone who wants any of these symptoms, or to come down with the flu, can you?

Influenza vaccination research has clearly documented the benefits of receiving the flu vaccine (Google it - you will find a plethora of information...however, I will list some links at the end of this article for your information). However, even though there is sufficient evidence to prove the benefits of receiving the flu vaccine, vaccination rates among healthcare workers are pitifully low. In 2013, only 55% of nurses in the frontlines were vaccinated.

Organizations such as The Joint Commission, the American Nurses Association, the American Academy of Family Physicians, the American Academy of Pediatrics, American College of Physicians, Infectious Diseases Society of America, the Association for Professionals in Infection Control and Epidemiology, the Centers for Medicare & Medicaid Services, the Centers for Disease Control, Healthy People 2020, etc., etc., have stated their position on recommending the flu vaccine for healthcare workers in order to decrease the risk of exposure and reduce deaths. Due to this recommendation, many healthcare facilities are now creating mandatory flu vaccine policies as a condition of employment.

Employers who create mandatory policies will have exemptions, of course. Exemptions are made for medical and religious exceptions. For places that do not have a mandatory flu vaccine, they may "strongly recommend" the vaccination and may have a declination form for employees to submit if they refuse the vaccine. Additionally, some employers will enforce refusers to wear a mask during flu season while they are at work in order to protect the patients and the employee.

What is the purpose behind the push toward flu vaccines?

Evidence has shown that there are more than 36,000 deaths in the US each year related to influenza, and more than 200,000 hospitalizations. Influenza is the 6th leading cause of death. Healthcare workers are the leading cause of influenza outbreaks in the healthcare system. up to 50% of people who are infected by the flu virus do not fill ill for several days and can spread the virus to people at risk of complications and death from the flu. Additionally, evidence shows vaccination decreases mortality by 40%, decreases the spread of nosocomial infections by 43%, and decreases absenteeism by 20-30%.

Additionally, there is the ethics to consider. As healthcare workers, we have all taken an oath to "do no harm". As a nurse caring for patients who are not in their most physically healthy state, do we take the vaccination in order to prevent spreading the flu to our vulnerable patients, in order to "do no harm"? We must consider this when we make our decision to take or refuse the vaccination.

What hospitals have created a mandatory flu vaccine policy?

I have the names of a few hospitals, and this is by no means a comprehensive list. This is based on a ListServe survey of hospitals and these are the responses received:

  • Children's Hospital of Philadelphia (Philadelphia, PA) - since 2009
  • Children's Mercy Hospitals and Clinics (Kansas City, MO)
  • Children's Colorado (Aurora, CO)
  • Children's Hospital of the King's Daughters (Norfolk, VA)
  • Children's Medical Center Dallas (Dallas, TX) - since 2012
  • Riley Children's (Indianapolis, IN) - since 2012
  • East Tennessee Children's (Knoxville, TX) - since 2013
  • Boston Children's (Boston, MA)
  • Sharp Mary Birch Hospital for Women and Newborns (San Diego, CA) - since 2013
  • Roger Williams Medical Center (Providence, RI)
  • Brookwood Medical Center (Birmingham, AL)
  • Johns Hopkins (all hospitals/clinics) (Baltimore, MD)
  • Driscoll Children's Hospital (Corpus Christi, TX)
  • Spohn Health System (Corpus Christi / San Antonio, TX)
  • All Connecticut Hospitals

What are some reasons that people refuse the flu vaccine?

Refusal may be largely due to misconceptions related to the vaccine. Fears that the immune system will cause them to get the flu, beliefs that hygiene and better nutrition are more helpful than the vaccine, fear of needles, beliefs that the vaccine does not work, and fear of side effects. Others believe that they have a constitutional right to refuse the vaccine and that mandatory policies are violating these rights.

Common concerns and myths about the flu vaccination

(taken from the Los Angeles County Department of Public Health outline of flu vaccine talking points for managers)

The flu shot will give me the flu

The flu shot does not give people the flu. It uses inactivated ("dead") virus. People may still catch a cold or other virus that the vaccine is not designed match.

I don't believe the flu vaccine actually works

Studies have shown that flu vaccination prevents flu in 70% to 90% of healthy adults younger than 65 years old.

I had the vaccination last year

You need a new vaccine every year - the virus changes over time.

What about possible adverse reactions

Serious adverse reactions are very rare. They are explained on the CDC's Vaccine Information Statement, which is distributed when the vaccine is administered.

Local short-term reactions - such soreness at the vaccination site, slight fever, achy feeling - may occur but usually do not last long. Over the counter medicines are helpful. Even short-term reactions are much less bothersome than catching the flu and feeling very sick for days.

I'm not in a high-risk group

Your patients are at-risk, and possibly some friends and family members. You can be infected with the flu virus but not feel ill - and can still transmit flu to at-risk patients.

The flu vaccine made every year does not match the circulating flu strain

Inactivated influenza vaccine is effective in preventing transmission and reducing complications of the flu. In years when there is a close match between the vaccine and circulating virus strains, the vaccine prevents illness among approximately 70%--90% of healthy adults under 65 years of age. Vaccinating healthy adults also has been proven to lead to decreased work absenteeism and use of health-care resources, including use of antibiotics. Strong protection is also expected when the vaccine is not a close match with circulating strains, with 50%--77% effectiveness in these instances. In addition, effectiveness against influenza-related hospitalization for healthy adults from inactivated vaccine is estimated at 90%.

Knowledge is Power

All healthcare facilities will be facing the choice of creating a mandatory influenza vaccination in the near future, if they have not already. In order to make an informed decision on the topic, we must have information. Knowledge is power. Before you make a blanket statement on pros or cons, have the information you need, know the research, and make an educated decision.

Please respond to this article by answering the following questions:

  1. Do you take the flu vaccine yearly? If you do not, what is the reason you do not participate (if you don't mind answering this question)?
  2. Does your employer have a mandatory influenza vaccination policy as a condition of employment? If yes, where do you work?
  3. What concerns do you have about the flu vaccine?
  4. Do you know if anyone who has been released from their job because they did not get the flu vaccine?

References

American Association of Family Practitioners. (2011). AAFP supports mandatory flu vaccinations for healthcare personnel. Retrieved from: AAFP Supports Mandatory Flu Vaccinations for Health Care Personnel

ATrain. (2014). To accept or refuse the flu vaccine. Retrieved from: ZZZ_133_Influenza: Module 7

CDC. (2014). Vaccination: Who should do it, who should not and who should take precautions. Retrieved from: Vaccination: Who Should Do It, Who Should Not and Who Should Take Precautions | Seasonal Influenza (Flu) | CDC

Influenza Action Coalition. (2015). Influenza vaccination honor roll. Retrieved from: Honor Roll: Mandatory Influenza Vaccination Policies for Healthcare Personnel

Los Angeles County Department of Public Health. (2014). Talking points for managers. Retrieved from: http://tinyurl.com/p6nbg2u

National adult and influenza immunization summit. (2015). Vaccinating healthcare personnel. Retrieved from: Vaccinating Healthcare Personnel - National Adult and Influenza Immunization Summit

NursingTimes. (2014). Why do health workers decline flu vaccination? Retrieved from: http://www.nursingtimes.net/Journals/2014/11/28/y/k/x/031214-Why-do-health-workers-decline-flu-vaccination.pdf

TJC. (2012). R3 Report: Requirement, rationale, reference. Retrieved from: http://www.jointcommission.org/assets/1/18/R3_Report_Issue_3_5_18_12_final.pdf

Specializes in Critical Care and ED.

1)__ Do you take the flu vaccine yearly? If you do not, what is the reason you do not participate (if you don't mind answering this question)?

Yes. It is enforced and against my will.

2)__ Does your employer have a mandatory influenza vaccination policy as a condition of employment? If yes, where do you work?

It is mandatory, and my facility clearly state that anyone refusing it will be terminated unless they have medical or religious reasoning to not get it. I work in a major Level 1 facility in the state capitol.

3)__ What concerns do you have about the flu vaccine?

I don't want anything like that in my body. I don't agree with enforced vaccination as it should be my right to put what I choose into my body. I have had many years of suffering chronic medical issues and have finally gotten to a point where it is sustainable (immune disorder) and I do not like having the apple cart upset by putting something in my body I fear may harm me. I have done many plasmapheresis treatments on people who suspected that they had gotten Guillian Barre syndrome because of the flu shot. Of course there's no way to prove that but I've seen it enough times to make me anxious. I always make sure they give me a single dose vial and not a multi dose vial that has thimerosal preservative in it, as that is often the agent that causes problems. Problem is...I like to be employed and employable so I stand in line like a good little nurse. The flu strain changes constantly and we don't even know if that year's vaccine is even appropriate.

4)__ Do you know if anyone who has been released from their job because they did not get the flu vaccine?

Yes, several people. Two here at my facility and another couple over at the other major Level 1 facility in my state.

Specializes in Adult Internal Medicine.
From the CDC website:

These updated estimates were derived from data collected from the U.S. Flu VE Network from November 10, 2014, through January 30, 2015, and include an additional four weeks of data in comparison to CDC's early VE estimates released in mid-January.

When VE against all influenza viruses was combined, the overall VE estimate was 19% (95% CI: 7%– 29%). In practical terms, this means the flu vaccine reduced a person's risk of having to seek medical care at a doctor's office for flu illness by 19%.

Sure keep telling yourself it's EBP. SO sad bandwagon misinformation is spread in our profession….and others claiming people with data are the ones spreading misinformation.

"It's 19% effective, so you should just take it"….simple minds, simple minds.

Which paper are you citing? This one?

Flannery B, Clippard J, Zimmerman RK, Norwalk MP, Jackson ML, Jackson LA, Monto AS, Petrie JG, McLean HQ, Belongia EA, Gaglani M, Berman L, Foust A, Sessions W, Thaker SN, Spencer S, Fry AM. Early Estimates of Seasonal Influenza Vaccine Effectiveness – United States, January 2015. MMWR Morb Mortal Wkly Rep. 2015 Jan 13;64(1);10-15.

or

Jefferson, T., Di Pietrantonj, C., Rivetti, A., Bawazeer, G. A., Al-Ansary, L. A., & Ferroni, E. (2010). Vaccines for preventing influenza in healthy adults. Cochrane Database Syst Rev, 7(7).

Specializes in orthopedic/trauma, Informatics, diabetes.

1)__ Do you take the flu vaccine yearly? If you do not, what is the reason you do not participate (if you don't mind answering this question)? Yes

2)__ Does your employer have a mandatory influenza vaccination policy as a condition of employment? If yes, where do you work? Yes. Large teaching facility in the SE

3)__ What concerns do you have about the flu vaccine? None

4)__ Do you know if anyone who has been released from their job because they did not get the flu vaccine? No, but that policy is changing this year, I believe. They are limiting exemptions drastically;

you CAN pass on what you don't "have", in the sense that you can harbor the virus and be symptom free.

CMS, want 80% compliance by next year, I think...

In the absence of better evidence, vaccines and antivirals must be viewed as only partial and uncertain defenses against the flu. And they may be mere talismans. By being afraid to do the proper studies now, we may be condemning ourselves to using treatments based on illusion and faith rather than sound science.

That is the last two sentences in the articleGreen cites. Please, all of you vax. advocates, please read.

Specializes in Adult Internal Medicine.
In the absence of better evidence, vaccines and antivirals must be viewed as only partial and uncertain defenses against the flu. And they may be mere talismans. By being afraid to do the proper studies now, we may be condemning ourselves to using treatments based on illusion and faith rather than sound science.

That is the last two sentences in the articleGreen cites. Please, all of you vax. advocates, please read.

The article cited by GreenTea is an editorial. It is a well written piece, as most of the articles on The Atlantic are, and makes a compelling argument, but as medical professionals we need to read the actual studies.

The most compelling study out there, at least for me, is the 2014 meta-analysis (of which Dr. Jefferson was an author) which was one of the first major studies to demonstrate that the influenza vaccine is likely not nearly as effective as had been previously published. The authors concluded that "The overall effectiveness of inactivated parenteral vaccine against influenza-like illness (ILI) is 16% (95% confidence interval (CI 5% to 25%), with a corresponding number needed to vaccinate (NNV) of 40 (95% CI 26 to 128). " and this has been widely distributed by those opposing the influenza vaccine (and all vaccines).

However, if one reads the study, the very next line of the authors' conclusion reads "The overall efficacy of inactivated vaccines in preventing influenza is 60% (95% CI 53% to 66%) with a NNV of 71 (95% CI 64 to 80)". This relates to the "influenza-like illness" in the initial statement; as we all know, the influenza vaccine does not prevent non-influenza ARIs. This leads the authors to conclude that "Influenza vaccines have a very modest effect in reducing influenza symptoms and working days lost in the general population, including pregnant women". The conclusion is true when discussing influenza-like symptoms, the majority of which do not come from influenza.

I am a big supporter of vaccination. I get the flu shot and I recommend the flu shot to my patients, but I am also honest with them, and I tell them it affords them some mild to moderate protection against an illness that is generally medically mild but also has a small chance to significant impact their health or the health of a family member or friend. I do believe that HCWs should be vaccinated as they are exposed to a much higher percentage of laboratory-confirmed influenza than the general public and the NNV is theoretically much lower. Theya re also exposed to more critically ill patients than the general public, where even a limited benefit is worthwhile given the lack of any significant ADRs.

Do you take the flu vaccine yearly? If you do not, what is the reason you do not participate (if you don't mind answering this question)?

Yes.

Does your employer have a mandatory influenza vaccination policy as a condition of employment? If yes, where do you work?

Not Yet, but the policy is under review.

What concerns do you have about the flu vaccine?

None.

Do you know if anyone who has been released from their job because they did not get the flu vaccine?

None personally. There was a handful released from a local hospital when the policy was started years ago.

Specializes in Oncology; medical specialty website.

JustBeachy: There are several places that will give flu vaccines free.

Specializes in Complex pedi to LTC/SA & now a manager.
JustBeachy: There are several places that will give flu vaccines free.

Only to qualified & high risk people in my area. My present employer offers it for free and my insurance covers it

Specializes in Peds Urology,primary care, hem/onc.

I have always gotten the flu vaccine. I have asthma so I have to regardless of what my employer mandates.

I have no problem with mandatory (or STRONG incentive) to get employees to be vaccinated.

I do NOT like how my place of employment does it though. They set up in the employee parking lot. They line up tables at the entry way to the hospital and we are rounded up and asked to bare our arm in the parking lot with 100 people watching and get the shot. There is no privacy, no real discussion about risk/benefits, what shot to get (FluMist etc which they do have). One of my coworkers was early stage in her pregnancy but had not wanted to disclose to work yet (which is her right). One of the things you HAVE to answer is regarding possible pregnancy. Her manager was nearby and she had to disclose she was pregnant in front of everyone way before she was ready and had NO privacy.

They herd everyone going into the hospital before work up like cattle. It is awful. I keep wondering what they are going to do if someone vaso-vagals and faints (onto the hard concrete) or gets an allergic reaction out in the middle of the parking lot.

Can you imagine if we lined up our patients like that? The only reason they do it that way is because it is easier on the administrators to get everyone done in one step. We have a huge auditorium and classrooms so there is no reason to do it like this.

Second, they have a masking policy for everyone who does not get a flu shot. They have to wear a surgical mask the entire time they are in the hospital the entire flu season. Even if you have a valid reason for not getting the flu shot. We all know, a surgical mask does not protect you or a patient from the flu. They make us wear the TB respirators when a patient is admitted with the flu. If it was actually protecting something, I would be ok with it but it is not. It is to "brand" people so everyone knows they did not get the flu shot.

One of my coworkers has been mandated by her physician to NOT receive the flu shot (I cannot remember why but it was a real reason) and she has to wear that stupid mask for 6 months of the year.

So... I have NO problem for mandating flu vaccines AT ALL. I think they are very important!!! I just an appalled by how my place of employment goes about it. Getting it done by my own doctor's office (to avoid this nonsense) is not an option because the process to PROVE that you actually did it is a nightmare so it is not worth it.

Specializes in CVICU.
Which paper are you citing? This one?

Flannery B, Clippard J, Zimmerman RK, Norwalk MP, Jackson ML, Jackson LA, Monto AS, Petrie JG, McLean HQ, Belongia EA, Gaglani M, Berman L, Foust A, Sessions W, Thaker SN, Spencer S, Fry AM. Early Estimates of Seasonal Influenza Vaccine Effectiveness – United States, January 2015. MMWR Morb Mortal Wkly Rep. 2015 Jan 13;64(1);10-15.

or

Jefferson, T., Di Pietrantonj, C., Rivetti, A., Bawazeer, G. A., Al-Ansary, L. A., & Ferroni, E. (2010). Vaccines for preventing influenza in healthy adults. Cochrane Database Syst Rev, 7(7).

The CDC Website. Definitely not a 2010 article citing 2015 stats. :sarcastic:

CDC Presents Updated Estimates of Flu Vaccine ...

And I want to people to understand the "estimate" is based on wording that can be broad and non-specific allowing for the number to be improved on the 19% VE. (You have to think for yourself, being told info is not understanding info)