Healthcare Workers and the Flu Vaccine: The Backlash

The 2012-2013 flu season is officially over, but the consequences due to the refusal by many healthcare workers to get vaccinated against the influenza virus are all too real. Unfortunately, the full impact of the spread of the flu from unvaccinated healthcare workers to the public will never be known, but this issue is especially troublesome during seasons with high levels of flu activity. And this past season was one of the worst in recent years because it started significantly earlier than normal. “This is the earliest flu season we’ve had in nearly a decade, since the 2003-2004 flu season,” said Centers for Disease Control and Prevention (CDC) spokesman Thomas Frieden. In fact, this season is in stark contrast to last season, which set a record for the lowest and shortest peak for influenza-like illness. By mid-January, flu was widespread in most states, and at least 20 children had died. Five states were particularly hard hit: Tennessee, Mississippi, Alabama, Louisiana and Texas.

Curbing the spread of flu is difficult in the best of circumstances, but it is especially compounded when healthcare workers refuse to be vaccinated. Every day on the job, these workers have a high rate of contact with those who are most vulnerable such as the very young, the very old and the immunocompromised — populations that are most susceptible to suffering severe consequences from the flu, including death. In fact, this year’s strain of the influenza virus is killing seniors at the highest rate (116 deaths per 100,000 cases) since age-related tracking began in 2005.¹

The Irrefutable Risk of Contagion

A recent study indicates that the flu is much more contagious than once thought. Researchers at the Wake Forest School of Medicine in North Carolina sampled the air for flu-like symptoms in rooms of patients who visited the hospital during the 2010-2011 flu season. Using devices that were placed 1, 3 and 6 feet away from the patients while they lay in bed, they found potentially infectious flu virus particles at each of the sample locations. It was previously thought that the flu spreads mainly through large particles, or droplets, in the air that travel short distances, from 3 to 6 feet. But this study showed that most flu viruses are found in very small particles, which can travel farther than larger ones, in the air. And because the study didn’t look at distances beyond 6 feet, the researchers can’t say whether the flu virus can travel farther.²

Because healthcare ranks among the nation’s largest industries, providing more than 14 million jobs, healthcare workers represent a significant source of potential spread of the flu. And when they’re infected by the flu virus, patient avoidance isn’t always an option. Indeed, a little known fact is that a person who has acquired the influenza virus is contagious for nearly a week, starting a day before any symptoms appear. Thus, it is possible to spread the flu over the course of an entire working day before workers even know they are sick.

During the 1991-1992 flu season, 65 nursing home residents in New York contracted the flu, and two died; only 10 percent of the home’s healthcare workers had been vaccinated before the outbreak. In 2000, 19 babies in a neonatal intensive care unit in Ontario, Canada, were infected with the flu and one died; only 15 percent of healthcare workers were immunized. In 2008, nearly 100 patients caught the flu at Royal Liverpool University Hospital in England, including those on high-dependency wards treating blood diseases and kidney problems. And, several years ago, two pediatric patients at Children’s Hospital in Philadelphia couldn’t get the flu shot because they were receiving cancer treatment; both died from getting the flu at the hospital.³

The Stats

The CDC’s goal is for 90 percent of healthcare workers to receive influenza vaccinations by 2020. According to Dr. Arthur Caplan, a bioethicist at New York University’s Langone Medical Center, 90 percent is the level of immunity that will provide sufficient protection to the sick. “You don’t get the ‘herd immunity’ until you hit 90 percent,” said Caplan, a proponent of mandatory vaccinations.

Yet while the percentage of healthcare workers receiving the flu vaccine is growing, the CDC’s goal remains elusive. According to a CDC survey of 2,006 healthcare personnel, the overall rate of flu vaccination for healthcare personnel across all settings is only 62.9 percent. So far this year, pharmacists have led the way with 88.7 percent receiving a flu vaccination, followed by 83.8 percent of physicians, 81.5 percent of nurses, 73.3 percent of nurse practitioners and physician assistants, and 76.7 percent of other clinical professionals (allied health professionals, dentists, technicians and technologists). When looking at the healthcare setting, 83.4 percent of workers at hospitals have been vaccinated this year, compared with 77.8 percent in 2011; 65.4 percent of staff at physician offices or ambulatory care settings have been vaccinated, compared with 64.4 percent in 2011; and 56.6 percent of workers at other facilities such as dental offices, pharmacies, home-medical sites and medical schools have been vaccinated, compared with 57 percent in 2011. What’s particularly disturbing in this survey, though, is that only 48.7 percent of healthcare workers at long-term-care facilities have been vaccinated.⁴

Why would people committed to protect sick patients refuse a flu shot? The reasons vary, from religious objections to skepticism about whether the vaccine works and whether vaccinating healthcare workers will prevent flu in patients, to allergies or complications arising from the vaccine. But serious reactions to the flu shot are extremely rare: Fewer than five in a million.⁵ And, according to Dr. Carolyn Bridges, associate director for adult immunization at the CDC, the strongest evidence that vaccinating healthcare workers prevents flu in patients is from studies in nursing homes that link flu vaccination among healthcare workers with fewer patient deaths from all causes.⁶

Government and Private Organizations Step In

To combat healthcare workers’ resistance to getting vaccinated against the flu, both government and private organizations are stepping in. The Centers for Medicare & Medicaid Services (CMS) issued new regulations requiring hospitals to report employees’ flu vaccination rates as a means to boost the rates. The goal is to post the information on the agency’s “Hospital Compare” website.⁶ Even more significantly, the CMS will cut hospital reimbursements by 2 percent beginning in 2015 if they fail to report patient quality measures, including healthcare worker vaccination rates starting in February.⁷

Last year, the American College of Physicians issued a new recommendation that all healthcare providers receive a variety of immunizations, including the seasonal influenza vaccine.⁸ In addition, the Joint Commission, the top healthcare accreditation agency in the nation, enacted a plan to have hospitals train and educate staffs about the benefits of flu vaccines. While the commission is not demanding mandatory vaccinations, it is requiring hospitals to show they are progressing toward 90 percent compliance by 2020.⁷ On the other hand, the American Medical Association in November endorsed mandatory shots for those with direct patient contact in nursing homes. And, the American Nurses Association supports these mandates if they’re adopted at the state level and affect all hospitals.⁶ Even the National Workrights Institute, a spinoff of the American Civil Liberties Union, supports mandatory vaccinations. According to its president, Lewis Maltby, “You can’t stick a needle in somebody’s arm who doesn’t want it stuck in their arm. [But], if the hospital wants to make it mandatory, [it] should be able to.”⁷

Several states do have laws or regulations requiring flu vaccines for healthcare workers, and most provide exemptions for those with religious or medical reasons. But only three — Arkansas, Maine and Rhode Island — impose penalties for those who refuse. For instance, Rhode Island’s regulation, which was enacted in December, requires unvaccinated workers in contact with patients to wear face masks during flu seasons, and those who refuse can be fined $100 and may face a complaint or reprimand for unprofessional conduct that could result in losing their professional license.⁶

Setting an Example

A CDC analysis showed that factors associated with improved immunization rates against the flu among healthcare workers included employer requirements, promotion of influenza vaccination by an employer and having vaccines offered at no cost on multiple days at the workplace.⁸ And, most hospitals have implemented these practices to persuade their workers to get vaccinated. A survey by CDC researchers found that in 2011, more than 400 U.S. hospitals required flu vaccinations for their employees.⁹ Unfortunately, as the statistics show, many workers still fail to get an annual flu shot. Now, faced with losing Medicare dollars, the rule of simply encouraging workers to get vaccinated is over or about to end.

There is no official count of how many healthcare workers have been fired for refusing to get a flu shot or have resigned in protest. The CDC survey showed that in 2011, 29 hospitals fired unvaccinated employees.⁹ With today’s news reports, it’s safe to say that the numbers are likely in the hundreds.

Of course, many of these employees who have been fired have filed exemptions and others have filed lawsuits. In Rhode Island, more than 1,000 workers recently signed a petition opposing the state’s mandate, according to a labor union that has filed suit to end the regulation.⁶ But, in several instances, hospital officials are rejecting exemption applications using the guidelines provided by the CDC and the U.S. Equal Employment Opportunity Commission (EEOC). “The EEOC’s guidelines specify that just because there are beliefs that are strongly held does not mean that they are protected by a religious blanket, so social, political and economic philosophies and personal preferences, those are not religious beliefs,” said Melanie McDonald, a hospital spokeswoman for IU Health Goshen Hospital in northern Indiana that fired eight employees.¹⁰

Do No Harm

Considering CDC estimates that on average 200,000 hospitalizations and a range of 3,000 to 50,000 deaths occur annually due to influenza-related infection, getting a flu shot would seem to make sense, especially for those without religious or health exemptions. Vaccinating healthcare workers against the highly contagious flu reduces the spread of infection, reduces patient mortality and worker absenteeism, and in the long run, may save hospitals money. Most important, protecting the patient — already sick and susceptible to infection— is inherent to the healthcare profession. Paul Offitt, chief of infectious diseases at Children’s Hospital in Philadelphia where two children died from contracting the flu, says this to healthcare workers: “It’s not your inalienable right not to get a vaccine if you’re helping care for vulnerable patients.”