- The Washington Times - Tuesday, September 29, 2009

Health care institutions, concerned that less than half their workers got flu shots in previous years, are moving for the first time to make the shots mandatory in the face of an expected swine flu pandemic.

Centers for Disease Control and Prevention figures for the 2007-08 flu season, the most recent available, show that just 45.4 percent of U.S. health care workers ages 19 to 64 were immunized against seasonal flu that year. Three British surveys released in recent weeks suggest the same pattern with the novel H1N1 virus, commonly known as the “swine flu” virus.

But Dr. Tom Talbot, a professor at Vanderbilt University School of Medicine, said “there has been a big wave this year” of mandatory vaccination rules, ranging from small doctors’ offices to large medical care and hospital systems.

“A lot of people are leaning [toward mandatory vaccinations], pointing to it as a safety issue, akin to a surgeon refusing to do a scrub before surgery,” he said.

“I think H1N1 has prompted it,” he said, adding that rules for seasonal flu are in place and likely will be for H1N1 when the vaccine becomes available. He said that voluntary systems need resources to exhort workers into complying, making a mandatory policy cheaper and quicker.

The New York State Health Department, in what is thought to be the first statewide ruling of its kind, now requires all hospital, hospice and home health care workers to get both a seasonal and H1N1 flu shot. Those who defy the requirement without a religious or medical reason put their jobs at risk.

Policies for H1N1 are generally still being formulated, spokesmen at several hospitals, health care systems and professional groups nationwide told The Washington Times.

“Our policy is to strongly urge all [registered nurses] directly involved in patient care to get seasonal protection annually. We are taking a look at the situation regarding novel H1N1,” said Mary McNamara of the American Nurses Association.

But with seasonal flu, policies are already in full force. As of Aug. 27, the 26,000 personnel in the Washington-Baltimore region MedStar Health system must get seasonal flu shots. For the first time, failure to comply without a documented reason is grounds for dismissal.

Virginia Mason Medical Center in Seattle has had a similar policy in place for five years for the seasonal flu shot and has had a 99.5 percent compliance rate. Center spokeswoman Alisha Mark said at least nine other U.S. health groups are following suit for the first time.

“A handful” of people who chose not to get a shot in the first season were dismissed, she said.

“You can get a religious or medical accommodation, say if you have a proven allergy [to eggs, the basis of the vaccine], but you still have to abide by our infection control policy,” she said, meaning that such a worker would “have to wear a mask during all of flu season everywhere in the medical center except in the cafeteria while you are eating. It’s really important for patient safety.”

Jan Rodolfo, national outreach coordinator for the 86,000-member California Nurses Association, said she is skeptical of health care workers’ reception the H1N1 vaccine but that they retain their personal right to make decisions.

“If you have a perfectly safe vaccine to prevent swine flu, presumably you would say [a shot] is for the greater good,” she said. “In reality, there are a lot of questions about flu vaccines in general and this one in particular because of having to speed up the process of getting it approved.”

Ms. Garcia speculated that some of the reasons for the reluctance among health workers include: “They get busy. They think they don’t need it.” She said will have her entire office staff of 25 vaccinated against seasonal flu by Oct. 1.

Health professionals who are concerned about adverse reactions from the new vaccines “are not immune to what the rest of us feel, in not seeing themselves at risk,” said Sandra Quinn, a public health professor at the University of Pittsburgh. “Many, if they are older, may think they are not as much at risk.”

Dr. Jane Seward, deputy director of the CDC’s Division of Viral Diseases, said flu is “an invisible disease. It is not a rash illness like measles” for which two shots can vaccinate a person for life.

The British survey of general practitioners found that 71.3 percent were “concerned that the vaccine has not been through sufficient trials to guarantee safety,” while 50.4 percent said they thought “swine flu is too mild to justify taking the vaccine.”

Cindy Edward, a nurse in charge of the Montgomery County government’s disease-control efforts, suggested that such attitudes among health care workers wouldn’t necessarily carry over into the advice they give patients and relatives.

“They will say their parents should get it,” she said.

Inova Health System of Northern Virginia, covering 16,000 people, makes vaccination voluntary. New this year, however, is a “flu champion program,” said spokeswoman Rachel Lynch, whereby nurses are trained at each of the system’s hospitals to vaccinate people on site.

Gary Stephenson, a spokesman with Johns Hopkins Hospital in Baltimore, said a voluntary system remains in effect for the hospital’s 13,000 employees because compliance was so good last year, with more than 80 percent of workers immunized against seasonal flu.

He said all employees wear color-coded badges. Last year, he said, a green card indicated a person had the seasonal flu vaccination and other employees had to wear a mask when working around patients.

BJC HealthCare in St. Louis, which has 26,000 employees in 13 hospitals and four service organizations, last year required everyone to get a seasonal flu shot as a condition of employment and found that fewer than 10 people lost their jobs because of noncompliance.

The hospital system had 70 percent of its workers immunized and the rest secured waivers, spokeswoman Kim Kitson said. Because of the H1N1 outbreak this year, the system is “pushing for even more,” Ms. Kitson said.

Bryan L. Anderson, a spokesman for the Mayo Clinic in Rochester, Minn., reports having “a pretty educated [employee] population” that, without making the vaccine mandatory, had “more than 80 percent of staff vaccinated.”

The World Health Organization has stated that doctors and nurses should be the first people immunized against the H1N1 virus, in order to maintain functional health care systems and keep such personnel from transmitting the virus to patients hospitalized for other conditions.

The CDC defines health care workers as physicians, nurses, respiratory therapists, laboratory technicians, physical therapists and home health aides.

Dr. Anthony Fauci of the National Institute of Allergy and Infectious Diseases has vouched consistently for the safety and efficacy of the forthcoming vaccine, saying it is made similarly to the seasonal vaccine but uses a slightly different antigen to combat the new strain. Studies have suggested that the new flu pandemic can be controlled if at least 70 percent of the U.S. population is vaccinated.

Dr. Seward, however, said that “we certainly can do better with health care workers.”

“It is important to make sure health care workers understand the disease. Perhaps there hasn’t been as much attention to that. We are hoping it is a matter of educating and, this year, taking advantage of more visibility” for flu-related issues.

But doctors are capable of making ill-informed medical diagnoses.

Dr. Talbot said a physician recently told him in a casual conversation at a medical conference that he did not plan to get a flu vaccination because “he said ‘all my patients are vaccinated.’ ”

However, Dr. Talbot said, the other doctor in the conversation specializes in kidney transplants. His patients therefore should be on immune-system suppressants and a flu vaccination wouldn’t help their immune systems, leaving both him and them just as vulnerable.

Dr. Conrad Fischer, an infectious disease specialist and director of educational development at Nassau University Medical Center in New York, said that refusing a flu shot is “not a rational decision.”

“It is odd at this time in the world of routine miracles,” said Dr. Fischer, the author of a newly published book about modern medicine titled “Routine Miracles.”

“They refuse because of a fundamentally false belief system - that vaccines cause disease,” he said. “Frankly, that is why we have public health laws so you can have sane, rational people look at evidence. I would have mandatory vaccinations: You can’t drive drunk; you can’t walk around the streets with TB.”

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