The American Academy of Pediatrics has vigorously reiterated its call for mandatory influenza vaccination of healthcare workers, saying religious or philosophical objections to immunizations do not override the ethical imperative to protect patients and coworkers.
“Unless you have a medical problem, there is in my opinion no excuse — zero, none — for healthcare workers not be vaccinated,” says co-author of the AAP statement Jeffrey R. Starke, MD, chief of infection control at Texas Children’s Hospital in Houston.
The AAP takes something of a “no healthcare worker is an island” stance, arguing that individuals embedded in societies and groups cannot consider their illness in isolation.
“Employees of healthcare institutions are obligated to honor the requirement of causing no harm and to act in the best interests of the health of their patients,” the AAP stated.1 “Medical exemptions to required influenza immunization (i.e. severe allergy to a vaccine component) should be kept at a minimum to ensure high coverage rates and granted only on an individual basis. Granting specific medical exemptions is constitutionally required, but states do not have to grant philosophical or religious opt-outs.”
The AAP calls for the development of “consistent policies” for exempted healthcare workers. For example, although scientific evidence for requiring unvaccinated employees to wear a mask is scant, some institutions require non-immunized workers to do so during flu season.
With an increasing number of facilities requiring flu vaccination, coverage among healthcare personnel rose to 75% in the 2013-2014 season. The public health Healthy People 2020 objective is 90%. During that same flu season, 58% of healthcare workers reported that their hospitals had some version of a mandate or work requirement tied to vaccination.
“Mandating influenza vaccine for all HCWs is ethical, just, and necessary,” the AAP argued. “Hospital-acquired influenza has been shown to have a particularly high mortality rate, with a median of 16% among all patients and a range of 33% to 60% in high-risk groups such as transplant recipients and patients in the ICU.”2
Influenza vaccination of HCWs has the potential to reduce both morbidity and mortality among patients, the AAP noted. While there have been influenza outbreaks3,4 and even patient deaths linked to linked to non-immunized flu infected workers, the quality of the evidence supporting a protective effect in overall populations has been moderate at best.5 A 2013 Cochrane review concluded that there were “no accurate data” supporting the vaccination of healthcare workers to prevent laboratory-confirmed influenza in long-term care residents age 60 years and older.6
“Specifically, the authors did not find a significant decrease in respiratory illness or in deaths related to respiratory illness,” the AAP noted.
Voluntary programs have proved ineffective, in part because healthcare workers have persistent misconceptions about the risks and benefits of the influenza vaccine. The most commonly reported barriers to vaccination were concerns about vaccine safety and effectiveness and low perceived susceptibility to influenza. Some continue to believe the long-dismissed concern that the vaccine actually causes flu.
While influenza vaccine efficacy will vary year to year depending on the match with circulating strains, it seems clear enough that healthcare workers acquire flu and infect patients and coworkers. A prospective surveillance study of laboratory-confirmed influenza among hospitalized adults in a network of Canadian hospitals from 2006 to 2012 found that 17.3% of influenza cases were healthcare-associated.7
Healthcare workers fail to lead by example if they recommend universal immunization, including influenza vaccine, to their patients but do not require it of themselves. Furthermore, unvaccinated healthcare workers feed the growing public distrust and fear of vaccines, which has resulted in the resounding return of measles, the AAP concluded.
REFERENCES
- Bernstein HH, Starke JR. American Academy of Pediatrics Committee on Infectious Diseases, 2015–2016. Influenza Immunization for All Health Care Personnel: Keep It Mandatory. Pediatrics 2015;136:809-818.
- Salgado CD, Farr BM, Hall KK, et al. Influenza in the acute hospital setting. [erratum in Lancet Infect Dis. 2002;2(6):383] Lancet Infect Dis 2002;2:145–155.
- Cunney RJ, Bialachowski A, Thornley D, et al. An outbreak of influenza A in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2000;21(7):449–454.
- Weinstock DM, Eagan J, Malak SA, et al. Control of influenza A on a bone marrow transplant unit. Infect Control Hosp Epidemiol. 2000;21(11):730–732.
- Ahmed F, Lindley MC, Allred N, et al. Effect of influenza vaccination of healthcare personnel on morbidity and mortality among patients: systematic review and grading of evidence. Clin Infect Dis 2014;58:50–57.
- Thomas RE, Jefferson T, Lasserson TJ. Influenza vaccination for healthcare workers who care for people aged 60 or older living in long-term care institutions. Cochrane Database Syst Rev 2013;7(7):CD005187pmid:23881655.
- Taylor G, Mitchell R, McGeer A, et al., Canadian Nosocomial Infection Surveillance Program. Healthcare-associated influenza in Canadian hospitals from 2006 to 2012. Infect Control Hosp Epidemiol. 2014;35(2):169–175.
The American Academy of Pediatrics has vigorously reiterated its call for mandatory influenza vaccination of healthcare workers, saying religious or philosophical objections to immunizations do not override the ethical imperative to protect patients and coworkers.
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