Mandatory flu vaccination and other sick policies

by Quinn O'Neill

If you were a patient in a hospital, whom would you rather have caring for you: a healthy professional or someone who was febrile, coughing, and struggling to stay awake? If you’re like most people, you’d want to be treated by someone who seemed healthy. It's a no-brainer.

Unfortunately, health care professionals have a tendency to show up to work even when they have the flu or a flu-like illness. According to one study more than 80% of medical practioners and over 60% of nurses, nurse’s aides, allied professionals, and administrative staff do not routinely take sick leave when experiencing influenza-like illness (ILI).

Though paid sick leave policies aren’t the norm in the US, they can have a huge impact on the spread of disease. A study looking at the 2009 flu pandemic estimated that the absence of paid sick leave could add an additional 5 million cases of ILI in the general population. It's worth noting that ILI may be caused by a wide range of pathogens (in addition to influenza viruses) for which flu vaccination offers no protection.

The issue of sick leave - whether it’s paid or not, and whether or not it’s taken when it should be - is particularly interesting in the context of mandatory vaccination of health care workers. A number of employees were recently fired by an Indiana hospital for refusing the flu shot. This wasn't an isolated incident - 29 hospitals fired unvaccinated workers last year. It seems like a pretty extreme measure. Is it justified? In determining this, we should first consider a couple of other questions.

Does the flu vaccine actually prevent influenza? There is evidence that it does pretty well in this respect. According to the CDC, preliminary data for the 2010-2011 season indicate a vaccine effectiveness of approximately 60%. To put this in perspective, this means that if 10% of unvaccinated people got the flu, only 4% of vaccine recipients would’ve been infected. So the vaccine didn’t offer complete protection against the flu but it did significantly reduce the risk of infection among vaccinees.

As the CDC notes, the level of protection conferred by the flu vaccine varies among individuals and from season to season. Important factors include the immune status of the recipient, how well the viruses included in the vaccine match those in circulation, and the type of vaccine used. For the 2010-2011 season, unpublished CDC data indicate that “almost all influenza viruses isolated from study participants were well-matched to the vaccine strains.”

The flu kills a large number of people every year and serious adverse events following vaccination are very rare. Though the benefit of flu vaccination to individuals is modest and variable, there is good reason to roll up your sleeve. While not perfectly protective, it will lower your chances of being infected by the included strains.

Health care workers are a special group. They fall within a narrower age range than the general population and are probably less likely to be immunocompromised. While on the job, they’re expected to take certain precautions to reduce the risk of getting and transmitting infections. These include handwashing and the use of protective barriers like masks and gowns. Given the circulation of other dangerous pathogens for which vaccines aren't available, we hope that these practices (and ideally, the appropriate use of sick leave) offer considerable protection. With the unique characteristics of health care workers, it would be helpful to know if vaccination prevents influenza in this group, specifically.

Unfortunately, reliable studies looking at this group are limited and somewhat conflicting. A systematic review published last year looked at the effect of vaccination of health care workers on a number of outcomes: laboratory-confirmed influenza, influenza-like illnesses, and working days lost. Based on their analysis of the included studies, the authors concluded: "No evidence can be found of influenza vaccinations significantly reducing the incidence of influenza, number of ILI episodes, days with ILI symptoms, or amount of sick leave taken among vaccinated HCWs". They emphasized that the limited number of relevant studies precluded drawing a definitive conclusion.

Getting a flu shot and forcing someone to get one are very different things. The justification for mandatory vaccination of health care providers typically rests on the belief that it will protect patients. A spokesperson for the Indiana hospital that recently fired its vaccine decliners predictably stressed patient safety in a public statement: “As a hospital and health system, our top priority is and should be patient safety, and we know that hospitalized people with compromised immune systems are at a greater risk for illness and death from the flu.”

This sounds reasonable, but does vaccinating health care workers actually protect vulnerable patients? Research that specifically addresses this question is limited and difficult to interpret. A 2010 Cochrane review examined studies that looked at vaccinating health care workers and rates of influenza, its complications, and influenza-like illnesses in elderly residents of long-term care facilities. The authors reported no effect for laboratory-proven influenza, pneumonia, and death from pneumonia.

Interestingly, an effect was found for non-specific outcomes, including influenza-like illness, physician consultations for influenza-like illness and all-cause mortality. The authors note, however, that the non-specific outcomes are difficult to interpret, since influenza-like illness may be caused by a variety of pathogens, and winter influenza is responsible for a minority of all-cause mortality in this age group. As for whether vaccination of health care workers prevents laboratory-proven influenza, pneumonia and deaths from pneumonia in these elderly residents, they state “we cannot draw such conclusions.”

An Israeli researcher, Zvi Howard Abramson, published another critical review of the evidence for mandatory vaccination a couple of months ago. He came to a similar conclusion: "The arguments for uniform healthcare worker influenza vaccination are not supported by existing literature. The decision whether to get vaccinated should, except possibly in extreme situations, be that of the individual healthcare worker, without legal, institutional, or peer coercion."

The appropriateness of mandatory flu vaccination is ultimately a subjective call. It depends not only on the degree to which vaccination confers protection to the recipient or to his patients, but on how much we value autonomy. Some might argue that even a tiny reduction in influenza rates would be sufficient to warrant a coercive policy. I place great value on my right to make informed choices and I think that if we’re going to deny people their right to informed decision making, we’d better have a damned good reason. In my opinion, the available evidence falls short of providing one.

In the context of other hospital-associated risks and policies, firing vaccine refusers is outrageous. A far greater risk to hospital patients than the flu, for example, is medical error. Sanjay Gupta, writing in the New York Times, estimated that about 200,000 Americans die every year as a result of medical error, making it one of the leading causes of death in the US. For comparison, influenza and pneumonia take the lives of just under 54, 000, and hospital-acquired cases would be only a small proportion of those. For hospital patients, medical error is a much greater threat than the flu.

A major contributing factor in medical error is sleep deprivation and it’s known to be problematic in the medical profession. A 2012 study of orthopedic surgery residents reported that residents were fatigued 48% of their time awake and “impaired” 27% of the time. The authors considered this impairment to be as severe as that expected with a blood alcohol level of 0.08. That’s the level we’d expect for a 180 lb man who’s had four drinks. The authors estimated that overall, residents' fatigue levels could increase the risk of medical error by 22%.

A 2007 study reported similar findings looking at resident physicians and nurses. The researchers concluded: “The weight of evidence strongly suggests that extended-duration work shifts significantly increase fatigue and impair performance and safety. From the standpoint of both providers and patients, the hours routinely worked by health care providers in the United States are unsafe.”

If patient safety is such a priority for health authorities and administrators that firing flu shot refusers would be justified, what measures might they take in the face of a much greater threat than the flu? Concern about the effects of exhaustion in medical residents led the Accreditation Council for Graduate Medical Education to set work limitations for residents. These were established in 2003 and revised in 2011. Residents' duty hours are now limited to “80 hours per week, averaged over a 4-week period”. That’s more than seven 11-hour days in a row and that’s intended to be an average week, with some weeks presumably being more full. Residents "must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty" and strategic napping after 16 hours of continuous duty is "strongly suggested". Did they seriously expect these lax limitations to keep residents well rested and sharp? Unsurprisingly, a recent systematic review suggests that the limitations have had little impact.

As it currently stands, hospitals will fire staff members for refusing a flu shot but routinely allow doctors and nurses to work while they're effectively impaired and visibly infectious. So long as they've been vaccinated, physicians and nurses may treat you while they're dangerously exhausted and sneezing virus-laden snot droplets all over the place. If the safety of patients is truly driving hospital policy making, something is amiss. A combination of respect for employees’ autonomy and proportional attention to risks to hospital patients would make for a healthier and saner approach.