Friday, October 16, 2009

Mandated H1N1 Vaccination: Right or...Oh, so Wrong?

A good friend and former colleague inspired this post (thanks Joanne) after realizing how media attention to mandated H1N1 vaccination among health workers has grown in the past few weeks. NPR, Time, the New York Times, ABC News all are covering what is an unprecedented move to require health care workers to be vaccinated against swine flu.

While many hospitals and clinics are requiring employees to get vaccinated, the state of New York is requiring all health care workers with patient contact to receive the H1N1 vaccine or face job loss; resistance to this mandate among health care workers has been overwhelming. Fear of side effects and privacy issues top health workers' concerns. However, an August poll shows a vast majority of the public to be supportive of these vaccine requirements among healthcare employees.

There seem to be several streams of thought regarding this issue:
  1. Vaccination of all health care workers is needed to protect the public against swine flu spread by providers who come into contact with sick patients
  2. Mandatory vaccination is needed to protect other patients in the hospital setting with compromised immune systems (meaning they easily can come down with an illness, like the flu).
But many nurses object, saying that they have never gotten flu in past seasons, so why now? Why this flu shot? Additionally, opponents to mandatory vaccination highlight the fact that the vaccine is not effective 100% of the time. Nurses also worry about the potential side effects of vaccination, particularly whether it would cause them to get sick with the flu.

Proponents of mandatory vaccination say that the potential risks of health care workers being vaccinated outweigh the potential harm to patients and the public's health.

However, is there evidence that health care workers transmit disease around the hospital setting? In schools, vaccination of students can be explained through lack of classroom hygiene and hand-washing taken by children, as well as the enormous risks they face if they do get sick. The CDC just released a report indicating that child deaths due to H1N1 already total 76 since April, and normally that number totals 46 to 88 for the entire year (April-April).

On the other hand, health care workers act under strict regulation and in some of the most "clean" conditions (if you ignore the threat of super-bugs resistant to any and all traditional medicine that float around the hospital corridors). They wash their hands and used alcohol-based sanitizer everywhere they go, after every patient they see. I am unaware of any studies that link health care workers to the spread of infectious disease, particularly flu, in hospital settings in order to give an evidence base to the current mandatory vaccine policies.

Yet, public health action often, if not always, needs to be taken despite the lack of the most rigorous scientific evidence; randomized controlled trials and experimental studies are not always feasible, ethical, or available. In many cases the studies that may be needed could take years of research, when what a policymaker really needs to know is already in front of them. Sometimes, you have to settle for the evidence available in the moment of crisis (and H1N1 has been a public health crisis) and do the best to protect public health and prevent illness.

I believe this is what the vaccination requirement is all about; doing the best with the scant evidence that you have in order to promote public health to the highest degree possible.

As a side note, in human rights literature, we find exception for limiting rights if it is needed to protect public health. While health care workers may be upset that mandatory vaccination violates their "right" to choose treatment, concern for public health has long been recognized as a legitimate reason to withold or even violate rights as long as it meets a set of criteria (determined by experts, there is no magic formula). Nonetheless, if there is a way to protect public health without violating individuals' rights then that course of action should be taken. It is considered a last resort. Could mandatory vaccination of health workers in New York and in hospitals across the country fit this type of human rights framework? (can you tell I am knee deep in human rights literature for a paper due next week?!)

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