Is it ethically permissible to mandate influenza vaccination for health care workers?

The World Health Organization estimates that influenza causes severe illness in 3 million to 5 million people and 250,000 to 500,000 deaths annually.¹ Seasonal influenza epidemics affect 5% to 20% of the US population annually and result in more than 225,000 hospitalizations and 36,000 deaths.² In persons older than 65 years, influenza is related to one in every 20 deaths.³ Vaccination is the most effective means of preventing infection and outbreaks of influenza; it is also the most effective method for preventing transmission of the virus to patients by health care workers.² 


Influenza vaccination is reported to confer 70% to 90% protection in healthy people younger than 65 years.⁴ Despite this, the percentage of health care workers who are vaccinated annually against influenza remains at less than 50%. Hofman and colleagues reviewed 32 studies on immunization rates of health care workers conducted between 1985 and 2002; the rates reported by these studies varied from 2.1% to 82%.⁵ In the United States, the vaccination rate among health care workers was 42% in 2006.² 


Voluntary measures have not produced significant increases in vaccination rates of health care workers, and efforts to increase the vaccination rate have been met with resistance. Many health care organizations mandated vaccination for workers during this past year's influenza season because of concern over the low rates of immunization and the possible consequences of the novel H1N1 strain. Legal action and vocal opposition against this mandate caused some organizations to back off.^6-8 


THE ETHICAL QUANDARY


Is mandatory influenza vaccination for health care workers ethically permissible? Can a PA, or any other health care worker, ethically refuse to be vaccinated against a communicable disease, specifically influenza?


As health care workers, our first obligation and fiduciary duty is to our patients. Two of the founding principles of bioethics are autonomy, wherein each individual has the right to make independent choices and decisions, and nonmaleficence, to do no harm or to avoid imposing unnecessary or unacceptable burden upon the patient.⁹ Will the act of not being immunized affect the principle of justice and result in excessive costs? Does refusal of influenza vaccination by a health care worker violate the principles of ethics?


DISCUSSION


Influenza is readily spread through the respiratory route, and a person may be asymptomatic yet still spread the virus. Viral shedding can occur at least 1 day before symptoms manifest; furthermore, only half of infected persons will be symptomatic and possibly continue to spread the virus for 5 to 10 days.⁴ 


Nosocomial spread has been documented by several researchers. Cunney and colleagues reviewed an outbreak of influenza A in a neonatal ICU.¹⁰ Six of the 19 neonates who tested positive for the virus were asymptomatic, and only 15% of the 150 staff involved in their care during this incident had been vaccinated.¹⁰ After an outbreak of influenza in a bone marrow transplant unit, investigators found that only 12% of the health care workers had been vaccinated that year.¹¹ 


Some investigators have demonstrated that vaccination of health care workers reduces mortality and morbidity in various settings.^12,13 However, a Cochrane review concluded that both the elderly living in institutions and the health care workers who care for them could be vaccinated for their own protection, but an incremental benefit of vaccinating health care workers for the benefit of the elderly cannot be proven without better studies.¹⁴


Beneficence and nonmaleficence If one is not vaccinated and becomes symptomatic, avoiding patients greatly reduces the chances of transmitting the virus to them. Unfortunately, many health care workers continue to work when ill.^15,16 This action increases the risk of transmission to both patients and coworkers.


Harris and Holm state that when an infection that could have been prevented is transmitted to another person, harm has been done to that person.¹⁷ Knowledge of infection is not necessary; if a preventive measure was not taken to inhibit the transmission of an infectious agent, harm has occurred. Simple measures, such as hand washing, glove use, and sterile technique, are applications of this principle. Verweij asserts that not being vaccinated is morally wrong when it increases a risk of infection that would have been decreased.¹⁸ Vac­cination greatly diminishes the probability of becoming infected, as well as the chance of spreading the infection to others. A health care worker would be taking an important step toward preventing harm to others.