Forced Flu Vaccine Science or Politics?

I am an avid vaccine advocate, and I personally recommend that everyone get vaccinated for all preventable diseases. I live and work in a state that recently passed a law mandating Flu vaccine for healthcare workers. For a vaccine advocate this law sounds like a slam dunk. Interestingly many healthcare workers are objecting to this mandatory injection. Most of the complaints about this law are based on personal choice and risks of vaccination. Given the controversy, I thought it reasonable to ask the question is this science or politics?

Rhode Island is the first state, in the United States, to require that healthcare workers have a mandatory flu vaccine by December 15 of every year. This includes all workers, volunteers, and anyone who has direct patient contact.Health care workers also may refuse to be vaccinated, but they must provide written notice of their refusal to their employer prior to Dec. 15 of each year. During any declared period of widespread flu outbreak, unvaccinated workers must wear surgicalface maskswhenever they have direct patient contact, or face a fine.

Like most healthcare workers in the United States we are offered flu vaccines, usually free of charge, every winter. I always take advantage of the opportunity and get the flu vaccine. So domost of my coworkers. Usually when I go to the hospital center, for the injection, there is a line of people waiting to receive their vaccine. As a vaccine advocate it never even entered my mind to avoid the flu vaccine. I often hear other's concerns about the vaccine. Commonly they describe reasons for avoiding it; a localized reaction, it doesn't work, I haven't had the Flu in X-years. As a provider people do listen to my opinion, and I do my best to provide the facts.

Still when I received a letter from the Department of Health informing me that my hospital privileges could be suspended or revoked if I did not obtain a flu vaccine my initial reaction was anger. I, like most human beings, do not like to be told what to do by an impersonal threatening letter. The American Civil Liberties Union shared my initial reaction and currently are pursuing legal action to prevent this law from remaining in place.

This put me at odds with my normal staunch pro-vaccine position. Normally I spend time with my patients in the office explaining to them why I think vaccines are necessary, safe, and effective. I discuss the risks, the benefits, and problems with remaining unvaccinated. I spend my time doing this teaching, not because I'm required to, but because I believe in vaccines. I believe they are the single most effective medical treatment bar none. I do this despite the fact that I work in an orthopedic specialty. There is little or no direct medical relationship with infectious disease. We do not stock or give vaccines.

So why was I and others of my profession, instinctually objecting toa vaccine. For most I think it was the "mandatory" part. For me it was an automatic skepticism of a political decision not a medical decision. It sounds very plausible that forcing vaccinations on healthcare workers would in fact help prevent the spread of infectious disease.Plausibilitydoes not justify forced injections. Immediately I thought to myself what does the science say? What are the risks, and what are the benefits?

In skepticism you always ask the basic questions first. Does the vaccine work?The flu is a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs. It can cause mild to severe illness, and at times can lead to death.The single best way to prevent the flu is to get a flu vaccine each season. There are two types of flu vaccines:

• “Flu shots” �" inactivated vaccines (containing killed virus) that are given with a needle. There are three flu shots being produced for the United States market now.
  
  • The regular seasonal flu shot is “intramuscular” which means it is injected into muscle (usually in the upper arm). It has been used for decades and is approved for use in people 6 months of age and older, including healthy people, people with chronic medical conditions and pregnant women. Regular flu shots make up the bulk of the vaccine supply produced for the United States.

  • A hi-dose vaccine for people 65 and older which also is intramuscular. This vaccine was first made available during the 2010-2011 season.

  • An intradermal vaccine for people 18 to 64 years of age which is injected with a needle into the “dermis” or skin. This vaccine is being made available for the first time for the 2011-2012 season.

• The nasal-spray flu vaccine �" a vaccine made with live, weakened flu viruses that is given as a nasal spray (sometimes called LAIV for “Live Attenuated Influenza Vaccine”). The viruses in the nasal spray vaccine do not cause the flu. LAIV is approved for use in healthy* people 2 to 49 years of age who are not pregnant.

• About two weeks after vaccination, antibodies develop that protect against influenza virus infection. Flu vaccines will not protect against flu-like illnesses caused by non-influenza viruses.The seasonal flu vaccine protects against the three influenza viruses that research suggests will be most common.(CDC)

The CDC's health care provider's information page is complicated. There are no hard numbers that you can state for vaccine effectiveness. This is due to a variety of factors. The effectiveness varies slightly across different ages. Effectiveness is affected by multiple strains of influenza, disease mutation, and the lagbetween the vaccine and the actual production of antibodies. I've included the link to the CDC webpage. Flu Vaccine Effectiveness CDC. I will try to strip it down to basic elements for brevity. If the CDC, and the World Health Organization, have appropriately planned for the strains of influenza that will commonly occur this flu season, the vaccine is very effective. It is less effective in people who are elderly, immune compromised, or under two years of age. Even in lower efficacy groups it helps attenuate the severity and the duration of the flu effects.

Is the vaccine safe? There are risks for any medical treatment. Bottom line. Having the Flu and not having the vaccine is much riskier than getting the vaccine. There are groups of people with specific risk factors and should not have the vaccine.

They include:

• People who have a severe allergy to chicken eggs.

• People who have had a severe reaction to an influenza vaccination in the past.

• Children younger than 6 months of age (influenza vaccine is not approved for use in this age group).

• People who have a moderate or severe illness with a fever should wait to get vaccinated until their symptoms lessen.

• People with a history ofGuillain-Barré Syndrome(a severe paralytic illness, also called GBS) that occurred after receiving influenza vaccine and who are not at risk for severe illness from influenza should generally not receive vaccine. Tell your doctor if you ever had Guillain-Barré Syndrome. Your doctor will help you decide whether the vaccine is recommended for you. (CDC)

Even the CDC is recommending that you and your doctor should decide if the vaccine is right for you. So what right does a state governing body have to require that any group received any medical treatment? For the most part government already does this. The Northeast United States is a fairly liberal political environment. Rhode Island specifically is what we call in the US a very Blue State. Vaccines are required for enrollment in schools. Students are not allowed to attend schools if they are not fully vaccinated. There are of course ways around child vaccination laws . The requirements to avoid childhood vaccines is similar to the requirements laid out in the Rhode Island law for healthcare workers. RI leads the nation in childhood vaccination rates I am proud to say.

This is not a political blog, this is the science blog. The questions I'm asking are scientific. Does requiring healthcare workers to be vaccinated with the seasonal flu vaccine prevent the spread of the disease? The answer is no, not directly. There issufficient scientificevidence to state that if a large portion ofhealthcareworkers are left unvaccinated it would worsen an outbreak. There is no evidence that vaccinated healthcare workers would blunt the impact of the disease.

The CDC recommends that all healthcare workers and people that have contact with patients should have the flu vaccine. The CDC does not say that the science demands that healthcare workers should be forced vaccinated. Surgical masks, the next best option, is a poor substitute.

There is no direct research demonstrating a decreased risk of transmission in a hospital setting for surgical masks.It is assumed because influenza is a droplet disease that surgical mask can help prevent direct person-to-person transmission. Since influenza is just as easily passed by direct contact, touching your eye and touching a doorknob, surgical masks are limited. There is a goodBritishstudy that looked at the mechanics of influenza and surgical masks. "Surgical masks may provide adequate protection against large droplets, splashes and contact transmission. They may also reduce any residual aerosol risk but it remains unclear whether this level of protection sufficiently reduces the likelihood of transmission via this route so as tominimizethe risk of infection to as low as reasonably practicable. With this in mind, it isrecommended that HSE draw the results of this research to the attention of DH/HPA so that it can be considered as part of the wider issue of modes of influenza transmission."(http://cid.oxfordjournals.org/content/49/2/275.full). In short, it's plausible, reasonable and there is evidence to support that surgical masks help. It is not as good as the vaccine.

The evidence clearly shows that health care workers should be vaccinated. Research has shown that more than 40% of healthcare workers do not get vaccinated. There have been several studies, mostly statistical analysis, that shows that a pandemic flu would likely spread quicker and be far more disabling if healthcare workers were not completely vaccinated. Surgical masks, although helpful, would not be enough. Additionally healthcare worker fatigue and illness would be a compounding factor in anover-stressedand taxed healthcare system. There is no evidence that vaccinating healthcare workers would prevent a pandemic, or significantly prevent the spread of flu. There is evidence that unvaccinated healthcare workers couldseverelyworsen a pandemic.

One can certainly argue that this is a significant restriction of a personal freedom. It removes your ability to choose and decide on your personal health to some degree. Public health issues always are a balance between the needs of the many and the needs of the individual. We as a society have to make a reasonable decision on the best evidence.

In my opinion the research clearly indicates that there is a strong benefit for requiring healthcare workers to receive the flu vaccine. In case of a significant and life-threatening flu pandemic this would improve staff both in numbers and in quality(healthy). In the case of a lethal flu pandemic, the kind of which affected the country in 1918, and was feared in 2010, vaccinations would be required to have enough trained personnel to keep patients alive. I feel that the evidence supports the need for surgical masks in healthcare workers who cannot have the flu vaccine.

Generally politics has little correlation with scientific recommendation. In this case I think the state of Rhode Island is spot on.

On a personal note I believe that when you accept the responsibility of being a physician, nurse, nursing assistant, or hospital personnel you accept some risk. The risk, in forced flu vaccine, is far less than the benefit. Yes I do see the irony of a US state that requires healthcare workers to get flu vaccine, but has mostly unrestricted gun laws, and no motorcycle helmet law.

Any political decision that follows the science is a start in the right direction. I am happy to say, in this case, the government telling me to do something for my own good, is in fact good. Still when it comes to politics and science I am always skeptical.

REFERENCES

• Vaccine.2012 Jul 6;30(32):4733-43. doi: 10.1016/j.vaccine.2012.05.018. Epub 2012 May 27.

• Vaccine.2011 Sep 2;29(38):6472-84. Epub 2011 Jul 12

• Vaccine.2012 Jul 6;30(32):4733-43. doi: 10.1016/j.vaccine.2012.05.018. Epub 2012 May 27.