Vaccine. Mandate or Not?

Vaccine. Mandate or Not? CDC says no. Other infectious disease experts say yes.

As you may recall, New York State attempted to mandate H1N1vaccine for all health care workers despite a lack of vaccine or a declared public health emergency. Yes, there was a pandemic declared, but no public health emergency. There was considerable debate as to who, exactly, was considered health care workers...did it include EMS? Firefighters? Or simply, anyone who would walk into a hospital? The New York State Nurses Association came out swinging hard against the vaccine mandate. We posted on this way back on July 31, 2009. See NYS Nurses Opposes Mandates for Vaccine in Mitigation Journal.

In June, 2010, the Centers for Disease Control and Prevention issued a statement saying they would not endorse mandated flu vaccines for health care workers this year. The announcement by the CDC was a reversal from their controversial stance in 2009 that anyone working in a hospital must be vaccinated against the H1N1 Swine Flu. The details of this CDC decision were posed in the Mitigation Journal Blog (CDC: Vaccine Not a Requirement. 12 Aug 2010) The full text of the CDC's June 22 statement can be found here.

What will it be for the 2010-2011 flu season? Mandated vaccine or not? Well, the CDC has their opinion and other infectious disease experts have another view. The Society for Health care Epidemiology of America (SHEA) has released a position paper endorsing mandated vaccination with endorsement from the Infectious Disease Society of America. According to the SHEA media release:

"...influenza vaccination of health care personnel [is] a core patient safety practice that should be a condition of both initial and continued employment in health care facilities."

There is more than one controversy in this situation.

Should flu vaccine be mandated? I think a better question is: "what rights do I forfeit to work in health care?" We already require health care workers to undergo TB testing. Hepatitis vaccine is offered, but can be declined. The SHEA position paper states "a condition of employment" in regards to flu vaccination...but who will enforce it? You may recall that the United States Army had to resort to disciplinary action against soldiers who refused mandated Anthrax vaccine. That 2003 mandate for Anthrax vaccine was in preparation for soldiers who were deploying to a area with a credible Anthrax threat and was eventually halted by federal court in 2006 (note: the Army is planning to restart the program 2010-2011). If the Army cannot mandate vaccine soldiers in the presence of a credible threat, how can anyone mandate civilian health care workers to be vaccinated in the absence of public health emergency or credible threat?

Are we following the CDC, WHO or other groups such as SHEA? What are policy makers to do when these expert groups disagree? Last years NY mandate covered anyone who had patient contact in a health care facility. That included some EMS personnel...and here is the lunacy...only commercial (private) ambulances were included in the mandate. The rationale was that commercial or private ambulance services had a higher call volume and, therefore, higher risk. There was no consideration for the numerous EMS providers who work/volunteer for multiple agencies (and hence, have a higher exposure). Also, the 2009-2010 H1N1 vaccination plan had EMS near the bottom of the list to receive vaccine. The point is, if health care workers are going to be mandated to receive vaccine, EMS should fall under that...if EMS responders refuse, if hospital health care workers refuse...what will the system impacts be? I would predict a near-crippling effect on our ability to manage daily volumes.

There is no doubt in my mind that flu vaccination will prevent the spread of flu...seasonal or otherwise. Public health history reminds us that viruses like Smallpox can be eradicated from nature by a staunch vaccination effort. But can we expect to vanquish Type A influenza by mandating seasonal flu vaccination? That answer is no. I'm also concerned about the "what's next" factor. If we mandated to be vaccinated for flu or loose jobs today, what will be mandated (under pain of unemployment) tomorrow? 

More to follow. Feel free to comment (constructively) or email for discussion.