Elsevier

Vaccine

Volume 26, Issue 44, 16 October 2008, Pages 5562-5566
Vaccine

The ethics of mandatory vaccination against influenza for health care workers

https://doi.org/10.1016/j.vaccine.2008.08.002Get rights and content

Abstract

Vaccination of health care workers (HCW) in long-term care results in indirect protection of patients who are at high-risk for influenza. The voluntary uptake of influenza vaccination among HCW is generally low. We argue that institutions caring for frail elderly have the responsibility to implement voluntary programmes for vaccination against influenza of HCW. When uptake falls short a mandatory programme may be justified. The main justification stems from the duty of care givers not to harm one's patient when one knows there is a significant risk of harm and the intervention to reduce this chance has a favourable balance of benefit over burdens and risks.

Introduction

Many think of influenza as a trivial disease. However, this is certainly not the case, at least among the elderly population, where up to 90% of influenza-associated mortality, directly or indirectly, occurs. There will be considerable season-to-season variability, but the incidence of hospital admissions has been reported to be 10% and mortality rates to exceed 5% [1]. Vaccination against influenza infections of the elderly may reduce morbidity, mortality and hospital admission rates, but the response of the immune system of the elderly is generally weaker, resulting in a protection of 50–70% of the population at best, even after being vaccinated. Therefore, in spite of high compliance with vaccination, the risk of influenza-related complications among patients who are often both frail and elderly, is particularly high and the possibilities for the individual patients to protect themselves are limited.

Vaccination of health care workers (HCW) in long-term care facilities results in indirect protection of patients who are at high-risk for influenza [1], [2]. Furthermore, influenza can have a disrupting effect on the continuity of care and research has shown that vaccinating the personnel reduces influenza infections and therefore less working days are lost [3]. The costs per life year gained of vaccinating HCW are low [4]. On these grounds some organisations have issued guidelines in which influenza vaccination of HCW is recommended [5], [6], [7]. In 2003, the WHO officially welcomed the initiatives of countries to administer influenza vaccination to health care workers in contact with high-risk persons [8].

In spite of these recommendations the uptake of influenza vaccination among HCW in response to voluntary vaccination programmes is generally incomplete. One may ask therefore whether it is necessary and morally justifiable to impose a mandatory vaccination programme. Such a mandatory policy raises several ethical issues. It is one thing to speak of a general duty of beneficence of HCW, but is not clear that this implies a duty to accept vaccination. One could also argue that given the respect due to autonomy, HCW should not be pressured to be vaccinated. Moreover, HCW might consider it unreasonable if they are expected to be vaccinated themselves for the sake of others. The aim of this article is to discuss some of these important ethical questions and to draw a conclusion about the justifiability of mandatory vaccination. We focus our discussion on vaccination of HCW in long-term care facilities. By HCW we mean all those who have contact with residents, be it as a professional providing direct care or otherwise.

Section snippets

Is the efficacy and cost-effectiveness of HCW vaccination sufficiently demonstrated?

In two British randomized trials the effectiveness of HCW vaccination was studied [2], [9]. A rise in vaccination rates among the HCW resulted in a relative reduction of mortality among patients of about 40%, but the incidence of influenza-like illness did not change. These results have led some to conclude that vaccination of HCW has considerable (indirect) effects on the health of patients [4]. However, the authors of a 2006 Cochrane meta-analysis concluded that there is no evidence that

Have strategies to raise voluntary uptake of vaccination been sufficiently demonstrated to fail?

As stated above, based on the evidence described several professional organisations have advised vaccination of HCW. This is likely to have only a limited effect on vaccine uptake. For instance, 1 year after the introduction of the 2004 guideline of the Dutch Society for Nursing Home Physicians the proportion of vaccinated HCW had risen from 5–8% to 10.5% only [13]. Even where campaigns to increase uptake accompany voluntary programmes vaccination usually remains incomplete. Several strategies

Who should act upon this data?

At present there is evidence for the efficacy of vaccinating HCW in long-term care institutions for the elderly such as nursing homes. Vaccination of nursing home HCW leads to a significant reduction of the risks for residents. Health care institution boards have a moral obligation to reduce avoidable risks for persons within the institution. Therefore, they ought to implement voluntary vaccination campaigns directed at HCW who during their work are in close contact with residents. The form of

What is meant by mandatory vaccination?

To speak of mandatory programmes may be misleading. No one will suggest that HCW should be vaccinated against their will by force. Most so called mandatory programmes in reality are conditional, in the sense that objectors are refused the ability to work either completely or temporarily. A further question in the latter case is whether salary should be paid for the days off work. We think that question can be put aside because the strategy of temporarily limiting access to the institution is

The duty not to harm others

Generally speaking people have a moral obligation not to harm each other. When infecting someone else could have been prevented, but is not, this can be regarded as harming that person [16]. This is relevant not only in cases where one knows oneself to be infected (e.g. HIV-positive persons), but also when one is not aware of being infected with a specific agent and transmission thereof may be prevented by taking general preventive measures, like washing one's hands. This does not imply an

Freedom of choice of HCW

Above we mentioned mandatory vaccination as a burden because of the infringement of one's autonomy. But even when an individual HCW does not have strong opinions about being vaccinated or not, mandatory vaccination programmes involve constraints to personal autonomy and freedom of choice. The least one can say is that a strong justification is needed for such constraints. Such a justification would seem to follow from the serious effects an influenza infection may have on the frail elderly.

What place for conscientious objectors?

Arguments from conscience or philosophical objection have a long tradition in the debate about mandatory vaccination. Conscientious objection was created in British common law in 1916 for resistance to small pox vaccine [26]. These objections are arguably protected under the Siracusa Principles [27]. For some, illness need not always be a bad thing. In this view a period of illness can also be an opportunity to restore the natural balance. Others may consider the vaccination a considerable harm

Conclusion

In conclusion we think that long-term care institutions caring for frail elderly have the moral responsibility to implement voluntary programmes for vaccination against influenza of HCW who are in direct contact with these residents. Obviously, it would be morally superior if voluntary influenza vaccination programmes result in sufficient uptake. Thus, if voluntary programmes are able to increase vaccine uptake to over 50% of the relevant HCW, mandatory programmes will not be necessary.

Acknowledgements

This article has been written on the initiative of the European Scientific Working group on Influenza (ESWI), a multidisciplinary group of key opinion leaders in influenza who aim to combat the impact of epidemic and pandemic influenza in Europe. The views expressed in this article are those of the authors.

Conflict of interest statement: None declared.

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