Flu shot mandates spur a backlash

Fed panel split on recommendation

Late in her pregnancy and fearful of the flu vaccine, the nurse wanted to hold off on immunization. At her hospital, though, the flu vaccine was mandatory. Get the shot or lose your job, her supervisor told her.

She was worried about thimerosal in the vaccine, even though the Centers for Disease Control and Prevention says the vaccine is safe and recommends flu shots for pregnant women. Faced with the dilemma, she resigned.

"This is a basic human rights issue, sovereignty over our own bodies," asserts Barbara Skurnowicz of Bloomfield Hills, MI, president of Michigan Health Care Professionals for Vaccine Choice, an organization formed in response to the growing number of hospitals mandating flu vaccination. She related the story of the nurse to explain why some health care workers are balking at vaccination.

While mandatory influenza vaccination of health care workers gains momentum, so does a backlash. Skurnowicz's organization, for example, is lobbying the Michigan legislature to allow a waiver for health care workers who decline vaccination for medical, religious or philosophic reasons, similar to the waivers available from childhood vaccination.

Concerns about the punitive nature of some mandatory policies have led to some back-pedaling. A working group of the National Vaccine Advisory Committee (NVAC), a federal panel that advises the U.S. Department of Health and Human Services, recently took a straw poll on whether to recommend mandatory vaccination of health care workers. Only 12 of 25 members wanted a full mandate, with exceptions only for medical contraindications or religious beliefs.

In a written statement to the panel, the U.S. Occupational Safety and Health Administration noted that flu vaccine technology is "problematic" and that the protection the vaccine provides is variable. "[T]here is insufficient scientific evidence for the federal government to promote mandatory influenza vaccination programs that do not have an option for the [health care personnel] to decline for medical, religious and/or personal philosophical reasons," OSHA said.

Exceptions to the mandate?

The split opinions on the NVAC panel reflect debate about how to define "mandatory" and whether to emphasize other methods to increase immunization. The panel is charged with making recommendations on reaching the HealthyPeople 2020 goal of at least 90% influenza vaccination of health care workers.

The most recent CDC survey showed that 71% of hospital-based health care workers received a flu vaccine last year, and that 13% of health care workers had a mandate from their employers.

"All of the experts want healthcare workers to accept flu vaccination if they can," says Melanie Swift, MD, FACOEM, medical director of the Vanderbilt Occupational Health Clinic in Nashville and a member of the panel.

"Everyone agrees education about the vaccine is important to reduce fears. Everyone agrees that people with medical contraindications to the vaccine should not be fired. No controversy there," she says. "But experts are divided on how to handle individuals with religious, philosophic or personal objections to vaccine."

Those who support a mandate frame it as a patient safety issue — vulnerable patients who could be harmed by unvaccinated health care workers who acquire influenza. It is supported by major professional organizations, including the American Hospital Association, the American College of Physicians, the American Public Health Association and several infection control associations.

Bill Borwegen, MPH, safety and health director of the Service Employees International Union (SEIU) and a member of the working group, asserts that the risk to patients of acquiring influenza from health care workers has been overstated.

"When all of the hospitals that have mandatory programs haven't been able to show any reduction in influenza among their patients [even after] five or six years, it's hard to make the case that the science has been firmly established that in fact the vaccine makes that much of a difference," he says.

Borwegen also has warned that vaccine mandates that lead to the firing of health care workers could just lead to more skepticism about vaccines.

In fact, Skurnowicz's group works with Michigan Opposing Mandatory Vaccination (MOM), which advocates for "the right of individuals and parents to make their own vaccine choices."

Skurnowicz says concern about the flu vaccine is based on scientific evidence and not myths or misconceptions. She cites the Cochrane review of vaccine effectiveness in which the authors concluded: "Influenza vaccines have a modest effect in reducing influenza symptoms and working days lost. There is no evidence that they affect complications, such as pneumonia, or transmission."1

Skurnowicz's twin daughters are anesthesia nurses, and both have had serious adverse reactions to other vaccines, she says. If they were required to have the flu vaccine, they would resign. "No one should be required in this country — not in America, not now, not ever — as a condition of employment to be vaccinated with anything," she says.


1. Jefferson T, Di Pietrantonj C, Rivetti A, et al. Vaccines for preventing influenza in healthy adults. Cochrane Database of Systematic Reviews 2010; 7: CD001269. Available at http://bit.ly/i3FyBt