Is there a case for mandating influenza vaccination in healthcare workers?

Increasing influenza immunization rates among healthcare providers in an ambulatory-based, University Healthcare Setting☆

OBJECTIVE

Despite its 'best practice' status as an intervention to combat healthcare-related influenza, many healthcare personnel (HCP) do not seek vaccinations themselves. The objective of this study was to achieve the Healthy People [HP] 2020's influenza vaccination goal of 90% among our HCP.

DESIGN

The study utilized the model for improvement, consisting of Plan-Do-Study-Act (PDSA) cycles. Each influenza season served as a PDSA cycle until the HP 2020 vaccination goal was achieved. The quality improvement (QI) study was conducted over four influenza seasons (i.e. 2014-15; 2015-16; 2016-17 and 2017-18).

SETTING

The study's setting was an ambulatory-based, university health center within a suburban university located in central New Jersey.

PARTICIPANTS

Adapting the National Vaccine Advisory Committee's definition of HCP, clinical and non-clinical staff members (n = 110) participated in the QI-study.

INTERVENTIONS

QI-interventions were centered on staff education/outreach, improved accessibility to influenza vaccines and frequent communication to staff over several PDSA cycles.

MAIN OUTCOME & RESULTS

The QI-interventions significantly increased our overall vaccination coverage on our influenza vaccination status survey from 70.2% (2011-14 influenza seasons; n = 102) to 84.9% (2014-15 influenza season; n = 93) in PDSA 1, and 91.1% (2015-16 influenza season; n = 90) in PDSA cycle 2 (χ2 = 309.53, P < 0.001). Vaccination rates remained above the 90% performance goal during our quality control/assurance measuring periods (i.e. the 2016-18 influenza seasons).

CONCLUSIONS

This study demonstrates that influenza vaccination coverage can significantly improve among HCP through the application of concurrent and multifaceted QI-interventions.

Knowledge, attitudes and beliefs towards compulsory vaccination: a systematic review

Currently, many countries are dealing with groups refusing available recommended vaccinations. Despite several studies having demonstrated the efficacy of mandatory vaccinations in ensuring herd immunity, opposition is widespread. The aim of our study was to systematically review published studies evaluating attitudes towards mandatory vaccination programs. PubMed and Scopus scientific databases were searched and 4,198 results were returned, of these 29 met the inclusion criteria. Twenty-two studies assessed attitudes towards mandatory vaccination programs in general, while 9 papers focused specifically on the Human Papilloma Virus (HPV) vaccine. Most of the studies were performed in Europe and North America. According to the assessed studies, the majority of the population seems to be in favour of compulsory vaccinations, although attitudes differed among studies. The results presented in this review could be an important starting point to further understand the issue of vaccine hesitancy and support the implementation of effective vaccination strategies.

Should influenza vaccination be mandatory for healthcare workers?

Each year, many healthcare organizations deal with low influenza immunization rates among staff. Mandatory influenza vaccination programs may be considered in order to address this issue. These types of programs have caused controversy in the past, as staff has argued that they infringe upon their liberties and right to autonomy. However, if viewed from a public health perspective, mandatory vaccination programs are beneficial for both employees and patients and can be justified. When individuals make the decision to work in the medical field, it is assumed that their values align with those of the organization for which they work. This overrides their right to autonomy, since they are expected to put the safety of their patients ahead of their own personal interests. Although some may argue that receiving a flu shot is unsafe, evidence has demonstrated the opposite, and the minimal discomfort that may result from a vaccine is not enough to negate the responsibilities that healthcare workers have toward the patients they serve.

Ethical considerations in the uptake of influenza vaccination by healthcare workers

OBJECTIVES

The World Health Organization (WHO) recommends annual seasonal influenza vaccination of healthcare workers (HCWs). Under the current voluntary scheme in England, uptake of vaccine in this group remains well below the 75% target. A mandatory scheme may improve rates, but raises the ethical issue of imposed vaccination. However, the existing voluntary scheme could also potentially infringe autonomy if those not wanting to join feel pressured or coerced into vaccination. The aim of this study was to explore HCW views and experiences with the current influenza vaccination programme.

STUDY DESIGN

Questionnaire survey.

METHODS

Between March 2015 and April 2016, a total of 140 questionnaires were completed across seven HCW groups, with the demographic, vaccination and opinion data statistically analysed using the chi-squared test, Kruskal-Wallis test and Mann-Whitney U-test as appropriate.

RESULTS

No staff group met the national influenza vaccination target of 75% and vaccination rates varied between HCW groups. All groups reported some degree of external pressure to be vaccinated and there were mixed views on the concept of mandatory vaccination, with a lack of certainty over the vaccine's efficacy and/or a lack of information the most common reasons for not supporting it.

CONCLUSION

The current voluntary influenza vaccination scheme has a number of flaws. Improvements in the quality and availability of information provided to employees may help Trusts increase vaccination rates, or achieve acceptance of any proposed mandatory programme.

Interventions to increase seasonal influenza vaccine coverage in healthcare workers: A systematic review and meta-regression analysis

Influenza vaccination is recommended for healthcare workers (HCWs), but coverage is often low. We reviewed studies evaluating interventions to increase seasonal influenza vaccination coverage in HCWs, including a meta-regression analysis to quantify the effect of each component. Fourty-six eligible studies were identified. Domains conferring a high risk of bias were identified in most studies. Mandatory vaccination was the most effective intervention component (Risk Ratio of being unvaccinated [RRunvacc] = 0.18, 95% CI: 0.08-0.45), followed by "soft" mandates such as declination statements (RRunvacc = 0.64, 95% CI: 0.45-0.92), increased awareness (RRunvacc = 0.83, 95% CI: 0.71-0.97) and increased access (RRunvacc = 0.88, 95% CI: 0.78-1.00). For incentives the difference was not significant, while for education no effect was observed. Heterogeneity was substantial (τ(2) = 0.083). These results indicate that effective alternatives to mandatory HCWs influenza vaccination do exist, and need to be further explored in future studies.

Detrimental effects of introducing partial compulsory vaccination: experimental evidence

BACKGROUND

During outbreaks of vaccine-preventable diseases, compulsory vaccination is sometimes discussed as a last resort to counter vaccine refusal. Besides ethical arguments, however, empirical evidence on the consequences of making selected vaccinations compulsory is lacking. Such evidence is needed to make informed public health decisions. This study therefore assesses the effect of partial compulsory vaccination on the uptake of other voluntary vaccines.

METHOD

A total of 297 (N) participants took part in an online experiment that simulated two sequential vaccination decisions using an incentivized behavioural vaccination game. The game framework bases on epidemiological, psychological and game-theoretical models of vaccination. Participants were randomized to the compulsory vaccination intervention (n = 144) or voluntary vaccination control group (n = 153), which determined the decision architecture of the first of two decisions. The critical second decision was voluntary for all participants. We also assessed the level of anger, vaccination attitude and perceived severity of the two diseases.

RESULTS

Compulsory vaccination increased the level of anger among individuals with a rather negative vaccination attitude, whereas voluntary vaccination did not. This led to a decrease in vaccination uptake by 39% in the second voluntary vaccination (reactance).

CONCLUSION

Making only selected vaccinations compulsory can have detrimental effects on the vaccination programme by decreasing the uptake of voluntary vaccinations. As this effect occurred especially for vaccine hesitant participants, the prevalence of vaccine hesitancy within a society will influence the damage of partial compulsory vaccination.

Adding justice to the clinical and public health ethics arguments for mandatory seasonal influenza immunisation for healthcare workers

Ethical considerations from both the clinical and public health perspectives have been used to examine whether it is ethically permissible to mandate the seasonal influenza vaccine for healthcare workers (HCWs). Both frameworks have resulted in arguments for and against the requirement. Neither perspective resolves the question fully. By adding components of justice to the argument, I seek to provide a more fulsome ethical defence for requiring seasonal influenza immunisation for HCWs. Two critical components of a just society support requiring vaccination: fairness of opportunity and the obligation to follow democratically formulated rules. The fairness of opportunity is informed by Rawls' two principles of justice. The obligation to follow democratically formulated rules allows us to focus simultaneously on freedom, plurality and solidarity. Justice requires equitable participation in and benefit from cooperative schemes to gain or profit socially as individuals and as a community. And to be just, HCW immunisation exemptions should be limited to medical contraindications only. In addition to the HCWs fiduciary duty to do what is best for the patient and the public health duty to protect the community with effective and minimally intrusive interventions, HCWs are members of a just society in which all members have an obligation to participate equitably in order to partake in the benefits of membership.

Early vaccine availability represents an important public health advance for the control of pandemic influenza

BACKGROUND

Traditional processes for the production of pandemic influenza vaccines are not capable of producing a vaccine that could be deployed sooner than 5-6 months after strain identification. Plant-based vaccine technologies are of public health interest because they represent an opportunity to begin vaccinating earlier.

METHODS

We used an age- and risk- structured disease transmission model for Canada to evaluate the potential impact of a plant-produced vaccine available for rapid deployment (within 1-3 months) compared to an egg-based vaccine timeline.

RESULTS

We found that in the case of a mildly transmissible virus (R0 = 1.3), depending on the amount of plant-based vaccine produced per week, severe clinical outcomes could be decreased by 60-100 % if vaccine was available within 3 months of strain identification. However, in the case of a highly transmissible virus (R0 = 2.0), a delay of 3 months does not change clinical outcomes regardless of the level of weekly vaccine availability. If transmissibility is high, the only strategy that can impact clinical outcomes occurs if vaccine production is high and available within 2 months.

CONCLUSIONS

Pandemic influenza vaccines produced by plants, change the timeline of pandemic vaccine availability in a way that could significantly mitigate the impact of the next influenza pandemic.