To Be or Not to Be Vaccinated? The Ethical Aspects of Influenza Vaccination among Healthcare Workers

Influenza is a highly contagious airborne disease with a significant morbidity and mortality burden. Seasonal influenza (SI) vaccination has been recommended for healthcare workers (HCWs) for many years. Despite many efforts to encourage HCWs to be immunized against influenza, vaccination uptake remains suboptimal. Sometimes there is a significant sign of improvement, only if numerous measures are taken. Is 'the evidence' and 'rationale' sufficient enough to support mandatory influenza vaccination policies? Most voluntary policies to increase vaccination rates among HCWs have not been very effective. How to close the gap between desired and current vaccination rates? Whether (semi)mandatory policies are justified is an ethical issue. By means of a MEDLINE search, we synthesized the most relevant publications to try to answer these questions. Neither the 'clinical' Hippocratic ethics (the Georgetown Mantra: autonomy, beneficence, non-maleficence, and justice), nor the 'public health' ethics frameworks resolve the question completely. Therefore, recently the 'components of justice' framework was added to the ethical debate. Most options to increase the uptake arouse little ethical controversy, except mandatory policies. The success of vaccination will largely depend upon the way the ethical challenges like professional duty and ethics (deontology), self-determination, vaccine hesitance, and refusal ('conscientious objector') are dealt with.

Factors contributing to declination of annual influenza vaccination by healthcare workers caring for cancer patients: An Australian experience

Healthcare workers (HCWs) at an Australian cancer centre were evaluated using a voluntary declination form program to determine factors contributing to declination of annual influenza vaccination. Overall, 1835/2041 HCWs (89.9%) completed a consent or declination form; 1783 were vaccinated and 52 declined. Staff roles with minimal patient contact were significantly associated with lower vaccine uptake (adjusted odds ratio 0.48, 95% confidence interval 0.23-0.99). Reasons for vaccine refusal included personal choice (41%), previous side-effect/s (23.1%), and medical reasons (23.1%). Of these, a large proportion may not be amenable to intervention, and this must be considered in setting threshold targets for future campaigns.

Influenza vaccination responses: Evaluating impact of repeat vaccination among health care workers

OBJECTIVE

To compare the antibody response to influenza between health care workers (HCWs) who have received multiple vaccinations (high vaccination group) and those who have received fewer vaccinations (low vaccination group).

DESIGN

Prospective serosurvey.

SETTING

Tertiary referral hospital.

PARTICIPANTS

Healthcare workers.

METHODS

Healthcare workers were vaccinated with the 2015 southern hemisphere trivalent influenza vaccine. Influenza antibody titres were measured pre-vaccination, 21-28days post-vaccination and 6months post-vaccination. Antibody titres were measured using the haemagglutination inhibition assay. Levels of seropositivity and estimated geometric mean titres were calculated.

RESULTS

Of the 202 HCWs enrolled, 182 completed the study (143 high vaccination and 39 low vaccination). Both vaccination groups demonstrated increases in post-vaccination geometric mean titres, with greater gains in the low vaccination group. Seropositivity remained high in both high and low vaccination groups post-vaccination. The highest fold rise was observed among HCWs in the low vaccination group against the H3N2 component of the vaccine.

CONCLUSIONS

Both high and low vaccination groups in our study demonstrated protective antibody titres post-vaccination. The findings from the current study are suggestive of decreased serological response among highly vaccinated HCWs. More studies with larger sample sizes and a greater number of people in the vaccine-naïve and once-vaccinated groups are required to confirm or refute these findings before making any policy changes.

Increasing the coverage of influenza vaccination in healthcare workers: review of challenges and solutions

Seasonal influenza vaccine uptake rate of healthcare workers (HCWs) varies widely from <5% to >90% worldwide. Perception of vaccine efficacy and side-effects are conventional factors affecting the uptake rates. These factors may operate on a personal and social level, impacting the attitudes and behaviours of HCWs. Vaccination rates were also under the influence of the occurrence of other non-seasonal influenza pandemics such as avian influenza. Different strategies have been implemented to improve vaccine uptake, with important ones including the enforcement of the local authority's recommendations, promulgation of practice guidelines, and mandatory vaccination polices. Practised in some regions in North America, mandatory policies have led to higher vaccination rate, but are not problem-free. The effects of conventional educational programmes and campaigns are in general of modest impact only. Availability of convenient vaccination facilities, such as mobile vaccination cart, and role models of senior HCWs receiving vaccination are among some strategies which have been observed to improve vaccination uptake rate. A multi-faceted approach is thus necessary to persuade HCWs to participate in a vaccination programme, especially in areas with low uptake rate.

An effective strategy for influenza vaccination of healthcare workers in Australia: experience at a large health service without a mandatory policy

Background

Annual influenza vaccination of healthcare workers (HCWs) is recommended in Australia, but uptake in healthcare facilities has historically been low (approximately 50%). The objective of this study was to develop and implement a dedicated campaign to improve uptake of staff influenza annual vaccination at a large Australian health service.

Methods

A quality improvement program was developed at Alfred Health, a tertiary metropolitan health service spanning 3 campuses. Pre-campaign evaluation was performed by questionnaire in 2013 to plan a multimodal vaccination strategy. Reasons for and against vaccination were captured. A campaign targeting clinical and non-clinical healthcare workers was then implemented between March 31 and July 31 2014. Proportional uptake of influenza vaccination was determined by campus and staff category.

Results

Pre-campaign questionnaire responses were received from 1328/6879 HCWs (response rate 20.4%), of which 76% were vaccinated. Common beliefs held by unvaccinated staff included vaccine ineffectiveness (37.1%), that vaccination makes staff unwell (21.0%), or that vaccination is not required because staff are at low risk for acquiring influenza (20.2%). In 2014, 6009/7480 (80.3%) staff were vaccinated, with significant improvement in uptake across all campuses and amongst nursing, medical and allied health staff categories from 2013 to 2014 (p < 0.0001).

Conclusions

A non-mandatory multimodal strategy utilising social marketing and a customised staff database was successful in increasing influenza vaccination uptake by all staff categories. The sustainability of dedicated campaigns must be evaluated.