This article first appeared in the St. Louis Beacon, Oct. 19, 2009 - Given their proximity to people with illnesses, health-care workers are often the first in line for seasonal flu shots. This fall, many doctors, nurses and hospital administrators will also be among the first to receive the H1N1 vaccine, even as it arrives more gradually than originally anticipated.
It's no surprise that people in health care appear on the high-priority lists for vaccines. Not only are they at a heightened risk of exposure to viruses, but many regularly come into contact with patients whose weakened immune systems make them particularly ill-equipped to fend off the flu.
Still, just over half of health-care workers get flu shots during a typical flu season, estimates William Schaffner, president-elect of the nonprofit health education group National Foundation For Infectious Diseases. "It's not off the charts by any means," he said. (Federal data, which are several years old, show that about 42 percent of health-care workers get the vaccination.)
Across the country, mandatory vaccinations of health-care employees have been controversial. New York became the first state this year to require that all hospital, home health and hospice workers get both seasonal and swine flu vaccinations. The New York state health department's policy has angered unions and other groups who say they weren't consulted. Nurse associations are among the organizations protesting the idea of hospitals in other states requiring that all employees get vaccinated.
Kit Wagar, a spokesman for the Missouri Department of Health and Senior Services, said flu vaccine policies are "a matter between the employer and their staff." Because health-care workers are among the priority groups, "we're encouraging everyone to get it," he said. Spokesmen at the St. Louis County Department of Health and St. Louis Health Department said the decision to require or recommend vaccination for employees belongs to the hospital or health organization.
A Range of Vaccination Policies
Across St. Louis, it's a mixed picture. For the second year, all BJC HealthCare employees are required to get the seasonal flu shot. Exceptions are made for people who have religious exemptions or could have adverse reactions to the vaccine.
"It's purely a patient safety issue," said Kathy Holleman, a BJC spokeswoman. "We are caring for people who are sick, often immune-compromised, and so we owe it to patients to provide the safest care possible. That includes making sure that the people who they come into contact with have had the flu shot."
Holleman said that out of about 25,000 employees, only a handful of people who didn't have an exemption have refused the shot, which led to their termination.
No such mandatory policy is in effect for the H1N1 vaccine, which will first be available for BJC employees with direct contact with patients -- among them people in the emergency units and those who interact with another high-risk group, pregnant women.
"Anyone in patient care is being encouraged to get the vaccine if we have enough to go around," Holleman said. "Any mandate would evolve as it becomes clear how much of the vaccine we are going to get. At this point we're in the preliminary stages of acquiring it."
St. Louis-based SSM Health Care, which includes Cardinal Glennon Children's Health Center, St. Mary's Health Center and St. Clare Health Center, as well as other health-care facilities around the Midwest, is requiring all employees to attend an informational session about the flu. At that meeting, employees will either opt to receive a shot or sign a declination saying they will not be getting vaccinated.
In past years, the system hasn't had a policy mandating participation in a flu program. Deena Fischer, network director of communications for SSM Health Care-St. Louis, said only about half of its health-care workers would typically receive the seasonal flu shot.
This season, however, SSM wants documentation for everyone by Dec. 1. "It'll be interesting to see how the number will change now that we're requiring that everyone be informed about the risks of getting and spreading the flu," Fischer said.
Across the St. Louis network, employees with the most direct patient care, including people working in emergency departments and at flu clinics, are required to sign a form in person stating whether they will get the H1N1 vaccine. The system began its vaccinations late last week. For everyone else, there is no H1N1 requirement yet. "Right now it's based on supply," Fischer said. "Ideally we'd like to vaccinate everyone, but we're just starting to get the vaccine, and it's difficult to know how much we'll get and when it will arrive."
Bob Davidson, a spokesman at Cardinal Glennon, which sees young people, who are among the most vulnerable to H1N1, agreed that the medical center isn't ready to make H1N1 vaccinations mandatory. Initial doses of the mist-based vaccine just arrived late last week and are being offered to workers who come into contact often with patients. Employees who are at highest risk of exposure -- from physicians to nurses to housekeepers in the emergency department -- are being "strongly encouraged" to get vaccinated, Davidson said.
Once more shipments of the H1N1 vaccine arrive, he added, Cardinal Glennon will offer the immunization to high-risk groups of patients, including those with chronic health conditions.
St. Louis University Hospital is also requiring that every employee and person who works for an on-site vendor either get the seasonal and H1N1 vaccine or sign a declination in person. Failure to take part in the program will lead to termination, said Laura Keller, director of the hospital's marketing and media relations.
Keller said since the hospital instituted the in-person opt-out policy, instead of giving employees the option of simply not showing up for vaccination clinics, participation has skyrocketed.
"People don't want to show up and say no," Keller said. "Our feeling is that as health-care workers we have an obligation to protect our patients and ourselves from transmittable diseases. Vaccination is something we strongly recommend. However, if there's a legitimate reason someone can't or shouldn't get a shot, we aren't going to take their job away."
At the Visiting Nurse Association of St. Louis, employees are being "strongly encouraged" to get a seasonal flu shot, according to Beverly White, the group's president and CEO. About 90 percent of its employees opt to get that vaccine, she said.
The St. Louis VNA is requiring that staff giving direct care to patients get the H1N1 vaccine, and it's recommended for everyone else. No such vaccines have arrived yet.
"Because people are going into nursing homes, it's very important that we not put our patients at risk," White said. "I feel strongly that we are there to protect individuals and shouldn't be a means of causing their condition to worsen."
Barb Meyer, a spokeswoman for the Sisters of Mercy Health System, which includes St. John's Mercy Medical Center, said the policy is to recommend strongly that employees who provide direct patient care get the H1N1 vaccine when it becomes available. The system also encourages employees get the seasonal flu shot, but neither vaccines are mandatory. "We believe employees should be vaccinated, but it's difficult if not impossible to actually mandate/enforce that," Meyer said in an e-mail. "Therefore, the logical approach is to strongly recommend that they get the vaccine."
At the St. Louis VA Medical Center, H1N1 and seasonal flu shots are not mandatory but "strongly encouraged" for all employees. "To date, rather than imposing a mandate for health care worker vaccination, VA has chosen to emphasize strategies that remove barriers to vaccination, including education and making vaccines free and convenient," said Marcena Gunter, a spokeswoman for the medical center, in an e-mail.
The Ethics of Requiring Vaccination
Schaffner, the National Foundation for Infectious Diseases president-elect, said his organization echoes the recommendations of the CDS's immunization advisory committee that every health-care worker get vaccinated against the flu on an annual basis. His group doesn't take a position on vaccination mandates.
"Speaking for myself, this is indeed both a professional and ethical responsibility of every health-care worker," Schaffner said. "We recognize that the flu vaccine isn't the perfect vaccine, but it's the best we have, and we need to do the rest we can do not to put our patients at risk."
Schaffner said he doesn't buy the argument that health-care workers can simply stay home if they are sick. People in the field have a tendency to come to work even when they are ill, he said. And even if people did stay home, they might have exposed patients the day before when they already had the virus.
People often focus on medical staff on the front lines of patient care, but Schaffner said everyone from back-office workers to hospital janitors should be included in any policy regarding immunization.
Ronald Munson, a professor of the philosophy of science and medicine at the University of Missouri-St. Louis, said he agrees that health-care workers should think about the greater good.
"There's a question here about infringing on the autonomy of the individual," Munson said. "If I'm an individual and I don't work with people providing health care, I can exercise my judgment of what's in my self-interest. But if I become responsible for taking care of others, it imposes a duty on me that I can't think about just my self-interest, but about the interests of those who I'm taking care of."
There is precedent for such mandates, Munson said. Health-care workers who come into contact with patients are typically required to be tested for tuberculosis and other infectious diseases.
"We aren't accustomed to public-health laws having teeth, but we're also not used to facing epidemics," he said. "We can imagine a circumstance where it's required that anyone who comes into contact with the public is required to get vaccinated, but we're nowhere near that point of the disease category yet."
Ira Kodner, director of the Washington University Center for the Study of Ethics and Human Values, agrees that precedent exists for mandatory vaccination. Children attending public school, for instance, are often required to get vaccinated for transmittable diseases before they can enroll.
Both Kodner and Stuart Yoak, executive director of the center, said they understand that people view the decision about whether to get vaccinated as a personal choice. But they agree that private medical institutions should have the right to set vaccination policies. "The overriding concern is what's best for the patients we serve," Kodner said. "That becomes the basis for the institution to set its policy."