Compulsory jabs not just a shot in the dark
ABOUT five years ago, two young girls died in a Philadelphia hospital. They were being treated for cancer, and caught the flu. Their immune systems were suppressed by the assault of chemotherapy drugs, so the flu overwhelmed their bodies’ shattered defences, and killed them.
For Professor Paul Offit, the hospital’s chief of infectious diseases, this was more than just a tragic accident. The deaths haunted him because both girls had caught their flu from a hospital staff member.
”No doubt,” Offit says. ”Neither of them had flu when they came into the hospital … both of them caught influenza in the hospital.
”So the question was, as a healthcare worker, working with a vulnerable population of hospitalised children, is it your right to catch and transmit a potentially fatal infection? We thought the answer was ‘no’.”
There is a simple way to try to prevent such deaths: hospital staff get the flu vaccination every year. But, surprisingly, often they don’t. When it comes to flu vaccination rates, doctors’ performance is more hypocritical than Hippocratic.
Offit works at the Children’s Hospital of Philadelphia. At the time the girls died, years of effort, raffles and lectures and reminders and prizes had boosted the hospital’s rate of annual influenza vaccination among clinical staff to about 60 per cent – still not enough to prevent the girls’ infection.
Australia can’t boast any better performance. In fact, ours is much worse. On the most recent figures, not yet published but made available to The Sunday Age, fewer than two in five medical staff at Victoria’s hospitals took the time to get a flu shot in 2011 – even though most would likely, if asked, have advised patients, friends and family to get one.
This situation is ”just terrible”, says Australian Medical Association federal president Dr Steve Hambleton. ”We are not doing well enough,” he says, commenting on the below-50 per cent vaccination rate for healthcare workers in Australia. ”Fifty per cent is terrible [the figure in Victoria is 39.8 per cent]. Healthcare workers are well informed. Our responsibility is to maintain the health of our patients. We need to be at the 90 per cent-plus mark.”
Professor Mike Richards is the head of VICNISS, the Victorian Health Department’s body set up to monitor infectious diseases in hospitals. He agrees with Hambleton. ”I don’t think it’s reached a level of being taken seriously enough,” he says.
Which leads to the obvious question: have people died, have children died in Victoria, as they did in Philadelphia, from influenza they caught from a hospital worker while too sick to fight the infection?
There is an agonising wait for the answer. Richards’ voice creaks and strains, as what he wants to say battles with what he thinks prudent to reveal.
”I don’t want to name names and places,” he hedges. ”But people do acquire influenza in hospitals. It’s inevitable that some people have died as a consequence.”
Offit’s response is simple: hospitals should force healthcare workers to get the flu vaccine. Every healthcare worker, every year. On pain of losing their job.
It’s a controversial idea, but it’s gaining support, overseas and in Australia. Some believe that, 10 years from now, we’ll wonder why we did it any other way.
Australia appears set for its worst influenza season since 2009’s swine flu. As of last week, 8183 cases of flu had been reported this year, 1034 of them in Victoria. This was up from 698 during the same period in Victoria last year and 226 in 2010.
The culprit is the influenza strain H3N2. H3N2 was the main strain in the northern hemisphere’s winter, so the flu vaccine (recalibrated every year to anticipate the mix of strains) guards against it.
But a fraction of the community can’t take the vaccine or benefit directly from it. Some children are too young. Some have allergies that prevent them. Some people are too old to develop an effective antibody response. Some are getting chemotherapy, or are taking immune-suppressing drugs (for instance, after a transplant). And many of these are in hospitals.
Since 2002, Offit has been trying to persuade staff at his hospital of the risk. The hospital is big: there are several hundred inpatient beds and thousands of staff (it’s roughly the same size as Melbourne’s Royal Children’s Hospital). It’s not only medical staff who could expose a child to infection: there are nurses, dietary services, cleaners. Back in 2002, only 35 per cent of staff got the flu vaccine, which was typical at the time.
”We’d have town hall meetings where we educated [staff] about the vaccine,” Offit says. ”We supplied the vaccine for free, we brought the vaccine to the [hospital units], we tried to make it fun, we had raffles and giveaways to try and make this as easy as possible.”
It worked … to a degree. Vaccination rates crept up to around the mid-60 per cent mark.
And then the girls died, and Offit decided to get tougher. He brought in a ”declination form” every staff member had to sign if they did not get the flu vaccine.
”It frankly read like it should have a skull and crossbones on it,” he said. ”It basically said, ‘I know that children within my care may be especially vulnerable to influenza, so much so that they could die from the disease. And I am choosing not to get a vaccine.”’
Remarkably, 20 per cent of hospital staff chose to sign the form instead of getting the jab. There was a space on the back for their reasons. ”They were not all science based,” says Offit. ”They were ‘I never get the flu’, or ‘I got the flu vaccine and it gave me the flu’ [a medical impossibility], or even ‘I take herbs and therefore never get the flu’. Whatever it was, it wasn’t a good enough reason.”
So in 2009 he decided to drop the bomb. Workers at the hospital were told that anyone who came into close proximity with sick children had to get the flu vaccine. If they refused, they had two weeks’ unpaid leave to think about it. If they still refused, they got the sack.
About 30 people took the time off. Most came back and got the shot. But nine people insisted they did not want the vaccine.
”So we fired nine people,” says Offit. ”It saddened us greatly. It’s a tough economy. To lose your job is awful and, worse, it’s losing your job for all the wrong reasons. It was tragic.”
The sacked workers were furious. Gary and Tyrika Cowlay went to the media. ”I am a Christian, and my religion prohibits me from receiving vaccines,” said lab technician Tyrika. Gary from environmental services said he had been with the hospital for nine years. ”Love working there – friendly staff, friendly people – but I never thought this stance would be taken on us.”
Part of the problem was religion. Some of the sacked workers were followers of the Nation of Islam, whose leader Louis Farrakhan had proclaimed that the vaccine contained pork products and could not be used (in fact, only the nasal spray, not the shot, contains porcine gelatin).
Another problem was race. The US has a shameful history with black patients. In the Tuskegee experiment, the Public Health Service left impoverished black farmers with syphilis untreated to study the progress of the disease. Henrietta Lacks’ tumour cells were infamously taken without consent or payment to create an incredibly valuable ”immortal cell line” for medical research.
”When we said, ‘But look, the shot doesn’t contain [pork]’, they didn’t trust us,” says Offit. ”And I suspect at its heart is that feeling that African Americans shouldn’t trust the healthcare system because they had been treated poorly in the past.”
The hospital has since slightly softened its approach. Twice in the past few years it has granted an exemption on religious grounds (you get the feeling the decision was taken out of Offit’s hands, as he forcefully argues there is no genuine anti-vaccine message in most religions).
But Offit is immensely proud of the result: a near fully vaccinated hospital. He believes all hospitals should follow – and many are. In the US, about eight other hospitals have mandatory flu vaccination for healthcare workers. Others chose a halfway house that is now law in some states: that unvaccinated staff must wear masks at all times, an uncomfortable and annoying imposition that takes vaccination rates into the 90 per cent range.
In Australia, hospitals are wondering if they should follow.
AMA chief Steve Hambleton says mandatory vaccination ”should be considered”. Though there isn’t a policy at the moment ”this may be one we will go and have another look at. Healthcare workers can benefit from influenza vaccine themselves, and have a wider and larger responsibility.”
Richards at VICNISS says the idea of mandatory vaccination has been discussed in Victoria, but encountered ”a civil libertarian attitude that everyone should be able to decide everything themselves”, he says. ”Personally I think if it’s actually putting patients at risk it’s pretty hard to argue that, but that doesn’t mean all my colleagues would agree. There isn’t a strong commitment at senior levels of medical staff and the executive.”
He believes it is only a matter of time before flu shots are mandated at a few centres in Australia. Already there are hospital units in Melbourne where staff are told informally they are expected to be vaccinated. He knows of a bone marrow transplant unit where medical students trooped in ”and the charge nurse has come up and said, ‘Are you all vaccinated?’, and if some of them aren’t they have been told to go away and come back when they are”.
However, some believe mandatory vaccination is going too far. At the Austin Hospital, which is a leader in countering swine flu, director of infectious diseases Professor Lindsay Grayson says he is in favour of the flu vaccine, and a rigorous program to persuade staff to get it.
”I’ve been sitting at my desk and the nurse has just come in, rolled up my sleeve and before I’ve even got off the phone I’ve had my shot,” he says.
But mandatory vaccination on pain of the sack? ”I think it’s probably a little extreme,” he says. ”It’s well meaning but you’re picking the wrong disease to be so insistent.”
He points out that unlike diseases such as measles, there is a short and clear ”prodrome” (the earliest symptoms) for influenza, and staff are sent home.
Grayson is much more in favour of mandatory vaccination at hospitals for diseases such as measles (with a longer prodrome, increasing the risk of infection) and hepatitis B (which can be caught from one needlestick injury).
”The key ground for insisting on vaccination is that it is of benefit to the individual [staff member] as well as the patient,” he says.
Offit, of course, disagrees. ”There are certain facts that are not a matter of debate,” he says.
”People can come in without influenza and catch it in the hospital. If you increase the rate of vaccination among healthcare employees, you reduce [that] rate. I guess the question is, where is it good enough? Do you accept 85 per cent, 90 per cent? We would argue that we should do everything we can for our patients.”
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