Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 The Obligation of HCWs to Get Flu Shots The Center for Vaccine Ethics and Policy a program of the Center for Bioethics, University of Pennsylvania, The Wistar Institute and Children’s Hospital of Philadelphia Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Facts About Flu Some argue flu vaccine is not that effective Cochrane collaborative challenges effectiveness Some argue not safe Effectiveness is dependent on herd immunity/exposure Effectiveness for vulnerable Effectiveness is not just ‘death’ but availability to work and symptom control Safety is very very good

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Influenza kills 3,000 to 49,000 people in the United States every year. Most of these are small children, the elderly, and people with chronic diseases Causes 200,000 hospitalizations Flu vaccines prevent influenza in 70-90% of vaccinated healthy adults of working age Rates of flu in patients fall in direct proportion to vaccination rates of HCWs in institutional settings such as hospitals and nursing homes Studies show few ill effects of vaccines Facts About Flu

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 So, bottom line, Flu is deadly, especially among the most vulnerable patients. Flu takes a huge toll in terms of hospitalizations and impact on workforce Vaccine for influenzas are effective and safe source: American College of Physicians Facts About Flu

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 CDC Recent Recommendation Shortage shaped recommendation H1N1 changed manufacturing shortage ACIP now recommends universal yearly vaccination for everyone ≥6 months old

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 HCWs Do Not Vaccinate Despite recommendations, national immunization rates among HCWs have remained near 50% for decades Many voluntary programs Still poor rates Rates are poor among HCWs in UK

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 VOLUNTARY PROGRAMS DO NOT WORK/HAVE NOT WORKED RATES IN PA HOSPITALS 45 percent for Lancaster Regional Medical Center; 50 percent for Heart of Lancaster Regional Medical Center; 56 percent for Brethren Village; 63 percent for Garden Spot Village; 51 percent for Ephrata Community Hospital NURSING HOMES AND HOME CARE???

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 HCWs and Poor Flu Rates I don’t need a shot because-- – I stay home – I don’t have much patient contact – I never get the flu – I can wear a mask

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 HCWs and Flu Influenza is highly contagious for 24 hours before symptoms begin—many people, including unvaccinated healthcare workers— are unwitting carriers You can be a carrier and not feel sick

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Health care workers work sick Health care workers do not know when they are infectious Health care workers are expected to show up for work even if they are sick Health care workers often do not get many sick days Masks do not work well HCWs and Flu

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Case for Mandates Efficacy Safety These alone did not work!! Add: Duty/obligation of role

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 HCWs (Docs Nurses) Ethical Duties Protect the vulnerable, weak and defenseless Put patient interests first! Do no harm

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 HCW Duties These duties do not permit of exceptions on religious or philosophical grounds given the potential to do harm to vulnerable and helpless and duty to put patients first Only health grounds allowed for exceptions

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Duty to Protect Vulnerable Flu preys upon – Babies – Young children – The pregnant – The elderly – Immune compromised They require protection

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Patients First Every Code of Ethics –AMA, ACP, ANA, SCCM, calls for putting patient interests ahead of professional self interest HCWs are professionals who put aside fears and doubts to help others—akin to police, soldiers, fire dept members, EMTs

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Do No Harm Infecting the weak and the vulnerable is to do the worst sort of harm Being unavailable to work in pandemics is to do harm Feeding vaccine fears and anti-vaccine sentiments is to do grave harm Drinking Chinese teas, immune boosting vitamins, bathing with eucalyptus leaves Vaccines are a key weapon in patient safety and cutting hospital based deaths

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Many People Face Vaccine Mandates Military Oil workers Astronauts School children Biological and weapons labs Immigrants

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Duty to be Vaccinated There is a clear obligation/duty to be vaccinated on the part of physicians and other HCWs Leadership of nursing, medicine and pharmacy should be insisting on making flu and swine flu vaccination a condition of employment for those with clinical duties Health care institutions should be ‘vaccine mandated’ zones for those who work there and have patient contact Every patient and long-term care resident has a right to request care from vaccinated HCWs for their own safety

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Mandate argument and policy Over 100 health systems have instituted mandates including CHOP/UPHS, Univ of Cincinnati, Abington Hospital, Virginia Mason, Barnes Hospital, Loyola University health system, HCA health systems, Emory, U of Maryland Mandatory vaccination now endorsed by Infectious Diseases Society of America, the American Academy of Pediatrics and the Society for Healthcare Epidemiology of America Duty to be Vaccinated

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 One Institution-- CHOP Went to a mandate in 2009 after failure of serious voluntary efforts started in 2004 Under the mandate, if an employee was not vaccinated and did not have a valid medical or religious exemption, they were placed on unpaid 2 week leave during which time they completed educational activities about vaccination. If the employee was not vaccinated after this 2 week period, their employment was terminated. 7 nurses were fired

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 A total of 9234 staff were vaccinated 55 medical exemptions were granted by Occupational Health and Human Resources 9 nurses continued to decline vaccination and had their employment terminated 99.3% vaccination rate New employees must be vaccinated One Institution-- CHOP

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Lessons-- CHOP Education and buy-in about mandate was key Talks about facts about vaccines and duties of HCWs were very important Facts alone are not enough to change behavior

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 Future of Mandates Nursing homes, home care What about non-professional hcws Patient Visitors? Other nations? Other vaccines? Setting an example for the public—impact??

Treuman Katz Center for Pediatric Bioethics Seventh Annual Pediatric Bioethics Conference July 22-23, 2011 The Center for Vaccine Ethics and Policy a program of the Center for Bioethics, University of Pennsylvania, The Wistar Institute and Children’s Hospital of Philadelphia