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I’ll get the shot, but what’s next?   

By Nicholas Genes, MD, PhD

When I first heard about the requirement that emergency physicians in New York receive the H1N1 vaccination, I shrugged. Doctors in general and newly-graduated residents (like me) in particular are used to jumping through a lot of hoops for the privilege of practicing medicine. This year alone I've paid thousands of dollars and filled out hundreds of pages of forms for insurers, hospital credentialing, state and DEA licensure, and board certification. I've provided countless administrators with bits of my medical record, from vaccination logs to viral titers to PPD results. If I skimped on any of this, I wouldn't be allowed to work.

From this standpoint, what's the big deal about a mandatory flu shot?
 
Plus, voluntary vaccination drives get around 50% (or less) compliance among healthcare workers, far below what's necessary to provide herd immunity for our vulnerable patient population (1,2). So I can see the need for *some* action. And I'm not one of those people who think the CDC 'cut corners' or that the H1N1 vaccine is insufficiently tested. It's pretty clear the side effects of this vaccine are mild and don't represent a great danger to the public (3).
 
And yet, I don’t like the position we find ourselves in. Before the NYS legislature mandated mandatory vaccinations for all state healthcare workers, there were only a few hospitals in the country that forced their employees to get annual flu shots. Suddenly half a million healthcare workers in one of the nation's most populous states are being threatened with termination if they don't comply (2).

Most people are prepared to accept some additional safeguards, rules or restrictions in times of extraordinary risk – a clear and present danger of a deadly outbreak or attack. But does H1N1 warrant these extraordinary measures? In NYC this spring, we endured unprecedented volumes in EDs – at its worst, a doubling of the census for already overcrowded departments – all for a disease that killed 45 (most of whom had comorbidities) (4). For context, in the same three-month period, somewhere between 10,000 and 15,000 New Yorkers died of other causes (5,6). Amazingly, the CDC believes we've had fewer respiratory infection-related deaths this year than in 2008 (7).
In the early days of the pandemic, with alarming reports from Mexico and high transmission rates seen in NYC, the efforts at containment and protection coming from government agencies (and maybe even some of the media frenzy) were warranted. But months later, it's clear this is a mild disease for the overwhelming majority of the population.

Foisting vaccinations on half a million healthcare workers, and threatening them with termination, seems like a regulatory overreaction.

I can't help but wonder, if this is the response to swine flu, what's next?

If the agencies tasked with setting standards for healthcare quality had a good record for establishing reasonable criteria to evaluate care, I'd be more comfortable with this new vaccination requirement. But the benchmarks we've seen so far – from timing of antibiotics for pneumonia to blood culture draws, have caused endless frustration for us and probably haven't helped patients much at all.

There are a lot of practices that are good for patients that healthcare workers don't always remember – washing hands before and after each patient encounter, observing proper isolation and infection control processes, sneezing 'the right way', not working while feeling sick. Hospital administrations have tried to facilitate and even incentivize good behaviors, but they've never made compliance with any of these guidelines a condition for employment (at least, I'm not aware of anyone who's been fired for failing to wash their hands enough – and unlike the H1N1 vaccine, hand washing doesn't have side effects).

Other ways to boost our herd immunity, beyond the threat of firings, should be investigated. Recently, our hospital's health insurance company presented us with a choice – fill out a survey of health habits (how often I work out, eat vegetables, wear seat belts) or face a 20% increase in premiums next year. Some mix of carrots and (smaller, appropriate-sized) sticks would likely boost vaccine compliance without compromising our autonomy.

In the end, I'll get the shot. I'm just at the start of my career and I've worked too hard to get to this point to jeopardize my new job. And the idea of inadvertently harming my patients is too abhorrent. But in an industry where good intentions and calls for safety have already led to innumerable unintended hassles, delays and indignities, I wonder what else is in store as my career unfolds.

REFERENCES
 
1. “Vaccine-Preventable Diseases.” Infectious Disease News, 1 March 2006. http://www.infectiousdiseasenews.com/article/33499.aspx
 
2. Stein, Rob. “Mandatory Flu Shot Hits Resistance.” Washington Post, 26 September 2009.
 
 
4. NYC DOHMH Health Alert #27, July 8, 2009, http://www.nyc.gov/html/doh/downloads/pdf/cd/2009/09md27.pdf
 
5. Summary of Vital Statistics of New York City, 2003 http://www.nyc.gov/html/doh/downloads/pdf/vs/2003sum.pdf
 
 
 

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