Health care workers have been bumped to the front of the line for swine flu shots this fall, but experts say the biggest worry isn’t whether doctors, nurses and other professionals can get the vaccine — it’s whether they will.
In a nation where less than half of all health care providers get annual flu shots, despite intense campaigns to convince them, infection control officials say the refusal to be immunized against the novel H1N1 influenza virus could increase spread of the disease and stress an already overwhelmed medical system.
“There isn’t a doubt that it’s a severe challenge,” said Dr. William Schaffner, professor and chairman of the infectious diseases division at Vanderbilt University in Nashville. “It’s primarily a patient safety issue.”
Research over the years has shown that health workers are a key source of seasonal flu, which causes about 200,000 hospitalizations and at least 36,000 deaths a year. Employees exposed constantly to sick people are prime targets for infection, and they easily can spread the virus before they become ill — and even when they don’t have symptoms themselves, Schaffner said.
So the concern is higher for H1N1, which flu experts say could infect half the U.S. population this fall, with more than a third developing symptoms. Though most cases are expected to be mild, a White House scientific advisory panel report released this week estimated that between 30,000 and 90,000 people, mostly children and young adults, could die as a result of the new virus.
“There will be some increased sense of urgency,” said Linda Greene, director of infection prevention and control at the Rochester General Health System in New York. “There’s something about a young person getting so ill with the flu.”
A matter of professional pride
Some workers, like Megan McGilvray, a 33-year-old advanced registered nurse practitioner in Seattle, understand the risks to themselves and others and make it a matter of professional pride to roll up their sleeves every year.
“I’m someone who always gets my flu vaccine,” said McGilvray, who works in a pain clinic and at a local hospital's emergency department. Because she’s expecting a baby in November, she’s also eagerly awaiting availability of the swine flu vaccine.
But many other doctors and nurses skip the annual shots — and there’s some evidence they may avoid the H1N1 vaccine as well.
A study published this week at bmj.com, the online version of the British Medical Journal, reported that nearly half of health care workers surveyed in Hong Kong earlier this year said they would refuse the swine flu vaccine because of fears of side effects and doubts about efficacy.
That study came on the heels of a United Kingdom poll that showed 30 percent of nurses would turn down the H1N1 shots, and researchers believe it’s a good indicator of health worker reluctance worldwide.
The reasons health staffers in the U.S. and elsewhere give for not getting flu shots range widely, said Robert M. Pestronk, executive director of the National Association of County and City Health Officials. Some say they never get sick, so they don’t get it. Others believe that the vaccine won’t work. Others say they’ll stay home if they get sick.
“And some say they don’t like needles,” Pestronk said.
Comments on Nurse.com, an online chat group for professionals, bear that out.
“I’m not rolling up my sleeve for anyone,” wrote one self-identified nurse. “It’s my opinion that flu vaccines are hit and miss at best, and by the time the virus mutates its way into the population, the original vaccine is kaput. Viruses are smarter than vaccines.”
Such attitudes frustrate officials like Cheryl Peterson, a registered nurse who is also director of practice and policy for the American Nurses Association in Silver Spring, Md. In public speeches and private conversations, she routinely tells nurses they’re neglecting their professional duty by avoiding vaccination.
“I say, ‘If you haven’t gotten the seasonal vaccine, you should,’” she said. “And shame on you for not doing it.’”
Flu shots mandatory in New York
At some hospitals across the country, health workers must be vaccinated against flu as a condition of employment unless they have medical or cultural objections to the shots. This month, the New York State Health Department adopted an emergency order requiring tens of thousands of health workers to be immunized against seasonal flu and H1N1.
Health workers are among priority groups government officials recommended to get the vaccine first. Others include pregnant women, children and young adults and adults with high-risk medical conditions.
The ANA stops short of endorsing mandatory immunization, saying that education and awareness are the best tools, Peterson said. In some health settings, workers who aren’t vaccinated must wear face masks when caring for patients. In others, all workers wear tags indicating whether they’re vaccinated or not, so that it’s obvious who has opted out.
Such actions can help create a climate where peer pressure contributes to higher vaccination rates among health workers. Greene, the New York infection prevention official, said rates are higher than 80 percent in some health care settings and the average is creeping up nationwide. In 2006, about 42 percent of health care workers received flu shots; by 2007 it rose to 44 percent, according to the federal Centers for Disease Control and Prevention.
The intense focus on H1N1 could bode well for health care worker immunization in general, said Greene, who is also a representative for the Association for Professionals in Infection Control and Epidemiology.
“I’m really optimistic that we’re going to see increased rates,” said Greene.
Critic calls vaccine campaign ‘an overreaction’
But a prominent critic of vaccines, including the H1N1 vaccine, said that if the majority of health workers don’t want to be immunized, it should be a warning to the rest of the population.
“We have to take seriously the concerns of health workers,” said Barbara Loe Fisher, co-founder of the National Vaccine Information Center. “If they do not want to take it, it should give everyone pause."
So far, the H1N1 outbreak has resulted in mostly mild, if widespread, illness, said Fisher, who is critical of the intensive push to immunize half the nation against swine flu.
“In this country, I do think it’s an over-reaction to operate under a public health emergency when there’s no evidence that this is more virulent than seasonal flu,” she said.
Drugmakers have been granted immunity from liability for the H1N1 vaccine, Fisher noted. That means consumers harmed by the vaccines may have little recourse for injuries or death in the future.
In the long run, natural immunity conveyed by actually getting the virus may provide stronger, longer-lasting benefits, she added. It’s likely the reason that people older than 60 largely have been spared by H1N1, because they were exposed to similar strains years ago.
Allowing infection could create immunity — or it could spawn severe illness and death, health officials contend.
No one knows how the novel flu virus will evolve, or whether it may turn more dangerous, CDC officials say. In the face of such a gamble, and in the presence of clinical trials of a vaccine that appears so far to be safe, it’s up to health care workers to make sure they protect themselves and their patients as much as possible, Schaffner said.
“It’s a professional and ethical responsibility of every health care worker to be vaccinated,” he said.