Review
The issue of mandatory vaccination for healthcare workers in Europe Expert Review of Vaccines Downloaded from informahealthcare.com by Arizona State University on 05/29/14 For personal use only.
Expert Rev. Vaccines 13(2), 277–283 (2014)
Emmanouil Galanakis*1, Fortunato D’Ancona2, Andreas Jansen3, Pier Luigi Lopalco4 and VENICE (Vaccine European New Integrated Collaboration Effort) National Gatekeepers, Contact Points4 1 Department of Paediatrics and Interfaculty Graduate Programme in Bioethics, University of Crete, Heraklion 710 03, Greece 2 National Centre for Epidemiology, Surveillance and Health Promotion (CNESPS), Istituto Superiore di Sanita, Rome, Italy 3 European Centre for Disease Prevention and Control, Stockholm, Sweden 4 VENICE National Gatekeepers and Contact Points for this survey† *Author for correspondence: Tel.: +30 2810 392 012 Fax: +30 2810 392 827 [email protected]
Mandatory policies have occasionally been implemented, targeting optimal vaccination uptake among healthcare workers (HCWs). Herein, we analyze the existing recommendations in European countries and discuss the feasibility of implementing mandatory vaccination for HCWs. As reflected by a survey among vaccine experts from 29 European countries, guidelines on HCW vaccination were issued in all countries, though with substantial differences in targeted diseases, HCW groups and type of recommendation. Mandatory policies were only exceptionally implemented. Results from a second survey suggested that such policies would not become easily adopted, and recommendations might work better if focusing on specific HCW groups and appropriate diseases such as hepatitis B, influenza and measles. In conclusion, guidelines for HCW vaccination, but not mandatory policies, are widely adopted in Europe. Recommendations targeting specific HCW groups and diseases might be better accepted and facilitate higher vaccine uptake than policies vaguely targeting all HCW groups. KEYWORDS: Europe • healthcare workers • mandatory vaccination • policies • vaccine recommendations
The rationale of healthcare worker vaccination
† Austria: Elisabeth Kanitz, Daniela Schmid; Belgium: Martine Sabbe, Pierre Van Damme; Bulgaria: Mira Kojouharova; Cyprus: Soteroulla Soteriou; Czech Republic: Bohumir Kriz; Denmark: Palle Valentiner-Branth; Estonia: Irina Filippova, Natalia Kerbo; Finland: Tuija Leino, Hanna Nohynek; France: Daniel Le´vy-Bruhl; Germany: Ole Wichmann; Greece: Theodora Stavrou; Hungary: Zsuzsanna Molna`r; Iceland: Thorolfur Gudnason; Ireland: Suzanne Cotter; Italy: Fortunato D’Ancona; Latvia: Jurijs Perevoscikovs; Lithuania: Ausra Lileikyte; Luxemburg: Franc¸oise Berthet; Malta: Tanya Melillo Fenech; The Netherlands: Hester de Melker; Norway: Berit Feiring; Poland: Iwona Paradowska-Stankiewicz; Portugal: Teresa M. Alves Fernandes, Paula Valente; Romania: Chicin Gratiana; Slovakia: Helena Hudecova´, Alexandra Zampachova; Slovenia: Alenka Kraigher; Spain: Aurora Limia; Sweden: Ingrid Uhnoo; United Kingdom: Richard Pebody.
Healthcare workers (HCWs) are at increased risk of contracting infections from patients and further spreading them to patients. Infections are often subclinical and may be transmitted before symptoms develop, thus permitting HCWs to continue working and spreading the disease. Nosocomial transmission involving HCWs has been reported in various healthcare facilities and for the majority of vaccine-preventable diseases, including seasonal and pandemic influenza, measles, mumps, rubella, varicella, pertussis, hepatitis A, hepatitis B, meningococcal disease and tuberculosis, and often leading to nosocomial outbreaks and fatal cases for both patients and HCWs [1–13]. Vaccination would protect HCWs themselves, prevent transmission to vulnerable patients and healthcare staff and maintain the healthcare force during emergency outbreaks. However, vaccination uptake rates among HCWs have often been not as high as anticipated [8,10,14–21], thus raising the
www.expert-reviews.com
10.1586/14760584.2014.869174
question whether voluntary uptake should be replaced by vaccination requirements. Mandatory policies are increasingly adopted by healthcare institutions, professional societies and public health authorities in some settings but have generated discussions, debate and legal issues [22–25,101]. Surveying policies & trends in Europe
Policies in European countries regarding HCW vaccination in acute healthcare facilities have been reported by Maltezou et al. [26]. We conducted two surveys from October 2012 to December 2012, in order to review the existing vaccination recommendations for HCWs in all healthcare settings and to investigate and discuss the rationale and potential of implementing mandatory policies in European countries. The first survey was conducted among 35 national experts from the Vaccine European New Integrated Collaboration Effort (VENICE) network covering all 27 European Union Member States and Iceland and Norway. Participants were called to complete an online preconstructed questionnaire [102] on the recommendations for HCWs in each
Ó 2014 Informa UK Ltd
ISSN 1476-0584
277
Review
Galanakis, D’Ancona, Jansen, Lopalco & VENICE
Expert Review of Vaccines Downloaded from informahealthcare.com by Arizona State University on 05/29/14 For personal use only.
country SUPPLEMENTARY APPENDIX 1 (available at www.informahealthcare.com/doi/Suppl/10.1586/14760584.2014.869174) and then contacted at least twice for validation of data and vaccine policies. A second questionnaire on the feasibility of mandatory policies for HCWs (SUPPLEMENTARY APPENDIX 2) was distributed among vaccine experts participating in the Eurovaccine.net meeting, Barcelona, 21–23 November 2012. Both questionnaires focused on 15 diseases, commonly included in the vaccination programs of European countries (TABLE 1). Vaccines of local interest, for example, tick-borne encephalitis, were not included. Definition issues
Considerable definition issues arise when investigating vaccination policies for HCWs, for example, who is considered to be an HCW, what is the meaning of mandatory and whether any policy targets HCWs as a whole or distinct HCW groups. In this survey, a vaccination was defined as recommended if it was officially declared so by public healthcare authorities. Mandatory was further defined as a vaccination, for which there was some sort of penalty for noncompliance. Mandatory vaccination without enforcement was defined as a vaccination that was officially declared to be mandatory, but enforcement measures were rather theoretical and refusal would not incur penalties. Only recommendations issued specifically for HCWs were included, that is, recommendations for the general population were not considered (e.g., for polio which is mandatory for all in many national vaccination programs). HCWs were defined as any professional or volunteer, employed in acute or chronic care facilities, in direct contact with patients/residents. Specific groups of HCWs were defined as groups working in particular areas of care, such as in child health, with elderly residents or with immunocompromised patients. Postexposure vaccination policies were not included. The first aim of this study, that is, surveying recommendations for HCWs in Europe, has already been explored in a previous study [26]. As compared to that study, we used a more restricted definition for HCWs by emphasizing direct contact with patients and a wider definition for healthcare facilities, including chronic care, and asked for policies on the influenza pandemic A (H1N1) 2009 as a measure of response to outbreaks. We strictly used the criterion of patient contact, as it is questionable whether the same policies should be recommended for HCWs with or without patient contacts and as HCWs themselves have been reported to believe that policies should better target appropriate HCW groups rather than HCWs vaguely [27,28]. Furthermore, we included chronic healthcare facilities as well, as it is exactly in the latter facilities that prevention of patients and residents through HCW vaccination has been proven, for example, against influenza [15,29–31]. Current vaccination policies in Europe
All experts from the 29 European countries answered the questionnaire. Recommendations for HCW vaccination were issued in all countries (TABLE 1). Most vaccinations were in the category ‘recommended’ (51.5%) either for all HCWs (36.3%) or for 278
specific HCW groups (15.2%). The least recommended were vaccines for pneumococcal and meningococcal disease and tuberculosis (in three, seven and nine countries, respectively). Mandatory vaccination policies were uncommon (5.5%); 19 countries had no mandatory policies for any vaccine and 10 had mandatory policies for 1–6 (median, 1) vaccines. Hepatitis B was the disease mostly targeted with mandatory policies (10 countries). Mandatory policies were not applied for pertussis, varicella, influenza and pneumococcal disease in any country. No recommendations at all were issued in 43% of the total countries and vaccines. As it is true with national immunization programs, guidelines among countries or even among regions of the same country considerably differed in terms of vaccines and HCW groups [32,33]. Exemptions included recommendations for pandemic influenza A (H1N1) 2009, which was the only vaccine recommended for all HCWs in all countries, and to a lesser degree for seasonal influenza and hepatitis B. These exemptions might be attributed to sustained vaccination campaigns and recommendations by authorities such as the WHO and the European Union [10,103]. The lack of recommendations for measles, mumps, rubella and pertussis vaccines (not recommended at all in 10, 12, 10 and 12 countries) is remarkable, given the often low rates of vaccine uptake among the adult population and the persistence of these diseases [8,20,21]. Measles elimination was not achieved for Europe in 2010, and outbreaks still occur [20]. Susceptibility rates to measles have been found to range from 3 to 17% among HCWs [21,27,28]. Low vaccination rates have been reported for the pertussis booster as well, despite the reemergence of the diseases [8]. The value of BCG vaccine is questionable; however, the emergence of extensively drug-resistant tuberculosis stands in opposition to the paucity of recommendations for HCWs. Immunity to diphtheria and poliomyelitis should not be neglected, given the existence of disease foci out of Europe and the increasing movement of populations. Our findings did not seem to substantially differ from those previously reported for Europe [26] despite differences in methodology. Mandatory or recommended vaccines were more common in the present study than in the previous one (57 vs 45.7%), but this should rather be attributed to the different definition than to changing policies over Europe. Policies in European countries are often difficult to be precisely categorized, given the different interpretation of the term mandatory in such a wide array of cultures and given that recommendations may differ even from region to region in the same country. Furthermore, despite our efforts to ensure that study definitions were homogenously used by all experts, recommendations issued for HCWs in particular could not always be distinguished from those issued for the general population, nor could recommendations for acute care facilities be distinguished from those issued for chronic care facilities. Different HCW vaccination policies might also originate from different recommendations for the general population, for example, in some countries routine booster diphtheria vaccination is recommended to all adults, which makes an additional diphtheria Expert Rev. Vaccines 13(2), (2014)
Ra
nR
Rs
nR
Ra
nR
nR
Ra
nR
Ma
nR
Ra
nR
Ra
Rs
Rs
Ra
Ra
nR
Ra
nR
nR
Ra
nR
nR
Ms
Ra
Belgium (1)
Bulgaria (0)
Cyprus (0)
Czech Republic (1)
Denmark (0)
www.expert-reviews.com
Estonia (0)
Finland (0)
France (5)
Germany (0)
Greece (0)
Hungary (1)
Iceland (0)
Ireland (0)
Italy (0)
Latvia (1)
Lithuania (0)
Luxemburg (0)
Malta (0)
Norway (0)
Poland (1)
Portugal (0)
Romania (0)
Slovakia (3)
Slovenia (6)
Spain (0)
Rs
Rs
nR
nR
nR
Rs
Rs
Ra
nR
nR
nR
Rs
Rs
Ra
nR
Ra
Ra
Ra
Rs
Ra
nR
nR
Ra
nR
Rs
Ra
Pertussis
nR
nR
nR
nR
Rs
nR
nR
Ra
nR
nR
nR
nR
Rs
Ra
nR
Ra
Rs
Ma
nR
nR
nR
nR
Ra
nR
Rs
Ra
Polio
Ra
Ma
nR
nR
Ra
Rs
nR
Ra
nR
Ra
nR
Ra
Ra
Ra
nR
Ra
Ra
Rs
Ra
Rs
nR
nR
Ra
nR
Rs
Ra
Measles
Ra
Ma
nR
nR
nR
Rs
nR
Ra
nR
Ra
nR
Ra
Ra
Ra
nR
Ra
Ra
Rs
Ra
Rs
nR
nR
Ra
nR
Rs
Ra
Mumps
Ra
Ma
nR
nR
Ra
Rs
Rs
Ra
nR
Ra
nR
Ra
Ra
Ra
nR
Ra
Rs
Rs
Ra
Rs
nR
nR
Ra
nR
Rs
Ra
Rubella
Ra
Ra
nR
nR
nR
nR
Rs
Ra
Ra
Ra
nR
Ra
Rs
nR
Rs
Ra
Ra
Ra
Rs
Rs
nR
nR
nR
nR
Rs
Ra
Varicella
nR
nR
Ms
nR
nR
Rs
nR
nR
nR
Ra
nR
nR
Rs
nR
Rs
Ra
Ra
nR
nR
nR
nR
Rs
nR
Rs
Rs
Ra
Hepatitis A
Ra
Ma
Ma
Ra
Ra
Ma
Ra
Ra
Ra
Ra
Ms
Ra
Ra
Ra
Ma
Ra
Ra
Ms
Rs
Ra
Rs
Ma
Ra
Ra
Ma
Ra
Hepatitis B
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Rs
Ra
Ra
Ra
Ra
Ra
Flu, seasonal
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Flu, pandemic
Ma: Mandatory for all HCWs; Ms: Mandatory for specific HCW groups; nR: No recommendations; Ra: Recommended for all HCWs; Rs: Recommended for specific groups.
Ra
nR
nR
nR
Ra
nR
nR
Ra
nR
nR
Ra
Rs
Rs
Ra
nR
Ra
nR
Ma
nR
Ra
nR
nR
Rs
Ra
Ra
Austria (0)
Teta nus
Diphtheria
Country (mandatory vaccines)
Table 1. Policies for vaccination recommendations for healthcare workers in European countries (as of 2012).
Expert Review of Vaccines Downloaded from informahealthcare.com by Arizona State University on 05/29/14 For personal use only.
nR
Ms
nR
nR
nR
nR
nR
nR
nR
nR
nR
nR
Rs
nR
Rs
Rs
nR
nR
Rs
nR
nR
nR
nR
nR
Rs
Ra
Neisseria meningitidis
nR
nR
nR
nR
nR
nR
nR
nR
nR
nR
nR
nR
nR
nR
nR
Rs
nR
nR
nR
nR
nR
nR
nR
nR
Rs
Ra
Streptococcus pneumoniae
nR
nR
Ms
nR
nR
nR
Ra
Ra
nR
nR
nR
Rs
Rs
nR
nR
nR
nR
Ma
nR
nR
nR
Rs
nR
nR
nR
nR
BCG
Issue of mandatory vaccination for healthcare workers
Review
279
280
4
vaccination recommendation for HCWs unnecessary. Therefore, HCW recommendations must be interpreted in the context of the national immunization programs.
2
The potential of implementing mandatory policies in Europe
Ma: Mandatory for all HCWs; Ms: Mandatory for specific HCW groups; nR: No recommendations; Ra: Recommended for all HCWs; Rs: Recommended for specific groups.
5 0 1 3 7 4 Rs (66, 15.2%)
4
9
5
5
4
6
7
3 1 1 29 27 16 11 11 9 Ra (158, 36.3%)
10
8
5
12
11
4
20 26 10 12 15 nR (187, 43.0%)
13
12
18
10
11
0 1 0 Ms (11, 2.5%)
1
0
0
1
1
17
0
1
0
22
1 0 1 0 0
0 6 0 1 1 0 1 1 Ma (13, 3.0%)
Recommendation (number of total recommendations, %)
1
1
0
4
0 0
Ra Ra Ms Rs Ra Ms Rs UK (4)
Rs
Rs
Rs
Ms
Ms
1
1 0
Ra nR nR
nR nR nR nR The Netherlands (1)
nR
nR
Rs
Rs nR nR
nR
Ms
Ra
Ra
nR
Rs nR nR nR Sweden (0)
nR
nR
nR
nR nR nR
nR
Rs
nR
Ra
nR
BCG Rubella Diphtheria
Teta nus
Pertussis
Polio
Measles
Mumps
Varicella
Hepatitis A
Hepatitis B
Flu, seasonal
Flu, pandemic
Neisseria meningitidis
Streptococcus pneumoniae
Galanakis, D’Ancona, Jansen, Lopalco & VENICE
Country (mandatory vaccines)
Table 1. Policies for vaccination recommendations for healthcare workers in European countries (as of 2012) (cont.).
Expert Review of Vaccines Downloaded from informahealthcare.com by Arizona State University on 05/29/14 For personal use only.
Review
The majority of experts who responded to the questionnaire on the potential of implementation of mandatory policies for HCWs (30/55, 54.5%) found that such policies could be applied in their countries but only with considerable difficulty, whereas 18 (32.7%) found that this would be practically unachievable and only 7 (12.7%) found that this could be applied with a little effort. Regarding potential targets for mandatory policies, experts indicated hepatitis B (75%) infection, influenza (72%) and measles (58%), followed by diphtheria-tetanus-pertussis (49%), mumps (42%), rubella (42%), tuberculosis (25%), varicella (23%) and Streptococcus pneumoniae (19%), hepatitis A (14%) and Neisseria meningitidis (11%) infections. To most experts’ opinion, mandatory vaccination would be more acceptable if targeting specific HCW groups (32/55, 58.2%); fewer (11, 20%) reported that mandatory policies for all HCWs would work better and 12 (21.8%) reported that specific guidelines for HCW groups would work without the need for mandatory policies. To our knowledge, experts’ opinions have not been explored up to date. However, this information only reflects opinions by a small proportion of professionals participating in the survey and should only be interpreted under this limitation. Barriers to & rationale of vaccination policies
Barriers to vaccination include not only concerns about vaccine effectiveness and safety, medical contraindications, religious beliefs and conscientious objection but also inconvenience and underestimation of the risk of acquiring and transmitting the disease [14,34–37]. The benefits of vaccination are well recognized [36–44], but issuing mandatory recommendations has been controversial and occasionally has met intense resistance by HCWs [14,37,44], who seem to better accept these policies for well-defined specific HCW groups [27,28]. In European countries, recommendations have been issued, but enforcement or even sustained promotion seems to have been exceptional up to date. Common policies on occupational vaccination for HCWs across Europe would obviously promote both HCW and patient safety. Expert commentary
Vaccine recommendations for HCWs are widely issued all over Europe, though with considerable differences in recommended vaccines, targeted HCW Expert Rev. Vaccines 13(2), (2014)
Expert Review of Vaccines Downloaded from informahealthcare.com by Arizona State University on 05/29/14 For personal use only.
Issue of mandatory vaccination for healthcare workers
groups and type of recommendation. A common recommendation in all countries was only issued for pandemic influenza A (H1N1). Mandatory vaccination policies are uncommon and enforcement seems to be minimal, if existent at all. Emphasis on mandatory policies will be of uncertain results, at least in the close future and at least regarding policies vaguely targeting all HCW groups and not focusing on specific vaccine-preventable diseases. Thoughtful implementation of tailored recommendations for distinct HCW groups working in settings with vulnerable patients may work better. Interestingly, recent cocoon vaccination strategies have similarly focused on specific groups and disease targets, for example, HCWs working in maternity units in the case of pertussis prevention in the very young infant. Improving the communication to the HCW on this topic could also help, and understanding that non-immune HCWs, further to being at risk to infection themselves, may act as vectors of disease to their own patients might become a strong motivation toward vaccine uptake. This communication effort should start already in university colleges and university for medical and paramedical students. This would make the future generation of HCWs aware of the importance of being adequately vaccinated. Considering compliance to welldefined vaccines as a fitness-for-job condition and implementing a vaccination card that would facilitate movement of
Review
HCWs through Europe might further contribute to higher vaccination rates among HCWs. Five-year view
The re-emergence of vaccine-preventable diseases in Europe and the preparedness plans following emerging threats will fuel the discussion about optimal vaccination recommendations for HCWs. In this context, arguments for mandatory policies for HCWs are to increase, and more attention to monitor the uptake of these categories is expected in the next years. As HCWs have often been reluctant to conform to vaccine recommendations, in particular when these are not issued for well-defined HCW groups at high risk, implementation of balanced vaccination tailored for specific HCW groups and diseases seems to be the optimal policy. New strategies for vaccination, as offering information and the vaccines during the HCW training than once HCWs are already employed, would result in better coverage. Financial & competing interests disclosure
E Galanakis was at the ECDC on Sabbatical from the University of Crete, Greece. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript.
Key issues • Our findings from two surveys are consistent with those previously reported, showing that mandatory vaccination policies for healthcare workers (HCWs) in European countries have been rather uncommon up to date; in addition, our findings further suggest that mandatory policies may not be easily accepted in the close future. • Nevertheless, a common European-wide policy on HCW vaccination, not necessarily mandatory, would substantially contribute to adequate levels of HCW vaccination. • Recommendations for HCW vaccination should thoughtfully take into consideration recent epidemiological data, and both potential individual risks for specific HCW groups and the risk of patients in the healthcare setting; furthermore, monitoring system on vaccination uptake would be helpful. • Vaccination recommendations tailored for distinct HCW groups and appropriate diseases seem to be more promising than implementation of broad vaccination policies for HCWs.
equipment. Am. J. Infect. Control 40(7), 611–616 (2012).
References Papers of special note have been highlighted as: • of interest •• of considerable interest 1
2
Salgado CD, Giannetta ET, Hayden FG, Farr BM. Preventing nosocomial influenza by improving the vaccine acceptance rate of clinicians. Infect. Control Hosp. Epidemiol. 25(11), 923–928 (2004). Mitchell R, Ogunremi T, Astrakianakis G et al. Impact of the 2009 influenza A (H1N1) pandemic on Canadian health care workers: A survey on vaccination, illness, absenteeism, and personal protective
www.expert-reviews.com
3
Botelho-Nevers E, Gautret P, Biellik R, Brouqui P. Nosocomial transmission of measles: an updated review. Vaccine 30(27), 3996–4001 (2012).
4
Gilroy SA, Domachowske JB, Johnson L et al. Mumps exposure of a health care provider working in a neonatal intensive care unit leads to a hospital-wide effort that prevented an outbreak. Am. J. Infect. Control 39(8), 697–700 (2011).
5
Singh MP, Diddi K, Dogra S, Suri V, Varma S, Ratho RK. Institutional outbreak of rubella in a healthcare center in
Chandigarh, North India. J. Med. Virol. 82(2), 341–344 (2010). 6
Fac¸anha MC, Monroe AC. Occupational and nosocomial transmission of varicella. Braz. J. Infect. Dis. 10(2), 156–158 (2006).
7
Baugh V, McCarthy N. Outbreak of Bordetella pertussis among oncology nurse specialists. Occup. Med. (Lond.) 60(5), 401–405 (2010).
8
Bechini A, Tiscione E, Boccalini S, Levi M, Bonanni P. Acellular pertussis vaccine use in risk groups (adolescents, pregnant women, newborns and health care workers): a review of evidences and recommendations. Vaccine 30(35), 5179–5190 (2012).
281
Review 9
Doebbeling BN, Li N, Wenzel RP. An outbreak of hepatitis A among health care workers: risk factors for transmission. Am. J. Public Health 83(12), 1679–1684 (1993).
20
Wicker S, Poland GA. Measles vaccination in health care personnel: mandates, ethics, and patient safety. Vaccine 30(30), 4407–4408 (2012).
31
10
Hu DJ, Kane MA, Heymann DL. Transmission of HIV, hepatitis B virus, and other bloodborne pathogens in health care settings: a review of risk factors and guidelines for prevention. World Health Organization. Bull. World Health Organ. 69(5), 623–630 (1991).
21
Ziegler E, Roth C, Wreghitt T. Prevalence of measles susceptibility among health care workers in a UK hospital. Does the UK need to introduce a measles policy for its health care workers? Occup. Med. (Lond.) 53(6), 398–402 (2003).
Lemaitre M, Meret T, Rothan-Tondeur M et al. Effect of influenza vaccination of nursing home staff on mortality of residents: a cluster-randomized trial. Am. Geriatr. Soc. 57(9), 1580–1586 (2009).
32
22
Helms CM, Polgreen PM. Should influenza immunisation be mandatory for healthcare workers? Yes. BMJ 337, a2142 (2008).
23
Ottenberg AL, Wu JT, Poland GA, Jacobson RM, Koenig BA, Tilburt JC. Vaccinating health care workers against influenza: the ethical and legal rationale for a mandate. Am. J. Public Health 101(2), 212–216 (2011).
Palmore TN, Vandersluis JP, Morris J et al. A successful mandatory influenza vaccination campaign using an innovative electronic tracking system. Infect. Control. Hosp. Epidemiol. 30(12), 1137–1142 (2009).
33
Haverkate M, D’Ancona F, Johansen K, van der Velden K, Giesecke J, Lopalco PL. Assessing vaccination coverage in the European Union: is it still a challenge? Expert. Rev. Vaccines 10(8), 1195–1205 (2011).
34
Head S, Atkin S, Allan K, Ferguson C, Lutchmun S, Cordery R. Vaccinating health care workers during an influenza pandemic. Occup. Med. (Lond.), 62(8), 651–654 (2012).
35
Backer H. Counterpoint: in favor of mandatory influenza vaccine for all health care workers. Clin. Infect. Dis. 42(8), 1144–1147 (2006).
36
Chor JS, Pada SK, Stephenson I et al. Seasonal influenza vaccination predicts pandemic H1N1 vaccination uptake among healthcare workers in three countries. Vaccine 29(43), 7364–7369 (2011).
37
Lugo NR. Will carrots or sticks raise influenza immunization rates of health care personnel? Am. J. Infect. Control 35(1), 1–6 (2007).
38
Steckel CM. Mandatory influenza immunization for health care workers – an ethical discussion. AAOHN J 55(1), 34–39 (2007)
39
Poland GA, Ofstead CL, Tucker SJ, Beebe TJ. Receptivity to mandatory influenza vaccination policies for healthcare workers among registered nurses working on inpatient units. Infect. Control. Hosp. Epidemiol. 29(2), 170–173 (2008).
40
Poland GA. Mandating influenza vaccination for health care workers: putting patients and professional ethics over personal preference. Vaccine 28(36), 5757–5759 (2010).
41
van Delden JJ, Ashcroft R, Dawson A, Marckmann G, Upshur R, Verweij MF. The ethics of mandatory vaccination against
11
Expert Review of Vaccines Downloaded from informahealthcare.com by Arizona State University on 05/29/14 For personal use only.
Galanakis, D’Ancona, Jansen, Lopalco & VENICE
Gehanno JF, Kohen-Couderc L, Lemeland JF, Leroy J. Nosocomial meningococcemia in a physician. Infect. Control. Hosp. Epidemiol. 20(8), 564–565 (1999).
12
James P, Christopher DJ, Balamugesh T, Gupta R. Death of a health care worker with nosocomial extensively drug-resistant tuberculosis in India. Int. J. Tuberc. Lung Dis. 13(6), 795–796 (2009).
13
Wilde JA, McMillan JA, Serwint J, Butta J, O’Riordan MA, Steinhoff MC. Effectiveness of influenza vaccine in health care professionals: a randomized trial. JAMA 281(10), 908–913 (1999).
14
•
15
16
Hofmann F, Ferracin C, Marsh G, Dumas R. Influenza vaccination of healthcare workers: a literature review of attitudes and beliefs. Infection 34(3), 142–147 (2006). A review of attitudes and beliefs among healthcare workers (HCWs) regarding influenza vaccination. The review includes several studies from European countries. Potter J, Stott DJ, Roberts MA et al. Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients. J. Infect. Dis. 175(1), 1–6 (1997). Talbot TR. Improving rates of influenza vaccination among healthcare workers: educate; motivate; mandate? Infect. Control Hosp. Epidemiol. 29(2), 107–110 (2008).
17
Johansen K, Nicoll A, Ciancio BC, Kramarz P. Pandemic influenza A(H1N1) 2009 vaccines in the European Union. Euro Surveill. 14(41), 19361 (2009).
18
Kaltsas A, Sepkowitz K. Vaccinations for healthcare personnel: update on influenza, hepatitis B, and pertussis. Curr. Opin. Infect. Dis. 26(4), 366–377 (2013).
19
Baron-Epel O, Bord S, Madjar B, Habib S, Rishpon S. What lies behind the low rates of vaccinations among nurses who treat infants? Vaccine 30(21), 3151–3154 (2012).
282
•
A commentary on ethical rationale and legal foundations of HCW vaccine mandate in the USA.
24
Stewart AM. Mandatory vaccination of health care workers. N. Engl. J. Med. 361(21), 2015–2017 (2009).
25
Walkinshaw E. Mandatory vaccinations: No middle ground. CMAJ 183(16), 1830–1831 (2011).
26
Maltezou HC, Wicker S, Borg M et al. Vaccination policies for health-care workers in acute health-care facilities in Europe. Vaccine 29(51), 9557–9562 (2011).
••
A recent survey of vaccination policies for HCWs in European countries.
27
Maltezou HC, Gargalianos P, Nikolaidis P et al. Attitudes towards mandatory vaccination and vaccination coverage against vaccine-preventable diseases among health-care workers in tertiary-care hospitals. J. Infect. 64(3), 319–324 (2012).
28
29
30
Maltezou HC, Katerelos P, Poufta S, Pavli A, Maragos A, Theodoridou M. Attitudes toward mandatory occupational vaccinations and vaccination coverage against vaccine-preventable diseases of health care workers in primary health care centers. Am. J. Infect. Control 41(1), 66–70 (2013). Carman WF, Elder AG, Wallace LA et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial. Lancet 355(9198), 93–97 (2000). Hayward AC, Harling R, Wetten S et al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use
among residents: cluster randomised controlled trial. BMJ 333(7581), 1241–1124 (2006).
Expert Rev. Vaccines 13(2), (2014)
Issue of mandatory vaccination for healthcare workers
a sustained mandatory policy for HCWs regarding influenza vaccination.
Expert Review of Vaccines Downloaded from informahealthcare.com by Arizona State University on 05/29/14 For personal use only.
influenza for health care workers. Vaccine 26(44), 5562–5566 (2008). ••
Recommended European study to understand the ethical background of the issue of vaccine mandates for HCWs.
42
Verweij M. Obligatory precautions against infection. Bioethics 19(4), 323–335 (2005).
43
Rakita RM, Hagar BA, Crome P, Lammert JK. Mandatory influenza vaccination of healthcare workers: a 5-year study. Infect. Control. Hosp. Epidemiol. 31(9), 881–888 (2010).
•
The study summarizes the experience of Virginia Mason Medical Center, Seattle, WA, that is, the first institution to adopt
www.expert-reviews.com
44
Stewart AM, Cox MA. State law and influenza vaccination of health care personnel. Vaccine 31(5), 827–832 (2013).
medical-ethics/9133a.pdf (Accessed 30 September 2013) •
A detailed report by a professional association on ethics and policies of HCW vaccination.
102
SurveyMonkey. www.surveymonkey.com
103
World Health Organization, 2006. Global pandemic influenza action plan to increase vaccine supply. http://whqlibdoc.who.int/hq/2006/ WHO_IVB_06.13_eng.pdf (Accessed 30 September 2013)
Websites 101
American Medical Association. routine universal immunization of physicians for vaccine-preventable disease. CEJA report 5-1-10. www.ama-assn.org/resources/doc/code-
Review
283
The issue of mandatory vaccination for healthcare workers in Europe Expert Review of Vaccines Downloaded from informahealthcare.com by Arizona State University on 05/29/14 For personal use only.
Expert Rev. Vaccines 13(2), 277–283 (2014)
Emmanouil Galanakis*1, Fortunato D’Ancona2, Andreas Jansen3, Pier Luigi Lopalco4 and VENICE (Vaccine European New Integrated Collaboration Effort) National Gatekeepers, Contact Points4 1 Department of Paediatrics and Interfaculty Graduate Programme in Bioethics, University of Crete, Heraklion 710 03, Greece 2 National Centre for Epidemiology, Surveillance and Health Promotion (CNESPS), Istituto Superiore di Sanita, Rome, Italy 3 European Centre for Disease Prevention and Control, Stockholm, Sweden 4 VENICE National Gatekeepers and Contact Points for this survey† *Author for correspondence: Tel.: +30 2810 392 012 Fax: +30 2810 392 827 [email protected]
Mandatory policies have occasionally been implemented, targeting optimal vaccination uptake among healthcare workers (HCWs). Herein, we analyze the existing recommendations in European countries and discuss the feasibility of implementing mandatory vaccination for HCWs. As reflected by a survey among vaccine experts from 29 European countries, guidelines on HCW vaccination were issued in all countries, though with substantial differences in targeted diseases, HCW groups and type of recommendation. Mandatory policies were only exceptionally implemented. Results from a second survey suggested that such policies would not become easily adopted, and recommendations might work better if focusing on specific HCW groups and appropriate diseases such as hepatitis B, influenza and measles. In conclusion, guidelines for HCW vaccination, but not mandatory policies, are widely adopted in Europe. Recommendations targeting specific HCW groups and diseases might be better accepted and facilitate higher vaccine uptake than policies vaguely targeting all HCW groups. KEYWORDS: Europe • healthcare workers • mandatory vaccination • policies • vaccine recommendations
The rationale of healthcare worker vaccination
† Austria: Elisabeth Kanitz, Daniela Schmid; Belgium: Martine Sabbe, Pierre Van Damme; Bulgaria: Mira Kojouharova; Cyprus: Soteroulla Soteriou; Czech Republic: Bohumir Kriz; Denmark: Palle Valentiner-Branth; Estonia: Irina Filippova, Natalia Kerbo; Finland: Tuija Leino, Hanna Nohynek; France: Daniel Le´vy-Bruhl; Germany: Ole Wichmann; Greece: Theodora Stavrou; Hungary: Zsuzsanna Molna`r; Iceland: Thorolfur Gudnason; Ireland: Suzanne Cotter; Italy: Fortunato D’Ancona; Latvia: Jurijs Perevoscikovs; Lithuania: Ausra Lileikyte; Luxemburg: Franc¸oise Berthet; Malta: Tanya Melillo Fenech; The Netherlands: Hester de Melker; Norway: Berit Feiring; Poland: Iwona Paradowska-Stankiewicz; Portugal: Teresa M. Alves Fernandes, Paula Valente; Romania: Chicin Gratiana; Slovakia: Helena Hudecova´, Alexandra Zampachova; Slovenia: Alenka Kraigher; Spain: Aurora Limia; Sweden: Ingrid Uhnoo; United Kingdom: Richard Pebody.
Healthcare workers (HCWs) are at increased risk of contracting infections from patients and further spreading them to patients. Infections are often subclinical and may be transmitted before symptoms develop, thus permitting HCWs to continue working and spreading the disease. Nosocomial transmission involving HCWs has been reported in various healthcare facilities and for the majority of vaccine-preventable diseases, including seasonal and pandemic influenza, measles, mumps, rubella, varicella, pertussis, hepatitis A, hepatitis B, meningococcal disease and tuberculosis, and often leading to nosocomial outbreaks and fatal cases for both patients and HCWs [1–13]. Vaccination would protect HCWs themselves, prevent transmission to vulnerable patients and healthcare staff and maintain the healthcare force during emergency outbreaks. However, vaccination uptake rates among HCWs have often been not as high as anticipated [8,10,14–21], thus raising the
www.expert-reviews.com
10.1586/14760584.2014.869174
question whether voluntary uptake should be replaced by vaccination requirements. Mandatory policies are increasingly adopted by healthcare institutions, professional societies and public health authorities in some settings but have generated discussions, debate and legal issues [22–25,101]. Surveying policies & trends in Europe
Policies in European countries regarding HCW vaccination in acute healthcare facilities have been reported by Maltezou et al. [26]. We conducted two surveys from October 2012 to December 2012, in order to review the existing vaccination recommendations for HCWs in all healthcare settings and to investigate and discuss the rationale and potential of implementing mandatory policies in European countries. The first survey was conducted among 35 national experts from the Vaccine European New Integrated Collaboration Effort (VENICE) network covering all 27 European Union Member States and Iceland and Norway. Participants were called to complete an online preconstructed questionnaire [102] on the recommendations for HCWs in each
Ó 2014 Informa UK Ltd
ISSN 1476-0584
277
Review
Galanakis, D’Ancona, Jansen, Lopalco & VENICE
Expert Review of Vaccines Downloaded from informahealthcare.com by Arizona State University on 05/29/14 For personal use only.
country SUPPLEMENTARY APPENDIX 1 (available at www.informahealthcare.com/doi/Suppl/10.1586/14760584.2014.869174) and then contacted at least twice for validation of data and vaccine policies. A second questionnaire on the feasibility of mandatory policies for HCWs (SUPPLEMENTARY APPENDIX 2) was distributed among vaccine experts participating in the Eurovaccine.net meeting, Barcelona, 21–23 November 2012. Both questionnaires focused on 15 diseases, commonly included in the vaccination programs of European countries (TABLE 1). Vaccines of local interest, for example, tick-borne encephalitis, were not included. Definition issues
Considerable definition issues arise when investigating vaccination policies for HCWs, for example, who is considered to be an HCW, what is the meaning of mandatory and whether any policy targets HCWs as a whole or distinct HCW groups. In this survey, a vaccination was defined as recommended if it was officially declared so by public healthcare authorities. Mandatory was further defined as a vaccination, for which there was some sort of penalty for noncompliance. Mandatory vaccination without enforcement was defined as a vaccination that was officially declared to be mandatory, but enforcement measures were rather theoretical and refusal would not incur penalties. Only recommendations issued specifically for HCWs were included, that is, recommendations for the general population were not considered (e.g., for polio which is mandatory for all in many national vaccination programs). HCWs were defined as any professional or volunteer, employed in acute or chronic care facilities, in direct contact with patients/residents. Specific groups of HCWs were defined as groups working in particular areas of care, such as in child health, with elderly residents or with immunocompromised patients. Postexposure vaccination policies were not included. The first aim of this study, that is, surveying recommendations for HCWs in Europe, has already been explored in a previous study [26]. As compared to that study, we used a more restricted definition for HCWs by emphasizing direct contact with patients and a wider definition for healthcare facilities, including chronic care, and asked for policies on the influenza pandemic A (H1N1) 2009 as a measure of response to outbreaks. We strictly used the criterion of patient contact, as it is questionable whether the same policies should be recommended for HCWs with or without patient contacts and as HCWs themselves have been reported to believe that policies should better target appropriate HCW groups rather than HCWs vaguely [27,28]. Furthermore, we included chronic healthcare facilities as well, as it is exactly in the latter facilities that prevention of patients and residents through HCW vaccination has been proven, for example, against influenza [15,29–31]. Current vaccination policies in Europe
All experts from the 29 European countries answered the questionnaire. Recommendations for HCW vaccination were issued in all countries (TABLE 1). Most vaccinations were in the category ‘recommended’ (51.5%) either for all HCWs (36.3%) or for 278
specific HCW groups (15.2%). The least recommended were vaccines for pneumococcal and meningococcal disease and tuberculosis (in three, seven and nine countries, respectively). Mandatory vaccination policies were uncommon (5.5%); 19 countries had no mandatory policies for any vaccine and 10 had mandatory policies for 1–6 (median, 1) vaccines. Hepatitis B was the disease mostly targeted with mandatory policies (10 countries). Mandatory policies were not applied for pertussis, varicella, influenza and pneumococcal disease in any country. No recommendations at all were issued in 43% of the total countries and vaccines. As it is true with national immunization programs, guidelines among countries or even among regions of the same country considerably differed in terms of vaccines and HCW groups [32,33]. Exemptions included recommendations for pandemic influenza A (H1N1) 2009, which was the only vaccine recommended for all HCWs in all countries, and to a lesser degree for seasonal influenza and hepatitis B. These exemptions might be attributed to sustained vaccination campaigns and recommendations by authorities such as the WHO and the European Union [10,103]. The lack of recommendations for measles, mumps, rubella and pertussis vaccines (not recommended at all in 10, 12, 10 and 12 countries) is remarkable, given the often low rates of vaccine uptake among the adult population and the persistence of these diseases [8,20,21]. Measles elimination was not achieved for Europe in 2010, and outbreaks still occur [20]. Susceptibility rates to measles have been found to range from 3 to 17% among HCWs [21,27,28]. Low vaccination rates have been reported for the pertussis booster as well, despite the reemergence of the diseases [8]. The value of BCG vaccine is questionable; however, the emergence of extensively drug-resistant tuberculosis stands in opposition to the paucity of recommendations for HCWs. Immunity to diphtheria and poliomyelitis should not be neglected, given the existence of disease foci out of Europe and the increasing movement of populations. Our findings did not seem to substantially differ from those previously reported for Europe [26] despite differences in methodology. Mandatory or recommended vaccines were more common in the present study than in the previous one (57 vs 45.7%), but this should rather be attributed to the different definition than to changing policies over Europe. Policies in European countries are often difficult to be precisely categorized, given the different interpretation of the term mandatory in such a wide array of cultures and given that recommendations may differ even from region to region in the same country. Furthermore, despite our efforts to ensure that study definitions were homogenously used by all experts, recommendations issued for HCWs in particular could not always be distinguished from those issued for the general population, nor could recommendations for acute care facilities be distinguished from those issued for chronic care facilities. Different HCW vaccination policies might also originate from different recommendations for the general population, for example, in some countries routine booster diphtheria vaccination is recommended to all adults, which makes an additional diphtheria Expert Rev. Vaccines 13(2), (2014)
Ra
nR
Rs
nR
Ra
nR
nR
Ra
nR
Ma
nR
Ra
nR
Ra
Rs
Rs
Ra
Ra
nR
Ra
nR
nR
Ra
nR
nR
Ms
Ra
Belgium (1)
Bulgaria (0)
Cyprus (0)
Czech Republic (1)
Denmark (0)
www.expert-reviews.com
Estonia (0)
Finland (0)
France (5)
Germany (0)
Greece (0)
Hungary (1)
Iceland (0)
Ireland (0)
Italy (0)
Latvia (1)
Lithuania (0)
Luxemburg (0)
Malta (0)
Norway (0)
Poland (1)
Portugal (0)
Romania (0)
Slovakia (3)
Slovenia (6)
Spain (0)
Rs
Rs
nR
nR
nR
Rs
Rs
Ra
nR
nR
nR
Rs
Rs
Ra
nR
Ra
Ra
Ra
Rs
Ra
nR
nR
Ra
nR
Rs
Ra
Pertussis
nR
nR
nR
nR
Rs
nR
nR
Ra
nR
nR
nR
nR
Rs
Ra
nR
Ra
Rs
Ma
nR
nR
nR
nR
Ra
nR
Rs
Ra
Polio
Ra
Ma
nR
nR
Ra
Rs
nR
Ra
nR
Ra
nR
Ra
Ra
Ra
nR
Ra
Ra
Rs
Ra
Rs
nR
nR
Ra
nR
Rs
Ra
Measles
Ra
Ma
nR
nR
nR
Rs
nR
Ra
nR
Ra
nR
Ra
Ra
Ra
nR
Ra
Ra
Rs
Ra
Rs
nR
nR
Ra
nR
Rs
Ra
Mumps
Ra
Ma
nR
nR
Ra
Rs
Rs
Ra
nR
Ra
nR
Ra
Ra
Ra
nR
Ra
Rs
Rs
Ra
Rs
nR
nR
Ra
nR
Rs
Ra
Rubella
Ra
Ra
nR
nR
nR
nR
Rs
Ra
Ra
Ra
nR
Ra
Rs
nR
Rs
Ra
Ra
Ra
Rs
Rs
nR
nR
nR
nR
Rs
Ra
Varicella
nR
nR
Ms
nR
nR
Rs
nR
nR
nR
Ra
nR
nR
Rs
nR
Rs
Ra
Ra
nR
nR
nR
nR
Rs
nR
Rs
Rs
Ra
Hepatitis A
Ra
Ma
Ma
Ra
Ra
Ma
Ra
Ra
Ra
Ra
Ms
Ra
Ra
Ra
Ma
Ra
Ra
Ms
Rs
Ra
Rs
Ma
Ra
Ra
Ma
Ra
Hepatitis B
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Rs
Ra
Ra
Ra
Ra
Ra
Flu, seasonal
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Ra
Flu, pandemic
Ma: Mandatory for all HCWs; Ms: Mandatory for specific HCW groups; nR: No recommendations; Ra: Recommended for all HCWs; Rs: Recommended for specific groups.
Ra
nR
nR
nR
Ra
nR
nR
Ra
nR
nR
Ra
Rs
Rs
Ra
nR
Ra
nR
Ma
nR
Ra
nR
nR
Rs
Ra
Ra
Austria (0)
Teta nus
Diphtheria
Country (mandatory vaccines)
Table 1. Policies for vaccination recommendations for healthcare workers in European countries (as of 2012).
Expert Review of Vaccines Downloaded from informahealthcare.com by Arizona State University on 05/29/14 For personal use only.
nR
Ms
nR
nR
nR
nR
nR
nR
nR
nR
nR
nR
Rs
nR
Rs
Rs
nR
nR
Rs
nR
nR
nR
nR
nR
Rs
Ra
Neisseria meningitidis
nR
nR
nR
nR
nR
nR
nR
nR
nR
nR
nR
nR
nR
nR
nR
Rs
nR
nR
nR
nR
nR
nR
nR
nR
Rs
Ra
Streptococcus pneumoniae
nR
nR
Ms
nR
nR
nR
Ra
Ra
nR
nR
nR
Rs
Rs
nR
nR
nR
nR
Ma
nR
nR
nR
Rs
nR
nR
nR
nR
BCG
Issue of mandatory vaccination for healthcare workers
Review
279
280
4
vaccination recommendation for HCWs unnecessary. Therefore, HCW recommendations must be interpreted in the context of the national immunization programs.
2
The potential of implementing mandatory policies in Europe
Ma: Mandatory for all HCWs; Ms: Mandatory for specific HCW groups; nR: No recommendations; Ra: Recommended for all HCWs; Rs: Recommended for specific groups.
5 0 1 3 7 4 Rs (66, 15.2%)
4
9
5
5
4
6
7
3 1 1 29 27 16 11 11 9 Ra (158, 36.3%)
10
8
5
12
11
4
20 26 10 12 15 nR (187, 43.0%)
13
12
18
10
11
0 1 0 Ms (11, 2.5%)
1
0
0
1
1
17
0
1
0
22
1 0 1 0 0
0 6 0 1 1 0 1 1 Ma (13, 3.0%)
Recommendation (number of total recommendations, %)
1
1
0
4
0 0
Ra Ra Ms Rs Ra Ms Rs UK (4)
Rs
Rs
Rs
Ms
Ms
1
1 0
Ra nR nR
nR nR nR nR The Netherlands (1)
nR
nR
Rs
Rs nR nR
nR
Ms
Ra
Ra
nR
Rs nR nR nR Sweden (0)
nR
nR
nR
nR nR nR
nR
Rs
nR
Ra
nR
BCG Rubella Diphtheria
Teta nus
Pertussis
Polio
Measles
Mumps
Varicella
Hepatitis A
Hepatitis B
Flu, seasonal
Flu, pandemic
Neisseria meningitidis
Streptococcus pneumoniae
Galanakis, D’Ancona, Jansen, Lopalco & VENICE
Country (mandatory vaccines)
Table 1. Policies for vaccination recommendations for healthcare workers in European countries (as of 2012) (cont.).
Expert Review of Vaccines Downloaded from informahealthcare.com by Arizona State University on 05/29/14 For personal use only.
Review
The majority of experts who responded to the questionnaire on the potential of implementation of mandatory policies for HCWs (30/55, 54.5%) found that such policies could be applied in their countries but only with considerable difficulty, whereas 18 (32.7%) found that this would be practically unachievable and only 7 (12.7%) found that this could be applied with a little effort. Regarding potential targets for mandatory policies, experts indicated hepatitis B (75%) infection, influenza (72%) and measles (58%), followed by diphtheria-tetanus-pertussis (49%), mumps (42%), rubella (42%), tuberculosis (25%), varicella (23%) and Streptococcus pneumoniae (19%), hepatitis A (14%) and Neisseria meningitidis (11%) infections. To most experts’ opinion, mandatory vaccination would be more acceptable if targeting specific HCW groups (32/55, 58.2%); fewer (11, 20%) reported that mandatory policies for all HCWs would work better and 12 (21.8%) reported that specific guidelines for HCW groups would work without the need for mandatory policies. To our knowledge, experts’ opinions have not been explored up to date. However, this information only reflects opinions by a small proportion of professionals participating in the survey and should only be interpreted under this limitation. Barriers to & rationale of vaccination policies
Barriers to vaccination include not only concerns about vaccine effectiveness and safety, medical contraindications, religious beliefs and conscientious objection but also inconvenience and underestimation of the risk of acquiring and transmitting the disease [14,34–37]. The benefits of vaccination are well recognized [36–44], but issuing mandatory recommendations has been controversial and occasionally has met intense resistance by HCWs [14,37,44], who seem to better accept these policies for well-defined specific HCW groups [27,28]. In European countries, recommendations have been issued, but enforcement or even sustained promotion seems to have been exceptional up to date. Common policies on occupational vaccination for HCWs across Europe would obviously promote both HCW and patient safety. Expert commentary
Vaccine recommendations for HCWs are widely issued all over Europe, though with considerable differences in recommended vaccines, targeted HCW Expert Rev. Vaccines 13(2), (2014)
Expert Review of Vaccines Downloaded from informahealthcare.com by Arizona State University on 05/29/14 For personal use only.
Issue of mandatory vaccination for healthcare workers
groups and type of recommendation. A common recommendation in all countries was only issued for pandemic influenza A (H1N1). Mandatory vaccination policies are uncommon and enforcement seems to be minimal, if existent at all. Emphasis on mandatory policies will be of uncertain results, at least in the close future and at least regarding policies vaguely targeting all HCW groups and not focusing on specific vaccine-preventable diseases. Thoughtful implementation of tailored recommendations for distinct HCW groups working in settings with vulnerable patients may work better. Interestingly, recent cocoon vaccination strategies have similarly focused on specific groups and disease targets, for example, HCWs working in maternity units in the case of pertussis prevention in the very young infant. Improving the communication to the HCW on this topic could also help, and understanding that non-immune HCWs, further to being at risk to infection themselves, may act as vectors of disease to their own patients might become a strong motivation toward vaccine uptake. This communication effort should start already in university colleges and university for medical and paramedical students. This would make the future generation of HCWs aware of the importance of being adequately vaccinated. Considering compliance to welldefined vaccines as a fitness-for-job condition and implementing a vaccination card that would facilitate movement of
Review
HCWs through Europe might further contribute to higher vaccination rates among HCWs. Five-year view
The re-emergence of vaccine-preventable diseases in Europe and the preparedness plans following emerging threats will fuel the discussion about optimal vaccination recommendations for HCWs. In this context, arguments for mandatory policies for HCWs are to increase, and more attention to monitor the uptake of these categories is expected in the next years. As HCWs have often been reluctant to conform to vaccine recommendations, in particular when these are not issued for well-defined HCW groups at high risk, implementation of balanced vaccination tailored for specific HCW groups and diseases seems to be the optimal policy. New strategies for vaccination, as offering information and the vaccines during the HCW training than once HCWs are already employed, would result in better coverage. Financial & competing interests disclosure
E Galanakis was at the ECDC on Sabbatical from the University of Crete, Greece. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript.
Key issues • Our findings from two surveys are consistent with those previously reported, showing that mandatory vaccination policies for healthcare workers (HCWs) in European countries have been rather uncommon up to date; in addition, our findings further suggest that mandatory policies may not be easily accepted in the close future. • Nevertheless, a common European-wide policy on HCW vaccination, not necessarily mandatory, would substantially contribute to adequate levels of HCW vaccination. • Recommendations for HCW vaccination should thoughtfully take into consideration recent epidemiological data, and both potential individual risks for specific HCW groups and the risk of patients in the healthcare setting; furthermore, monitoring system on vaccination uptake would be helpful. • Vaccination recommendations tailored for distinct HCW groups and appropriate diseases seem to be more promising than implementation of broad vaccination policies for HCWs.
equipment. Am. J. Infect. Control 40(7), 611–616 (2012).
References Papers of special note have been highlighted as: • of interest •• of considerable interest 1
2
Salgado CD, Giannetta ET, Hayden FG, Farr BM. Preventing nosocomial influenza by improving the vaccine acceptance rate of clinicians. Infect. Control Hosp. Epidemiol. 25(11), 923–928 (2004). Mitchell R, Ogunremi T, Astrakianakis G et al. Impact of the 2009 influenza A (H1N1) pandemic on Canadian health care workers: A survey on vaccination, illness, absenteeism, and personal protective
www.expert-reviews.com
3
Botelho-Nevers E, Gautret P, Biellik R, Brouqui P. Nosocomial transmission of measles: an updated review. Vaccine 30(27), 3996–4001 (2012).
4
Gilroy SA, Domachowske JB, Johnson L et al. Mumps exposure of a health care provider working in a neonatal intensive care unit leads to a hospital-wide effort that prevented an outbreak. Am. J. Infect. Control 39(8), 697–700 (2011).
5
Singh MP, Diddi K, Dogra S, Suri V, Varma S, Ratho RK. Institutional outbreak of rubella in a healthcare center in
Chandigarh, North India. J. Med. Virol. 82(2), 341–344 (2010). 6
Fac¸anha MC, Monroe AC. Occupational and nosocomial transmission of varicella. Braz. J. Infect. Dis. 10(2), 156–158 (2006).
7
Baugh V, McCarthy N. Outbreak of Bordetella pertussis among oncology nurse specialists. Occup. Med. (Lond.) 60(5), 401–405 (2010).
8
Bechini A, Tiscione E, Boccalini S, Levi M, Bonanni P. Acellular pertussis vaccine use in risk groups (adolescents, pregnant women, newborns and health care workers): a review of evidences and recommendations. Vaccine 30(35), 5179–5190 (2012).
281
Review 9
Doebbeling BN, Li N, Wenzel RP. An outbreak of hepatitis A among health care workers: risk factors for transmission. Am. J. Public Health 83(12), 1679–1684 (1993).
20
Wicker S, Poland GA. Measles vaccination in health care personnel: mandates, ethics, and patient safety. Vaccine 30(30), 4407–4408 (2012).
31
10
Hu DJ, Kane MA, Heymann DL. Transmission of HIV, hepatitis B virus, and other bloodborne pathogens in health care settings: a review of risk factors and guidelines for prevention. World Health Organization. Bull. World Health Organ. 69(5), 623–630 (1991).
21
Ziegler E, Roth C, Wreghitt T. Prevalence of measles susceptibility among health care workers in a UK hospital. Does the UK need to introduce a measles policy for its health care workers? Occup. Med. (Lond.) 53(6), 398–402 (2003).
Lemaitre M, Meret T, Rothan-Tondeur M et al. Effect of influenza vaccination of nursing home staff on mortality of residents: a cluster-randomized trial. Am. Geriatr. Soc. 57(9), 1580–1586 (2009).
32
22
Helms CM, Polgreen PM. Should influenza immunisation be mandatory for healthcare workers? Yes. BMJ 337, a2142 (2008).
23
Ottenberg AL, Wu JT, Poland GA, Jacobson RM, Koenig BA, Tilburt JC. Vaccinating health care workers against influenza: the ethical and legal rationale for a mandate. Am. J. Public Health 101(2), 212–216 (2011).
Palmore TN, Vandersluis JP, Morris J et al. A successful mandatory influenza vaccination campaign using an innovative electronic tracking system. Infect. Control. Hosp. Epidemiol. 30(12), 1137–1142 (2009).
33
Haverkate M, D’Ancona F, Johansen K, van der Velden K, Giesecke J, Lopalco PL. Assessing vaccination coverage in the European Union: is it still a challenge? Expert. Rev. Vaccines 10(8), 1195–1205 (2011).
34
Head S, Atkin S, Allan K, Ferguson C, Lutchmun S, Cordery R. Vaccinating health care workers during an influenza pandemic. Occup. Med. (Lond.), 62(8), 651–654 (2012).
35
Backer H. Counterpoint: in favor of mandatory influenza vaccine for all health care workers. Clin. Infect. Dis. 42(8), 1144–1147 (2006).
36
Chor JS, Pada SK, Stephenson I et al. Seasonal influenza vaccination predicts pandemic H1N1 vaccination uptake among healthcare workers in three countries. Vaccine 29(43), 7364–7369 (2011).
37
Lugo NR. Will carrots or sticks raise influenza immunization rates of health care personnel? Am. J. Infect. Control 35(1), 1–6 (2007).
38
Steckel CM. Mandatory influenza immunization for health care workers – an ethical discussion. AAOHN J 55(1), 34–39 (2007)
39
Poland GA, Ofstead CL, Tucker SJ, Beebe TJ. Receptivity to mandatory influenza vaccination policies for healthcare workers among registered nurses working on inpatient units. Infect. Control. Hosp. Epidemiol. 29(2), 170–173 (2008).
40
Poland GA. Mandating influenza vaccination for health care workers: putting patients and professional ethics over personal preference. Vaccine 28(36), 5757–5759 (2010).
41
van Delden JJ, Ashcroft R, Dawson A, Marckmann G, Upshur R, Verweij MF. The ethics of mandatory vaccination against
11
Expert Review of Vaccines Downloaded from informahealthcare.com by Arizona State University on 05/29/14 For personal use only.
Galanakis, D’Ancona, Jansen, Lopalco & VENICE
Gehanno JF, Kohen-Couderc L, Lemeland JF, Leroy J. Nosocomial meningococcemia in a physician. Infect. Control. Hosp. Epidemiol. 20(8), 564–565 (1999).
12
James P, Christopher DJ, Balamugesh T, Gupta R. Death of a health care worker with nosocomial extensively drug-resistant tuberculosis in India. Int. J. Tuberc. Lung Dis. 13(6), 795–796 (2009).
13
Wilde JA, McMillan JA, Serwint J, Butta J, O’Riordan MA, Steinhoff MC. Effectiveness of influenza vaccine in health care professionals: a randomized trial. JAMA 281(10), 908–913 (1999).
14
•
15
16
Hofmann F, Ferracin C, Marsh G, Dumas R. Influenza vaccination of healthcare workers: a literature review of attitudes and beliefs. Infection 34(3), 142–147 (2006). A review of attitudes and beliefs among healthcare workers (HCWs) regarding influenza vaccination. The review includes several studies from European countries. Potter J, Stott DJ, Roberts MA et al. Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients. J. Infect. Dis. 175(1), 1–6 (1997). Talbot TR. Improving rates of influenza vaccination among healthcare workers: educate; motivate; mandate? Infect. Control Hosp. Epidemiol. 29(2), 107–110 (2008).
17
Johansen K, Nicoll A, Ciancio BC, Kramarz P. Pandemic influenza A(H1N1) 2009 vaccines in the European Union. Euro Surveill. 14(41), 19361 (2009).
18
Kaltsas A, Sepkowitz K. Vaccinations for healthcare personnel: update on influenza, hepatitis B, and pertussis. Curr. Opin. Infect. Dis. 26(4), 366–377 (2013).
19
Baron-Epel O, Bord S, Madjar B, Habib S, Rishpon S. What lies behind the low rates of vaccinations among nurses who treat infants? Vaccine 30(21), 3151–3154 (2012).
282
•
A commentary on ethical rationale and legal foundations of HCW vaccine mandate in the USA.
24
Stewart AM. Mandatory vaccination of health care workers. N. Engl. J. Med. 361(21), 2015–2017 (2009).
25
Walkinshaw E. Mandatory vaccinations: No middle ground. CMAJ 183(16), 1830–1831 (2011).
26
Maltezou HC, Wicker S, Borg M et al. Vaccination policies for health-care workers in acute health-care facilities in Europe. Vaccine 29(51), 9557–9562 (2011).
••
A recent survey of vaccination policies for HCWs in European countries.
27
Maltezou HC, Gargalianos P, Nikolaidis P et al. Attitudes towards mandatory vaccination and vaccination coverage against vaccine-preventable diseases among health-care workers in tertiary-care hospitals. J. Infect. 64(3), 319–324 (2012).
28
29
30
Maltezou HC, Katerelos P, Poufta S, Pavli A, Maragos A, Theodoridou M. Attitudes toward mandatory occupational vaccinations and vaccination coverage against vaccine-preventable diseases of health care workers in primary health care centers. Am. J. Infect. Control 41(1), 66–70 (2013). Carman WF, Elder AG, Wallace LA et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial. Lancet 355(9198), 93–97 (2000). Hayward AC, Harling R, Wetten S et al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use
among residents: cluster randomised controlled trial. BMJ 333(7581), 1241–1124 (2006).
Expert Rev. Vaccines 13(2), (2014)
Issue of mandatory vaccination for healthcare workers
a sustained mandatory policy for HCWs regarding influenza vaccination.
Expert Review of Vaccines Downloaded from informahealthcare.com by Arizona State University on 05/29/14 For personal use only.
influenza for health care workers. Vaccine 26(44), 5562–5566 (2008). ••
Recommended European study to understand the ethical background of the issue of vaccine mandates for HCWs.
42
Verweij M. Obligatory precautions against infection. Bioethics 19(4), 323–335 (2005).
43
Rakita RM, Hagar BA, Crome P, Lammert JK. Mandatory influenza vaccination of healthcare workers: a 5-year study. Infect. Control. Hosp. Epidemiol. 31(9), 881–888 (2010).
•
The study summarizes the experience of Virginia Mason Medical Center, Seattle, WA, that is, the first institution to adopt
www.expert-reviews.com
44
Stewart AM, Cox MA. State law and influenza vaccination of health care personnel. Vaccine 31(5), 827–832 (2013).
medical-ethics/9133a.pdf (Accessed 30 September 2013) •
A detailed report by a professional association on ethics and policies of HCW vaccination.
102
SurveyMonkey. www.surveymonkey.com
103
World Health Organization, 2006. Global pandemic influenza action plan to increase vaccine supply. http://whqlibdoc.who.int/hq/2006/ WHO_IVB_06.13_eng.pdf (Accessed 30 September 2013)
Websites 101
American Medical Association. routine universal immunization of physicians for vaccine-preventable disease. CEJA report 5-1-10. www.ama-assn.org/resources/doc/code-
Review
283
