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106 thoughts on “Influenza Vaccine Mandates

  1. Ah, the Ypsitucky moniker has been controversial of late. A big dispute over whether the Ypsitucky Bluegrass festival should change it’s name.

    I’m not surprised you haven’t heard Pollockcentric, since I recently made it up when describing to my husband the tendency of people to focus on a few very famous artists rather than broad range of diverse artists within that style. Jackson Pollock being one of those very famous artist. I think it was too obscure a reference without the context of the conversation. That is a flaw of mine.

    If they had a vaccine for that I’d be sure to get it, whether it caused 1-2 days of “flu-like” symptoms or not.

  2. rork says:

    I had not realized a week or two ago, but my institution (U of Michigan) has adopted a policy where if you fail to get the flu vaccination, you will be obliged to wear a face mask when entering patient rooms or having other patient interactions for several months coming up. They make you fill out a declination form too.

    Blurb of Sep 23 (second link of http://www.med.umich.edu/u/flu/) says “dozens of other health care institutions nationwide” are also doing it, and there are more educational materials than ever before there too. I see commenter Zetetic reports this tactic for Washington state above.

    If you do get the jab, they put a sticker showing a virus particle with red slashed circle over it on the ID card. Sounds like a dumb “gold star” perhaps, but it’s conspicuous when you wear the card (like you are supposed to) and absence of the sticker identifies non-complying members of the herd – even for research nerds like me who would probably never need to wear that mask. Opportunity to get vaxed has been more than ever too.

    I hope there are ongoing studies of the effectiveness of the strategy, not just in getting folks vaxed, but in reducing flu in the patients and the larger community, cause it sure would be sweet to have some data and have it look good.

  3. Reductionist Nurse says:

    @ rork

    There are some studies out there that support this for reducing mortality, from what I originally posted:

    http://www.ncbi.nlm.nih.gov/pubmed/8985189
    Potter J, Stott DJ, Roberts MA, et al. Influenza vaccination of healthcare workers in long-term care hospitals reduces the mortality of elderly patients.
    J Infect Dis. 1997;175(1): 1-6.

    http://www.ncbi.nlm.nih.gov/pubmed/10675165
    Carman WF, Elder AG, Wallace LA, et al.
    Effects of influenza vaccination of healthcare workers on mortality of elderly people in longterm care: a randomised controlled trial.
    Lancet. 2000;355(9198):93-97.

  4. rork says:

    I have (now) read those papers and the Cochrane report, and despite being wildly enthusiastic about flu vax mandates, do think the critics have a point.
    The commentary by Karl Nicholson in the Lancet does seem a fair summary (http://www.ncbi.nlm.nih.gov/pubmed/10675161). This part about the Carman paper mostly, but the Potter paper has problems too. Nicholson’s discussion is better than that in the Carmen paper itself, where they are ducking the issue a bit.

    “The patients in hospitals where HCWs were routinely offered vaccine and those in hospitals where they were not were well matched for age and sex, but less well for Barthel scores. Vaccination rate was higher among patients in vaccine hospitals than in non-vaccine hospitals. The two groups of hospitals were similar in proportions of patients with routine nose and throat swabs that were positive for influenza. Carman and colleagues found that the odds ratio of all-cause mortality was significantly decreased (0·58 [95% CI 0·40–0·84]) by vaccination of HCWs, and a similar result was seen in several statistical models, except for the model that adjusted for patient’s vaccination status, Barthel score, age, and sex. No data about influenzal illness, lower-respiratory-tract infection, or deaths associated with pneumonia were presented for patients. Similarly, no sickness or virological data were collected from HCWs. Thus, it is unclear whether the reduction in mortality associated with vaccination of HCWs in the unadjusted analysis is due to prevention of influenza.
    Although vaccination of HCWs may benefit both HCWs and patients, more robust data are needed-ideally from randomised double-blind placebo controlled trials. These studies should be powered to show reductions in virologically confirmed cases of influenza and its complications (in patients and HCWs) and in HCW absenteeism. These data, along with favourable health-economic analyses, could provide convincing evidence to encourage health-care purchasers and HCWs to change policy, practice, or both.”

    Mainly I was distressed by no differences in lab-confirmed influenza, in a study well-designed to detect it. Maybe Nicholson (and in the Cochrane report, T. Jefferson) have some biases of their own, but when they make that point, they seem correct. I immediately would agree that overall death is a compelling and easily quantitated endpoint – I work in cancer where we have lots of anxiety when using anything less, since you can easily fool yourself with “weaker” endpoints – but it does not seem impossible to me that this difference could have come about by some other indirect effects of the (here, non-blinded) intervention. For example the vaxing campaigns themselves might lead to high infection-control awareness – it gets people talking. Like all of you, I will take any placebo effect in my favor that I can get, but that’s not an effect of the contents of the jab.

    I’m getting heat when debating these issues in my local area lately, where mandates have been recently instituted, and folks are waving Cochrane around, and sometimes they sound lucid (mama, don’t you faint). It’s why I was reviewing. Before I was wanting studies comparing places with and without mandates, but now worry that this will be open to criticism that differences there might not be due to the contents of the vaccine. Maybe Nicholson’s call for double-blind placebo controlled studies is warranted. (I do think mandates will spread despite that, since it’ll save money, and look good to patients, whether the effect is placebo or not, but I really want a science to leave scorched earth here.)

    Just to be clear: I consider it my (and your!) ethical responsibility to get flu vax, and that would be true no matter what work I did. I am frightened by worst-case scenario of outbreak, not just the averages. These are merely worries of a statistician applying skepticism on himself, on one very particular point.

  5. rork says:

    More after thinking – t’ain’t ethical. Shazbat.

    I don’t see how to make a placebo controlled trial like Nicholson is asking for (in health care delivery settings) ethical. A common conundrum. Not just cause of the health care workers, but also since I think I want the patients to be consented, which seems impossible.

    Maybe the Hutterite vaccine study from 2010 (PMID:20236548) and such will have to serve as some of the evidence.

    I’m no lawyer, but word is that hospitals can have mandates calling for immunity to many infections, perhaps regardless of evidence of efficacy. I worry more about units of governments having mandates, and what the level of evidence for (expected) harm has to be for the people to force you to do something. The answer to that may frighten me if it’s as scientific as the rest of our legal system. (Yeah, I like B. Russell, not just cause of his math book centennial.)

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