Upload
neviah
View
59
Download
0
Tags:
Embed Size (px)
DESCRIPTION
Ethics Influenza vaccines Healthcare workers. Johan Bester ( MBChB , Mphil Applied Ethics) Department of Family Medicine, University of Calgary. Is there a shift?. Many hospitals and states in the US have mandatory policies. Is there a shift?. - PowerPoint PPT Presentation
Citation preview
EthicsInfluenza vaccines Healthcare workersJohan Bester (MBChB, Mphil Applied Ethics)Department of Family Medicine, University of Calgary
Is there a shift?• Many hospitals and states in the US have mandatory policies
Is there a shift?• Many hospitals and states in the US have mandatory policies• Los Angeles County
Los Angeles County• “Every healthcare worker in an acute care hospital, nursing
facility or intermediate care facility to either receive the influenza vaccination annually, or wear a mask during flu season when in contact with patients.”
British Columbia• Recently passed similar requirement
Pushback• Not accepted by all staff
Pushback• Not accepted by all staff• This differs from other required vaccinations – MMR, Hep B
Objectives• Ethical basis for such requirements
Objectives• Ethical basis for such requirements – THUS:• The usual ethical argument for these requirements
Objectives• Ethical basis for such requirements – THUS:• The usual ethical argument for these requirements• Analyze the argument in light of current evidence
Objectives• Ethical basis for such requirements – THUS:• The usual ethical argument for these requirements• Analyze the argument in light of current evidence• Conclude whether argument is successful
Objectives• Ethical basis for such requirements – THUS:• The usual ethical argument for these requirements• Analyze the argument in light of current evidence• Conclude whether argument is successful• Implications
Caplan’s argument• Professional duty to place patients first, vaccination benefits
patients
Caplan AL. Morality of influenza Vaccine Mandates. Clinical Therapeutics Volume 35, Number 2, 2013
Caplan’s argument• Professional duty to place patients first, vaccination benefits
patients• Duty to do no harm, vaccination prevents harm
Caplan AL. Morality of influenza Vaccine Mandates. Clinical Therapeutics Volume 35, Number 2, 2013
Caplan’s argument• Professional duty to place patients first, vaccination benefits
patients• Duty to do no harm, vaccination prevents harm• Protect the vulnerable, vaccination prevents spread to the
vulnerable
Caplan AL. Morality of influenza Vaccine Mandates. Clinical Therapeutics Volume 35, Number 2, 2013
Caplan’s argument• Professional duty to place patients first, vaccination benefits
patients• Duty to do no harm, vaccination prevents harm• Protect the vulnerable, vaccination prevents spread to the
vulnerable• Obligation to set an example for the public
Caplan AL. Morality of influenza Vaccine Mandates. Clinical Therapeutics Volume 35, Number 2, 2013
Caplan’s argument• Professional duty to place patients first, vaccination benefits
patients• Duty to do no harm, vaccination prevents harm• Protect the vulnerable, vaccination prevents spread to the
vulnerable• Obligation to set an example for the public• Voluntary measures failed to ensure adequate vaccination
Caplan AL. Morality of influenza Vaccine Mandates. Clinical Therapeutics Volume 35, Number 2, 2013
Caplan’s argument• Professional duty to place patients first, vaccination benefits
patients• Duty to do no harm, vaccination prevents harm• Protect the vulnerable, vaccination prevents spread to the
vulnerable• Obligation to set an example for the public• Voluntary measures failed to ensure adequate vaccination• Mandatory vaccination policies increase vacc rates
Caplan AL. Morality of influenza Vaccine Mandates. Clinical Therapeutics Volume 35, Number 2, 2013
Caplan’s argument• Professional duty to place patients first, vaccination benefits
patients• Duty to do no harm, vaccination prevents harm• Protect the vulnerable, vaccination prevents spread to the
vulnerable• Obligation to set an example for the public• Voluntary measures failed to ensure adequate vaccination• Mandatory vaccination policies increase vacc ratesTHUS: Ethical to have a mandatory vaccination policy
Caplan AL. Morality of influenza Vaccine Mandates. Clinical Therapeutics Volume 35, Number 2, 2013
Zimmerman’s argument• Vaccinating HCW benefits patients, prevents harm, and has
low risk of harm
Zimmerman RK. Ethical analyses of institutional measures to increase health care worker influenza vaccination rates. Vaccine 31 (2013) 6172-6176
Zimmerman’s argument• Vaccinating HCW benefits patients, prevents harm, and has
low risk of harm• Beneficence and non-maleficence trump personal autonomy
for HCW in this case
Zimmerman RK. Ethical analyses of institutional measures to increase health care worker influenza vaccination rates. Vaccine 31 (2013) 6172-6176
Zimmerman’s argument• Vaccinating HCW benefits patients, prevents harm, and has
low risk of harm• Beneficence and non-maleficence trump personal autonomy
for HCW in this case• Best way to prevent harm is vaccinating HCW; other measures
may not be feasible (eg work absence or neg press ventilation)
Zimmerman RK. Ethical analyses of institutional measures to increase health care worker influenza vaccination rates. Vaccine 31 (2013) 6172-6176
Zimmerman’s argument• Vaccinating HCW benefits patients, prevents harm, and has
low risk of harm• Beneficence and non-maleficence trump personal autonomy
for HCW in this case• Best way to prevent harm is vaccinating HCW; other measures
may not be feasible (eg work absence or neg press ventilation)• Mandatory programs with infect control measures for non-
compliance ensures best vaccination coverage
Zimmerman RK. Ethical analyses of institutional measures to increase health care worker influenza vaccination rates. Vaccine 31 (2013) 6172-6176
Zimmerman’s argument• Vaccinating HCW benefits patients, prevents harm, and has
low risk of harm• Beneficence and non-maleficence trump personal autonomy
for HCW in this case• Best way to prevent harm is vaccinating HCW; other measures
may not be feasible (eg work absence or neg press ventilation)• Mandatory programs with infect control measures for non-
compliance ensures best vaccination coverage• This also provides a way to opt-out for those with objections –
wear a mask the whole flu season
Zimmerman RK. Ethical analyses of institutional measures to increase health care worker influenza vaccination rates. Vaccine 31 (2013) 6172-6176
The Argument • Significant illness/burden of disease
The Argument • Significant illness/burden of disease• HCW vaccination prevents spread to patients
The Argument • Significant illness/burden of disease• HCW vaccination prevents spread to patients• High rate HCW vaccination lowers M&M in patients
The Argument • Significant illness/burden of disease• HCW vaccination prevents spread to patients• High rate HCW vaccination lowers M&M in patients• Voluntary programs – low rate HCW vaccination
The Argument • Significant illness/burden of disease• HCW vaccination prevents spread to patients• High rate HCW vaccination lowers M&M in patients• Voluntary programs – low rate HCW vaccination• Duty to benefit and to do no harm
The Argument • Significant illness/burden of disease• HCW vaccination prevents spread to patients• High rate HCW vaccination lowers M&M in patients• Voluntary programs – low rate HCW vaccination• Duty to benefit and to do no harm• Professional duty limits HCW autonomy/rights
The Argument • Significant illness/burden of disease• HCW vaccination prevents spread to patients• High rate HCW vaccination lowers M&M in patients• Voluntary programs – low rate HCW vaccination• Duty to benefit and to do no harm• Professional duty limits HCW autonomy/rightsThus: Justified to impose program of mandatedInfluenza vaccination on HCWOpt-out: wear a mask during flu season
An Argument:• Premise 1• Premise 2 Conclusion: Follows from premise 1 and 2
An Argument:• Premise 1• Premise 2 Conclusion: Follows from premise 1 and 2
Examining an argument:Are the premises true?Is the logic sound?
Important premises in The Argument• Influenza is an important public health problem with
significant mortality and morbidity
Important premises in The Argument• Influenza is an important public health problem with
significant mortality and morbidity• Vaccination is very successful in limiting spread and impact
Important premises in The Argument• Influenza is an important public health problem with
significant mortality and morbidity• Vaccination is very successful in limiting spread and impact• Vaccinating HCW provides protection to patients
Important premises in The Argument• Influenza is an important public health problem with
significant mortality and morbidity• Vaccination is very successful in limiting spread and impact• Vaccinating HCW provides protection to patients• Vaccination has an acceptable risk of harm
Important premises in The Argument• Influenza is an important public health problem with
significant mortality and morbidity• Vaccination is very successful in limiting spread and impact• Vaccinating HCW provides protection to patients• Vaccination has an acceptable risk of harm• Masks are effective(preventing spread in unvaccinated)
Influenza is important• Seems to be true; does seem to have significant M&M
Influenza is important• Seems to be true; does seem to have significant M&M• Exact burden of disease not known
Influenza is important• Seems to be true; does seem to have significant M&M• Exact burden of disease not known• Part of larger problem “Influenza-like-illness”
Influenza is important• Seems to be true; does seem to have significant M&M• Exact burden of disease not known• Part of larger problem “Influenza-like-illness”• Don’t routinely test those with ILI for influenza
Influenza is important• Seems to be true; does seem to have significant M&M• Exact burden of disease not known• Part of larger problem “Influenza-like-illness”• Don’t routinely test those with ILI for influenza• Pub Health Canada reported 3,450 hospitalizations and 189
deaths in their report 2-8 March 2014
Influenza is important• Seems to be true; does seem to have significant M&M• Exact burden of disease not known• Part of larger problem “Influenza-like-illness”• Don’t routinely test those with ILI for influenza• Pub Health Canada reported 3,450 hospitalizations and 189
deaths in their report 2-8 March 2014• Mathematical models say 2000-8000 deaths each year
Influenza is important• Seems to be true; does seem to have significant M&M• Exact burden of disease not known• Part of larger problem “Influenza-like-illness”• Don’t routinely test those with ILI for influenza• Pub Health Canada reported 3,450 hospitalizations and 189
deaths in their report 2-8 March 2014• Mathematical models say 2000-8000 deaths each year• May be more, may be less.
Influenza is important• Can accept this, with proviso – morbidity and mortality not
exactly known
Vaccine is very effective • “Vaccine is very successful in limiting the spread and impact of
influenza.”
Vaccine is very effective • Bad year = 44% effective (95% CI 23% to 59%)• Good year = 73% effective (95% CI 54% to 84%)
Jefferson T et al. Vaccines for preventing influenza in healthy adults (Review). Cochrane Database of Systematic Reviews, Issue 6, 2013
Vaccine is very effective • Bad year = 44% effective (95% CI 23% to 59%)• Good year = 73% effective (95% CI 54% to 84%)• Results of review: Influenza vaccination had modest effect in
time off work and limiting influenza duration.
Jefferson T et al. Vaccines for preventing influenza in healthy adults (Review). Cochrane Database of Systematic Reviews, Issue 6, 2013
Vaccine is very effective • Bad year = 44% effective (95% CI 23% to 59%)• Good year = 73% effective (95% CI 54% to 84%)• Results of review: Influenza vaccination had modest effect in
time off work and limiting influenza duration. • No evidence for reducing complications of ILI or transmission
Jefferson T et al. Vaccines for preventing influenza in healthy adults (Review). Cochrane Database of Systematic Reviews, Issue 6, 2013
Vaccine is very effective • No impact on influenza mortality by raising vaccine coverage
rates• Even rates up to 65% made no difference• Observational studies have substantially overestimated benefit
of influenza vaccination
Simonsen et al. Impact of the Influenza Vaccination on the Seasonal Mortality in the US Elderly Population. Arch Intern Med 2005;165:265-272
Vaccine is very effective • Vaccine “modest” in over 65’s• Some data that vaccinating children prevents spread to
household members• Thus, focusing on “super-spreaders”
World Health Organization. Vaccines against influenza WHO position paper - November 2012. Weekly epidemiological record. No. 47,2012,87,461-476
Vaccine is very effective • “Vaccine is very successful in limiting the spread and impact of
influenza.”
Vaccine is very effective • “Vaccine is very successful in limiting the spread and impact of
influenza.”• Would have to dispute this premise. Evidence of moderate
efficacy with modest benefit.
Vaccinating HCW protects pt’s
“Vaccinating healthcare workers provides protection to patients”or “Vaccinating healthcare workers prevents harm to patients”
Possibly the key premise.
Vaccinating HCW protects pt’s
Question 1: What is a healthcare worker?
Vaccinating HCW protects pt’s
Question 1: What is a healthcare worker?
Question 2: What is the evidence for this?
Vaccinating HCW protects pt’s
Many ethical writers employ “The Argument”
Vaccinating HCW protects pt’s
Many ethical writers employ “The Argument”Refer to 1 or more of 3 studies:
1) Potter et al. Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients. Journal of Infectious Diseases 1997;175(1):1–6.
2) Carman et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in longterm care: a randomised controlled trial. Lancet 2000;355(9198):93–7.
3) Hayward et al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomisedcontrolled trial. BMJ 2006;333(7581):1241
Vaccinating HCW protects pt’s
Two interesting facts about these 3 articles:
Vaccinating HCW protects pt’s
Two interesting facts about these 3 articles:
1) All done in nursing home/care home setting
Vaccinating HCW protects pt’s
Two interesting facts about these 3 articles:
1) All done in nursing home/care home setting
2) All 3 have been included in a meta-analysis
Thomas RE, Jefferson T, Lasserson TJ. Influenza vaccination for healthcare workers who care for people aged 60 or older living in long-term care institutions (Review). The Cochrane Database of Systematic Reviews, Issue 7, 2013
Vaccinating HCW protects pt’s
Cochrane review found:- No evidence that vaccinating HCW prevents laboratory-proven
influenza of its complications in LTC- No evidence that supports mandatory vaccination of HCW- These three studies were at some risk of bias, and none
showed positive protection to patients- High quality RCT is needed
Thomas RE, Jefferson T, Lasserson TJ. Influenza vaccination for healthcare workers who care for people aged 60 or older living in long-term care institutions (Review). The Cochrane Database of Systematic Reviews, Issue 7, 2013
Vaccinating HCW protects pt’s
“Vaccinating healthcare workers provides protection to patients”or “Vaccinating healthcare workers prevents harm to patients”
Vaccinating HCW protects pt’s
“Vaccinating healthcare workers provides protection to patients”or “Vaccinating healthcare workers prevents harm to patients”
- No evidence of this
Vaccinating HCW protects pt’s
“Vaccinating healthcare workers provides protection to patients”or “Vaccinating healthcare workers prevents harm to patients”
- No evidence of this- Not clear how to define HCW
Vaccinating HCW protects pt’s
“Vaccinating healthcare workers provides protection to patients”or “Vaccinating healthcare workers prevents harm to patients”
- No evidence of this- Not clear how to define HCW - Vaccine moderately effective, many HCW stillsusceptible despite vaccine
Low risk of harm• Minor side-effects• Only serious ones: AnaphylaxisGuillain-Barre (possible link, less than 1 in a million)
THUS: very low risk of harm from getting vaccine
Masks are effective• “Using masks is effective to prevent spread in the
unvaccinated”
Masks are effective• Is there evidence?• Study shows that masks do not stop influenza droplets.
(Neither does cough etiquette)
Zayas G, Chiang MC, Wong E, MacDonald F et al. Effectiveness of cough etiquette maneuvers in disrupting the chain of transmission of infectious respiratory diseases. BMC Public Health 2013, 13:811
Masks are effective• Conundrum:
Masks are effective• Conundrum:• If masks work – we should all use them!
Masks are effective• Conundrum:• If masks work – we should all use them!• Same justification as The Argument.
Masks are effective• Conundrum:• If masks work – we should all use them!• Same justification as The Argument. • Vaccine only provides protection to some; thus ALL should
mask
Masks are effective• Conundrum:• If masks work – we should all use them!• Same justification as The Argument. • Vaccine only provides protection to some; thus ALL should
mask • If masks don’t work – why use them as alternative to
vaccination?
Masks are effective• Conundrum:• If masks work – we should all use them!• Same justification as The Argument. • Vaccine only provides protection to some; thus ALL should
mask • If masks don’t work – why use them as alternative to
vaccination?• Is this punitive? Surely there are more effectivepunitive measures?
Masks are effective• “Using masks is effective to prevent spread in the
unvaccinated”
Masks are effective• “Using masks is effective to prevent spread in the
unvaccinated”• Masks are not effective
Masks are effective• “Using masks is effective to prevent spread in the
unvaccinated”• Masks are not effective• Unreasonable to use as punitive measure. No place in
contemporary healthcare.
Masks are effective• “Using masks is effective to prevent spread in the
unvaccinated”• Masks are not effective• Unreasonable to use as punitive measure. No place in
contemporary healthcare.• If it was effective, everyone would have to use masks,
vaccinated or not
The Argument • Burden of disease uncertain, but significant
The Argument • Burden of disease uncertain, but significant• Vaccine only moderately effective.
The Argument • Burden of disease uncertain, but significant• Vaccine only moderately effective. • No evidence of benefit to patients or preventing harm by
vaccinating HCW
The Argument • Burden of disease uncertain, but significant• Vaccine only moderately effective. • No evidence of benefit to patients or preventing harm by
vaccinating HCW• Low risk of harm - acceptable
The Argument • Burden of disease uncertain, but significant• Vaccine only moderately effective. • No evidence of benefit to patients or preventing harm by
vaccinating HCW• Low risk of harm – acceptable• Masks don’t work. If they did everyonewould have to use them. Unreasonable to usepunitive measures.
The Argument • Burden of disease uncertain, but significant• Vaccine only moderately effective. • No evidence of benefit to patients or preventing harm by
vaccinating HCW• Low risk of harm – acceptable• Masks don’t work. If they did everyonewould have to use them. Unreasonable to usepunitive measures.THUS:The Argument is not successful.
Other ethical considerations• Unjustified use of power; Freedom a cherished value, need
strong ethical reason to overrule
Other ethical considerations• Unjustified use of power; Freedom a cherished value, need
strong ethical reason to overrule• Money/time spent on mandatory vaccination could be spent
elsewhere – justice in distribution of finite resources
Other ethical considerations• Unjustified use of power; Freedom a cherished value, need
strong ethical reason to overrule• Money/time spent on mandatory vaccination could be spent
elsewhere – justice in distribution of finite resources• Industry’s influence. Studies and some ethics writers.
Other ethical considerations• Unjustified use of power; Freedom a cherished value, need
strong ethical reason to overrule• Money/time spent on mandatory vaccination could be spent
elsewhere – justice in distribution of finite resources• Industry’s influence. Studies and some ethics writers.• Industry: urgently need better vaccine
Other ethical considerations• Unjustified use of power; Freedom a cherished value, need
strong ethical reason to overrule• Money/time spent on mandatory vaccination could be spent
elsewhere – justice in distribution of finite resources• Industry’s influence. Studies and some ethics writers.• Industry: urgently need better vaccine• Too much focus on moderate efficacy vaccine may dilute public confidence invery effective vaccines
Conclusion• Mandated HCW influenza vaccinations seem unjustified
Conclusion• Mandated HCW influenza vaccinations seem unjustified• Can recommend influenza vaccine to HCW and pt’s –
moderate efficacy and very low risk of harm
Conclusion• Mandated HCW influenza vaccinations seem unjustified• Can recommend influenza vaccine to HCW and pt’s –
moderate efficacy and very low risk of harm• Should focus efforts on “super-spreaders”
Conclusion• Mandated HCW influenza vaccinations seem unjustified• Can recommend influenza vaccine to HCW and pt’s –
moderate efficacy and very low risk of harm• Should focus efforts on “super-spreaders”• Review the influence of industry
Conclusion• Mandated HCW influenza vaccinations seem unjustified• Can recommend influenza vaccine to HCW and pt’s –
moderate efficacy and very low risk of harm• Should focus efforts on “super-spreaders”• Review the influence of industry• We need a better vaccine. Is this perhaps where moral weight
lies?