Obligatory vaccination against influenza for Brazilian health professionals

We aim to encourage the reflection and productive discussion over the theme, not only in the academia, but overall, in our scientific societies, professional associations and those responsible for public policies in the sector

It is unnecessary to emphasize the role of vaccines controlling, reducing, eliminating and eradicating infectious diseases in the world and the time is extraordinarily proper to discuss the obligation to immunize against the flu, since in 2018 we celebrate the Spanish Flus 100th birthday, responsible for 50 to 100 million deaths. Currently, to make matters worse, experts warn the H5N1 and H7N9 viruses are possible origins for a new pandemic¹. In turn, the discussion of obligatory immunization is very old, dating back to 1853, when England approved a bill for obligatory vaccination against smallpox, and later in the same century, the first anti-vaccine movement emerged. Vaccination rates in risk groups are dropping in the entire world, re-emerging outbreaks and epidemics of infectious preventive diseases and anti-vaccination groups have much to be blamed.

As a result, it is said that Theres a war going on out there – a quiet, deadly war^2, where health professionals are called to fight for their important role in this confrontation of knowledges, arguments and convincement. Vaccines are held as victims of their own success and the success of global vaccination relies in maintaining the populations confidence in the immunization programs, in those responsible for public policies, in the health professionals enrollment and recommendations to their patients, since they are the most trustworthy source of information³. However, how could they recommend their patients to vaccinate if they themselves do not vaccinate? The vaccination against influenza rates are tragically inexpressive in the entire world, mainly with coverages below 50%⁴, inclusive Brazil⁵. The non-vaccination causes vary: a. do not want to get vaccinated; b. the vaccine is unnecessary; c. the vaccine is not effective; d. the vaccine can cause side effects; e. the vaccine could cause influenza; f. the risk of infection is very low; g.  time and place for vaccination are inappropriate. h. Fear of aversion for needles⁶. This way we conclude that voluntary adherence policy for these workers in the war against influenza is ineffective to increase vaccination rates through the years. The war is declared and the winner will be the one that uses most strict rules to combat the mortal influenza virus and the army of anti-vaccination movements.

This way, in this borderless war against influenza, we propose to include a scientifically effective, cheap and diffusing weapon, as is the obligatory annual vaccination for health professionals. Obligatory vaccination exists in first-world countries for a long time and is recommended by numerous health organizations, especially North-American organizations (College of Physicians, Academy of Pediatrics, Infectious Diseases Society, Society of Healthcare Epidemiology, National Safety Foundation and many others)⁷. For some years, hospitals condition health professionals employment to annual vaccination against influenza, disregarding philosophical or religious excuses. In the USA, every year, from 10% to 20% of health professionals acquire influenza and are able to transmit it to colleagues and patients and around 10% of nosocomial infections are caused by them⁷. Using this effective weapon, the battles have been successful, reaching vaccination levels above 95%, although this is just one of the many battles to be fought. What about us, third world countries, what will we do? Not taking this war seriously and pretending everything is ok? Keeping the same autonomy defense posture while our children and elders die?

From an ethical perspective, the obligation debate focuses in the old dilemma between respect for autonomy and the common well-being. Bioethicists who claim that, generally, depending on the etiological agent and epidemic circumstances, the collective interest should overcome the individuals autonomy, in name of social justice and solidarity principles. Caplan, one of the most eminent bioethicists, while defending this tool in the vaccination against influenza war, in opposition to the autonomy principle, asks: Rights? What rights could these be? The right to ignore all vaccine safety and efficacy evidences, perpetuating a public and irrational fear of the best protection for babies, pregnant women, elder and fragile ones against influenza? These rights? If this behavior is already widely used in developed countries, it should be – with great obviousness – defended in countries where the number of vulnerable and/or malnourished/undernourished individuals is much greater, as in Brazil, making them immunologically susceptible to the agents of seasonal and epidemic influenza.

Compulsory vaccination is an ethical and moral imperative, since the health professionals ethical principles put the patients interests in first place (beneficence), not harming their patients (non-maleficence) and protecting the vulnerable (justice). In addition, their moral duty to act as an example for the public, avoiding to reinforce the anti-vaccination feelings. The cultural issue is the hardest to overcome for historical reasons and our societys predominance of my rights value over responsibility and commitment to others. It is vital to be successful that health professionals fully understand the ethical and moral reasons for such proposition, and putting in practice for such, extensive educational programs⁸.

In conclusion, we aim to encourage the reflection and productive discussion over the theme, not only in the academia, but overall, in our scientific societies, professional associations and those responsible for public policies in the sector. It is vital that the Academia, who has the peoples trust, clearly and permanently opposes to the social medias fake news in order to health professionals to stand in the ethical side of the trench. As for us, researchers and professors in the field, we must support this chain in this secular war, encouraging health attention institutions to provide appropriate conditions and encourage their health workers to the noble act of vaccination against influenza. In order to avoid deaths in the next season, tomorrow is today and today is to take new combat strategies to fight this deaf and unfair war, with the primary and exemplar measure of compulsory vaccination of health professionals in Brazil.

References

1. The European Scientific Working Group on Influenza (ESWI). Report of The Fourth European Influenza Summit. Brussels, 2015. Available from: http://eswi.org/flusummit/. [Accessed 2017 12 04]
2. Offit PA. Deadly choices. How the anti-vaccine movemente threatens us all. New York: Basic Books; 2015.
3. Schwartz JL, Caplan AL, editors. Vaccination ethics and policy. An introducing with readings. Cambridge: The MIT Press; 2017.
4. Weber DJ, Rutala WA. Vaccines for health care personnel. In: Plotkin AS, Orenstein WA, Offit PA, editors. Vaccines. 6^th ed. New York: Elsevier Saunders; 2015.
5. Schlemper Junior BR, Beltrame V, Hellmann F. The Ethical Duty of Physicians to Strengthen their Own Immunization and Childhood Vaccination. In: Morales-González JA, Nájera EA. Bioethics. InTechOpen, 2018 (no prelo). ISBN: 978-953-51-6051-9.
6. Stewart AM, Cox MA, O’Connor ME. Influenza Vaccination of the Health Care Workforce: A Literature Review. The George Washington University. School of Public Health and Health Services. Spring 2011.
7. Poland G, Jacobson RM, Tilburt J, Wicker S. Mandating Influenza Vaccination of Health Care Workers: A Patient Safety, Quality of Care, and Public Trust Issue. Annals of Respiratory Medicine. 2011;2:(1)1-6.

8. Caplan AL. The art of medicine. Time to mandate influenza vaccination in health-care workers. Lancet. 2011;378 July 23:310-311.…