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Health Care Workers, Flu Vaccines, and Work Place Discrimination

dorit-reissGuest blog by Dorit Rubinstein Reiss. Dr. Reiss is a Professor of Law at the University of California Hastings College of  the Law in San Francisco, CA. Dorit writes extensively in law journals about the social and legal policies of vaccination. This article discusses employer and employee rights regarding vaccination requirements in healthcare institutions.

In a previous post, I described a New Jersey Court of Appeals case in which Ms. Valent was denied unemployment benefits because she refused to be vaccinated against the flu without claiming the religious exemption. I explained that the hospital was not constitutionally required to provide a religious exemption, and that doing so was a losing proposition from a hospital’s point of view.

In the comments following that post, it was correctly pointed out to me that there is another claim I should have addressed: a claim that the hospital was required to provide a religious exemption under the Civil Rights Act of 1964. This did not come up in the case itself: the court reinstated the nurse’s unemployment benefits on constitutional grounds, though problematic constitutional grounds. But since I argue that hospitals should not offer a religious exemption, I need to address whether the hospital is required, under Title VII, to offer an accommodation. 
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Why we vaccinate–mandatory flu vaccines reduce risk of hospitalization

flu-shot-smiley-faceAccording to the unsurprising results reported in a new study, published in the Morbidity and Mortality Weekly Report, in areas where laws mandate that children receive a seasonal flu vaccination, before entering preschool or day care, the rate of flu-related hospitalizations drops significantly. In this study, after Connecticut enacted a law that mandated the vaccine, the rate of children requiring hospitalization because of the flu declined by 12%.

Connecticut’s regulation for flu vaccination (pdf), which took effect in 2010, increased the uptake of childhood flu vaccinations from 67.8% to 84.1%. According to Dr. James Hadler, the lead researcher for the study, “That difference, we feel, has resulted in children attending daycare being better protected against influenza and its severe complications.”

Even though Connecticut’s regulations for flu vaccination allows for some exemptions (the child has a scheduled appoint for the shot soon after the start of school, medical contraindication, or religious belief), it’s obvious that the effort was highly successful in driving up the level of uptake of the flu vaccination, a vaccine that is often ignored by parents for occasionally odd reasons.

Since 2010, the U.S. Centers for Disease Control and Prevention (CDC) has recommended that everyone older than six months should get a flu shot every year. Unfortunately, only New Jersey and New York City mandate the flu vaccine (along with all other vaccines recommended by the CDC at that age group). With this evidence, it is possible that other states will include the flu vaccine in the vaccination requirements for children entering school.

Parents seem to think that the flu is not very dangerous, so they tend to ignore the flu shot, even if they are strongly pro-vaccine for almost all of the other vaccines available for themselves or their children. Sadly, this year’s flu season is actually taking an larger toll on younger and middle-aged Americans, since so many of them neglect to get the vaccine. The influenza strain commonly known as “swine flu” is killing young and healthy people who typically don’t think they need to worry about this illness.

There is a belief that the flu is only dangerous to the very young, the very old or those with chronic diseases. However, many flu pandemics are not that particular about what age group is most affected. The infamous Spanish Flu Pandemic of 1918 is a case in point. Over 99% of the deaths were in individuals under the age of 65, and more than 50% of the deaths were in young adults, 20-40 years old.

Even though it’s late in the flu season, it’s not too late to get the flu shot, whether adult or child. And when the 2014 flu season starts, make sure you’re vaccinated then.

Oh, one more thing. This type of actual retrospective epidemiological data provides evidence that the flu vaccine is highly effective. Another trope of the antivaccination cult circling the drain of pseudoscience.

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Vaccines save lives–30K US adults die annually of preventable diseases

President Obama getting his flu shot.

President Barack Obama receiving his flu shot.

One of the consistent tropes of the antivaccination cult is that vaccine preventable diseases are not that dangerous, so why take the risk (mostly minor, although not in the cult’s mind) for little benefit. Except for one tiny issue–vaccine preventable diseases kill. Recent studies have shown that an average of approximately 30,000 adults die of these diseases every year, about 95% of the total deaths from vaccine preventable diseases.

Researchers at the University of Colorado at Denver surveyed USA physicians regarding adult vaccine delivery. The results and analysis were recently published in the Annals of Internal Medicine. The researchers found that rates for adult vaccination remain quite low.

Some of the more interesting results from the study were:

  • Only 62% of adults above the age of 65 received the pneumococcal vaccine.
  • Only 65% of adults in the same age group received the flu vaccine
  • This group is at high risk of death from pneumonia and flu, and in fact, deaths from these diseases in this age group, makes up a significant portion of vaccine preventable deaths in this group.
  • Physicians also reported significant barriers to providing vaccines to adults including stocking vaccines (pediatric offices are better equipped for vaccine storage) and reimbursement from insurance companies. In addition, some patients cannot afford the cost of the vaccines if they are not reimbursed by a third party payer. According to the study authors, “Physicians in smaller, private practice often assume more risks from stocking expensive vaccine inventories and may be particularly affected by these financial barriers.”
  • The authors noted the Affordable Care Act addresses the cost barrier to vaccination for privately insured patients by requiring insurers to cover recommended vaccines with no co-pay when delivered by in-network providers. 

Setting aside the embarrassment that the USA doesn’t make vaccines easier to get for those who cannot afford them, it is clear that the low rates of adult vaccination has lead to higher rates of vaccine-preventable illnesses and death. Saving 30,000 lives through proper vaccination and following the new adult vaccine schedule (see figure below) will help reduce that number quickly.

©Centers for Disease Control and Prevention, 2014. Current adult vaccination schedule.

©Centers for Disease Control and Prevention, 2014. Current adult vaccination schedule.

The authors concluded that,

Vaccines provide an important but underutilized opportunity to reduce the burden of vaccine-preventable disease among adults. Although primary care physicians appear motivated to ensure that patients are up to date on vaccinations, many barriers exist. Implementation of system changes, including adopting practices that improve communication between primary care physicians and alternate vaccinators, more widespread use of effective tools (IISs and clinic decision support systems), and removing policy-related barriers, could improve adult vaccination in the United States.

Vaccines really do save lives.

 Visit the Science-based Vaccine Search Engine.

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Potential apocalyptic influenza pandemics-H2N2

Posting at the Brooklyn Navy Yard during the 1918 Spanish Flu pandemic.

Posting at the Brooklyn Navy Yard during the 1918 Spanish Flu pandemic.

From January 1918 through December 1920, humanity suffered through the one of the worst pandemics of infectious disease for the last 100 years or so. The world was hit by what was called the Spanish Flu (not because it started there, but because news of the flu was censored in most countries involved in World War I, but Spanish news wasn’t censored, so it appeared that Spain was being devastated by the disease). According to conservative estimatesdespite how antivaccination cultists portray flu pandemic estimates, nearly 500 million people worldwide were hit with this flu, and somewhere between 50 and 100 million people died, nearly 5% of the world population at the time. Moreover, the majority of deaths were amongst healthy young males, not, as antivaccination tropes often claim, just to those who are sick and weak already.

A recent article called the 1918 flu pandemic the “mother of all pandemics,” and not just for some rhetorical, literary effect. In fact, the 1918 flu, an H1N1 subtype, is the mother of nearly all subsequent influenza A (for avian) pandemics since 1918–in other words, the original H1N1 subtype has mutated into nearly all of the other subtypes of avian flu.

For example, H2N2 influenza A viruses, which derived from a mutation in the H1N1 subtype while it circulated in birds, were the cause of the 1957-1958 pandemic, which killed nearly 1.5 million people worldwide. Currently, the H2N2 subtype has disappeared from humans, but it persists in wild and domestic birds. Claims that the subtype is extinct are premature.

Unfortunately, a potentially dangerous reemergence of the H2N2 subtype in humans continues to be a significant threat due to the absence of immune system memory of the H2N2 within the adaptive immune system of individuals under the age of 50. In other words, those individuals who were born after 1963, have no immunity to H2N2, and may be susceptible to it.

Researchers examined the presence and potential risk of over 22 strains of avian H2N2 viruses isolated from domestic and wild birds over the past 60 years. Most of the strains replicated in mammalian cell culture, and three transmitted to ferrets, usually used a model for human infection from new flu viruses. The H2N2 virus remains highly pathogenic for mammals, including humans, and there continues to be a major risk for quickly moving from the avian reservoir to humans

The point of this story is not to say that a global apocalyptic event is just around the corner, but it could be. It’s just that if you speak with any infectious disease specialist, their greatest fears are HIV/AIDS and influenza, not some obscure novel pathogen arising quickly then dying out of existence. The influenza A virus mutates quickly, allowing it to avoid human humoral immune responses, it transmits from other species to humans easily, it spreads quickly, and it can be deadly. As recently as 2009, the H1N1 pandemic killed approximately 150,000-500,000 people worldwide.

Of course, the CDC constantly monitors when the virus jumps from the bird reservoir to humans, and if given enough time, can prepare a vaccine to help prevent it. Let’s hope people are smart enough to get it.

Visit the Science-based Vaccine Search Engine.

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Healthcare worker fist bumps–maybe it’s all about being cool

©ABC, 2014. Donald Faison and Zach Braff give each other a fist bump in the TV show, Scrubs.

©ABC, 2014. Donald Faison and Zach Braff give each other a fist bump in the TV show, Scrubs.

This article is all about fist bumps. And diseases. And bad science.

For the handful of you who are culturally naïve, let’s quickly describe the fist bump itself. It is a greeting, in lieu of a handshake, which is performed when two individuals acknowledge each other with a closed fist gently tapping each other. There are, of course, all kinds of flourishes and embellishments added to a fist bump, which are unique expressions of individuality. I like the hand explosion after a fist bump, but that’s probably uncool.

If you thought fist bumps are a recent cultural creation, you’d be wrong. Apparently, Greek charioteers did it. And motorcycle riders who pulled up next to each other at red lights have been doing it since the 1940′s. The gesture has been relatively popular in the American game of baseball for at least 50 years. President Barack Obama regularly fist bumps instead of offering a handshake, even with his wife, Michelle. Researching this story, I always thought it was modern and fashionable, but I find out it’s antiquated, but possibly still fashionable.

During the 2009 H1N1 flu pandemic, many medical professionals recommended that healthcare workers greet each other with the fist bump with colleagues and patients rather than the traditional handshake. My anecdotal observations are that I’ve done more fist bumps in the last two or three years during visits to hospitals and physicians than I had in my whole life before (which may have included approximately 0 fist bumps , but I’m not cool). I had a 5 day stay in a hospital a couple of years ago, and not one single nurse, physician, surgeon, attending, resident, janitor, or nutritionist shook my hand. Not one. But I certainly got the fist bump every time, even when I extended my hand for a handshake (I was bored in the hospital, so I started to experiment). 
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Student Nurse Perspective: The Flu Vaccine.

Nurses attending to soldiersIngvar Árni Ingvarsson, a student nurse in the UK, wrote an excellent perspective on vaccines from his nursing eyeballs, which he graciously allowed me to re-post here.  

Little intro might be handy for this. This post has been on my mind for a long time now and finally I decided to pull my finger out and actually write it. What is to follow will be a mixture of factual, scientific and anecdotal writings. Because that is the way I roll. I have been itching to write something, anything about vaccinations for a little bit now, but so far decided not to because there are so many out there who do it and do a better job of it then I would dream of, so I’ll list some. Skeptical Raptor, Respectful Insolence, Red Wine & Apple Sauce, Just The Vax and many many more. 

Prior to starting my nursing course I was very much into my slightly alternative medicine. I was on the fence regarding vaccines, not just the flu vaccine but all vaccines. Now that I think back on it I’m not really sure why. It was never really something that I thought about properly until I started my university course. What was probably a turning point for me was the amount of patients over 70 I came across who had to use callipers and wheelchairs because they contracted polio when they were kids. I have never come across a patient under 70 who has had polio. Never. This sort of got me thinking about the importance of vaccination, and if there is one thing that I have learned since starting uni is that evidence is the key.
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Why we vaccinate–the cost of catching the flu

Syringe with moneyThe tropes of the antivaccination horde would be laughable if it weren’t for the seriousness of the diseases that are prevented by vaccines. Even among those people who vaccinate their children for everything, they’ll make up all kinds of lame excuses for not getting the flu vaccine, all easily debunked. And someone will call you a “dumbass” if you use any of those worthless excuses. 

One of the most annoying tropes of the vaccine deniers is that somehow Big Pharma (even though some vaccines are sold by Baby Pharma) is forcing dangerous, expensive, and highly profitable vaccines on the market because Big Pharma is nothing more than greedy, unethical executives sitting in their huge offices figuring out which Ferrari they’re going to purchase next week. Setting aside the fact that most Big Pharma execs are far too conservative to drive a Ferrari, does this even make any sense whatsoever? 

Let’s get this out first. Big Pharma corporations are generally public, and as such, their shareholders expect them to make profits. But corporations don’t generate profits by turning on a cash printing machine, they must invent, develop and manufacture products, distribute it to the market, and do it well enough to actually generate profits to not only pay their shareholders, but also to invest in the next round of invention, development and manufacturing for the next set of products. Big Pharma has an extremely complex relationship with its market because bringing new products to their customers requires a huge investment in resources (from research to engineering to manufacturing). And Big Pharma has a wide variety of customers including the patient, the physician, the hospital, the insurance company (or government versions of insurance, like Medicare), the government and its regulatory arms, and many others.

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Dumb Asses who don’t get the flu vaccine

flu-shot-mythsThe 2013-14 flu season is just getting started, and early data seems to indicate it could be tough one. One of the best ways, if not the only real way, to prevent catching the flu virus is by immunization with the seasonal flu vaccine.

By now, flu vaccines have been delivered to hospitals, physician’s office, health clinics, and government health departments. And it’s time for intelligent, reasonable, and rational people to get their flu shots. We’ve dispensed with many of the myths that are cherished by vaccine refusers, and many reseachers have shown that getting the flu vaccine can improve health outcomes

A couple of years ago, Infectious Disease specialist Dr. Mark Crislip published A Budget of Dumb Asses which righteously states that healthcare workers who refuse to get a flu vaccine are Dumb Asses. Yes, complete and utter Dumb Asses. Even though this broadside against vaccine deniers is about the flu vaccine, it’s all right to search and replace flu with say meningitis, pertussis, measles or anything. And just because it’s about healthcare workers, it’s all right to replace that with your neighbor, co-worker, or some other anti-scientific antivaccination Dumb Ass.

So every few months, I like to resurrect this article, just to remind everyone how much of a dumbass they are if they don’t get the annual flu shot.

Warning: this is funny (unless you’re a vaccine denier, in which case you have no sense of humor, irony or sarcasm, something probably gained by getting vaccinated). So, if you’re reading this list while sipping on coffee, I take no responsibility for damage to your computer, smart phone, or tablet if you snort out your drink. Them’s the rules. 
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Why we vaccinate–because the flu can be deadly to healthy people

flu-shot-coolThe Centers for Disease Control and Prevention has published its most recent weekly report for the current flu outbreak in the United States (note: this link is to a non-static website where the numbers are updated weekly, so they may not match what is posted below). Here’s some of the most important data:

  • 2,622 laboratory-confirmed influenza-associated hospitalizations have been reported since October 1, 2013. This represents a cumulative rate of 9.7 hospitalizations per 100,000 people in the United States.
  • Of the 2,622 influenza-associated hospitalizations that have been reported this season, 61.6% have been in people 18 to 64 years old, much younger than typical flu outbreaks where most flu hospitalizations occur in people 65 and older. This pattern of more hospitalizations among younger people was also observed during the 2009 H1N1 pandemic.
  • Widespread influenza activity was reported by 35 states.
  • Ten pediatric deaths have been reported for the flu since the beginning of the flu season–traditionally the peak numbers for deaths of children from the flu happens in the first three months of the year.

So, based on this information, flu doesn’t just send the elderly or those with chronic diseases to the hospital. Influenza related hospitalizations have hit healthy young adults in higher proportions. And the flu kills children. Despite all the garbage that’s placed on the internet, the black hole of accurate, scientific data, there is only one way to boost your immune system to prevent getting the flu–the seasonal flu vaccine.

In case you believe in some myth about the flu vaccine, here’s some real science about the flu and the flu vaccine for you:

If the science of flu vaccines doesn’t convince you, then you really are a dumbass.

Use the Science-based Vaccine Search Engine.

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Boosting the immune system–sorting science from myth

foods-boost-immune-system

For New Year’s Day, I’m republishing the top 10 articles I wrote in 2013. Well, actually top 9, plus 1 from 2012 that just keeps going.

#8. This article was published on 26 September 2013, and has had nearly 6000 views. This was one of the most difficult articles I’ve ever written. Anyone who thinks that the immune system is so simple that they can make broad proclamations about what does what to the immune system simply lacks any real education in immunology. And only vaccinations can really boost the immune system.

One of the most ubiquitous pseudoscientific claims that I keep hearing from the junk medicine crowd is that this supplement or that food “boosts” the immune system. These type of claims ignore one basic physiological fact: the immune system is a complex interconnected network of organs, cells, and molecules that prevents invasion of the body by hundreds of thousands, if not millions of pathogens every day. And no matter how much individuals try to trivialize how complicated the immune system is by claiming that downing a few tablets of echinacea will boost the immune system to prevent colds (it doesn’t), it doesn’t make it science.

And it isn’t that simple.

Using the Graham Coghill’s Science Red Flags, which are indicators of either bad science or unscientific nonsense (and which I’ve used with respect to GMOs), let’s do a quick review of a few outlandish claims of the junk medicine horde. I just cherry picked a few, because their pseudoscience is not the focus of this article. I don’t have that much time to find all the “immune system” rubbish on the internet!
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