Mandate the shot or not?

Debate over mandated vaccination continues

Voice your opinion, take our informal poll located in the right sidebar. 

What rights do I forfeit to work in health care?

Do health care workers have a "duty" to be vaccinated against seasonal flu? 
The answer to that question is "yes" ccording to the New York Times  who published an article suggesting that health care workers "should know better and anyone". The article cites a recent survey conducted by the CDC and claims that while doctors and nurses are "getting the message" about flu vaccination, mid-level providers and other health staff are not. They goe on to state that "Vaccinations of health care personnel should be required, either by state laws or by employers" and further notes that compliance is 95% when flu vaccination is mandated by an employer.

Should health care employers "mandate" workers to be vaccinated?
According to an opinion published in Medscape, Why Hospital Workers Should Be Forced To Get Flu Shots, by Arthur L. Caplan, PhD, the answer to the question of mandated flu vaccine is clearly affirmative. Correctly noting that seasonal influenza impacts high risk groups such as extremes of age, immune-compromised, and those living in long term care facilities, he states -

"Ethically, your first obligation is to do no harm. If you are there to do no harm and that is your primary obligation, then you cannot put your personal choice or your personal reluctance to get that shot above doing harm. And you are likely to do harm to others if you do not get that shot."

He goes on to say -

"...every code of ethics that I have seen -- medical, nursing, and others -- says that we put patient interests first. It is not in the patient's interest for you to not get a flu shot. If we are putting patient interests first, if that rhetoric is what we believe in our codes of ethics, what we teach in our medical and nursing schools, there is no excuse for not getting a flu shot."

Can a seasonal influenza vaccine be mandated as a "condition of employment" be enforced?
New York State attempted to mandate vaccine during the 2009 H1N1pandemic for all health care workers. The vaccine mandate was made by then Governor David Patterson despite a lack of vaccine, a sustainable mass vaccination program or a declaration of public health emergency. There was also considerable debate as to who, exactly, was considered health care workers. Most studies overlook non staff health care professionals such as EMS providers, firefigters and other public safety responders who contact the public in and out of the hospital setting.

Should we include environmental/support service staff or provide for blanket inclusion of anyone who would walk into a hospital?

Not everyone agrees with vaccine mandates.
New York State Nurses Association vigorously opposed the vaccine mandate in 2009. (See NYS Nurses Opposes Mandates for Vaccine) In June, 2010, the Centers for Disease Control and Prevention issued a statement saying they would not endorse mandated flu vaccines for health care workers for that year. The announcement by the CDC was a reversal from their controversial stance in 2009 that anyone working in a hospital must be vaccinated against the H1N1 Swine Flu. The full text of the CDC's statement can be found here.

Can vaccination be mandated without a formal declaration of a public health emergency?
You may recall that the United States Army (2003) had to resort to disciplinary action against soldiers who refused mandated Anthrax vaccine in preparation for deployment to a area with a credible Anthrax threat. The Army Anthrax vaccination program was eventually halted by federal court in 2006.  

If the Army cannot mandate vaccine soldiers in the presence of a credible threat, can anyone mandate civilian health care workers to be vaccinated in the absence of public health emergency?

If health care providers are mandated to be vaccinated today, what will be mandated tomorrow? 
What do the experts say? The opinion of the CDC is echoed by other infectious disease. The Society for Health care Epidemiology of America (SHEA) has released a position paper endorsing mandated vaccination with endorsement from the Infectious Disease Society of America. According to the SHEA media release:

"...influenza vaccination of health care personnel [is] a core patient safety practice that should be a condition of both initial and continued employment in health care facilities."

More than one controversy in this situation.
There is no doubt that flu vaccination will prevent the spread of flu, seasonal or otherwise. Public health history reminds us that viruses like Smallpox can be eradicated by a staunch vaccination effort. But can we expect to vanquish Type A influenza by mandating seasonal flu vaccination?

Don't listen to me! Recording without consent in healthcare

Is recording without consent a real concern?

 Are you being recorded without consent? Imagine your reaction when you discover a patient or family member has been secretly recording your interactions with them. A MJ follower recently had such a discovery and was (not surprisingly) concerned...

T.U. is an RN from Central New York and writes:
"...I was appalled to find that a patient had coordinated with family to record interactions with their health providers. A family member recorded (our voices) on a smartphone by simply leaving it on the table while another filmed encounters on another phone. All this without the nurses knowing about it. We found out about it only when a recording was accidentally played while a housekeeper was cleaning the room."

 Discovering you've been recorded without your knowledge or permission stirs emotion and puts us on the defensive. Why would a patient or family want to record our actions? Are they upset about our care or waiting to catch proof of a mistake? Perhaps the family just wants to have a record of the conversation to remind themselves of our instructions. Those who provide care outside the hospital environment may be more aware of the potential for being recorded. EMS providers and firefighters frequently provide care in public locations and are always in a position to be recorded by bystanders. Radio transmissions are also recorded and often are played on various websites.

Recording devices have come along way

While there are many reasons why someone would record (audio/video) we often jump to the negative conclusion...a reasonable defense mechanism when were recorded without our permission or knowledge. If nothing else, finding out you've been recorded without your knowledge or permission, taints the environment of care.


The ever increasing popularity of smartphones and other portable devices makes covert recording an almost certain eventuality.  And here in New York, its perfectly legal to do. Okay, disclaimer time - I'm not a lawyer, I have no background in legal matters and Mitigation Journal is not (emphasis not) a blog for legal opinion or recommendation.With that in mind, lets move on...

Recording your healthcare providers conversation without consent is perfectly legal in New York and many other states. There are only 12 states with "all-party" legislation that requires consent for recording. That being said, I think its important to take a calm approach to the situation.
 

Upsetting as the situation may be, recordings made covertly (or overtly, for that matter) may not be of benefit during legal proceedings. While medical records are seldom questioned for authenticity, recordings made by patients and families may be. They can be edited, tampered with and it may be difficult to prove exactly who is talking on the recording.


Here are a few articles that I found helpful:

Be Careful Who and What You Are Recording

When Patients Audio Record Without Your Consent

Family may use secret recording in medical negligence suit

Secretly recording conversations with doctors... Is it legal?

 

Schools fail at biologic events

U.S. Schools receive a failing grade in pandemics

If a biological agent targeted schools and children would try to prevent it?

Despite the global awareness of biological terrorism, emerging infectious diseases and the impact of diseases such as influenza, a majority of schools in the United States remain unprepared for a biological event. Only 40 percent of schools have updated their infection control/pandemic preparedness according to a study published in the American Journal of Infection Control. The study, conducted by Saint Louis University suggests that many schools in the United States are not prepared for a biological event despite experiences from the 2009 H1N1 pandemic event. As the threat from naturally occurring infectious disease and intentional acts of bioterrorism grow, the importance of community preparedness will increased. We know that one of the keys to a successful outcome in disaster situations is the preparation of local response agencies. Traditional responders and non-traditional responders (public health, hospitals) are the primary responders in any community during times of crisis. Unfortunately, hospital and public health preparedness may still be lacking. Schools should be included in the non-traditional responder group, considered part of critical infrastructure and as such, should be given direction for biologic preparedness according to their role in a biologic event. Best media coverage from Science Daily (http://www.sciencedaily.com/releases/2012/08/120830105323.htm)

• For biologic agent details, see Understanding Flu and Biologic events
• Need help writing your biologic response plan?
• Planning tips: What good plans have that bad ones don't
• Avoid these four pitfalls in biologic planning

Could school preparedness be any worse? Yes.
These findings question the general preparedness of critical infrastructure. The Saint Louis study looked at responses from about 2000 school nurses encompassing only in 26 states. If the results truly represent the biological preparedness efforts (or lack thereof) the school preparedness situation could be much, much worse and equate to greater risks. Closing schools during a biologic or pandemic event will not replace preparedness as studies have shown that kids don't often stay home.

Traditional elementary and high schools draw students together from a variety of social, economic, and cultural background. Bringing a student population together to share ventilation systems, food, water and sanitation, in close quarters, provides opportunity for disease spread. With this in mind, school systems must be a leader in educating students on proper hygiene and infection control measures. Non-pharmacological  interventions are vital to prevent the spread of disease and include hand hygiene, respiratory etiquette and appropriate social distancing. These simple measures are important for everyday health promotion but could be even more important in preventing or limiting the spread of influenza.

• Three things everyone should be doing to get bio-event ready

By the numbers, per the Saint Louis study.
According to the Saint Louis study, less than one-third of the sample schools maintained a supply of personal protective equipment (PPE). Even more concerning is the over 20% of the staff in these schools have no members trained in the schools disaster plan. Infection control training for students was reported by only one third of schools and conducted usually once a year or less.

The study also asserts a positive note, finding that nearly 75% of school nurses have recieved seasonal flu vaccination.While this is good news, its only a drop in the bucket. One person (school nurse) vaccinated for seasonal influenza will do little to stop the spread of the disease. When it comes to emerging diseases and intentional biologic releases there may be no vaccine and we'll need to rely on those non-pharmacological interventions.

West Nile Virus 2012. Hype or Threat?

 Is West Nile virus 2012 a serious public health concern or matter of media hype? 

The Centers for Disease Control and Prevention (CDC) tell CNN that the recent 2012 West Nile Virus outbreak is the largest ever seen in the United States.  Read CNN: West Nile outbreak largest ever.

Really? Worse by geographical distribution? By total number of cases? Fatalities? Not according to the CDC's Statistics, Surveillance, and Control Archive its not...at least not yet.

West Nile Virus (WNV) has hit the mainstream media in a big way over the last weeks of August, 2012. The virus is being dramatically portrayed as spreading, seemingly out of control, from state to state. As of this publication date, the Centers for Disease Control and Prevention (CDC) is reporting 1,118 human cases of WNV with 41 deaths attributed to the mosquito-borne disease. Going by these (most recent as of posting) numbers, the 2012 WNV situation is actually fairly average when guaged against previous years.  See How does 2012 WNV measure up to past years below.

Is the CDC intentionally contributing to the hype or are we missing something?

CDC categorizes WNV into broad groups; neuroinvasive and non-neuroinvasive disease. In other words, a severe form (neuroinvasive) that produces meningitis or encephalopathy and a less severe form. The 2012 data-to-date demonstrate that 56% of WNV cases are neuroinvasive, with 44% non-neuroinvasive or less severe.

Signs and Symptoms
As many as 80% of people infected with WNV will have no symptoms at all. Few may have mild symptoms resembling other viral illness such as influenza. One out of every 150 people infected with WNV go on to develop severe disease  - high fever, various neurological abnormalities, and weakness that may last several weeks. Neurological effects may be permanent.

How does 2012 measure up to past years? 

2012. An average year for WNV?

Looking back at the CDC data from 2011 to 2006 we find some interesting (albeit less dramatic) numbers. For that six-year period there were a total of 11,708 cases of WNV and 477 fatalities. That's an average of 1,951.3 cases/yr and 79.5 fatalities/yr. making 2012 look like an average year (of the last 6 years) for WNV.

Interestingly, the CDCs archived statistics 2003 would reign supreme as the worst outbreak ever. In 2003 there were 9862 reported cases of WNV and 264 deaths spanning 46 states.


According to the CDC West Nile Virus homepage:

• People over 50 at higher risk to get severe illness. People over the age of 50 are more likely to develop serious symptoms of WNV if they do get sick and should take special care to avoid mosquito bites. 
• Being outside means you're at risk. The more time you're outdoors, the more time you could be bitten by an infected mosquito. Pay attention to avoiding mosquito bites if you spend a lot of time outside, either working or playing. 
• Risk through medical procedures is very low. All donated blood is checked for WNV before being used. The risk of getting WNV through blood transfusions and organ transplants is very small, and should not prevent people who need surgery from having it. If you have concerns, talk to your doctor. 

Vector control. Key to prevention or hazard trade-off?
The main countermeasure against WNV is to kill the mosquito that carries the virus by way of pesticide use. Substances such as malathion and parathion have been used. Both are organophosphate-based chemicals that can produce illness and cause reactions similar to chemical weapon nerve agents at toxic doses. More recently, the pesticide Zenivex has been used. Zenivex E4 is a skin and eye irritant that contains petroleum distillates and poses an aspiration pneumonia hazard. The NFPA rating is Health: 2 Fire: 2 Reactivity: 0. Zenivex has an oral toxicity LD50>5,000 mg/kg and an inhalational toxicity of LC50>2mg/L (4-hour).

WNV: hype or example of emerging infectious disease

Special podcast from Mitigation Journal with the MedicCast and This Week in Virology

Read Mitigation Journal

What is it about West Nile virus that has everybody talking? Do the number of infections and deaths from WNV this year make sense? Is this hype or example of emerging infectious disease threats to come?


Join Rick Russotti (Mitigation Journal), Jamie Davis (MedicCast/Nursing Show/Insights in Nursing), Dr. Vincent Racaniello and Dr. Dickson Despommier (This Week in Virology) for everything you wanted to know about West Nile virus and more!


In this episode:

• Where did WNV come from? 
• How did WNV get to the United States? 
• What's driving the 2012 epidemic and is this really the worst ever? 
• How can we apply current knowlege to other emerging infectious diseases?

See also WNV Hype or Threat (Mitigation Journal 8/2012)

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MedicCast

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Has public alerting technology made warning sirens obsolete?

Is hanging on to your siren warning system worth it? Many of the alerting siren systems are aging and becoming difficult if not impossible to maintain and operate. Siren systems have limited ability to do anything more than make noise. They can't tell the public what they need to know in order to take meaningful actions. In other words, for a siren-based alerting system to truly be functional, the public must know ahead of time what the activation means. Is there an storm coming or is there a meltdown at the local nuclear power plant? Is this simply a test activation? The cause may not be that easy to define but the fact remains that the public needs to know the message prior to the activation because the activation will not be able to give that message. We also like to convey  to the public what actions we'd like them to take based on our warnings. Do we want them to shelter in place or evacuate? We'd ideally like to be able to tell them or have them know ahead of time. Not only do communities need to know their role in advance of crisis, they need to pay attention and react to the situation - and the alert or warning.

So far, we've outlined some of the shortcomings of a siren system that a web-based or cellular messaging system might be able to fix.

Back to basics
A warning system has to be able to be get the job done in time of need. It has to be maintained and tested. The public has to be educated on what the alert or warning actually means. These things are universal regardless of the system used. Awareness and alert meaning are usually the result of emergency management public education public education efforts. Engaging the public is key.  A warning system must be able to do a minimum of three things:

1. Tell the public why its been activated or what hazard is expected
2. Tell the public what to do and why
3. Tell the public how long they have to do it

These three simple items are asking a lot for even the best of siren-based systems. Should siren-based alerting systems be discarded in favor of web-based or cellular text alerting systems? Some people would argue that they should. New technology, social media, SMS/cellular messaging systems can solve the problems of awareness, notification, and meaning. New technology can produce real-time alerts, provide updated information on expected actions and hazards. Technology can even help educate the public. 

History lesson

The Control of Electromagnetic Radiation system or CONELRAD was developed in the cold war era and used from 1951 to 1963. As a radio-based system, it focused on key AM radio stations to deliver messages. AM 640 and 1240 were the designated stations. This system  worked because the AM radio was nearly a universal household item. Most automobiles were equipped with an AM radio, too. People were accustomed to getting their news, information, and entertainment from a radio during that time period.

The next generation of CONELRAD came into use around 1963 and functioned as the familiar Emergency Broadcast System or EBS. The familiar tone alert followed by the statement "this is a test - if this had been an actual emergency..." became well known to many in my generation. The EBS was upgraded for peacetime use to include FM radio and television as well as AM frequency.

In 1997 changes in technology made possible the Emergency Alert System. This system was maintained and tested by the FCC, FEMA, and the National Weather Service. One of the cornerstones of this system was that it claimed to be able to deliver a Presidential address to the nation within 10 minutes.

The Integrated Public Alert System (IPAWS) was designated in 2006. FEMA leads this project along with DHS, FCC, and NOAA. Later, in 2007, FEMA established the IPAWS program management office. With IPAWS, FEMA acknowledged new media as a method of message delivery. This system is estimated to be able to reach about 40% of the United States population during the day. Including new media and technology, the IPAWS system could reach the ever-expanding population that recieves a a majority of information from internet based technology.

An interesting note
Nation-wide emergency alerting systems were not used during September 11, 2001. When siren based systems were activated for more recent natural events, they were largely ignored by the public. Although newer technology was tested on a nation-wide basis in November, 2011, it is not clear exactly how successful those tests were.

When EMS could make a difference but doesn't.

Prenotification as important as EMS treatment

Early hospital notification from EMS could speed the care of stroke patients, yet in one third of stroke situations, there was no prenotification. Those are the findings from 2 published studies looking at the treatment of acute ischemic stroke patients.

Alerting the hospital of ischemic stroke patients allows for appropriate teams to be assembled and speeds evaluation, imaging and treatment such as tPA.

Early prenotification in these situations is based on recognition of the problem. The EMS provider has to be able to identify even the subtle indications of an ischemic stroke event. Abnormal findings in mental status, cranial nerve exam, and motor function are warnings signs of stroke that should be transmitted to the receiving facility as soon as possible.

Although patient history is vital in these situations, remaining on scene for a prolonged period of time to obtain a history or detailed exam may not benefit the patient. Keep it simple and focus on:

• patient info: when was the patient last seen as normal by family/caregiver?
• obtain vital signs including blood glucose. 
• history points: any history of trauma? Of headache?

Continual assessment is required as symptoms may evolve after the initial exam is conducted. Its estimated that 80% of strokes are ischemic - resulting from an occluded cerebral artery as a result of thromboembolism. Clot formation can come from the heart or another blood vessel.

The goal of any EMS system should be to identify and prioritize patient needs, treating accordingly. Early prenotification to the appropriate receiving facility has to fit into this line of treatment. The question then becomes one of identifying why prenotification is not taking place as often as it should. Are signs and symptoms of stroke not being recognized in one-third of stroke patients? I find that hard to believe. Or, is technology the problem. The modes of communication between ambulance crews and hospital workers varies from location to location. Perhaps one way of correcting this situation is to improve the means of communication and information delivery.