Maximizing influenza vaccination uptake among healthcare personnel in Israel: lessons learned from mandatory vaccination policy in the United States

Critical document analysis was conducted on relevant literature and policy discussing influenza prevention interventions among HCP within the United States, with a focus on mandatory vaccination policies. A discussion of HCP professional responsibility to vaccinate against influenza precedes such analysis. Case studies of hospitals in the United States that implemented mandatory vaccination policies for their employees are explored. The article concludes with analyzing how aspects of HCP mandatory influenza vaccination policy could be applied in Israel, urging health policy makers to reflect on American case studies.

Mandatory influenza vaccination of HCP can be ethically justifiable based on four key principles: (1) the professional duty to prioritize patients’ interests above all else, (2) the obligation to ‘do no harm’, (3) the requirement to protect those who cannot protect themselves; and (4) the obligation to set a good example for the public [9]. Beneficence, non-maleficence, and justice are guiding principles of medical practice [28]. All HCP are expected to uphold the core medical ethicof “First Do Not Harm”. The same obligation applies to HCP employers (healthcare and medical-providing institutions) in order to establish a workplace culture of promoting influenza vaccination. The viewpoints of both employers (healthcare and medical settings) and employees (HCP) contribute to the multi-layered complexity of the ethical debate surrounding HCP mandatory influenza vaccination policies.

Patients expect that healthcare facilities and HCP take “reasonable measures to ensure that their care is as safe as possible (non-maleficence)” [28]. Under this assumption, HCP take all reasonable measures to prevent the transmission of communicable, infectious diseases such as influenza [28]. Tilburt et al. suggests that preferable prevention methods exist in the form of safe, effective vaccines [28]. However, counterarguments may suggest other influenza-prevention methods are equally sufficient in fulfilling expected “reasonable measures” [28]. Even still, the majority of ethical appeals to HCP mandatory influenza vaccination policies are rooted in claims of personal autonomy and right-to-choice [22]. This leads to the question of whether HCP perceptions of influenza vaccination translate into action (getting vaccinated), or inaction (not getting vaccinated) which uphold their professional “duty” to patients [22].

Anti-mandatory vaccination arguments are rooted in claims of personal autonomy infringement and professional responsibility. Mandatory influenza vaccination policies are employment-contingent policies which generally maintain courtesy towards HCP autonomy via medical and religious exemptions. Autonomy, defined as acknowledging a person’s right to make choices and decisions [19], is one of many moral considerations that must be weighed in when ethically evaluating mandatory influenza vaccination policies targeted at HCP. Anti-mandatory vaccination stances rooted in concerns regarding professional responsibility appeal to private choice. Such claims do not view vaccination as a justifiable required action based on the professional duties of HCP, claiming that it intrudes on private (mental and bodily) rights [29].

Alternative non-mandatory vaccination policies targeted at HCP usually take form in opt-out vaccination policies which are implemented via declination forms. If HCP do not wish to be vaccinated, they “opt-out”, and their appeal to personal autonomy in refusing vaccination is respected [19]. A major consequence of this “softer” policy, in comparison to mandatory vaccination, is that HCPs’ compliance to influenza vaccination is largely unpredictable and varied at best. Vulnerable patients are not maximally protected against harm (influenza) [19]. Perhaps a policy that implements restricted mandatory vaccination in addition to opt-out declination forms could offset sub-par vaccination uptake resulting from opt-in policies [19]. When a compelling institutional threat of influenza is officially recognized, more attention is usually drawn to the lacking HCP influenza vaccination uptake achieved through opt-in programs. For this reason, among others, Tilburt et al. and Gostin argue that HCP mandatory influenza vaccination policies are ethically justifiable and merit implementation. Despite potential legal and ethical soundness, in certain countries, including Israel as of 2019, mandatory vaccination of HCP is not a feasible immediate policy decision thanks to a variety of political and systematic hurdles [17]. With this in mind, this paper emphasizes the importance of weighing social, cultural, and political environments before implementing mandatory vaccination policies. Additionally, even if mandatory policies are not implemented, certain successful characteristics can be applied to inventing creative alternative policies.

Current policy regarding HCP influenza vaccination in the United States is inconsistent. This is largely due to varying state governance and regulations usually in the form of recommendations [26]. For over 30 years, several governmental and non-governmental societies have consistently recommended HCP influenza vaccination [4]. Such organization is the Advisory Committee On Immunization Practices, which first recommended annual influenza vaccination of HCP in 1984 [4]. The Society for Healthcare Epidemiology, the Association for Professionals in Infection Control, and the Infectious Disease Society of America also heavily endorse influenza vaccination of HCP [4]. One of the Healthy People 2020 goals is to achieve 90% influenza vaccination coverage among HCP in the United States [4]. Given that recommendation and encouragement from the employer, governmental organizations, and non-governmental institutions results in suboptimal influenza vaccination uptake among HCP, the Healthy People 2020 goal bolstered debate on policies that can successfully and sustainably increase HCP influenza vaccination uptake [4].

National and cultural specificity might be a way to point out how other non-medical influences inform how HCP think and act in different medical-social-legal-cultural environments. These similarities and differences are important both in the justification but perhaps more in the implementation of mandatory influenza vaccination policies directed at HCP.

This study uses Israel as a case study for cultural specificity regarding mandatory influenza vaccination policy of HCP. Yamin et al. suggests that socio-demographic and socio-economic diversity in the Israeli population may necessitate disease prevention interventions be customized to the preferences of sub-populations [36]. Even still, there are qualities that characterize specific societies and cultures. Results of a study of the willingness of Israeli HCP to risk their lives for patients during the peak of the 2009 influenza A H1N1 pandemic suggest that investing resources in increasing the safety of HCP significant increased the chances of HCP attending work during pandemic avian flu [5]. Trust in colleagues and HCP willingness to risk their lives for others suggest a correlation to the military maxim, “one for all and all for one”, when soldiers are willing to risk their lives for their peers because they know the behavior is reciprocal [5]. Applying this axiom to HCP decision-making is not out of the ordinary within an Israeli context. The influence of military and healthcare disaster preparedness and management is historically tied to the curriculum of HCP training in Israel [5].

While seasonal influenza vaccination for HCP is recommended by the Israeli Ministry of Health, it is not consistently regulated across Israel [3]. Sometimes, contradictory messages emerge. Deputy Health Minister Yaakov Litzman told the Jerusalem Post that influenza vaccines “apparently didn’t work” because he “got the flu” after being vaccinated [24]. According to the Israeli Ministry of Health Director General, it is the responsibility of medical administrations within workplaces to promote and regulate influenza vaccination among HCP. Naturally, this leads to diverse regulation, implementation, and ultimately influenza vaccination uptake among HCP across healthcare settings in Israel. Overall, the influenza vaccine remains largely optional for HCP.

Kamin-Friedman examined the legality of mandatory vaccination in Israel in light of the 2013 detection of polio in Israeli sewage. Though vaccinating children proved to be significantly more difficult than vaccinating HCP for polio, legal justification used for imposing polio vaccination on children in 2013 could be similar to that of mandatory influenza vaccination of HCP, if supportive socio-political circumstances arose in Israel. Kamin-Friedman suggests that mandatory polio vaccination supported by criminal sanctions would probably be perceived as infringing on the Israeli constitutional right to autonomy in a greater way than established by law and case precedents. Still, the Israeli Basic Law: Human Dignity and Liberty states that the government has an obligation to protect the life, body, and dignity of every individual [17].While the right to health has not been recognized as a basic right in Israel [17], the importance of eradicating infectious diseases to protect human dignity, life, and body could potentially uphold the feasibility of at minimum applying mandatory influenza vaccination policy to specific populations of HCP working with immunocompromised populations, the elderly, and children.

Value is found in new public health law and policy that authorizes public health officials (or healthcare institutions) to oblige vaccination when nonrestrictive measures (such as influenza vaccination recommendation and/or opt-in vaccination campaigns) are ineffective [17]. While government should always use the least invasive/restrictive alternative to achieve public health objectives, vaccination requires the large majority of a given population to be vaccinated in order to generate “herd” immunity [13]. Mandatory vaccination, according to Gostin, is well within the “harm principle” which justifies compulsion to prevent individuals from putting others at risk [13]. Applying this logic to influenza vaccination of HCP is sound given their professional duties and work setting. However, given strict laws protecting workers’ rights as of 2019, the feasibility of implementing mandatory influenza vaccination policy targeted at HCP in Israel is low [35].

Nevertheless, the non-feasibility of implementing mandatory influenza vaccination policy for HCP does not mean that there is no room for strengthening efforts targeted at influenza prevention in Israel. Within an Israeli context, this will most likely not take form in regulative measures. This leaves a large responsibility among healthcare administrators, managers, and bosses to create a culture around rewarding influenza vaccination and “reprimanding” those who do not choose to vaccinate for non-medical or non-religious reasons. Such “punishments” need not take shape in termination, which is prohibited anyway under Israeli law [35]. Employers can choose to hire only vaccinated HCP to work in certain departments, which complies with worker’ protection laws, since the HCP is employed, just perhaps not in their preferred department. Campaigns to wear “I vaccinated!” stickers or to promote wearing masks for those unvaccinated is another tool that could be used to generate stigma among unvaccinated HCP. However, generating stigma among HCP for choosing not to vaccinate against influenza may be less appealing within Israeli society, given the value and respect placed upon the individual right to choice. Still, it is a tactic worth exploring.

Public health recognizes state power and responsibility to protect health and safety without overstepping [13]. In 2005, SHEA defined influenza vaccination of HCP as “a core patient and HCP safety practice with which noncompliance should not be tolerated” [26]. Healthcare facilities have responsibilities to take “reasonable measures” to ensure that influenza prevention interventions are as safe and effective as possible [28].

Cognizant of policy alternatives and respectful of professional ethical concerns, this article explores mandatory HCP influenza vaccination policies within the United States in order to extrapolate potential applications to an Israeli context. There is a time and place for coercive and persuasive influenza vaccination interventions [11]. Coercive policies regarding HCP and influenza vaccination raise HCP influenza vaccine uptake to levels that can generate herd immunity and lower influenza incidence in healthcare settings [33]. Case studies and lessons learned from the United States provide scientific and ethical support for the implementation of mandatory HCP influenza vaccination policies. Nevertheless, cultural, legal, political, and social sensitivities often take precedent, as is the case in Israel in 2019. Even still, successful characteristics of American mandatory influenza vaccination policies targeted at HCP can be integrated in Israel in non-coercive ways. HCP influenza vaccination uptake in Israel has plenty of room for improvement. Public health professionals, healthcare setting administrators, and HCP alike can learn from the successes of American mandatory influenza vaccination policies for HCP when rethinking regulation and practices in Israel.