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The Vaccination War and the Workplace

What's really interesting right now is which side OSHA is fighting on.

Now that we have immunizations for many of the diseases that can be transmitted to health care workers, the debate has become: Do we use them? If so, which should be mandatory? And, how much information do we need to override an employee's anti-vaccination belief?

These questions are currently playing out in the debate over whether influenza vaccinations should be mandatory for health care workers.

First, some background information on the vaccination war....

On Jan. 3, 2012, attorneys for Dr. Andrew Wakefield filed a defamation lawsuit in the Travis County, Texas District Court against the British Medical Journal, Brian Deer, and Dr. Fiona Goodlee. This lawsuit is one more skirmish in the ongoing vaccination war that began in February 1998 when The Lancet published a research article by Dr. Wakefield and 12 others that concluded:

"We have identified a chronic enterocolitis in children that may be related to neuropsychiatric dysfunction. In most cases, onset of symptoms was after measles, mumps, and rubella immunisation. Further investigations are needed to examine this syndrome and its possible relation to this vaccine."

In a Feb. 26, 1998, press release from the Royal Free Hospital School of Medicine about the study, Dr. Wakefield is quoted:

"This study has identified a possible link between gut disorders in children and autism. In the majority of cases the onset of symptoms occurred soon after the MMR vaccination. We clearly need research to examine this new syndrome, and to look into a possible relation to the MMR vaccine."

These seemingly benign statements -- possible identification of an intestinal disorder needing further investigation that might possibly be to related neuropsychiatric dysfunction like autism, and that might possibly be related to Mump-Measles-Rubella (MMR) vaccination -- caused a furor and help fuel an anti-vaccination movement already skeptical of scientific justifications for vaccination. Wakefield's study and its aftermath have been blamed for significant reductions in rates of MMR immunization in children and Britain's 2008 measles epidemic. Nearly 12 years after publication, editors of The Lancet formally retracted the study, stating that it had "become clear that several elements of the 1998 paper by Wakefield et. al are incorrect." On May 24, 2010, after an extensive review, the General Medical Council banned Dr. Wakefield from practicing medicine in Great Britain. On Jan. 5, 2011, Dr. Fiona Goodlee and other editors of the British Medical Journal published an editorial entitled "Wakefield's article linking MMR vaccine and autism was fraudulent," which said, in part:

"In a series of articles starting this week, and seven years after first looking into the MMR scare, journalist Brian Deer now shows the extent of Wakefield's fraud and how it was perpetrated. Drawing on interviews, documents, and data made public at the GMC hearings, Deer shows how Wakefield altered numerous facts about the patients' medical histories in order to support his claim to have identified a new syndrome; how his institution, the Royal Free Hospital and Medical School in London, supported him as he sought to exploit the ensuing MMR scare for financial gain; and how key players failed to investigate thoroughly in the public interest when Deer first raised his concerns."

On April 5, 2011, Brian Deer won the British Press Award, which is similar to the Pulitzer Prize, for his three-part series in The Sunday Times investigating the study. In the series, he reported that "Wakefield was paid £435,643 in fees, plus £3,910 expenses" from "£3.4m distributed from the legal aid fund to doctors and scientists who had been recruited to support a now failed lawsuit against vaccine manufacturers."

Award judges said Deer demonstrated "outstanding perseverance, stamina and revelation on a story of major importance." The award's citation noted: "It was a tremendous righting of a wrong."

Where OSHA Stands on the Controversy
Dr. Wakefield's lawsuit challenges these characterizations of his work and ethics. In a sense, the lawsuit pits the anti-vaccination movement, which sees Dr. Wakefield as a serious scientist who has been unfairly attacked by the medical establishment for daring to question the prevailing vaccination orthodoxy, against public health officials who see Dr. Wakefield as an irresponsible physician who distorted data for his personal gain and in the process helped trigger a serious crisis of under-vaccination of children.

This battle has developed almost religious overtones in which the fundamental question has become whether one believes in vaccination, not how effective the vaccination is in preventing disease.

This controversy sharply contrasts with vaccination in my youth. I remember riding my bicycle to baseball practice worried that I would get polio before I could receive the newly released Salk vaccine. Iron lungs were a real and present worry for children, and summer was polio season.

When the oral Sabin polio vaccine came out, there was a citywide immunization program. We were sorted alphabetically and given our assigned night to show up at the high school. The lines were long, but the atmosphere was festive. I remember a bake sale. As we took our sugar cubes laden with the Sabin vaccine, we celebrated elimination of the risk of contracting a feared disease. Science had triumphed.

Vaccination is critical to protect health care workers. When I was a surgery resident, I was called to the intensive care unit where a woman in her 20s with severe hepatitis was massively hemorrhaging from her esophagus. Several other residents and I scrambled to stop the bleeding and save her life. We temporarily succeeded, but she ultimately died. After our hours of work, we were soaked with blood and had to change our scrubs. Her blood had even saturated my underwear. Only then did we ask: "Do you think we could catch her hepatitis?" We searched for some gamma globulin and got shots. Hepatitis vaccination was still a dream.

In the minutes of the Sept. 13-14, 2011 meeting of the National Vaccine Advisory Committee (NVAC), Bill Borwegen, Occupational Health and Safety director for the Service Employees International Union (SEIU), provided a statement on the Occupational Safety and Health Administration's position on mandatory influenza vaccination for healthcare workers:

"OSHA believes there is insufficient scientific evidence for the federal government to promote mandatory influenza vaccination programs that do not have an option for the HCP to decline for medical, religious and/or personal philosophical reasons."

OSHA's interpretation of the current scientific data on influenza vaccination and its position on mandatory workplace vaccination is in direct opposition to major scientific organizations. The Infectious Diseases Society of America (IDSA), the Pediatric Infectious Diseases Society (PIDS), and the Society for Healthcare Epidemiology of America (SHEA) outlined their position in a Jan. 12, 2012 letter to Jennifer Gordon, Ph.D., of the National Vaccine Program Office. In the letter, the three organizations urge the National Vaccine Program to change draft recommendations to strongly recommend policies for mandatory influenza vaccination of all health care personnel, unless valid medical contraindications exist, as the most efficient and reliable way of achieving targeted immunization rates....

Professional societies such as the American College of Physicians, Association of Professionals in Infection Control, National Patient Safety Foundation, the American Academy of Pediatrics, the American Public Health Association, the National Foundation for Infectious Diseases, the American Medical Directors Association, the American Hospital Association, as well as the Department of Defense, many large health care systems, and individual hospitals have adopted policies supporting mandatory influenza immunization. Many of these policies have resulted in vaccination rates greater than 95 percent.

So the vaccination war continues. What's really interesting right now is which side OSHA is fighting on.

References
1. To see the court filing: http://www.courthousenews.com/2012/01/04/BritMedJ.pdf
2. Wakefield AJ, Murch SH, Anthony A, Linnell, Casson DM, Malik M, et al. Ileal lymphoid nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 1998; 351:637-41.
3. "New Research Links Autism and Bowel Disease," Press Release form the Royal Free Hospital School of Medicine February 26, 1998. http://briandeer.com/mmr/royal-free-press-1998.pdf
4. The Lancet, Volume 375, Issue 9713, Page 445, 6 February 2010
5. Burns J. "British Medical Council Bars Doctor Who Linked Vaccine With Autism" New York Times, May 24, 2010 http://www.nytimes.com/2010/05/25/health/policy/25autism.html
6. Goodlee, F., J. Smith, and H. Marcovitch and "Wakefield's article linking MMR vaccine and autism was fraudulent" BMJ 2011;342:c7452 http://www.bmj.com/content/342/bmj.c7452
7. Brian Deer "MMR doctor given legal aid thousands" The Sunday Times Dec. 31, 2006. http://briandeer.com/mmr/st-dec-2006.htm
8. Video of the award ceremony is available at: http://briandeer.com/brian/press-awards-2011-win.htm
9. National Vaccine Advisory Committee (NVAC) September 13–14, 2011, Meeting Minutes http://www.nvic.org/CMSPages/GetFile.aspx?nodeguid=da4b451c-b83e-4eb4-9b64-5c210aad1ec3
10. Letter to Jennifer Gordon, Ph.D. of the National Vaccine Program Office, Jan. 12, 2012 http://www.idsociety.org/uploadedFiles/IDSA/Policy_and_Advocacy/Current_Topics_and_Issues/Immunizations_and_Vaccines/Health_Care_Worker_Immunization/Comments/IDSA-PIDS-SHEA%20Joint%20Comments%20on%20NVAC%20%20HCP%20Influenza%20Vaccination%20011312.pdf

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