Tens of thousands of health care workers who typically avoid flu shots are under more pressure than ever to get vaccinated as hospitals and clinics prepare for a spike in swine flu cases this fall and winter.
Roughly half of health workers skip the immunizations, raising two concerns: If doctors and nurses get sick, who will treat what could be millions of Americans reeling from seasonal or swine flu? And could infected health workers make things worse by spreading flu to patients?
New York, the first state to be hard-hit by swine flu, is requiring all health workers to get immunized against both types of flu. Other states are weighing whether to follow suit.
But shots for all health workers may not be an easy sell.
Fewer than half of them got flu vaccinations last year, according to a Centers for Disease Control and Prevention survey of about 1,000 workers. That includes physicians in clinics, lab technicians, respiratory therapists and home health aides. Rates are highest among doctors and nurses in hospitals — 70 to 80 percent, but the overall rate shows many still shun the shots.
Why? The reasons vary from safety concerns to skepticism over vaccine effectiveness.
Sandra Morales, a labor and delivery nurse in New York City, had her last flu shot 16 years ago. She says she got the flu anyway.
She objects to New York's new law, saying it infringes on free-choice rights. "It's crossing the line, and I'm opposed to that."
Hospital workers "are at risk for being exposed to many, many diseases," she said. "Imagine if we had to take a vaccine for everything that comes in the door."
Morales worries she might lose her job if she refuses — it will be up to individual clinics and health centers to decide how to enforce the law. She has until Nov. 30 to get her shots. Both the seasonal flu vaccine (available this month) and swine flu vaccine (expected in October) are required for workers in hospitals, treatment centers and in home care.
That may mean three separate shots, if the swine flu vaccine requires two doses to be effective. Testing in the U.S. is still under way to determine the dose.
The uncertainty about the new swine flu vaccine has added to the challenge.
"If health care workers have concerns about the safety and efficacy of a vaccine that has been around for decades, I'm sure they're going to have those same concerns about a vaccine that we've never used before," said Dr. Gregory Poland, a Mayo Clinic vaccine specialist.
He says health workers are ethically obligated to get vaccinated for both kinds of flu. He supports requiring them. New York, which had the first big surge of swine flu cases in the spring, is the only state doing that, although some states are considering the issue.
The theory that health care workers could spread the infection is supported by only isolated evidence, but the fear persists.
Some large hospitals have adopted rules requiring employees to get flu shots. Loyola University Medical Center near Chicago and Charleston Area Medical Center in West Virginia recently joined a handful of hospitals that have made seasonal flu shots mandatory for all workers. Some also plan to include swine flu. Several infectious disease groups support required flu vaccination for health workers.
Federal health officials say health care workers are among the priority groups for flu shots, but the government is not ordering anyone to get shots.
In New York, Health Commissioner Dr. Richard Daines notes that health employees are already required to get other vaccinations, including rubella and measles shots.
Under the new flu shot law, workers can opt out only for certain health reasons, including an allergy to flu shots.
Bill Van Slyke of the Healthcare Association of New York state, which represents hospitals, said hospitals have concerns about what action they can legally take if staffers refuse vaccinations.
"We don't expect that to happen to any significant degree — we think most recognize the value of doing this, but there are one or two challenging scenarios out there," he said.
Dr. Brian Currie, an infectious disease specialist at Montefiore Medical Center in the Bronx, supports the law but said including swine flu vaccinations could be a headache.
"It means twice as much time, tracking people to make sure they get a timely second vaccination" if required. "It's a lot more work," Currie said. "We'll do our best."
Though infectious disease specialists say they have seen no serious complications during the swine flu vaccine testing that began last month, some critics say it is being fast-tracked without adequate safety tests. Some also fear a repeat of a rare paralysis called Guillain-Barre syndrome that occurred during a 1976 swine flu vaccination effort, though there is no evidence the vaccine caused that condition.
Dr. William Schaffner has had two swine flu shots during testing at Vanderbilt University, with no ill effects. The current flu virus is molecularly different from the one circulating in 1976, so Schaffner, who has consulted for the swine flu vaccine makers, said similar problems are unlikely.
Deborah Burger, a president of the California Nurses Association/National Nurses Organizing Committee, said safety concerns persist. That union, with 86,000 members in 50 states, is weighing whether to support required flu shots for nurses.
She said the union believes patients should be protected but also wants to protect nurses from any potential vaccine-related problems, saying, "It's a difficult tightrope to walk right now."
More than 550 U.S. deaths have been attributed to the new H1N1 swine flu. So far it does not appear to be more deadly than regular seasonal flu. Projections for the upcoming season vary. A worst-case scenario from a scientific panel advising the White House said up to half the population might get sick and up to 90,000 might die.
An estimated 36,000 Americans die from regular influenza each year.
At Virginia Mason Medical Center in Seattle, the first U.S. hospital to require flu vaccination for staffers, employees who object must wear a face mask during flu season or possibly be fired. Only a handful of objectors have been fired, all in the first season, 2005-06, said hospital spokeswoman Alisha Mark.
Dr. Joyce Lammert, Virginia Mason's chief of medicine, said if testing shows the new vaccine is safe and effective, and if supplies are adequate, the hospital will make that mandatory, too.
"We feel that getting immunized is so important," Lammert said. "In some ways, I'm glad H1N1 is out there. It raises awareness of the seriousness of the disease."