Pregnant nurse fired for refusing flu shot

[statlerwaldorf]

Is my ob/gyn the only one that recommends not getting the flu shot during the first trimester?

[sushi]

Yeah, my question was mostly rhetorical. "Boosting" our "strengthening" the immune system is generally woo language. So I was curious to see the explanation for how it relates to avoiding a vaccine, something that in most results in the building of antibodies. You know, those things that are a sign of a functioning immune system (auto immune issues aside).

[NewOrleans]

There is some cosmic shit happening in here. 

(huh)

[sushi]

Vaccines as supplement. I'll admit that's new to me.

[kimibrighteyes]

Dec 31, 2013 18:27:39 GMT -5 mr+ms said:

Dec 31, 2013 17:22:03 GMT -5 Catlawdy said:

Just avoid the flu? You mean by getting a flu shot? And by encouraging others to get flu shots to decrease transmission?

That's one way. I think the flu shot has a little too much hype surrounding it, however. Since it can have no observed effect some years, it's not as effective on people with compromised immune systems (like pregnant women) and we can't achieve herd immunity with it, it should be thought of as a supplement to hand washing, getting enough sleep, etc. But we like that instant gratification of pharmaceutical = all fixed/I did something! so I can understand the excitement. 

What evidence do you have to support this?  As far as I am aware, the flu shot is effective in pregnancy.  I have seen so many pregnant women sick with influenza in hospital this year, and all of the ones sick enough to be in hospital didn't get the flu shot. 

[ttt]

Dec 31, 2013 18:27:39 GMT -5 mr+ms said:

Dec 31, 2013 17:22:03 GMT -5 Catlawdy said:

Just avoid the flu? You mean by getting a flu shot? And by encouraging others to get flu shots to decrease transmission?

That's one way. I think the flu shot has a little too much hype surrounding it, however. Since it can have no observed effect some years, it's not as effective on people with compromised immune systems (like pregnant women) and we can't achieve herd immunity with it, it should be thought of as a supplement to hand washing, getting enough sleep, etc. But we like that instant gratification of pharmaceutical = all fixed/I did something! so I can understand the excitement. 

Why can we not achieve herd immunity with the flu vaccine? I understand it may not be possible in certain years, but that's not always true. 

www.ncbi.nlm.nih.gov/pubmed/22414740

[rugbywife]

I get the feeling that people don't really 'get' how influenza works...how there isn't just one type, how it is constantly evolving...so no, one single shots, any one year, isn't going to eradicate the flu (and it certainly won't get rid of stomach flu, lol)...but that doesn't mean that it isn't a) significantly reducing the symptoms that people do see for certain strains (anecdote: I have never had the full fledged on your ass for 2 weeks flu. I have suffered from the consequences of my body fighting the flu off, which usually results in at least 2-3 days of feeling like ass) and b) it helps to protect those with suppressed immunity (children, elderly, the generally sick) to avoid the significant consequences of the flu that would like end in death for them.

So yeah, it works. It isn't a cure but it serves a purpose.

[curbsideprophet]

Dec 31, 2013 13:35:02 GMT -5 statlerwaldorf said:

Is my ob/gyn the only one that recommends not getting the flu shot during the first trimester?

Interesting. My midwife/OBGYN practice gave me a flu shot in first tri. They also only give flu shots to their pregnant patients. I have asked in the past while not pregnant and was told they are saving them for the pregnant patients.

[kimibrighteyes]

Jan 2, 2014 21:28:40 GMT -5 mr+ms said:

Dec 31, 2013 19:11:36 GMT -5 kimibrighteyes said:

What evidence do you have to support this?  As far as I am aware, the flu shot is effective in pregnancy.  I have seen so many pregnant women sick with influenza in hospital this year, and all of the ones sick enough to be in hospital didn't get the flu shot. 

Even in a year where there is a good match between vaccine and the viruses circulating the vaccine is not completely effective in healthy individuals. Good luck finding the actual % for any given year but CDC is using examples like 50-70% here: 
www.cdc.gov/flu/about/qa/vaccineeffect.htm

You can also read about what they say about efficacy in different populations... Most effective in healthy adults and older children. It goes downhill from there.

Regarding vaccinating children under 2yrs, apparently there is only one study that looked at efficacy in that population. 

Protecting against transmission: Influenza vaccines have a modest effect in reducing influenza symptoms and working days lost. There is no evidence that they affect complications, such as pneumonia, or transmission.
summaries.cochrane.org/CD001269/vaccines-to-prevent-influenza-in-healthy-adults

Herd immunity typically requires at least 70-80% of the population to be vaccinated and that's for vaccines that are hopefully much more effective than for flu. Add to that the variability every year and the fact that one needs to be vaccinated every year... It's not really possible.

To get back to the original point, if this lady's employment contract had this as a requirement well then I guess it is what it is. My unpopular opinion is that terminating her is a pretty stiff punishment considering the inconsistency and unpredictability surrounding the flu vaccine.

    You said that the flu vaccine is not as effective in pregnant women.  I am aware that the flu vaccine is not 100% effective.  I am a physician who looks after pregnant women and I am not aware of any evidence that the flu vaccine is less effective in pregnant women than in non-pregnant individuals. If you have data to support this, I would be interested in knowing about it.

[ringstrue]

Jan 2, 2014 21:28:40 GMT -5 mr+ms said:

Dec 31, 2013 19:11:36 GMT -5 kimibrighteyes said:

What evidence do you have to support this?  As far as I am aware, the flu shot is effective in pregnancy.  I have seen so many pregnant women sick with influenza in hospital this year, and all of the ones sick enough to be in hospital didn't get the flu shot. 

Even in a year where there is a good match between vaccine and the viruses circulating the vaccine is not completely effective in healthy individuals. Good luck finding the actual % for any given year but CDC is using examples like 50-70% here: 
www.cdc.gov/flu/about/qa/vaccineeffect.htm

You can also read about what they say about efficacy in different populations... Most effective in healthy adults and older children. It goes downhill from there.

Regarding vaccinating children under 2yrs, apparently there is only one study that looked at efficacy in that population. 

Protecting against transmission: Influenza vaccines have a modest effect in reducing influenza symptoms and working days lost. There is no evidence that they affect complications, such as pneumonia, or transmission.
summaries.cochrane.org/CD001269/vaccines-to-prevent-influenza-in-healthy-adults

Herd immunity typically requires at least 70-80% of the population to be vaccinated and that's for vaccines that are hopefully much more effective than for flu. Add to that the variability every year and the fact that one needs to be vaccinated every year... It's not really possible.

To get back to the original point, if this lady's employment contract had this as a requirement well then I guess it is what it is. My unpopular opinion is that terminating her is a pretty stiff punishment considering the inconsistency and unpredictability surrounding the flu vaccine.

The 50%-70% doesn't mean the actual vaccine itself is that ineffective. It speaks to surrounding variables that are not predictable enough themselves to anticipate accurately year to year. While pregnant people have immuno-suppression, it's not accurately to compare their immune systems state to that of a truly sick person. It wouldn't be recommended that pg people get the vax, and it wouldn't be saved just for them, if the odds were against them.

[rugbywife]

Jan 3, 2014 8:02:25 GMT -5 mr+ms said:

Jan 2, 2014 23:45:49 GMT -5 kimibrighteyes said:

    You said that the flu vaccine is not as effective in pregnant women.  I am aware that the flu vaccine is not 100% effective.  I am a physician who looks after pregnant women and I am not aware of any evidence that the flu vaccine is less effective in pregnant women than in non-pregnant individuals. If you have data to support this, I would be interested in knowing about it.

That's my educated guess. I cant find data to prove or disprove it. It's possible that it doesn't exist or we'd be hearing about how awesomely well the flu shot works in pregnancy. If every other population with decreased immune function does not respond as well to flu vaccination is there a good reason that pregnant women would buck this trend? As a healthcare provider I'm sure this must have crossed your mind.

Now you just sound like Jenny McCarthy.

[orangeblossom]

I don't think mr+ms is articulating it well, but yes, for some groups like the 65+ They have a higher potency vaccine, because by that age their immune system may not work as well, and they need a higher dosage.

When I got my flu shot his year, there was a choice for the shot, flu mist or high dose (not exact name, but similar concept). The high dose was only for 65+, and I can't get flu mist.


I have never seen the same for pregnant women, even though their immune system is compromised to an extent while pregnant.

The bottom line is this nurse is not complying and has no documented medical exemption, so yes, she should be fired at this institution that does not allow for declinations without medical exemptions.

It is not a harsh penalty. She's not only protecting her patients by getting the shot, but protecting herself. A flu outbreak in a hospital is serious business, why do you think they have masks for people who even think they may have it as soon as you walk in, so why should a nurse who is within close proximity to an ill patient bf exempt.

[orangeblossom]

Jan 3, 2014 8:46:20 GMT -5 Lucy Honeychurch said:

I simply fail to understand why someone who works exclusively with immunosuppressed and immunocompromised persons on a daily basis would refuse a vaccine that could lessen the severity of or complications from an illness that has been established to be devastating to those persons otherwise.

Regardless of the controversial and constantly-fluctuating studies regarding the efficacy of the vaccine, which varies from year to year and outbreak to outbreak, it strikes me as inherently irresponsible at best and shockingly negligent at worst not to at least make every attempt at retarding transmission and infection.

It's a useless point at best. The whooping cough vaccine is fairly effective, and yet the increasing population of anti-vaccinating parents has caused new outbreaks in both vaccinated and unvaccinated persons. If this woman had refused a pertussis vaccine, she'd absolutely have been fired. If she refused a rubella vaccine, she'd likewise have been fired. The fact remains that there are certain standards of care within the framework of this facility. She failed to meet those standards, was given every opportunity to rectify this (or, in the alternative, to provide adequate exception), and did not. The company gave her several chances, and in the end had no choice but to terminate her employment.

I fail to see why the efficacy of the vaccine should render an employer's standards of care moot.

This.

In most places you cannot even start work without proof or immunity to measles, mumps, rubella, varicella and more, so why is the flu different just because you have to get it every year.

People are so short sided and only think, well I'm not getting it and don't think about their patients or themselves. In their shortsightedness, they don't think about getting it from a sick patient and then taking f home to their family or friends. It's the profession you chose, to protect and care for patients and that means getting vaccines. Period.

[Deleted]

How the heck is this thread only on page 4 yet still going 6 days later?! Lol

[kimibrighteyes]

Jan 3, 2014 8:02:25 GMT -5 mr+ms said:

Jan 2, 2014 23:45:49 GMT -5 kimibrighteyes said:

    You said that the flu vaccine is not as effective in pregnant women.  I am aware that the flu vaccine is not 100% effective.  I am a physician who looks after pregnant women and I am not aware of any evidence that the flu vaccine is less effective in pregnant women than in non-pregnant individuals. If you have data to support this, I would be interested in knowing about it.

That's my educated guess. I cant find data to prove or disprove it. It's possible that it doesn't exist or we'd be hearing about how awesomely well the flu shot works in pregnancy. If every other population with decreased immune function does not respond as well to flu vaccination is there a good reason that pregnant women would buck this trend? As a healthcare provider I'm sure this must have crossed your mind.

I don't have a lot of time this morning as I have patients to see, but I believe your educated guess is incorrect.  Dissemination of information like this (flu vaccines not being effective in pregnant women) is one of the factors that leads to the low rate of vaccination for influenza in pregnancy.  Pregnant women are not more likely to get influenza, but are more likely to get sick from influenza and have more severe illness. As well, there are adverse pregnancy outcomes that can occur with influenza during pregnancy and vaccinated women have better outcomes.  If the mother is immunized during pregnancy, then the baby will also have some passive immunity for the first few months of life, which is important as neonates are at risk and the vaccine is not licensed for infants until they are 6months age. 

Pregnant women are "immunocompromised", but the immune system is very complex and you can't lump all immunocompromised people together.  You are right that some immunocompromised groups such as the elderly have a less immunogenic response to the influenza vaccine.  I just pulled up a few abstracts that you might find useful.  :::steps off soapbox:::

1. Clin Infect Dis. 2013 Dec 19. [Epub ahead of print]

Effectiveness of Seasonal Trivalent Influenza Vaccine for Preventing Influenza
Virus Illness Among Pregnant Women: A Population-Based Case-Control Study During
the 2010-2011 and 2011-2012 Influenza Seasons.

Thompson MG, Li DK, Shifflett P, Sokolow LZ, Ferber JR, Kurosky S, Bozeman S,
Reynolds SB, Odouli R, Henninger ML, Kauffman TL, Avalos LA, Ball S, Williams JL,
Irving SA, Shay DK, Naleway AL; for the Pregnancy and Influenza Project
Workgroup.

Author information:
Influenza Division, Centers for Disease Control and Prevention (CDC), Atlanta,
Georgia.

Background. Although vaccination with trivalent inactivated influenza vaccine
(TIV) is recommended for all pregnant women, no vaccine effectiveness (VE)
studies of TIV in pregnant women have assessed laboratory-confirmed influenza
outcomes. Methods. We conducted a case-control study over 2 influenza seasons
(2010-2011 and 2011-2012) among Kaiser Permanente health plan members in 2
metropolitan areas in California and Oregon. We compared the proportion
vaccinated among 100 influenza cases (confirmed by reverse transcription
polymerase chain reaction) with the proportions vaccinated among 192 controls
with acute respiratory illness (ARI) who tested negative for influenza and 200
controls without ARI (matched by season, site, and trimester). Results. Among
influenza cases, 42% were vaccinated during the study season compared to 58% and
63% vaccinated among influenza-negative controls and matched ARI-negative
controls, respectively. The adjusted VE of the current season vaccine against
influenza A and B was 44% (95% confidence interval [CI], 5%-67%) using the
influenza-negative controls and 53% (95% CI, 24%-72%) using the ARI-negative
controls. Receipt of the prior season's vaccine, however, had an effect similar
to receipt of the current season's vaccine. As such, vaccination in either or
both seasons had statistically similar adjusted VE using influenza-negative
controls (VE point estimates range = 51%-76%) and ARI-negative controls
(48%-76%). Conclusions. Influenza vaccination reduced the risk of ARI associated
with laboratory-confirmed influenza among pregnant women by about one-half,
similar to VE observed among all adults during these seasons.

PMID: 24280090 [PubMed - as supplied by publisher]


2. BMJ. 2013 Feb 4;346:f393. doi: 10.1136/bmj.f393.

Influenza A/H1N1 MF59 adjuvanted vaccine in pregnant women and adverse perinatal
outcomes: multicentre study.

Rubinstein F, Micone P, Bonotti A, Wainer V, Schwarcz A, Augustovski F, Pichon
Riviere A, Karolinski A; EVA Study Research Group Estudio Embarazo y Vacuna
Antigripal.

Author information:
Institute for Clinical Effectiveness and Health Policy, Emilio Ravignani 2024,
Buenos Aires, Argentina. [e-mail]

OBJECTIVE: To assess the risk of adverse perinatal events of vaccination of
pregnant women with an MF59 adjuvanted vaccine.
DESIGN: Cross sectional multicentre study.
SETTING: 49 public hospitals in major cities in Argentina, from September 2010 to
May 2011.
PARTICIPANTS: 30,448 mothers (7293 vaccinated) and their 30,769 newborns.
MAIN OUTCOME MEASURE: Primary composite outcome of low birth weight, preterm
delivery, or fetal or early neonatal death up to seven days postpartum.
RESULTS: Vaccinated women had a lower risk of the primary composite outcome (7.0%
(n=513) v 9.3% (n=2160); adjusted odds ratio 0.80, 95% confidence interval 0.72
to 0.89). The propensity score analysis showed similar results. Adjusted odds
ratios for vaccinated women were 0.74 (0.65 to 0.83) for low birth weight, 0.79
(0.69 to 0.90) for preterm delivery, and 0.68 (0.42 to 1.06) for perinatal
mortality. These findings were consistent in further subgroup analysis. No
significant differences in maternal outcomes were found.
CONCLUSION: This large study using primary data collection found that MF59
adjuvanted A/H1N1 influenza vaccine did not result in an increased risk of
adverse perinatal events and suggested a lower risk among vaccinated women. These
findings should contribute to inform stakeholders and decision makers on the
prescription of vaccination against influenza A/H1N1 in pregnant women.

PMCID: PMC3563311
PMID: 23381200 [PubMed - indexed for MEDLINE]


3. Am J Obstet Gynecol. 2012 Sep;207(3 Suppl):S17-20. doi:
10.1016/j.ajog.2012.06.070. Epub 2012 Jul 9.

Benefits of influenza vaccination during pregnancy for pregnant women.

Jamieson DJ, Kissin DM, Bridges CB, Rasmussen SA.

Author information:
Division of Reproductive Health, National Center for Chronic Disease Prevention
and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA,
USA.

Influenza vaccination is a cornerstone of influenza prevention efforts among
pregnant women. Prior to 2005, data from studies conducted on pregnant women were
limited, with much of the supporting evidence coming from influenza vaccine
studies conducted among nonpregnant, age-matched populations. Since 2005,
however, an increasing number of studies have demonstrated the safety and
immunogenicity of influenza vaccine for pregnant women, including evidence of
maternal transfer of antibody. In addition, the clinical benefit of influenza
vaccination, both for the mother and infant, was demonstrated in a landmark
randomized clinical trial conducted in Bangladesh. Additional randomized clinical
trials with laboratory-confirmed influenza as the primary outcome are underway in
countries without a current influenza vaccination program, but such trials are
unlikely to be conducted in the United States or other countries that already
recommend the vaccination of pregnant women. However, current evidence supports
the safety and immunogenicity of inactivated influenza vaccine and its
effectiveness in reducing the risk of influenza-related illness among pregnant
women.

Copyright © 2012 Mosby, Inc. All rights reserved.

PMID: 22920053 [PubMed - indexed for MEDLINE]

[Kattey]

I guess Monday I need to call the doctor and get my flu shot. I don't know how people can get scared out of getting the shot. I've never had one, but ya'll have scared me into it.

[epphd]

I don't understand why we're discussing whether the vaccine prevents transmission. I mean, it would make sense if it wasn't already true that transmission can happen well before symptoms are overt. Meaning, all the best practices of staying home when you feel ill and covering your cough are moot if a health care provider is having close contact with immunocompromised people and can GIVE THEM FLU even before she know she has it. Which is why preventing getting it in the first place is so important.

And frankly, irrespective of "how effective IS it" is the question of why the hell wouldn't you get it? There is nothing that has called in to question the safety of the influenza vaccine in the vast majority of people. Team LHC.