 The director of the Children's Mercy Bioethic Center in Kansas City, Missouri. Many of us remember John, who spent 21 years here at the University of Chicago, leaving his professor of pediatrics, associate director of the McLean Center, and associate chair for academic affairs in the department of pediatrics. After leaving the University of Chicago, he spent two years as the John B. Francis chair in bioethics at the Center for Practical Bioethics, and then went on to Children's Mercy to start the Children's Mercy Bioethic Center. Dr. Lantos has served as president of the American Society of Law, Medicine, and Ethics, the American Society of Bioethics and Humanities, and he has also written or edited five books and has published more than 250 journal articles and book chapters on pediatrics and neonatal ethics. Welcome back, John. Thanks, Laney. Thanks, Mark, Barry, and Mary Ann if you're here, but especially Adam and Fiona, everybody knows one of the least desirable positions on Earth is to be one of Mark's helpers, and you guys have done fabulous work. Thank you. The first two talks might be called stories about doctors acting nobly when patients or parents act stupidly. This is going to be a talk about doctors acting stupidly, and it's really the story of mandating influenza vaccine and about a project we undertook with our hospital, the collaboration between the Bioethics Center and the hospital to figure out what to do about healthcare workers who didn't get their flu vaccines. And it's part of a larger story that's taken place societally, and I think there's been an interesting shift over the last few years, and it's really been sort of a drama in three acts. Voluntary immunization, which didn't work for motion of voluntary immunization through heavy persuasion, cajoling and all the things that Rick talked about. And finally, what we're starting to see, which is requiring immunization. That's one of those things where there's been a sea change, I think just in the last couple of years in the institutional policy, vaccines have been recommended for decades. Most hospitals offered them but didn't require them, and the immunization rates among healthcare workers were low, and suddenly in the last five years, people are starting to fire people. So let's look at how we got there. First of all, immunization kills people. 200,000 hospitalizations in the United States a year, about 50,000 deaths, 600,000 life years lost, and it's one of the leading causes of vaccine-preventable death. It's well known that there's no zocomial spread, especially among babies, children, and the elderly. And it's also well known that doctors and nurses are the vectors of this. 25% of unimmunized healthcare workers get the flu every year. They're contagious before they're symptomatic. Most don't recall that they had the flu when you ask them, you know, did you have flu-like symptoms? They didn't recall any respiratory illness. So you don't know when you're contagious. And even if you do, we don't stay at home when people surveyed healthcare workers. Most people say, oh, if I get sick, I'd just stay home. And if you asked them the last time you were sick, what did you do? More than half of them went to work. So the justification, usually when people do this, is they need me. I need to show up at work. Does immunizing healthcare workers actually work? This is an interesting question that I'm going to get back to at the end. There are some studies. If you actually look at the studies, they're really bad. But here's what they look like. 600-bed tertiary care hospital, 12 influenza seasons, healthcare immunization rates with a promotion of immunization program went from 4% to 67%. And nosocomial flu they reported went from 32% to 3%. That sounds pretty good. Although the CDC says 67% would not be enough to prevent this nosocomial spread. So it makes you wonder about the methodology. Similar study in long-term care facilities, healthcare workers offered free vaccine in some, not in others. So it was sort of a randomized trial. Vaccine uptake was higher where they were offered free vaccine, 50% versus 5%, and the mortality for patients in the long-term care facilities with free flu vaccine was lower than in those without, and this just is the graph from that table, as the vaccination rate for healthcare workers increased, the mortality rate for patients decreased. For children's hospitals, this is particularly important because premature babies are particularly vulnerable and there have been outbreaks in neonatal intensive care units. So if you look at how to prevent this, all the public health officials say prevention is the key, that staying home or wearing masks doesn't work. Immunization for healthcare workers has been recommended by virtually every professional society that has looked at that. Here's just the names of a few. The Joint Commission requires accredited institutions to provide flu vaccine, although not to require flu vaccine. And so there was widespread agreement that this was a good thing to do. And the question then is, what is wrong with healthcare workers and why don't they get immunized? And when you survey people, these are some of the reasons they give. The most common is, I never get sick. And then there are a bunch of other stupid reasons, like it's inconvenient, it's a nuisance, I'm afraid of shots, I don't want to pay. And the belief that the vaccine doesn't work, which is probably the most interesting and subtle of the arguments because in fact the vaccine doesn't work all that well, not as well as most vaccines. And every year they're guessing which strains of flu to include and some years it works better than others. So the big question I think for policymakers, both nationally and institutionally, is what to do when people who should be smart enough to do the right thing don't do it. Act two of the drama were programs of aggressive encouragement and many hospitals, many institutions tried education and current encouragement, convenient access, and it led to modest increases in vaccination rates. The best programs got up to maybe 50, 75%. One of the best was Barnes-Dewish in St. Louis and not large non-profit healthcare organization with 11 hospitals, urban, suburban, and rural, three long-term care facilities, 25,000 employees, and they started a campaign with free, convenient vaccine. They took carts around, they went to where the people were, they gave publicity, they gave encouragement, they had lotteries, they wore badges, they gave stickers, they had educational programs, successful practices were shared and they got their vaccination rate up to about half or a little over half of healthcare workers. They were added to the quality scorecard with a goal of 80%. Leadership incentives were provided. They made all employees who didn't want to be immunized sign a statement saying, I don't want this, I've been fully informed and I'm an idiot. And that got them up to about 71%, 16%. Signed the declination statements and 13% just said, screw you, I'm not going to get the vaccine and I'm not going to sign your damn statement either. That was just not good enough. So then Act 3 was some hospitals started playing hardball. The first one was Virginia Mason Medical Center in Seattle and they said to their doctors and nurses, although I don't think they did it for every hospital worker, get vaccinated or get fired. There was administrative support. They went through the flu champions, education, etc., etc. And guess what? It worked better than voluntary immunization. 98% immunization rates, but the nurses sued. The Washington State Nurses Association is utterly opposed to this policy, appalled that the hospital would threaten nurses with termination, forcing nurses to receive the flu vaccine is simply wrong. I'm shocked, shocked that the hospital would threaten to fire anybody. Nurses must have personal choice. And the court upheld the nurses. The nurses won their case against the hospital, at least on the first round, but on a technicality. They said this was not in the labor contract that the nurses had negotiated as a condition of employment. So, without it being in a labor contract, they couldn't add a new mandate and this would need to be addressed in the next collective bargaining agreement. So it was a delay, not a victory or a defeat. Barnes-Jewish was the next one. I'm going to skip through this one because time is short and I want to get to what we did at Children's Mercy. But they put in a mandate after their encouragement program. They communicated it widely. The CEO endorsed it. The policy was implemented with free vaccines, multiple sites, exemptions for medical and religious reasons, but with a hard deadline. If you don't have your flu vaccine, you're suspended without pay. You get a 30-day grace period. If you're not vaccinated at the end of the 30 days, you're out of here. The religious accommodation required a letter from human resources, medical exemption, a letter from a licensed physician. And they got up to almost 100% compliance with 98.5% immunization, with a few people getting medical exemptions, a few people getting religious exemptions, and 8 or .03% of employees just leaving their job. Mercy then decided to implement a program similar to the Barnes program, but with collaboration with the new bioethics center. So we started surveying employees about attitudes, beliefs about mandatory flu vaccine. We found lots of interesting things about what people believe. It turns out the only valid religious belief is libertarianism. That is my favorite comment when we surveyed employees because somebody who said, I get the flu vaccine every year, but if you required me to, I wouldn't. But here were the top 10 reasons, and they're pretty interesting as we rolled out this program and announced two years ahead of time that we were moving from voluntary to mandatory. Some interesting things happened. So the two columns are the two years. The one I want to point out in particular is the number of people claiming a religious belief precluding them from vaccination doubled as the possibility of a mandatory vaccine approached. Pregnancy. Yes, pregnancy is a fascinating one too because as most of you probably know, flu vaccine is indicated particularly for pregnant women but a lot of people claim either pregnant or intending to get pregnant as a reason not to get the vaccine. We didn't allow that one had to be an allergic reaction or bad adverse effect. This year we put the mandatory, or last year put the mandatory flu vaccine, no more signing declination statements. It was for every hospital employee and volunteer, students, volunteers, contract workers. Medical exemptions had to get a doctor signing a thing. There was a clause in the policy that religious exemptions would have to be evaluated by the head of chaplaincy. They didn't actually do that, and he was a little wary of how he would go about measuring the sincerity. For bona fide exceptions, people had to mask from October to April, and there was a hard deadline of November 15th. The program worked. Few exemptions for religious and medical. Three people left the hospital and said I'd rather quit than get the vaccine. And the reasons for success, I think, were a multi-year program to raise consciousness. High vaccine rates prior with persuasion. One year heads up. Big administrative buy-in and support. Actually a collaboration between administration, bioethics, infectious disease, and quality improvement. Pre-vaccine, lots of education. And I think a compelling philosophic rationale. No child should get the flu from one of us. The interesting question is why the shift? Why did we go for 15 years knowing what was the right thing to do and not do it? I'm not sure what the answer is, but it seems like the libertarian arguments are actually losing in this context. So is this a rare example of people behaving rationally? Is it that we're becoming a police or nanny pick your tyrant state? There's not much evidence that this actually works. That is, I haven't seen a good outcome study that hospitals with higher immunization rates have lower rates of nosocomial infection. I think it may be a more rigorous sense of professionalism as part of the professionalism movement. Or it may just be putting our money where our mouth is. And if we're going to go around advocating vaccines for other people, we really ought to get it ourselves. I predict though that this trend is unstoppable and that within five years we'll look at places that don't have mandatory policies the way we look at hospitals that allow smoking or did during the transition period and that this is the way we will do it from now on. Thank you very much.