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It’s not just about you – screw the flu!


The Ontario Nurses Association (ONA) recently won an arbitration against Sault Area Hospital striking down their ‘vaccinate-or-mask’ policy. The arbitrator Jim Hayes found the policy was unreasonable, and a “coercive” tool to force heath-care workers to get a flu shot.  While this decision is only binding to Sault Area Hospital, many hospitals across Ontario will now shy away from instituting a policy to increase healthcare worker vaccination rates because of this decision. And flu season is just around the corner.

While ONA president Linda Haslam-Stroud is touting this as a big win for her organization that represents over 60 000 registered nurses, I can’t help but think about the many people who stand to lose from this decision.  The flu virus infects thousands of Canadians annually, and some become critically ill and die. And while it has undeniable weaknesses, we have a vaccine that can significantly decrease the burden of influenza on Canadians.

 

I will be upfront that the flu vaccine is far from perfect. People who receive a vaccine may still get influenza. This is because vaccine protection is heavily dependent on the individual’s own immune system. It’s also dependent on timing. Getting the vaccine before influenza season is crucial because it takes people time to develop immunity. Logistically, influenza modeling teams gather in February to predict which strains will circulate the following winter because it takes time to manufacture several million flu vaccines. This means the flu virus has months to mutate between vaccine creation and distribution. By the time you get vaccinated, your specific vaccine will not match exactly the strains of influenza in your environment.

Given all this complexity, protection from the flu vaccine is never 100%. We typically average 60% in a good match year. The number of healthy individuals that need to be vaccinated to prevent one case of influenza is between 12 and 37 in a good year. This was estimated in healthy individuals and might be lower in hospitals during flu season given the vulnerable population and increased prevalence of the flu. It also does not factor in the potential benefit from herd immunity.

The exact benefit of the flu vaccine in hospitals is difficult to study because of all the potential variables beyond a researcher’s control. There are similar challenges in proving hand washing in healthcare prevents the spread of illness, but we do it because it just makes sense. While the jury is out on whether vaccinating the general public yearly against the flu is worth the risk and cost, most clinical experts agree that hospital workers should be vaccinated annually against the flu. Even vocal opponents of mandatory hospital vaccine policies, like UHN’s Dr. Michael Gardam, believe “that it makes perfect sense for health care workers to get immunized.”

However, what mandatory vaccine opponents are not acknowledging is how ineffective voluntary vaccine programs are. The CDC reports the average volunteer vaccine rate in healthcare workers to be only 44%. So if we agree that out of the Canadian population, health care workers in particular should be vaccinated against the flu, how do get from a 44% vaccine rate to a 100% without policies like vaccinate-or-mask?  I’m not sure that we can.

American institutions are beginning to enforce mandatory condition-of-employment flu vaccine policies – and they are working. Some hospitals have linked flu shot compliance to sizable financial incentives and have seen sustained increases in their vaccine rates. At the Children’s Hospital of Philadelphia (CHOP), vaccine expert Dr. Paul Offit implemented a “get vaccinated or get out” policy. CHOP ultimately fired only nine out of 9,300 employees, achieving almost 100% compliance. In Canada, we can’t expect to achieve similar success by just asking nicely.

At it’s worst, vaccinate-or-mask policies impose a negative consequence for choosing not to vaccinate. But at its best, it’s a happy medium between voluntary vaccine programs that prioritize employee choice over patient safety and condition-of-employment policies that force employees to get vaccinated.

Few healthcare workers are outright opposed to vaccines, but it’s clear they need a push. If we can’t impose a negative consequence like wearing a mask and we can’t make it mandatory for hospital employees to get the flu vaccine, I’m not sure how we will move the needle from a 44% voluntary vaccine rate to 100%. While I personally agree with Jim Hayes that masks are punitive, what other option is there? Even if ONA publicly committed to achieving a 70% voluntary vaccine rate amongst their members (which they haven’t), it’s probably not possible for them to achieve it. Do we just accept these abysmal vaccine rates and cross our fingers it doesn’t affect patient care?

So while ONA is out celebrating their arbitration win, and hospital policy makers are left deciding what to do this impending flu season, we are no further in coordinating an effort against the real common enemy – the flu virus.

As a frontline care provider, anything we can do to decrease the burden of flu on the system is worth doing in my mind. If I was a cancer patient or the mother of an unimmunized infant, I would expect there to be more than a 44% chance the person looking after me has been vaccinated against the flu. Wouldn’t you? And furthermore, if we can’t sort out this situation within healthcare, how will we ever win the big media battle that rages on with anti-vaxxers in general?

This arbitration decision against vaccinate-or-mask is not a win. It’s a loss for Ontarians. Hospitals in Ontario are even further handicapped at enforcing flu vaccines for their staff. Less health care workers will get vaccinated because they have an easy opt out. And more flu cases will be transmitted to patients. While I respect freedom of choice in the workplace, perhaps  freedom of choice means the freedom to find other work if you won’t be vaccinated and you work with vulnerable patients.

Seema Marwaha is a general internist at Trillium Health Partners. Follow Seema on Twitter @seema18m

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25 comments

  1. Sierra Marie

    This article is so skewed. A quick lit search shows that studies on mandatory flu vaccination do not support your argument.

    • Marcy W

      From what I see, the studies are not clear cut or simple in this area and there are a multitude of outcomes of varying relevance so I’m not sure what your ‘quick lit search’ revealed that was so convincing. Furthermore, argument here seems to be more that voluntary vaccine programs are ineffective and the literature is actually pretty clear cut in this space.

      This is an opinion piece, so authors are meant to take a side. Your comment seems to criticize this author for taking a side when that’s the whole point. Just my 2-cents.

  2. Laura L.

    I have studied this topic extensively. I agree with the author, a “quick lit search” shows that you have not done your homework on this topic. As a healthcare worker I do think vaccinations should be mandatory. We are in the business of protecting our patients and helping them heal- how can this be achieved if we aren’t protecting ourselves? The benefits of getting vaccinated far outweigh the consequences. The likelihood of suffering an adverse event as a result of the vaccination is almost non-existent compared to the likelihood of suffering an adverse event from the influenza virus. As healthcare workers we need to lead by example. Great opinion piece Seema!

  3. ff

    This goes to prove one thing and one thing only:

    Nurse lobbies are very powerful and persistent.

  4. Niche Wali

    A question, ‘vaccine or mask policy’, only applied to hospital employees or everyone coming in contact with patients? do clinicians and consultants that are not hospital employees, have to uniformly comply?

  5. Michael Gardam

    I agree with much of what you have said about the challenges of the influenza vaccine Seema; however there are a few important points that I think need to be made.

    First off, the vaccine or mask (VOM) policy in question is not a mandatory vaccine policy. Mandatory vaccine policies like those in the US are easier to understand: you have to be vaccinated as part of your job. The arbitrator pointed out that the Ministry of Health and Long Term Care has the legislative power to force such a policy, but it have not chosen to do so, perhaps because influenza vaccination is far more grey than black and white.

    The VOM policy offers a choice; however as the arbitrator concluded, the evidence for the masking of well individuals as a protective measure for patients was found wanting. Without scientific support, the masking option was seen as coercive. We can’t mislead people even if we believe that what we are trying to achieve is the right thing. Communications expert Peter Sandman calls this “misleading towards the truth” and concludes that when people find out they have been misled, they will be far less inclined to listen to you the next time around.

    Secondly, driving up vaccination rates has become an end unto its self. We have the missed the big picture here: what is the best way to protect ourselves and our patients from catching respiratory viruses in hospital? I specifically refer to respiratory viruses because as you know, most influenza like illness is not the flu, most staff and patients will not catch the flu in any given year, and there are many other viruses that can also cause morbidity and mortality. At UHN we view the flu shot as part of a larger staff and patient safety practice bundle that includes individual wellness, not coming to work when ill with influenza like illness, masking if you have to be at work while sick, practicing respiratory etiquette and appropriately using PPE and isolating symptomatic patients.

    Yes we should get our flu shots AND given the limitations, we cannot not rely on the vaccine to protect ourselves and our patients. As I have stated countless times, even though it is mediocre in comparison to other vaccines, I get mine every year because most years it offers moderate protection against influenza. I do feel however that this focus on driving up vaccination rates by any means necessary gives a false sense of security that we have done our part. We need to do much more as outlined above.

    Finally, with respect to achieving higher vaccination rates, we have been quite successful at UHN by dialing back the moral indignation and offering a “shot for a shot”: when you receive the flu shot, we donate to vaccination campaigns in other countries as well as provide safe drinking water to children in need.

    • Seema Marwaha

      Thank you for your insightful commentary Michael. I think we agree on most points.

      Just a few thoughts:

      – I agree with you that the focus of driving up vaccine rates alone is misguided. Campaigns need to be focused on the full spectrum of flu prevention like such as PPE and hand-hygiene.

      – Both THP and UHN took non-policy based approaches last year. THP was able to achieve a vaccine rate of 63% with a non-coercive, incentive-based campaign, but it was very resource intensive. I believe UHN’s rate was lower than 63%. Non-policy based approaches are simply not as effective for most things in a healthcare environment. In environments where there is not a consequence for inaction, both hand washing rates and PPE compliance is lower.

      – We have to decide organizationally whether we support flu vaccination as part of our flu prevention strategy. If we don’t believe in it and think it is too flawed to include, then we should stop investing the same intense amount of resources and time into pushing it and focus on other strategies. If we do believe it is a deserved part of the flu prevention strategy, we need both simple, non-misleading messaging and policies to help enforce this.

      While we can’t mislead toward the truth, both behavioral economics and advertising literature tells us we have to have a clear action and message in order to incent behavior change. Right now, our messaging over-zealously tells HCWs to get their flu shot, but our policies do not reinforce this message. I believe this results in a very resource-intensive way to achieve a mediocre flu-vaccine rate.

      Ideally, we should cast a wider-net of flu prevention, but this is not easy to do with our limited resources. Creating an effective flu prevention message without oversimplification is also not an easy task. While I agree with your overall sentiment, corporate polices and messaging have to be crystal clear, and this is a complicated message. How do we execute?

  6. Johnny Mccarthy

    Perhaps instead of assuming hospital workers are lazy, misinformed or Jenny Mccarthy clones, you might for a moment consider them intelligent front line workers who actually have years of experience with giving, getting and observing the results of the flu shot in both their patients and themselves. And perhaps our real world experience doesn’t exactly line up with what your experts having been touting for years. Do you really think that if the shot was clearly effective in reducing morbidity and mortality, that we wouldn’t be the first in line to get it? But that seems to be very far from the case.

    You mention there are too many variables to assess in hospital effectiveness (really?), but we should do it because it “just makes sense”. I think we’ve done away with that model of medicine when evidence based medicine came on the scene years ago. But instead of looking for real answers or having an open and honest conversation about this topic, we should publicly shame our health workers into compliance with a poorly effective program by using another ineffective program.

    Instead of viewing hospital workers as part of the problem, perhaps the medical community should use our compliance rate to reassess very real deficiencies in the flu vaccination strategy. Or you can choose to build stocks in the hospital atrium, or threaten to fire us all. It still won’t address your real problem though. After all, if we aren’t buying it, then there’s likely something wrong with what you’re selling.

    • Michael Gardam

      I agree with you that there are many challenges with the flu shot related to its effectiveness, having to get it every year and so on. And I also agree that most of the negative comments I hear about the vaccine are logical concerns re. how much good it does rather than “McCarthy-esque” conspiracy theories. I just got mine a couple of hours ago, and while I am not worried about side effects, I do worry about effectiveness, especially if we have another H3N2 year. I personally don’t see a down side to getting the vaccine but I certainly don’t rely on it either. Avoiding work while ill is the key–and I fully recognize that our system currently punishes those who stay at home while ill while our hero culture salutes whose who come to work while hacking up a lung. All the talk of forcing the vaccine on staff largely misses the point.

    • JJ

      Do you not hear your massive contradiction?

      First you say we should consider the observations and experience of staff working for years on the frontline. THIS IS NOT EVIDENCE, this is experience. So for you, it’s OK to listen to non-evidence based opinions of healthcare workers when it aligns with your beliefs.

      However, when something does not align, you take an evidence based high-ground? When people say the flu vaccine makes sense based on expert opinion, operational modeling and the best evidence we have (albeit not high-level), that is not rigorous enough for you? By this logic, why don’t we poll America on climate change – if people don’t think it’s happening, then they must be correct?

      I actually have no opinion for or against the flu shot. I also agree healthcare workers are intelligent with valuable opinions. But your comments were as contradictory as any internet anti-vacciner I’ve come across. Don’t they also dismiss evidence for lacking rigor, but place great weight on personal opinion and belief?

      • Johnny Mccarthy

        The post was intended to point out the fact that the reluctance of HC workers to receive the flu shot is not so much based on ignorance, as their own observations on the effectiveness and side effects of receiving the shot. It then goes on to point out the hypocrisy of using the “it just makes sense” rationale the author employed to justify mandatory vaccinations. No contradiction there.

        Your post does serve a good example of how to dismiss and deflect without actually dealing with any content or subject matter. Cast aspersions on the motivations of the poster (belief, high ground), redefine the terminology (evidence = expert opinion), employ spurious analogies (polling on what people THINK about climate change vs what health care professionals OBSERVE), declare your own neutrality on the subject, then relegate the poster into a discredited group (anti-vaxxers) – ironically, exactly what I asked not to be done.

        At the end of the day, you’ve contributed absolutely nothing to this discussion. I suspect that it’s not so much that you don’t have an opinion on the matter, as you just don’t have anything worth saying.

        • JJ

          Observations that are anecdotal are no different than a person’s opinion. If it’s in the constructs of an observational study, that is one thing. But your post implies that for some reason, non-objective healthcare worker opinions hold some increased weight.

          In the case of vaccinations, healthcare workers actually cite lack of access as the number one reason not to get vaccinated when surveyed. Their perceptions of vaccine efficacy are no better or informed that that of the general public (when studied). You are making some pretty lofty assumptions that the random observations of frontline health workers are more useful and I challenge that notion. Show me objective evidence of these observations and perhaps I will be convinced. Otherwise, like hand washing, I take no issue in using logic and common sense as a placeholder.

          No where in this post did it say HCWs were ignorant and I can’t comment on that. But what studies do show is intent to get vaccinated does not match action and policies can help drive that. Furthermore, do you think your assertion that healthcare worker opinions should be listened to is somehow groundbreaking? That is the first place policy makers and researchers go for guidance in this area.

          I welcome your provocative comments and opinions, but I don’t appreciate immature insults and attacks on my intellect. I do have valuable things to say and I will continue to comment. If this is your response to criticism (to insult the commenter and tell them their contribution is worthless), then perhaps you should refrain from public posting until you get that behavior sorted out.

          Kind regards and happy posting

  7. Heather MacDonald

    I think that all of us have an obligation to protect our health and stay home and away from others when we are “contagious”. That said, the last time I had a flu shot was in the early 1970’s when I used to listen to my GP and pretty well comply with her recommendations. The last time she gave me the shot, she commented that I was only being given half the dose because of my chronic asthma and lung problems. That got me thinking…. I think she was admitting that the shot itself could actually bring down my immune system and leave me susceptible to the flu.

    Since then, I have never had a shot for flu though I am now a senior and in a very high risk group. I do exercise common sense, stay away from others when I am unwell, take my vitamins and try to build up my immune system in every way. I’ve never had the shingles vaccine either although I had shingles at the early age of 13!

    For me, the key is keeping up your immune system and avoiding contact with others as long as you feel unwell. Maybe for those in contact with large numbers of people every day, the shot makes sense but for me, I will avoid it and hope we never get to the day when it is universally mandated. One size does not fit all.

  8. cindy campbell

    I value hearing Seema’s opinion, but am discouraged by the intolerance, and misdirected indigence that I hear coming from a young, intelligent woman.

    I am discouraged that practices of the USA, a country whose healthcare system and history of human rights violations that Canada would not wish to emulate, are endorsed. Or that practices of Philadelphia’s CHOP, who use alarming terms as ‘carrots and sticks ‘ to describe enforcement measures are depicted as admirable. Never is the impact of loss of staff autonomy and the long term detriment upon staff morale, institutional credibility and ultimately patient care considered. Nor is the necessity of equitable and measurable policy

    Be certain, the clinical outcomes of mandated influenza policies such as CHOPs’ will not be will not be forthcoming , since clinical outcomes of influenza mandates go unmeasured despite being in existence since 2006 ( Pitt et al 2014)

    What I am most saddened by however is the lack of acknowledgment that this arbitration was not merely selfish nurses but rather, was fought and won on compelling scientific evidence and testimony of high caliber expert witnesses.

    Opponents mourn the loss of an unsubstantiated mask to expose the non compliant. At the risk of sounding indignant myself, perhaps a scarlet letter would suffice? I heard it worked in the 18th century

    I would suggest that influenza prevention policies with an unreliable flu vaccine as their ” cornerstone” are are constructed on shaky foundations .
    There are numerous ways to fight influenza …. Polarizing, alienating and demoralizing staff with illogical, unreasonable policies is NOT one of them

    Cindy Campbell RN

    • Marcy

      This is an opinion piece. Your response opinion is welcome and provides a different insight. However, calling the author both personally ‘intolerant’ and speaking with ‘misdirected indigence’ is insulting and unnecessary. If you valued hearing the author’s opinion, you would not resort to such catty commentary in the next breath. It gave an indignant tone to the rest of your points, which I thought were otherwise insightful and though provoking.

      You can call the piece misdirected and intolerant, but insulting the young author of this piece directly as you chose to do was in poor taste.

      Marcy W (also an RN)

  9. Peter G M Cox

    I found this article and the comments it provoked disquieting. I have little medical knowledge and only became interested in healthcare from experience as a caregiver and advocate for a family member with chronic conditions, that experience including several failures of the healthcare “system” to intervene quickly enough and/or appropriately as well as some excellent treatment – the latter too often too late to prevent serious harm.

    With such limited medical expertise, I am none-the-wiser as to what all this controversy is about. I was advised to have flu shots in order to protect my family member whose immune system was impaired. I understand that the flu vaccine does not protect against all strains of the virus and that a very small minority have an adverse reaction to it but am I wrong in thinking that it provides a degree of protection? (I certainly haven’t had any flu since I started vaccinations.)

    What I find disquieting is that, if this is true, so few medical professionals want or are willing to have it themselves. It echoes the difficulty experienced with hand-washing compliance. My impression of most of the doctors and nurses I have encountered (a good number, I might add) is that they are dedicated to their patients welfare (but too often working under too much pressure – in terms of time and sometimes resources/facilities – to provide adequate responses.

    But what I don’t understand is the reluctance of so many to take what most of us would regard as very simple, non-intrusive and minimally inconvenient precautions about their own and patients’ health and, in some cases, safety. Has anyone ever asked them? This might provide a better insight into their motivation and, consequently, how “better” results might be achieved. Clearly, the “heavy-handed” approach of mandating behavior is not working – although, equally disturbing, it probably reflects a yawning gap between “frontline” practioners’ sense of what is in the patients’ interests and that of those trying to impose their view (right or wrong) on them!

    Any “healthy” organisation develops a shared set of values and behavior THROUGHOUT their ranks, all focused on fulfilling their “mission” – in this case, PATIENT care and safety.

  10. Blain Vandersteen

    In Australia kids aren’t allowed in school or daycare without their vaccinations being up to date. Definitely the flu vaccine should be similarly regarded in Canada and it should be mandatory for any public servant working with the public. Starting with all health care providers and carry through to teachers and students. So nurses really should just be a given.

  11. David Grant

    Why in this day and age, are we still having this debate? The evidence is pretty clear to those who have the ability to read and reason that the benefits outweigh the risks and yet there are people who can’t be persuaded to vaccinate themselves and their children-if they have them. We must work to push back against the anti-vaccine movement but we need to to make them mandatory. We cannot afford to do otherwise.

    • Jan Toff

      First, we are only talking about the flu shot here, not useful vaccines like the measles. The evidence is not as clear as you think. Read this amazing research on the flu shot. The poor science behind flu shot see links 52 to 60.
      -http://flushotcanada.blogspot.ca/

  12. Suzanne dEntremont

    how can we get access to the video again? it states above it is no longer available. we see it as a valuable tool to convince healthcare profressionals to get the flu shot. please make it available again!

  13. Jan Toff

    Good propaganda piece. Let me correct a few things.
    -1. 44% of Canadians do not take the flu shot.(That is US data). It is more like 32%
    -http://www.statcan.gc.ca/pub/82-624-x/2015001/article/14218-eng.htm
    2. The flu shot is not 60% effective. Overall it is more like 41% effective at best.
    -http://www.cdc.gov/flu/professionals/vaccination/effectiveness-studies.htm
    3.The science behind the flu shot is actually not very good. See links 52 to 60 here.
    -http://flushotcanada.blogspot.ca/ Also see links 19 to 27 Repeat flu shots bad.
    4. You say take the flu shot to protect people. You are not protecting anyone if the flu shot makes you more likely to get the flu. (No it does not give you the flu) see here.
    -http://www.ctvnews.ca/health/serial-flu-shots-may-limit-body-s-ability-to-fight-virus-in-future-researchers-1.3147903

    • Jan Toff

      Article has picture at top showing “87 child deaths” What! Where did you get that please-Link?
      http://www.phac-aspc.gc.ca/influenza/flu-stat-eng.php This shows there is an average of 11 child deaths a year. Then add 15% as one or two provinces do not always report, so 13 or 14 kid deaths a year aged 0 to 18.
      -http://gis.cdc.gov/GRASP/Fluview/PedFluDeath.html Note: Unlike Canada the US has mandatory reporting of all child (0 to 18)flu deaths, so their data is more accurate. Note that they have an average of 140 flu deaths. There population is 9 times ours. 9 times 14=126 so we may be a tad low. So in Canada to be the same as the US we have an average of 16 flu deaths, not 85. Now note that there is 8 million kids 0 to 19 in Canada. So that means the kid has only 2 chances in a million of dying of the flu. Probably less if he is healthy. He has about 5 to 10 chances in a million of a serious adverse event from the flu shot. Risk/benefit ratio. Flu shot also less than 50% effective.

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