Should health care workers be required to get the flu vaccine?

Each year several thousand Canadians die from influenza. Vaccinating health care workers against flu reduces transmission and would protect patients who are most vulnerable. 

However, only about 40% of hospital staff in Ontario were vaccinated last winter.

Is it time for Ontario to make the flu vaccine mandatory for health care workers?

Explaining the influenza vaccine

Although many of us use the term “flu” to refer to colds and other mild infections, most of these illnesses are not actually caused by the influenza, or flu virus. People infected by the flu virus usually feel very tired, have a headache and sore muscles, as well as fever. In Canada, the flu comes back each winter. A new vaccine is prepared each year to immunize people against the specific flu strains that are predicted to circulate that winter.

About one in ten Canadians gets the flu each winter. Most people just need to take a day or two off work or school to recover. However the flu can be more serious for some – especially people with chronic medical problems, very young children, pregnant women and older adults. Each year in Canada, several thousand people die from the flu. Although the flu vaccine is recommended for virtually everyone, high-risk individuals are especially encouraged to get the flu vaccine.

Health care workers are also strongly encouraged to get the flu vaccine, because they work with patients who are most vulnerable to the flu. Health care workers who become ill themselves might recover quickly, but if they pass the infection on to an older adult whose immune system doesn’t function as well, the patient might not be so fortunate.

High-quality research supports this assertion. A review of studies demonstrated that vaccinating health care workers against the flu reduced the the incidence of flu and death in their patients.

Health care workers and the flu vaccine

Each year, the flu vaccine is offered to all staff of Ontario’s hospitals through the Universal Influenza Immunization Program. In 2009, Toronto Public Health received reports on the immunization rates of health care workers across facilities in Toronto, and determined that they were too low. Toronto Public Health requested annual updates on influenza immunization coverage of health care workers in Toronto, and a report published in May 2011 found that for acute care hospitals the vaccination rate is declining each year. The median rate of vaccination among health care workers in Toronto hospitals was 37% last winter, ranging from a high of 65% at Toronto Western Hospital to a low of 14% at Rouge Valley Centenary Hospital.

Toronto Public Health made recommendations to the Ontario Ministry of Health that it should publicly report on health care worker flu vaccination rates, and to explore options to make annual flu vaccine mandatory for health care workers if rates did not improve.

Understanding decisions around flu vaccination

Ella Ferris, Executive Vice President Programs and Chief Nursing Executive at St. Michael’s Hospital notes that there is an annual campaign to encourage staff to get vaccinated which consists of an awareness campaign about the flu vaccine, plus many outreach mobile opportunities to get the vaccine. However, there continues to be low compliance rates amongst health care workers. Ferris says that “once the campaign is over there are effective mechanisms for management to receive feed back on the outcomes of the campaign. However, we really do not understand the reasons for low compliance. Perhaps we [hospital senior leaders] need to go to the clinical units and say to the staff let’s talk about compliance, as we wish to understand why some of you don’t get your flu shot.”

Janet Parsons, a researcher at St Michaels Hospital, interviewed a small number of health care workers to better understand why some staff chose not to get the flu vaccine. Some of the health care workers Parsons interviewed were skeptical that the vaccine really worked. Others worried about side effects. Many felt that ultimately getting the vaccine is a personal choice, and didn’t talk about the benefits of vaccination for their patients.

Jeff Kwong, a family doctor and influenza researcher at the University of Toronto suspects that many health care workers are skeptical about the evidence because of the “controversy in the past few years about how effective the flu vaccine actually is for adults aged 65 and older” as well as concerns about vaccine safety, due to “sensationalized media coverage of serious neurological events happening after the vaccine.” Matthew Muller, Medical Director, Infection Prevention and Control at St. Michael’s Hospital suggests that there has been “a tendency to list all the side effects [of the flu vaccine] with the goal of being transparent” but that communicating the risk of highly unlikely side effects may frighten people.

‘An ethical obligation’?

In October, a young doctor wrote a commentary in the British Medical Journal explaining why he won’t be vaccinated this year. “I don’t think that healthcare workers should be made to feel guilty about personal choices without solid evidence. The fundamental question is how much should our personal liberties be infringed to deliver better care for patients?” said Kinesh Patel.

Many disagree with Patel’s stance. A reply to his letter argued that “physicians and other healthcare providers accept an ethical obligation to make decisions and take actions that protect their patients from easily preventable harm.” This is the foundation of the medical obligation of ‘first do not harm.’

Ross Upshur, a family doctor and researcher in bioethics at the University of Toronto says that health care professionals have what appears to be a self-evident ethical obligation to be vaccinated, noting that health care workers agree to “do no harm to their patients, and if they are vectors of disease for hospitalized patients, they are putting patients at risk for increased harm.”

A few health care organizations have implemented mandatory vaccination programs for health care workers, such as Virginia Mason Medical Center, a Seattle hospital. Making the vaccine mandatory raised compliance from 54% to 98%. A major educational campaign was undertaken to demonstrate the benefits of the flu vaccine to staff, emphasizing improvements to patient safety, protection of staff and their families from the flu and reduced absenteeism from work due to the flu. A five-year study of the program found that there was a significant organizational commitment required to carrying this out, including high costs and administrative requirements to track staff who had been vaccinated.

Some vaccinations are mandatory in Ontario. For example, unless parents seek an exemption, they must ensure that their children are vaccinated against measles and other diseases before they can attend school. However, until now there has been reluctance to insist that a similar principle be applied to health care workers.

Upshur has questioned the language around mandatory vaccination, and argues for the importance of clarifying “what is meant by mandatory and whether it will interfere with health care workers’ rights.” He suggests that organizations can, however, tell workers “if you exercise your right to not be vaccinated, we exercise our right to keep you out of the workplace if there is an outbreak.”

The comments section is closed.

  • cypher says:

    9. Everyone has the right not to be arbitrarily detained or imprisoned.
    From the charter of rights and freedoms. Detaining healthcare workers for the flu shot arbitrarily is a violation of section 9. mandatory means they have no choice.
    There is no evidence that suggests the flu shot benefits us in anyway. In fact there is more evidence that suggests it is bad for us. Human kind has gone hundreds of years without a flu shot. Now suddenly, we need it? I have never had one and never will. The bottom line is this, if we begin to inject ourselves with things we know nothing about, we will eventually become so reliant that our own immune system will fail to develop normally.
    Health care workers 15 years ago never had to have the flu shot. So why now? What is the difference now?
    Health care workers and Unions, it is not a law that is requiring you to take the shot, therfore you are not required too. There is reason they are saying mandatory, because they know they cannot legally enforce it. Doctors who own private practices dont all get the shot. So why are you required too?
    Freedom of choice is everyone’s fundamental right. You cannot be forced to do something against your will, otherwise they have violated your charter rights.

  • Sharon says:

    Whether the health care worker receives it or not, there is just as much evidence out there that those who do get vaccinated still contract the flu! So they carry it back to the elderly after a couple of days off, but what about the family of the elderly in question?? Chances are they probably give it to them in the first place because they make personal contact ie kissing the goodbye, so there is the transmission do they now have to me mandatorily vaccinated because they visit their loved ones?? Where does it stop?! we are in control over our own bodies, we should be able to decide what goes in it. Common sense is the Word of the day. If youre feeling ill stay home! but there are tons of people that do not and that is how things get spread around! But ever wonder why dr.s are not so quick in prescribing anti-biotics? because they are not doing their jobs, if you vaccinated yearly against a virus that you may or may not get, is your body still going to learn to fight for itself?? No it is going to get lazier, and you will not be able to fight it off as quickly as you once could.
    Think about all that!

  • Juan Gérvas says:

    The information for patients and lay persons is simple, for example:
    Flu mortality of children under 5 years in developed countries as Canada is around 0.007%
    Global burden of respiratory infections due to seasonal
    infl uenza in young children: a systematic review and
    meta-analysis. Lancet 2011; 378: 1917–30.
    Or flu vaccines has no impact on morbidity-mortality of elderly people
    Or: What is important is to wash your hands (more important if you are a teacher or a health professionals)
    The ethical responsability is not to be vaccinated againts flu, but to wash our hands, as physicians.
    With this style of information during the swine pandemy 2009-2010, only 3 millions persons got vaccinated in Spain (the Government bought 13 millions vaccines, first thought in buying 37 millions for almost the whole population). Health professionals might transmit calm and scientific knowledge

  • Mark MacLeod says:

    OK, I’m sitting in a meeting that isn’t really holding my attention that well (all to common of a problem in medical circles – bad meeting design) and I”ve had a bit of time to look at some more of the comments. It seems I’m not the sole outlier in not believing the supposed benefit of vaccination.

    Thanks for the links – I looked at the systematic review and by admission I am not a researcher and I am not a statistics person or epidemiologist. However as a cynic I make a couple of notes. The first is this quote from the paper, ” Only two trials examined the impact of immunising HCWs against influenza on high-risk patients [10,11]. Sparse infor- mation on primary outcomes is therefore a major weakness.” The second point relates to who authored and who commissioned the paper. It has been my observation that individuals or groups rarely if ever put forward data or positions that reduce their value or place in the medical hierarchy – it’s just as true in orthopaedics as any other field. So I suspect it is highly unlikely that information will be presented in such a way to reduce the importance of vaccination or the role of public health care by those who are vested in their continuance. And in research, like politics, spin is everything.

    My 2 p.

    • Juan Gérvas says:

      In insist, we have no scientific base to recommend flu vaccines in general, nor for health professionals. In fact, we have scientific base for the opposite.
      See, about the 2011 flu vaccine:
      We cannot admit proposals for the whole population just because is a “preventive action”, a vaccine.

    • Andrew Holt says:

      It seems our collective challenge is deciding how do we provide a reasonable person, with reasonable information about reasonably straight forward and routine health care (e.g. flu prevention options) so they can decide for themselves or their loved one’s how best to manage the risks associated with a commonly experienced illness?

      For a lay person what are the relative risks of NOT having a flu vaccine versus the risks of HAVING a flu vaccine? How do these risks change for my children, teenagers, self, aging parents …? What is the quality of the evidence that I am basing my decision on?

      How do average people sort through the confusion of the many conflicting expert opinions, politics, spin, media and many ways research and evidence is reported or explained? Are policy setting and funding mechanisms sufficiently evidence based to help reduce the impact of the flu across as many people as possible and when are these scarce resources better used for other health services, education …?

  • Andrew Holt says:

    What is sufficient scientific and clinical evidence to warrant making a decision to provide or withhold flu shots? In the absence of consensus among the scientific/clinical experts most individuals, policy makers and funders are left with confusion and are forced to act on whatever basis makes sense to them at the time. I think everyone agrees this can improve.

    On a practical level what threshold standard of evidence can the average lay people and policy makers rely on when deciding if it makes sense to either take or fund flu vaccinations?

    Clearly there never will be 100% certainty about most critical decisions and we need a healthy questioning of current thinking but I would like to propose that good health policy should reflect a synthesis of the current level of knowledge and provide evidence based guidance to the broader community. How do we build this synthesis of current knowledge regarding flu vaccinations? Does the Cochrane Collaboration results provide a good starting point for people living in Ontario to consider? What other means should be created to support local decision makers and individuals?

  • Juan Gérvas says:

    No, the scientific base for flu vaccines is very week.
    I strongly disagree about it use in elderly and about mandatory vaccination of health professionals.
    See my full comment in
    A recent review about effectiveness in Lancet concludes “Evidence for protection in adults aged 65 years or older is lacking” Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis. Michael T Osterholm, Nicholas S Kelley, Alfred Sommer, Edward A Belongia. October 26, 2011

  • Mark MacLeod says:

    Hi. Can you provide the references for the studies referred to? Thanks

  • Allison McGeer says:

    There are actually four cluster randomized controlled trials of health care worker vaccination, three with all cause mortality as the primary endpoint, all demonstrating that increasing vaccination rates reduced mortality.

    One of the fascinating things about this debate (not just on these pages, but in general), is that after four randomized controlled trials with mortality as an endpoint, we still think there isn’t evidence. I don’t know any other situation in medicine where four RCTs wouldn’t be enough to generate changes.

    • Andrew Holt says:

      How do we accelerate the adoption of evidence based practices is the essential question
      Four RCTs that conclude health care worker vaccinations reduce patient mortality makes it hard to justify not making changes in the interests of the patients and broader community.

      It would be an interesting study for a sociologist to explore further. Do you have anyone in your team that has this background working on this type of research? If so, their perspective would be helpful to understand this ‘fascinating’ situation.

  • Mark MacLeod says:

    I think I’ll ask the question that targets the heart of this issue. Is there SOLID evidence that hospitals with a high rate of vaccination have any different rates of influenza contracted in the hospital after a period of admission where contact leading to infection could only have occurred after admission.

    I go back to my statement about the illusion of security. I really think this is one. Of course it’s intuitively obvious that vaccinating health care workers will make patiets safer – right? Wrong. It’s not intuitively obvious. And unless the evidence is solid, and I mean solid with sufficient power to make a serious statement, I won’t believe it either. 50 percent of current “research” is proven wrong or seriously disputed within 2 years of publication. As an academic physician I see continuously how data is mined and manipulated to prove a point(s); the infrequency of null data proves that our research system and ethics are corrupt.

    So let’s stop using common sense, and try and find a real answer to the question rather than just a few people’s opinions.

    • andreas laupacis says:

      To answer Mark’s question about the evidence that vaccinating health care workers benefits the patients they care for, the reference sited in the fourth paragraph of the “Explaining the influenza vaccine” section of the story mentions two cluster randomized trials. These were conducted in Scottish geriatric chronic care hospitals, and both found a decrease in MORTALITY in the patients in the hospitals allocated to more aggressive vaccination policies of their health care workers.

      Admittedly, these institutions weren’t acute care hospitals, but I was sufficiently impressed that the results were likely generalizable to an acute care hospital that I went to our occupational health department that day to get my flu shot (I am working on the wards at St. Michael’s this month).

  • Thomas says:

    Should health care workers be required to wash their hands after defecating? scrub before surgery? I trust that I’ll never cross Dr Kinesh Patel’s path.

  • Gloria says:

    If the health care workers object to getting vaccinated, perhaps they should get into another area of work. I find it objectionable that vulnerable adults in a LTC facility should be subjected to the dangers of an unvaccinated care worker.

  • Mark says:

    This is a difficult issue – but it boils down to the same as airport security – an illusion or a delusion of security/wellness/prevention. IF there is value in vaccination, then any person who enters the hospital – including all visitors – should be required to provide proof of vaccination. And I believe it is unclear whether or not someone is vaccinated prevents them from being an asymptomatic carrier. Does anyone know.

    I do think that health workers have responsibility – and one of those is to stay home when ill. And not be beaten up for doing so. However, physicians have no choice. Imagine the furor that would result if a surgeon didn’t show up for his/her day of surgery.

    Lastly and only anecdotally, I have had the flu shot a number of times and on every occasion I have a reaction of significant variability, the last of which meant 2 days off work. No thanks. Particularly on years when I have not had the flu shot I’ve not contracted the flu.

    Lastly, why not make sure that the most vulnerable in the system have mandatory vaccinations – those w chronic illness, the young, and the elderly? Oh we can’t do that, well then let’s not talk about health care workers differently. There is no ethical argument to make.

  • Doug says:

    Please note that vaccinations are not mandatory for school entry or attendance in Ontario, as noted in your article above. What is mandatory under the Immunization of School Pupils Act is that parents/guardians make a choice and have documentation of that choice: (i) to have their child fully vaccinated and up-to-date with age-specific vaccine recommendations; (ii) seek a medical exemption; or (iii) seek a religious/conscientious objection. The vast majority of parents chose option (i).

    • Karen Born says:

      Thanks very much for your comment Doug – we’ve made a change to that paragraph to note that parents can seek an exemption.

  • Claire says:

    I assume that the “40% of hospital staff” who received the flu shot last year is a statistic that includes those not providing direct patient care? I would be interested to know what percentage of direct-care providers get the vaccine – I would like to think that percentage would be higher.


Karen Born


Karen is a PhD candidate at the University of Toronto and is currently on maternity leave from her role as a researcher/writer with

Andreas Laupacis

Editor-in-chief Emeritus

Andreas founded Healthy Debate in 2011. He is currently the editor-in-chief of the Canadian Medical Association Journal (CMAJ)

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