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.
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.”