The evidence and politics of mandatory health care worker vaccination

The United States Center for Disease Control reports that while only 44% of employees get the influenza or “flu” shot on a voluntary basis, that number rises to 89% when it is required or mandated by the employer. With vaccination rates of 45% among health care workers in some Alberta hospitals and similar rates in Ontario, a debate has emerged among experts, employers, employees and the public about the best approach to increase vaccination rates for health care workers.

This article lays out some of the important things to consider when deciding whether or not to make vaccination of health care workers mandatory.  On one side is the patient safety argument and the public’s expectation that government and health care professionals will act in the best interest of patients. On the other is the concern that there is insufficient evidence supporting the benefits of the flu vaccine to warrant a mandatory policy. In addition, there is the question of whether a mandatory vaccination policy is worth the damage to the government’s and health care institutions’ relationships with unions.

Unions oppose mandatory vaccination policies

Health care unions across Canada have released statements  stating that policies mandating vaccination for health care workers are infringements of human rights. The Ontario Nurses Union (ONA) has filed grievances with a number of Ontario hospitals that have chosen to impose mandatory vaccinations on health care workers. ONA representative Vicki McKenna states that there is a lack of evidence to back up mandatory vaccination of health care workers. “The current immunization is, at best 70% effective… let’s have an adult conversation about how to protect patients instead of implementing these draconian measures that aren’t backed up by science”.

However, the BC government and New York State have instituted policies that require workers to either be vaccinated or wear a mask. Bonnie Henry, Medical Director, Communicable Disease Prevention and Control Services and Public Health Emergency Services in BC, describes a multi-year process in arriving at the decision.

The policy, implemented by the leadership council of the province’s Medical Officers of Health, came after several years of unsuccessful efforts to increase vaccination rates of workers from 30% – 40% in hospitals and from 60% in long term care homes. In the year after the pandemic of 2009 Henry says “the immunization rates fell to the lowest they had ever been… there seemed to be a kind of complacency about the impact of influenza. We were looking at evidence from the US that showed that worker vaccinations had an impact on patient safety”.

In contrast to BC, Ontario and Alberta are both relying on education and encouragement campaigns to increase worker uptake of the vaccine.  Arlene King, Ontario’s Chief Medical Officer says that this year  an aggressive vaccination campaign was targeted at workers.  “We have done everything we can do with approaches that are not conditions of service and when we have exhausted those, then we will consider others. We don’t want to be creating divisiveness; that’s not a helpful approach”.  Ontario has also negotiated language in the nurses’ collective agreement that allows the employer to place an employee on unpaid leave or to reassign a worker during an influenza outbreak. Alberta Health Minister Fred Horne has indicated that they are relying on an education and encouragement campaign, and would consider “a mandatory policy as a last resort”.

Balancing the benefits of vaccination with the risks of influenza

Efforts to encourage voluntary participation may not be successful. Alison McGeer, Director of Infection Control at Mount Sinai Hospital explains that low vaccination rates may in part be attributed to flawed logic in the assessment of the risks associated with vaccinations. There is evidence in the fields of psychology and neuroscience which shows that when people subconsciously weigh the risks and benefits of any choice, they often don’t respond rationally. If taking an action seems to bring little benefit, the risks automatically feel bigger.

McGeer says “the psychology of influenza tells us that it isn’t serious… in life, you worry about plane crashes and earthquakes. What you ought to be worried about is driving to work or slipping in the bathroom. In infectious disease, we worry about flesh eating disease or meningitis, but what we die from is influenza.”

McGeer believes that the true burden and risks of influenza are not well understood because of systematic under testing and under reporting. Since a positive Influenza result on a test does not change the course of treatment in most cases, clinicians don’t typically order it. However, if you consider that influenza is associated with serious complications, the impact on morbidity and mortality rates is much higher.

It is important to note that influenza is not the common cold – it is generally more severe with fever, cough, and body aches, and people with influenza often need to be in bed for a few days. There is evidence that shows that in the period of time following influenza, people are at greater risk of a cardiovascular event or stroke. When all complications are taken into account, McGeer believes the risks associated with getting the flu are higher than what people (including health care workers) consider when making the choice about the shot.

Besides the risk of transmission of the flu from worker to patient, low rates of vaccination send a powerful message to a public who are also weighing the risks and benefits of the vaccine. The public is seeking information and look closely at the behavior modeled by health care workers.  “It’s hard to feel compelled to go and get the flu shot when even the workers aren’t interested. I have not taken the time to do my research about it, so the best I can do is take my cue from nurses and doctors, who I believe know best” says a Toronto Resident who prefers to remain anonymous.

With stubbornly low rates of vaccination among health care workers, the debate boils down to two main factors:  whether vaccination of health care workers actually protects patients from illness and by how much; and if so should it be made mandatory for those who care for patients.

Understanding the evidence for, and against, mandatory vaccination

Experts say that there is no established threshold for when the evidence is sufficient to warrant making a practice mandatory for workers.  While most studies reveal an overall benefit to receiving the flu shot, the interpretation of studies specifically looking at the benefits of vaccinating health care workers to protect patients from influenza have been controversial.

Reviews of the four best studies that evaluated this issue agree that fewer patients died in institutions where vaccination of health care workers was mandatory. However, there is a disagreement about how to interpret these results. Some interpret it as strong evidence for mandatory vaccination, while others say that there are important flaws in the study designs, and the impact on death is so large, that they aren’t believable.

Michael Gardam, Medical Director of Infection Prevention and Control at University Health Network says that the debate has galvanized a growing group of experts, including the authors of the Cochrane review, who believe the limited efficacy of the flu shot generally does not warrant a policy of mandatory vaccination for workers. While Gardam adamantly states that “that it makes perfect sense for the public and health care workers to get immunized”, he says that making vaccinations mandatory requires a high level of evidence.

Gardam says “The evidence supporting the vaccination is much weaker than people who are pro vaccine like to believe. There are arguments that state that it is an ethical obligation for workers to get vaccinated, which then in turn lead to support for mandatory policies. These arguments are all based on a kernel of original studies. When you push into the territory of making something mandatory, unions and the anti vaccinationists will push back”. He suggests that if all of the arguments hinge on such controversial evidence, “you run the risk of undermining the whole [vaccination] program and public health’s reputation”.

While the experts continue to debate whether the evidence is strong enough for a mandatory vaccination program, the voice of the patient offers a compelling perspective. Amir Dhalla suffers from bronchiectasis, a chronic respiratory illness that makes him particularly vulnerable to complications from the flu. When asked about mandatory vaccinations for workers he says “It would be an advantage for people who have poor immune systems or suffer from illnesses such as mine. There are lots of things that are mandatory in this complex society. You cannot talk on a cell phone while driving, you must wear seatbelts and so on. This is something for the public good. It protects the public, so definitely it should be mandatory”.

The comments section is closed.

  • Ramandeep Kaur says:

    This information is accurate.

  • Randeep Kaur Brar says:

    It is accurate study because vaccination is necessary for health care workers

  • Manpreet kaur says:

    the above information is relevant because health care professionals are the front line workers who always on risk of getting infection.

  • C.A.H. says:

    If someone working at a hospital but without any patient contact has had multiple adverse vaccine reactions to the point of having some permanent injury, do you propose to fire him or to make him keep getting shot after shot until the side effects leave him unable to stand up? As someone who has suffered permanent harm from mandatory vaccinations, I believe nurses deserve a choice, and they must receive full compensation up to and including decades worth of long-term care if something goes wrong during a mandatory vaccination. I never received a penny to help pay my medical bills that are still piling up over ten years later.

  • ramandeep kaur says:

    reliable information

  • Henna says:

    Information given is reliable and i think vaccination will help the health care staff to get protected from disease transmission.

  • GRETA ANTONY says:

    Given information is reliable and i think it is mandatory to take the vaccination for the health care providers to work safely.

  • Jinet Tresa Jose says:

    Information given are good relevant and i think vaccination is mandatory for health care team members

  • Praveena Pradeep says:

    Vaccination according to the nation’s health history is obviously mandatory.

  • Prabhjot kaur sidhu says:

    yes,this vaccine should be mandatory,as it is for public as well as health care team safety.

  • Claire Tuazon says:

    The article provided useful knowledge and ideas on vaccination for healthcare workers.

  • manisha says:

    reliable information

  • Gurnek singh randhawa says:

    According to me, vaccination of health care workers against influenza should be consider standard patient care and it should be mandatory to vulnerable population.

  • jaspreet says:

    Reliable knowledge

  • sandeep kaur grewal says:

    it should be important for health care team.

  • Randeep kaur says:

    It is importajt for every medical professional.

  • Kirandeep Kaur says:

    Vaccination should be mandatory for the healthcare providers to be safe and provide care safely without the risk for transmission.

  • Mandeep kaur says:

    Vaccination against influenza should be given to all the staff of the hospitals. It improves the immunity against the flu.

  • Manpreet kaur says:

    Health care workers are extremely imperative as they have to provide care to sick patients .Therefore,health care workers safety is really important which is possible through vaccination .Influenza prevention is merely possible through immunization .

  • Navjot kaur says:

    I think vaccination must be mandatory for health workers to protect them from the infectious health problems.

  • Manpreet Kaur says:

    All above information is good and relevant.

  • Arshpreet Kaur Dhaliwal says:

    I think the non vulnerable people should not be vaccinated for various reasons.

  • Shashikala Sanjeev says:

    The information provided is good enough.. Thank you..!

  • Priyanka Roy says:

    The article is informative but it is not updated with the recent evidences.

  • Ruchika says:

    That was informative and relevant

  • Gurpreet Kaur says:

    Vaccination should be compulsory for health care workers because the the deal with the several patients who have communicable and non communicable diseases. If the health workers will be healthy only then they can provide care to promote and restore the health of others.

  • Navdeep kaur says:

    There are strong evidences that give rationals for mandatory vaccination of all health workers in hospitals as compare to to other preventive measures for the safety of patients and health workers.

  • Ramanjeet kaur says:

    The Vaccination is mandatory for all health care workers. The rate of communicable illnesses like flu is increasing.In emergency conditions, they may have to handle such critical problems.

    • Cypher says:

      Can you cite a single incident where a patient became sick(er) from a hospital worker? At the same time can you provide evidence that hospital workers pose a greater risk to patients than their visiting loved ones who routinely hug and kiss them?

  • Pardeep kaur says:

    As the health care workers are the important assets for every healthcare organisation so influenza flue vaccination must be mandatory for every health care professional because they have to deal with with the human beings and if first they are secure, then they can protect the whole society

  • Jim Boswell says:

    I love how the sheep think that if you get the shot then you are protected….the shot is only 60% effective on a good day, I would argue less.
    If you did any research and used a little common sense youd understand that this is weak science. The shots are not effective and arent stopping the spread or infection rates of influenza.
    To make this mandatory is an infringement and is complete nonsense.
    It doesnt protect the public and it isnt good. Its not effective at all, pull your head out of the sand and think for a few seconds…ahhh lightbulb moment…probably not

  • Ross Lesoskitiwa says:

    In my opinion, its comes down to risks. Long term risks of annual vaccinations are unknown, as well as not tracked. Prevention techniques, building on ones own immunity, are more effective than vaccinations, but relatively ignored by pharma. Also, I think that complications from the flu are the cause of seroius health harm, not the flu itself. Just my opinion.

  • Sheryl Jackson says:

    This supposedly unbiased article describes the ‘balance’ oddly – “balancing the BENEFITS of VACCINATION with the RISKS of INFLUENZA”. A balance would be between any BENEFITS of VACCINATION with the RISKS of VACCINATION. Or risks vs. risks.

    Not once in the article are any of the actual risks of vaccination identified. They are only mentioned as something that people are irrational about, due to the psychology of influenza being perceived as not serious.

    Of note, when healthcare workers are choosing whether to have influenza vaccinations, and this group would have motivation to be better informed than the general public… a significant majority choose against the vaccine. Even when mandatory, more than 10% still choose against it.

    And if the flu vaccine is at best 70% effective against a particular strain of flu (and not every year’s vaccine guesses right about the strain that will circulate)… Clearly a false sense of security is created by vaccination. Why are healthcare workers getting vaccinated and then allowed to not wear a mask, if a mask will help protect their patients and reduce spread of the flu??

    If a mask is helpful, it is masks that should be mandatory. (Can you imagine surgery without masks?)

    Or is the mask policy more an attempt to ‘out’ and shame workers who choose to not be vaccinated?

  • Dr. S. says:

    If we’re going to start to request mandatory vaccinations for workers, we should also request mandatory weight loss, mandatory exercise, and mandatory smoking cessation. Those would have more of an impact on health care than vaccinations.

    Institutions should not have the right to demand that their employees mandatorily incur the risks of a procedure or drug, no matter how logical incurring such risk may seem.

    I am entirely pro-vaccination, but nobody should have the right to tell someone what they can do with their own bodies.

    • Jonathan Sher, health reporter, Sun Media says:

      I would hope a doctor would have enough sense to distinguish between activities that we do that harm ourselves and activities that harm others. If one believes the research cited by Dr. Allison McGeer, when health care workers chose not to get vaccinated, more of their patients suffer illness and death. If we were to accept the argument of the anonymous Dr. S., than child care workers would be allowed to smoke in nurseries. The fact is we do place limits on what people can do to their own bodies.

    • Dan Flanders says:

      There are many vaccines that are mandatory for health care workers. For example: polio, pertussis, measles, mumps, etc. As a physician, I am not permitted to work in a hospital unless I provide evidence that my vaccinations are up to date. Mandatory vaccines for health care workers is not new.

  • Dan Flanders says:

    Is this an issue that is preferentially of concern to nurses? Or are nurses appearing more vocal because it is their unions who are most aggressively pursuing the agenda?

    • David Harrigan says:

      Dan: I am the chief negotiator for United Nurses of Alberta. I assure you that there is nothing about this issue that forms part of any union’s agenda. It is an issue that nurses feel strongly about – some on the pro-mandatory side and others on the anti-mandatory side. For this reason, the issue has been debated at length internally, and our members want us to take a stand. (By the way, in Alberta, the situation is much like Ontario – in the event of an outbreak those who have not been immunized are not permitted to work, and are not eligible for paid sick leave.

      • Dan Flanders says:

        That helps clarify, thank you. Do you/unions intend to take a stand?

      • David Harrigan says:

        We encourage all our members to be immunized, but we oppose mandatory immunization. We support the current policies.

      • Ramanjeet Kaur says:

        The vaccination should be mandatory.Life of a health care worker is more important than making policies.

  • Judith Glennie says:

    Agree whole-heartedly with your column, Andre. The cognitive dissonance that allows a health care professional to talk about caring for patients while not taking steps to avoid undermining that patient care astounds me. Hard to explain such an attitude to laypeople who assume that HCPs are leaders when it comes to promoting public health strategies.

  • Elizabeth Rankin BScN says:

    This is one of the better articles I’ve read on Healthy Debate. Personally I’ve never had the flu vaccine. Would I ever consider one? Yes, but like so many I have unanswered questions, including the ones raised.

    “It would be an advantage for people who have poor immune systems or suffer from illnesses such as mine. ” says Amir Dhalla who suffers from Bronchiectasis. The nature of a person’s condition can make them very vulnerable to “picking up” viruses like influenza, and other communicable diseases, and as a result they “suffer” more with greater complications than those at less risk for complications.

    Should we all be required to have a vaccine because groups of people have a greater susceptibility to contracting a communicable disease? IF ONE ASSUMES THAT VULNERABLE GROUPS DO PROTECT THEMSELVES from acquiring influenza, then the thinking seems to be, THESE GROUPS SHOULD BE PROTECTED from getting influenza. Those not in the vulnerable camp ask: why should I risk the possibility of getting side-effects from the vaccine that “could” put me at risk for other problems such as acquiring a hearing defect or other side-effects that can be related to the vaccine? That’s seems like a valid concern and factors into the “logic” of many.

    The bigger question for me is this: should all those who are considered “more vulnerable” be required to have a vaccine? Should this group get the vaccine to protect the less vulnerable who come into contact with sick people, who are often their care-providers?

    The next question: should all health care workers or families of those who are care-givers be required to have the current year vaccine? If the logic of those who believe “yes” is the answer to protecting the vulnerable patient, “then you first must prove beyond a reasonable doubt” that influenza vaccines prevent the spread of influenza, that those who acquire influenza from an unvaccinated person can prove it was A that caused B to acquire the virus because the virus the person acquired and transmitted to the vulnerable one may not be the virus that is in the vaccine .

    The next question? Does the non-vulnerable person who doesn’t acquire the flu symptoms still transmit the virus when not sick themselves? This question ties into the previous statement.

    Getting the flu vaccine, so I am told only protects you from getting viruses that are in the current vaccine, not the current circulating virus.

    Now, this is the basis for the next question: without testing each person who gets the influenza virus, vaccinated or not, how do you know which virus the person has acquired was the same virus that indeed caused the flu?

    In other words, if this years virus which is not in the vaccine affects the vulnerable person who is attended to by a health care worker, can the vulnerable person assume, that the virus the vulnerable person contracted, was from the non-vulnerable person who attended the sick person? Are those who work or are care-givers required to be tested to see whether they could be the “spreader” of the virus and if so, was the virus the “current” one not yet in the vaccine? If this was the case [proven by testing done] the you could make the case that it is impossible to prevent all vulnerable people from the current influenza virus and therefore you couldn’t make a case that it is mandatory for everyone to get a flu shot.

    Thank you for this well presented argument which I expect will generate an ongoing topic for discussion.

    Elizabeth Rankin

  • Jeff Johnson says:

    Another issue with the psychology of influenza is the over-estimation of risks of adverse effects with the vaccination. It seems that many health care workers avoid the vaccine because of the risk of Guillain–Barré syndrome. The evidence of this risk is also limited, and thus controversial.

    If ever there was a health issue in need of stronger evidence based, it is influenza and its prevention strategies including vaccines!

    • kim says:

      Mr. Picard, I’m curious where you got your medical degree from? Your lack of research and ignorance is appalling. If you even looked over the comments to your post you would realize this fact, yet it is obvious that you continue to be ignorant to the issues surrounding the flu vaccines. Very surprising that you do not do your research accurately consider you report on this for a living.


Sophia Ikura


Sophia Ikura is the founder and executive director of the Health Commons Solutions Lab, a not-for-profit health and social enterprise located at Sinai Health in Toronto.

Christopher Doig


Christopher is a Professor in the Departments of Critical Care Medicine, Community Health Sciences, and Medicine at Cumming School of Medicine at the University of Calgary.

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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