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.