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”.