Tuesday, January 17, 2017

Mandatory flu shots for health-care workers?

A perennial OHS issue is whether or not health-care workers (HCWs) should be compelled to get an annual flu shot. Paula Simons tackled this issue last week for the Edmonton Journal. Her arguments (implicit or explicit) for the government mandating vaccinations among HCWs are basically three:
  1. We require HCWs to be vaccinated for many diseases (such as mumps, measles and rhubella) and should do so for influenza as well.
  2. Immunization of HCWs can reduce the incidence and effects of influenza among patients. 
  3. Failing to get vaccinated is unethical behaviour for HCWs.
I spent some time looking through the research related to this issue. Before talking about that, I want to be clear that (1) I get a flu shot, (2) I have no time for anti-vaccer arguments, and (3) I’m not an expert in the efficacy of flu shots or influenza transmission.

From what I can tell, vaccination seems to prevent influenza some of time (overall, it is about 60% effective), including among HCWs. This finding seems pretty widely accepted; if you are interested, here is a study.

This is a significantly lower rate of effectiveness than MMR vaccinations (which are about 90% effective).  Opponents of mandatory influenza vaccination note the much lower effectiveness of the influenza vaccine undermines the argument for mandatory flu shots.

The evidence on whether vaccinating HCWs affects patient outcomes (since HCWs are not the only source of patient infection) is mixed. Some research supports this position, particularly when looking at elderly patients in geriatric facilities (example and example). Yet, every study has limitations. A systematic review of the literature (which controls for the quality of studies) concludes:
Our review findings have not identified conclusive evidence of benefit of HCW vaccination programmes on specific outcomes of laboratory-proven influenza, its complications (lower respiratory tract infection, hospitalisation or death due to lower respiratory tract illness), or all cause mortality in people over the age of 60 who live in care institutions. … This review does not provide reasonable evidence to support the vaccination of healthcare workers to prevent influenza in those aged 60 years or older resident in LTCIs.
This systematic review is not without controversy (it sets a high bar, for one). That said, it stands for the proposition that there is (as yet) no conclusive proof that vaccination programs reduce the incidence of influenza or its effects among older patients in long-term care facilities. I didn’t see any similar studies on effects among other patient groups or other kinds of helath-care facilities. Such studies may exist, I just didn’t find any in my search. Given this data, I think we can conclude the jury is out on the effectiveness of HCW vaccination on patients.

The final argument is essentially a moral one: if vaccination may reduce transmission to patients, then health care workers should be compelled to be vaccinated. As Simons puts it:
In a time of anti-vaccine hysteria, we need health-care workers to set an ethical example. We need them to demonstrate respect for science and for logic.
Setting aside that HCWs are not responsible for refuting anti-vaccer non-sense (that would be journalists’ jobs…), as we’ve seen above, the science on the effectiveness of mandatory flu shots for HCWs is not settled. Rather than engage with this nuanced issue, Simons opts for an ad hominem attack on HCWs:
But it’s time to stop making excuses for health workers who just can’t be bothered, or who think they’re invincible, or who just have some vague prejudice against vaccines.
As Jason Foster and I note in Chapter 5 of our new OHS textbook, the other side of this argument is that mandatory vaccinations interferes with the rights of HCWs to control their own health. Simons largely dismisses this concern, briefly noting “Forcing people to be vaccinated does sound coercive” and moving on to propose just that.

Health-care employers frequently advocate mandatory immunization. Presumably, they do so in pursuit of patient safety. Yet, this position is hard to square with the lack of evidence that vaccination affects patient outcomes. Some workers note that health-care employers have many motives for policies, including reducing sick leave claims.

Some employers (including the province of British Columbia) have attempted to manage this issue by giving workers a choice: get immunized or wear a mask when interacting with patients. This may be a more reasonable approach than the mandatory vaccinations that Simons advocates. An interesting question for those who like evidence-driven policy is what evidence of reduced rates of influenza has the BC experiment yielded?

-- Bob Barnetson


  1. Dear Bob. I was quite intrigued to read your blog post. I'd just like to say this. At absolutely no time did I suggest that any health workers be forced to have a flu shot. I held up the British Columbia model as an example, where those who refuse the shot must wear masks. I explicitly said that people who had medical or religious reasons to refuse a shot should be exempt. (Also? An ad hominem attack, by definition, is an attack against a specific individual, rather than against a political position. At no time in this column did I engage in ad hominem attack. I do, however, profoundly believe that health care workers have an ethical professional responsibility to promote vaccination as a sound public health practice, and to lead by example.

  2. Paula,

    Thanks kindly for your note and your interest.

    I inferred your support for mandatory vaccination from this statement:

    “But if health care staff won’t make the responsible choice -- maybe the minister should.”

    Perhaps you were advocating for BC’s policy (of shots or masks)? Yet, earlier in your piece, you note that accommodations would need to be made for (only?) those with medical issues or religious objections which suggests vaccination for the rest. Perhaps I mis-interpreted this collection of statements. If so, please accept my apology.

    On the question of an ad hominem attack, I concluded your were attacking health-care workers (individually and collectively) based on this statement:

    “But it’s time to stop making excuses for health workers who just can’t be bothered, or who think they’re invincible, or who just have some vague prejudice against vaccines.”

    Essentially you asserted that workers’ reluctance to get immunized stemmed from laziness, a misplaced sense of invulnerability, or being misguided in their view of vaccines. This appears to be an attack on the workers’ character since it ignores the many legitimate reasons workers might choose not to get vaccinated, not the least of which is the absence of evidence that influenza immunization reduces patient infection rates.

    In the end, I think we’re going to disagree on mandatory vaccination. I think public policy should be based on the best available evidence. What evidence I can find does not demonstrate that vaccinating health care workers reduces the risk of influenza among patients.

    If we can find compelling evidence that it does, then I’ll change my mind. And the discussion then shifts to balancing the interests of workers and patients, perhaps along the lines of the BC model.

    Thanks kindly,