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Mandatory flu vaccinations for health care workers

flu vaccine

CUPE encourages health care workers to get an influenza vaccination if they can safely do so.  But making flu shots mandatory for health care workers is a serious intrusion on the freedom and personal autonomy of health care workers that may sometimes have detrimental effects on their own health.   

Forcing people to take flu shots against their will may well undermine public confidence in vaccination programs, even vaccination programs with an excellent results and high safety standards. 

Employers do not provide any sick leave to half of CUPE hospital workers.  So when those workers have an adverse reaction to the vaccination, they will lose pay.  Even those workers who do qualify for sick leave may be harassed by employers if they take days off as, under austerity, hospitals are increasingly driven by cost cutting and are sharply targeting sick leave for reduction.

But, along with increased attacks on sick leave, some health care employers are demanding that health care workers get vaccinated or be fired.

Research:  A recent report from the prestigious medical journal, The Lancet Infectious Diseases, has thrown more doubt on mandatory flu vaccines for health care workers.  Instead of providing the comprehensive protection commonly supposed, the systematic review by Osterholm (and colleagues) found that, at best, the influenza vaccine provided moderate — about 60% — protection from laboratory-confirmed disease in healthy adults.  The experts added that such protection was greatly reduced or absent in some seasons.

In a subsequent policy paper, Osterholm and coauthors conclude that recent expanded recommendations for influenza vaccination are based on expert and organizational opinion rather than on data.  They also state that systematic overestimation of vaccine effectiveness has hampered the identification of better solutions.

Moreover, they note that if “the general public or professional groups such as health care workers perceive that public health officials have ‘oversold’ the effectiveness of the current influenza vaccines, substantial backlash and mistrust could occur.  Efforts now to increase vaccination rates must be consistent with building a strong and lasting foundation for vaccine acceptance over time, which will be even more valuable as new and better vaccines become available.”

Canadian medical experts reviewing this and other research have come out opposed to mandatory flu shots for health care workers — while still encouraging health care workers to get the flu shot.  Drs. Michael Gardam and Camille Lemieux from the Infection Prevention and Control Unit, University Health Network and the University of Toronto argue “that it is of paramount importance to critically analyze the benefits of influenza vaccination before making a decision that justifies the suspension of a health care worker’s right to refuse to be vaccinated.”

They cite a 2010 study (by Thomas [1]et. al.) involving 20,000 patients over the age of 60 who lived in long-term care facilities.  The study concluded that the vaccination of health care workers was not associated with a significant reduction in influenza-specific outcomes:  We conclude there is no evidence that vaccinating HCWs (health care workers) prevents influenza in elderly residents in LTCFs (long term care facilities).”  On this basis, there was insufficient evidence to support the vaccination of health care workers as a method of protecting patients in long-term care facilities.

Drs. Gardam and Lemieux note that it can be challenging to determine whether influenza actually played a direct or indirect role in mortality and most influenza-like illnesses in any given year are caused by other pathogens.

Medical proponents of mandatory vaccination suggest that even with 60% effectiveness, mandatory vaccination will provide more protection to patients than voluntary vaccinations, as more workers will be vaccinated. 

Gardam and Lemieux however, note that “influenza in immunized individuals can cause milder disease... In this circumstance one wonders whether immunized health care workers may mistake influenza symptoms for a more benign illness and continue to work.  Further, three recent large European vaccine effectiveness studies demonstrated that effectiveness waned to near zero or zero within roughly three months after vaccination for the 2011-2012 season.”

Finally, the authors note that “a small number of American facilities that have implemented mandatory vaccination and have seen their immunization rates increase to well over 95%.  What we have not seen is evidence that these policies have brought about a significant reduction in both nosocomial influenza and influenza-related deaths.”

New Attempts to Impose Mandatory Flu Shots

In British Columbia, mandatory flu shots or wearing a mask will be required for hospital and care home staff, and visitors as well.

The original B.C. policy, introduced in August 2012, included provisions requiring health care workers to wear an identifying badge if they had the flu shot and to notify a supervisor if they knew of someone violating the policy.  With the June 2013 revised policy, there is no requirement to wear a badge and workers are now “expected” rather than “required” to report non-compliance.

All health care workers in hospitals and residential care facilities and in community health are covered by the policy.  It also includes volunteers, outside contractors and visitors.  There are no distinctions made in the BC policy.  Some have suggested the policy would be less objectionable if it focused on protecting the most vulnerable. 

Notably, a grievance arbitration ruling on this matter emphasized that employers are legally obligated to accommodate health care workers who cannot comply with the policy.

The mask option:  “Very little information is available about the effectiveness of face masks and respirators in controlling the spread of pandemic influenza in community settings,” the U.S. government flu web site notes.

For many health care workers, there are occasions where a mask is required. However, wearing a mask all day is irritating and gets in the way of developing an interactive relationship with their patients. It will also cause patients and co-workers to potentially shun those who wear masks while feeling falsely secure with workers who don’t. Finally, some people will not be able to do their job at all with a mask (e.g. speech language pathologists).

Ontario:  Two major London, Ontario hospitals have recently announced that they will enforce the same policy as B.C.  Other hospitals may follow.

Doug Sider, medical director of communicable diseases at Public Health Ontario, the province’s health promotion agency, states “I suspect sooner rather than later it’s not going to be up to an individual hospital.  We are going to say ... ‘Here’s a standardized set of approaches we’d like all hospitals to engage in.’”

The Ontario government wants to see a dramatic increase in the number of health care workers who get the flu shot, but opposes making vaccinations compulsory.  “We don’t require health-care workers to be immunized in this province, but we do have a three-year strategy to ... strongly encourage health care workers to be immunized every year,” Dr. Arlene King, chief medical officer of health for the province told reporters earlier this year.

Ontario CUPE organized hospitals:  Ontario hospitals and the Ontario Council of Hospital Unions/CUPE have negotiated a protocol that recognizes the right of workers to refuse vaccination, while also protecting the public.  If government requires vaccination, workers who do not receive the vaccination will be reassigned, or if that is not possible, they will be placed on unpaid leave.  If the vaccine is medically contra-indicated for the employee they will be reassigned, or if that is not possible, the employee will be put on paid leave. 

[1]   Influenza vaccination for healthcare workers who work with the elderly. Cochrane Database Syst Rev 2010;(2):CD005187

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