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Should flu shots be mandatory for health-care workers?

Facts about Flu – Today we consider the ethics of requiring one group of people to have the flu shot as a condition of employment. We’re still looking for ways of preventing and treating influenza, and…

The idea of vulnerable patients becoming infected by their health-care practitioner has spawned mandatory vaccination policies in many places. Thompson Rivers University

Facts about Flu – Today we consider the ethics of requiring one group of people to have the flu shot as a condition of employment.

We’re still looking for ways of preventing and treating influenza, and several vaccines are available. But there’s a growing controversy about whether some populations should be forced to vaccinate for the health of others.

Health-care workers are prime targets for mandatory influenza vaccination because they must maintain good health while they assist the ill. The idea of vulnerable patients, including the elderly, becoming infected by their health-care practitioner has spawned mandatory vaccination policies in many places, but are they clinically and ethically sound?

Making rules

The 10th edition of the Australian Immunisation Handbook recommends influenza vaccination for all health-care workers, staff of nursing homes and long-term care facilities (including students).

And around the world, hospitals and health systems are creating policies requiring their health-care workers to be vaccinated against influenza.

Some require it as a condition of employment unless there’s a medical reason (for instance Capital Hill Nursing Center, Washington DC), while others impose work restrictions on those who refuse (such as requiring them to wear face masks).

In between are places such as the Peter MacCallum Cancer Centre in Melbourne, which, since 2009, has had a “mandatory” influenza vaccination program. But there are no punitive consequences for staff who refuse to participate.

According to the Immunization Action Coalition (IAC), a non-profit organisation led by four family physicians and a paediatrician:

Vaccination of health-care workers (HCWs) has been shown to reduce influenza infection and absenteeism among HCWs, prevent mortality in their patients, and result in financial savings to sponsoring health institutions.

But is there data to support this statement and therefore, mandatory vaccination measures?

Show us your data

The Cochrane Collaboration, an international research review organisation, insists there isn’t.

In their report, Influenza vaccination for health care workers who work with the elderly, they performed a meta-analysis, exploring data from five published research studies on the matter.

The report concluded that vaccination didn’t show any effect on laboratory-proven influenza, pneumonia or deaths from pneumonia. The Cochrane review also noted that there was “no accurate data on rates of laboratory-proven influenza in healthcare workers.”

Another study (by researchers based in Hong Kong) performed a similar meta-analysis of the effectiveness of seasonal influenza vaccination in health-care workers. It said:

No evidence can be found of influenza vaccinations significantly reducing the incidence of influenza, number of influenza-like-illness episodes, or days with influenza-like illness.

With this constellation of information, it’s difficult to see how the IAC and the Australian Technical Advisory Group on Immunisation (authors of the Australian Immunisation Handbook) draw their conclusions.

Given the lack of evidence supporting mandated influenza vaccination for health-care workers, what are the harms of initiating and enforcing such policies?

Ethical considerations

Health-care worker vaccination mandates are potentially harmful without evidence of the benefits they aim to produce. In terms of ethics, policies that lack supporting data can spread public fear; namely, that risks to patients are high unless mandates are in place.

Mandates could also result in a false sense of safety and less care with common-sense protections, such as hand-washing and drying, and covering the mouth and nose when sneezing and coughing.

And people who experience serious (even if not life-threatening) vaccination reactions will be unnecessarily burdened.

Mandates with harsh consequences, such as employment termination or hiring blockade, violate health-care workers' autonomy because of their inherent coerciveness.

On the other hand, vaccine manufacturers will benefit; sales from the top 10 vaccine manufacturers were estimated at US$2.65 billion in 2012. And employers and health systems will perceive risk-management benefit – and legal teams will stand by ready to defend the vaccine mandates.

But the ethical principle of non-maleficence (the goal of avoiding or minimising harm) requires policy bodies, employers, health systems and legal teams, to take a second look at such mandates because there’s no clinical evidence for this vaccination scheme to become standard care.

The notion of “protecting patients” creates a duty of care propped up by the vaccination mandate. But given the lack of evidence for benefits, there can be no imposed duty to make health-care workers get an influenza vaccination.

This is the sixth article in our series Facts about Flu. Click on the links below to read other instalments in the series.

Part one: Of influenza, flu, potions and key opinion leaders

Part two: Influenza vaccine for 2013: who, what, why and when?

Part three: H1N1, H5N1, H7N9? What on earth does it all mean

Part four: The Tamiflu saga shows why all research data should be public

Part five: CSL’s flu vaccine leaves a hole in Australia’s pandemic plan

Part seven: The Holy Grail of influenza research: a universal flu vaccine

Part eight: Is it really the flu? The other viruses making you ill in winter

Part nine: The heart of the matter: how effective is the flu jab really?

Join the conversation

30 Comments sorted by

  1. Guy Taylor

    IT Professional

    A quick pubmed search shows many articles which show efficacy, so one study against is hardly evidence.

    Meta-analysis are a great way of re-enforcing confirmation bias. Here's an article on why one shouldn't rely on them:

    http://www.sciencebasedmedicine.org/index.php/i-never-meta-analysis-i-really-like/

    To then start quoting how much money big pharma makes from vaccines make me think this article belongs on the AVN website not the conversation.

    Flu vaccines are highly effective and are about the strongly members of our community helping the weaker, so to get on one ethical moral high horse about not vaccinating in simply selfish.

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    1. Trent Yarwood

      Infectious Diseases Physician, Associate Lecturer at University of Queensland

      In reply to Guy Taylor

      Thanks for that meta-analysis link - it's a cracker.

      My concerns with the meta-analysis quoted (as I have said in most articles on this series) is that Jefferson is approaching the task from a position of "Influenza vaccination doesn't prevent ILI" rather than "influenza doesn't prevent influenza".

      The studies in healthcare workers are very small, and as he rightly identifies, very heterogenous.

      What we do know is that healthcare workers are at high risk of acute respiratory illness - look at SARS and the MERS-CoV have had very high attack rates in staff.

      Vaccination isn't a substitute for personal protective equipment and infection control, but I very firmly believe that staff have an ethical duty to reduce their risk of transmitting disease to patients as much as possible - and also an ethical responsibility to their future patients by making sure they aren't at home sick from a disease that could have been prevented with a vaccine.

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    2. Citizen SG

      Citizen

      In reply to Guy Taylor

      The flu shot is efficacious in terms of prevention of infection from another person. Therefore the best way for a patient or aged care resident to not become infected is to have a flu vaccination themselves.

      This article makes the point about degree of transmission from an infected health care worker. And the answer is that the degree of infection is small.
      Influenza is transmitted by droplet spread (usually from an unprotected cough from about a metre away) or by contact. An infected person…

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    3. Guy Taylor

      IT Professional

      In reply to Katrina Bramstedt

      I believe it is when it is just that. Opinion. Science isn't about opinions. And this 'opinion' can directly lead to the death of the sick and weak.

      There is such an overwhelming body of evidence for the benefit of vaccines vs drawbacks.
      The false equivalency fallacy is touted all the time by the media and ideologues that are morally opposed to them.
      This tactic is used by global warming deniers, anti-vaxers etc, who quote a few counter studies in an attempt to make it a 'balanced debate'.
      Science is about consensus and evidence not opinion and there really is no debate about vaccines.
      From my point of view, the benefits they provide to the weaker members of society trump any choice of the individual.

      Surely, from an ethical point of view, saving lives is more important that a personal choice?

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    4. Katrina Bramstedt

      Associate Professor, Medical Ethics at Bond University

      In reply to Citizen SG

      It's also important that these workers, if ill, stay home and not be a source of exposure for others. Acording to the CDC, "Most healthy adults may be able to infect others beginning 1 day before symptoms develop and up to 5 to 7 days after becoming sick."

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    5. Guy Taylor

      IT Professional

      In reply to Citizen SG

      Sadly, Vaccinations are less effective on the weak and more effective on the strong. so it is the health care workers that need them more than the elder.

      "... And the answer is that the degree of infection is small. "

      So some old people dying is ok then because it's a 'small' number? I would have though prevention to stop death is a good thing, no matter what the numbers. Maybe that's just me...

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    6. Guy Taylor

      IT Professional

      In reply to Trent Yarwood

      Hi Trent, I can recommend anything by Mark Crislip. He is an infectious disease physician too and has the most wicked sense of humour! Have a listen to his podcast Quackcast. I love it :)

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    7. Citizen SG

      Citizen

      In reply to Guy Taylor

      Then we should force vaccination on everybody, not just healthcare workers, because getting influenza from a healthcare worker (who uses standard precautions whilst in the prodromal period and goes on sick leave in the more infective 'droplet vector' pahse of the disease) is much less of a risk than getting it in the community and from visitors to the hospital.
      The question is about the moral imperitive of health care worker vaccination not the level of risk to the community. If it was about level…

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    8. Citizen SG

      Citizen

      In reply to Katrina Bramstedt

      healthcare workers are at much less risk of spreading the influenza virus in the prodromal period because they use Standard Precautions. The risk of spreading influenza by droplet (once symptomatic) is certainly when the healthcare worker should be removed from the workplace.
      UNless the patient is at especially high risk (ie immunocompromised) I would have thought that vaccinating the patient would be more logical than excluding the Healthcare worker due to vaccination status.
      There is an argument that healthcare workers should be vaccinated not because of potential infectivity but because of risk of infection themselve. Certainly this is both an OH&S safety issue and a factor in strategically planning for high virulence/high mortality pandemics such as the 1918 influenza strain.
      I agree that healthcare workers ought to be vaccinated but that is very different from mandation by exclusion from employment for non-immunocompromised patients..

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  2. T Packer

    Science Researcher

    Thank you Katrina for a balanced and well thought through article. The side effects of preventative medicine regimes can be serious and should be acknowledged, not ignored for the "common good". Vaccines are good, but not benign for everyone. Therefore care should be taken with over exuberant public health mandates. Better science needs to be conducted, better procedures and better vaccines developed where there are gaps - not development of better "fear" if you don't get a jab.

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  3. Jason Walters

    Researcher & perennial student

    Any bulk form of medication that is imposed on a population of individuals is an attempt (like much of the clothing currently available in Australia) to force one into a "one size fits all" solution to the problem. Not just undesireable but unethical as the "one-size-fits-all" solution doesn't exist and the ability to select an appropriate, alternative approach does not either.

    I freely admit that I also am skeptical of the conclusions drawn from many of the meta-analysis "studies" I have seen…

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    1. Guy Taylor

      IT Professional

      In reply to Jason Walters

      Yes nothing is perfect, that's medicine. But it does work for most with no to little side effects.
      The flu vaccine isn't perfect due to the mutating nature of the influenza virus but it's the best we currently have... Here's a good summary:

      http://www.sciencebasedmedicine.org/index.php/flu-vaccine-efficacy/

      If the strong choose not to, then 'herd immunity' drops, and the weak (and the eventually the strong too) will get the disease which can be fatal. Surely, this is a worse outcome then the low incidences of side effects.

      If it weren't for herd immunity, I would completely agree with the 'individual choice' argument but immunization relies of the group.

      I find it interesting that the modern individualism (the 'it's all about me and my family') seems to trend with the reduction of immunization.

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    2. Albert Rogers

      logged in via Facebook

      In reply to Guy Taylor

      You admit "The flu vaccine isn't perfect due to the mutating nature of the influenza" but could have added that the flu vaccine is annually desirable for exactly the same reason. What makes anybody think that people not convinced of the desirability of the vaccination will not also be less convinced of the necessity of hygeine?

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    3. Jason Walters

      Researcher & perennial student

      In reply to Guy Taylor

      If there is an error in the way scientific method is applied or if general approaches as used in the community fail to update themselves when better options become available in the research there remains a fundamental problem. Influenza vaccines are not as safe as is stated in the marketing material. Do you know the vaccine ingredients and know that they are safe for you or your children? What would you do if you had an adolescent child, required to be vaccinated to continue volunteer work at a hospital, who then bacame febrile and commenced having seizures the evening following the vaccine? Health care workers asked to vaccinate, need to have ALL of the sudies presenting both sides and be able to make their own unforced informed choice. There are igredients in many vaccines that are neurotoxic and nephrotoxic, besides the vaccine agent itself. If the healthcare worker concerned is the bread winner and is now disabled, what then?

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  4. Chris Del Mar

    Professor of Public Health at Bond University

    Yes: everything hinges on the effectiveness, or not, of influenza vaccines. Sadly these are not good vaccines at preventing influenza, especially in the elderly, and systematic review does provide any comfort for those who claim that vaccinating healthcare workers protects patients.

    If it was effective then I presume the ethical principal would be that vaccinating healthcare workers should become mandatory.

    Why do so many in high positions believe that the vaccine is more effective than empirical data show? It is easy to point to Big Pharma and the imperative for profit, but the reasons are more complex, and have been neatly analysed here: http://www.bmj.com/content/346/bmj.f3037?utm_medium=email&utm_campaign=8362&utm_content=BMJ%20-%20What%27s%20New%20Online&utm_term=Influenza%3A%20marketing%20vaccine%20by%20marketing%20disease&utm_source=Adestra_BMJ

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    1. Albert Rogers

      logged in via Facebook

      In reply to Chris Del Mar

      Nothing is perfect at beating the flu virus, because it is one of the most highly evolved life forms known. Every year, or sooner, a new strain able to fool the immune system that survived last year's attack evolves. It that strain is the one used for the vaccine, it might quite possibly have a descendant in a couple of months with yet another disguise. But at least the latest vaccine will provide warning of the intermediate strain.

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  5. Derek Mccue

    Mental health nurse

    . It is a sad indictment on us as clinicians that an argument has to be made for mandatory immunization because we are not already getting immunized voluntarily. If clinical staff staff do not want to be vaccinated they should not be working as clinicians

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  6. Alex Cannara

    logged in via LinkedIn

    Should dentists be required to use mouthwash?

    Should surgeons be required to wash hands?

    Should disease testing be required for Dutch prostitutes?

    Questions, questions, questions.

    Biggest question: wherefore art thou Common Sense?
    ;]

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    1. Albert Rogers

      logged in via Facebook

      In reply to Alex Cannara

      To all these questions: Why not?

      And "wherefore" is a useful variant of "why", not of "where".

      "Wherefore art thou Romeo?" means "For what purpose is it that Romeo is of the Montague family, enemy to the Capulets?"
      "Why" in Shakespeare's time meant "By what prior cause?"

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  7. Peter Hindrup

    consultant

    Perhaps TC ought require those who comment to reveal their interests, share holdings and such in any issues being discussed. The rapid and ferocious demands that inoculations ought to be mandatory, for kids to go to school, for people to work in various occupations gives cause for wonder.

    I would not work in, or support any occupation where inoculation was required. Nor would I support any action aimed at achieving such a result.

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  8. Karmen Wagler

    RN, BSN

    I have been a nurse for many years. I am also the parent of a severely vaccine injured teenage son. My previous role as an RN was the local vaccine nurse. I gave vaccines most everyday. I gave my own baby his first MMR. I witnessed his sudden health deterioration. He had seizures, quit speaking, broke out in a rash and continued to have rashy skin, his GI system was a mess. Daily diarrhea stools with undigested food, mucus, froth. His balance was off. He faded away. It took years of seeking…

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    1. Karmen Wagler

      RN, BSN

      In reply to Karmen Wagler

      Before anyone attacks my experience with these drugs look up post marketing surveillance. It is crucial consumers of these products report their experiences and patterns monitored. The problem with vaccines is the passive monitoring system. Parents have no idea what or how to report. Most healthcare workers are clueless. What are the symptoms of post vaccination encephalitis? Fever, lethargy, change in eating, somnolence, irritability, inconsolable, crying etc. these are also listed as the…

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    2. Karmen Wagler

      RN, BSN

      In reply to Karmen Wagler

      One more thought as I have to get back to work. Wy would healthcare workers, those on the front lines of this war on disease, have to be forced to take the best weapon (according to the CDC) to fight this disease? Are all these HCW's simply ignorant? Do they all want to spread disease and make their patients sick? They work first hand with their patients and they ask if each patient received the flu vaccine. They are witnesses to its real world efficacy (or lack thereof). Why would these educated HCW's have to be forced to receive these drugs?

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    3. Jason Walters

      Researcher & perennial student

      In reply to Karmen Wagler

      Karmen, I am very sorry for what you and your son have experienced. The perfect vaccine, like the perfect market does not exist, no matter what the marketing says and as long as the systems by which science, arts and basic research are funded remains locked to corporate profitability and individual reputations, the longer real innovative mprovements will take.

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  9. Albert Rogers

    logged in via Facebook

    This series of articles illustrates one of the absurdities of a health care "industry". The reward system of capitalism does not encourage the sharing of scientific information, and especially not information about what did not work. As a result, regulatory bodies are certain to lag behind the regulated companies, and this makes regulation slow and timid.
    In the worst cases, government-employed regulators may very well condition their behaviour so as not to spoil their chances of switching employment in the event of government cutbacks.

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  10. Albert Rogers

    logged in via Facebook

    There is a very sad story here of a child who very shortly after a vaccination suffered from very serious and complicated ailments. But with all sympathy, I do not see that there was any connection established between the vaccination and the tragic events that followed.
    I have read of an instance where a child about to be given a vaccination exhibited symptoms of some debilitating, unidentifiable health problem, I think it was mental health, without receiving the vaccnation. The physician who would have performed the vaccination expressed his relief at the timing.

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  11. Katrina Bramstedt

    Associate Professor, Medical Ethics at Bond University

    I appreciate all the comments received. Something to add is that this article has been painted by some with a very broad brush ["anti-vaccination"] when in fact the issue is mandatory vaccination of a specific type (influenza) for a specific cohort (health care workers). It should be noted that health care workers who have been refusing this vaccination have indeed received many other types of mandatory vaccinations as a condition of employment (e.g., MMR) but this particular vaccination presents an ethical dilemma for them.

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