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Should flu shots be mandatory for health-care workers?

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?

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