The case for Healthcare Workers to get mandatory flu shots.

In Editorial by Edmund Kwok4 Comments

It is a very interesting social phenomenon how some healthcare workers have come to put up such an emotionally charged and adamant fight against getting vaccinated. This issue reached a head with the recent battle in British Columbia over trying to make it mandatory for frontline nurses to get the flu shot.

I call this a “social phenomenon” because the surprising resistance is exponentially spurred by forces beyond any solid scientific evidence, despite repeated urgings from infectious diseases experts and leading health authorities worldwide.


Before we go any further, we need to be clear: this is an issue of patient safety, and how to provide the best patient-centered care. Refusing to get the flu shot as an individual is different than refusing to get the flu shot as a healthcare professional (but more on that later).

The most current literature on the flu shot suggests the potential for benefit far outweighs the potential for harm. Preventing healthcare worker-to-patient transmission of influenza is extremely important, especially in vulnerable populations like pediatrics, the elderly, and other immunosuppressed individuals. Skeptics often question whether the flu vaccine is 100% effective – well, of course not. No treatment in medicine is. The latest statistics on this year’s flu shot rates it at least in the range of around 60% effective which, for those keeping track, is much better than 0%.

If a doctor or nurse via the flu shot can reduce the chance of transmitting a disease that can cause significant morbidity and mortality to a patient by 50%, it is an effective intervention. Period.

Furthermore, this is additive to other infectious disease transmission prevention measures, such as proper contact precautions with gowns/gloves/masks and religious hand-washing. Hence, in order to provide patients with the best care in terms of preventing iatrogenic transmission of the flu, healthcare workers need to follow proper contact precautions as well as annual vaccinations … missing any one of those pieces by definition means giving suboptimal care.

So why are so many opposed to it? Various surveys and studies of healthcare workers who have refused the flu shot have identified several common themes, including:

“The vaccine doesn’t work”
“The vaccine can cause the flu”
“I never got the flu, why do I need one”

If that at all sound familiar to you, I recommend this latest article published in JAMA which refutes such common and unfounded arguments.

However, it seems that those are simply the tip of the iceberg. There are two other underlying reasons why some healthcare workers strongly refuse the flu shot … reasons that are more philosophically and ethically charged (and hence difficult to change even in the face of objective evidence).

The first is that many pride themselves on being healthcare professionals and well-educated, which they are. They believe that they can read the evidence themselves and make informed decisions. The trouble is, medical literature is not like a book or newspaper; you cannot just Google a topic, or read a couple of studies and expect to be an expert in interpreting the available data. The majority of healthcare workers, including physicians and nurses, are not properly trained to critically appraise and interpret the subtleties of the conclusions in published scientific studies. People dedicate whole careers into learning how to critically appraise medical literature: People who have Masters in Clinical Epidemiology. People who are infectious diseases experts. People who work for leading health authorities that put out clinical guidelines and recommendations after countless hours of dissecting and analyzing the available evidence. No offense, but being “well-educated” in general doesn’t equip someone with the specialized training and tools to objectively interpret the vast and varied studies published on the flu shot.

The second is an ethical argument based on principles of autonomy and bodily integrity. It is true that any individual should have the right to refuse any unwanted intervention after balancing the risks/benefits for themselves – however, medical ethics would argue that violations of personal autonomy as pertinent to a job is ethically justified in the face of compelling risk of harm to others. We practice according to this ethical responsibility in medicine daily: for example, a person’s freedom removed during mandatory quarantine for infectious outbreaks, or a patient’s right to confidentiality voided when a physician is mandated to report the patient’s confession of plans for imminent murder. Becoming a healthcare professional requires a commitment to providing optimal patient safety; it is a vocation that demands prioritizing patients’ best interests and not just one’s own.

Making vaccinations as a mandatory condition of the job (in order to provide the best patient-centered care) is completely acceptable; in fact we do it already. Hospitals require all physicians and nurses to have up-to-date Hep B, MMR, etc. vaccines, as well as annual TB testing, in order to be employed. They are all just as “intrusive” as the flu shot, with some being less effective and carrying greater side effect profiles. If for whatever reason (personal/religious/etc) one cannot comply with best practices, then perhaps our patients deserve someone else who can.

What’s funny is that the healthcare workers who are fighting the flu shot with such vigor probably have their other vaccinations up-to-date. So the resistance specific to the flu shot is indeed truly a social phenomenon and not a logical one, a sort of “herd” momentum that builds up and spreads from one well-educated individual to another. Come to think of it, not unlike how Jenny McCarthy started the snowball rolling for the lay public…

In summary: if we are to provide optimal patient-centered care, based on current evidence, expert recommendations, and medical ethics, there is a good case for making flu shots mandatory for frontline healthcare workers.

Edmund Kwok

Edmund Kwok

Emergency Medicine. Quality Improvement. Patient Safety. Change Management. Healthcare Administration.

Frontdoor 2 Healthcare

Frontdoor2Healthcare, founded by Dr. Edmund Kwok in 2012, provides editorial and commentary on issues affecting Canadian healthcare from the emergency department’s “front door” perspective. Frontdoor posts allow for open sharing of the diverse opinions and perspectives of emergency physicians from across the country.

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