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Hospital workers are supposed to be first in line for any pandemic influenza vaccine so they can keep Canadian hospitals running during an outbreak - but that strategy hinges on workers agreeing to take an unproven vaccine for an uncertain threat.

Across Canada, somewhere between 40 and 60 per cent of health-care workers opt for a flu shot each season, despite extensive efforts to persuade the entire work force to get immunized. In a normal flu season, that's not a major problem.

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But in a serious outbreak of H1N1, the unwillingness of large numbers of doctors, nurses, paramedics and others could lead to soaring absenteeism rates, draining the health-care system of workers just as they are needed most. Faced with lesser risks, Canadian health officials have tried to make flu shots mandatory, but those efforts have typically failed, with the rights of the individual trumping any broader societal concern.

That may leave the state of Canada's health-care system dependent on voluntary efforts that have so far proven unable to spur health-care workers to get flu shots.

Perry Kendall, British Columbia's chief medical officer, said that at least eight in 10 workers should be getting immunized - nearly double the current rates in many parts of the country, including his own province.

Unless health-care workers overcome their reluctance toward flu shots, he said, a serious outbreak of H1N1 would lead to soaring absenteeism rates, as doctors, nurses and others are forced home to sick beds. Dr. Kendall said he was at a loss to explain why there is such reluctance to get vaccinated. "I don't understand why people would be resistant to getting flu shots, particularly health-care workers."

However, any move by government to make inoculations mandatory is likely to be a non-starter, Dr. Kendall said, because it would encounter resistance from health-care workers and a possible legal challenge under the Charter of Rights and Freedoms. "It will be an extraordinarily contentious thing."

Unions for health-care workers have strenuously resisted efforts to make flu shots mandatory, and, in interviews, several unions and employee organizations said they would be prepared to go to court to battle such an order. "If it's made law, there may be legal challenges to that," said Glen Gilles of the Ontario Paramedic Association.

Mr. Gilles said a decision on a legal challenge would depend, in part, on the severity of the swine flu threat, and how well the vaccine works in warding off illness. He noted that the Ontario government is able to require paramedics and others to take inoculations against other, more serious, diseases.

Right now, it's not possible to gauge the extent of the threat, or the effectiveness of the vaccine. Adding to the uncertainty is the possibility that the vaccine administered to the first wave of people this fall may go only through initial clinical trials. Canadian medical officials are promising stepped-up monitoring of the vaccine's effects in that case.

Nine years ago, paramedics went to court to oppose the Ontario government plan to make flu shots mandatory, arguing the move violated their Charter rights. Ontario backed down, so the case was withdrawn. But in 2001, an Ontario labour arbitrator sided with health-care employees fighting mandatory flu shots, saying the hospital policy violated employees' constitutional right to "life, liberty and security of the person."

Ontario Nurses' Association president Linda Haslam-Stroud said her union would object to any attempt to make vaccines mandatory for the province's registered nurses.

The Vancouver Coastal Health authority said it requires that all staff be immunized, regardless of whether they have direct patient contact. In practice, the best it can do is threaten to send workers home without pay if they are assigned to work where there is a flu outbreak and they refuse to be immunized. It rarely comes to that - most are reassigned to another work area for the duration of an outbreak.

In Saskatchewan, typically fewer than half of nurses get a flu shot, a number that even their union president calls "surprisingly low."

Saskatchewan Union of Nurses president Rosalee Longmoore said her organization allows each member to decide whether to be immunized, and she expects the H1N1 vaccination to be no different. "We certainly encourage employees to obtain the vaccine but we also respect the individual's right to choose."

The numbers are even lower in Nova Scotia, where just 30 to 40 per cent of nurses receive the flu shot, according to the Nova Scotia Nurses' Union, with president Janet Hazelton adding that the number is slowly climbing each year as availability increases. Over all, about half of the province's health-care workers receive annual immunizations, the province's Health Ministry said.

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