Dr. Michael Gardam is the director of infection prevention and control at the University Health Network in Toronto. He has established a reputation as one of Canada's leading voices in the field of infection control and matters of public health.
Which is why some might be surprised to learn he thinks the growing trend toward mandating flu shots to health-care workers is a bad idea.
Across Canada, mandatory vaccinations for health-care workers during flu season have become a flashpoint. All British Columbia health-care workers, more than a dozen hospitals in Ontario and one health authority in New Brunswick now require health-care staff to be vaccinated or wear a mask at work during flu season.
The arguments in favour of such policies are strong: Flu causes thousands of deaths a year, and many of these can be prevented by vaccination. Health-care workers deal with the sick and vulnerable day and night, and, if they're not vaccinated, can infect them with a flu virus that could cause serious complications and death.
So why would one of Canada's foremost infection-control experts argue against mandatory flu shots for health-care workers?
"A few years ago, I was also for mandatory flu shots [for health-care workers]," Gardam says. "Then what happened is I started reading and I started going back to the original studies. I don't feel that I can sugar-coat those any more."
It turns out that the evidence in favour of mandatory vaccination policies is far from conclusive. For instance, a review of the medical literature published in the Cochrane Database of Systematic Reviews in July, 2013, found vaccinated health-care workers had no measurable benefit on flu rates or the number of related complications of long-term-care residents. Another review by researchers from the U.S. Centers for Disease Control and Prevention found the quality of evidence for reduced influenza death and total number of cases among patients to be moderate and low, respectively.
But when experts express doubts publicly about the effectiveness of mandatory flu-vaccination campaigns aimed at health workers, it tends not to go over well. Gardam says he is still being criticized by other public-health professionals for an opinion piece published in the summer in which he argued that such campaigns are not based in evidence. Another physician, based in Western Canada, is so concerned about the consequences of expressing his opposition to mandatory flu-shot campaigns that he agreed to be interviewed on condition of anonymity.
The physician argues that given the limited effectiveness of the annual flu shot and the lack of evidence showing that mandatory campaigns can reduce transmission rates, health-care workers should retain the ability to choose.
He also points out that a few of the loudest voices to have argued in favour of mandatory vaccination policies have received research and other funding from vaccine-makers.
Before members of the anti-vaccination movement get too excited, make no mistake: No one is arguing the flu shot is not the best defence available to protect against the flu. It is. Gardam and other experts encourage people to get the flu shot.
But they have real concerns that the current paternalistic tone, which does not permit any nuanced discussion, is actually serving to undermine important public-health messages.
Instead of acknowledging that, yes, the flu shot isn't 100-per-cent effective, the take-home message to the public is to simply get immunized. If you're a health-care worker in some parts of the country and you choose not to heed this message, then you are in for a world of trouble.
Every year, provincial public-health agencies, health advocacy groups and media organizations tell Canadians that up to 8,000 of us die annually as a direct result of the flu. But that figure is based on a computer model and doesn't reflect the actual number of influenza deaths (many experts believe it greatly overestimates the true figure). In reality, the total number of flu deaths isn't tracked across Canada, in part because most flu cases are not tested and confirmed by a lab. Without knowing the true scope of flu deaths, it's difficult to show whether well-intentioned policies, such as mandatory vaccinations, actually work.
Public-health officials may feel the need to use scare tactics and fear to counter the persistent anti-vaccination movement, which erroneously attributes a host of health problems to vaccines and has scared many away from getting them.
But heavy-handed messages can undermine the very important goals of public-health campaigns around the flu.
The flu is serious business. It kills every year. That's why it's so important to base the discussion around how to protect ourselves in reason and fact, instead of mounting divisive battles that aren't proven to have a meaningful positive impact on patient outcomes.
The truth is the flu shot is about 60-per-cent effective, on average, in healthy adults. Depending on the year, that number can vary. It's certainly better than nothing, and until a better vaccine comes along, it is the best way to prevent the flu.
It's also true that there's no reliable, high-quality evidence showing that vaccinating every health-care worker greatly reduces flu cases and deaths.
So why create a battle with health-care workers instead of using the facts to make a reasoned, compelling argument encouraging them to get the flu shot, wash their hands and stay home when sick?
Coercion and threats may work in the short term, but they surely aren't a good basis for truly effective health policy.