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opinion

Dr. William Ghali is the scientific director of the O'Brien Institute for Public Health at the University of Calgary.

Public health officials advocating for mandatory flu shots for health-care workers are using scare tactics, we're told. And we're also told that the research evidence that those "paternalistic vaccination zealots" point to in justifying their position is questionable. And some detractors are choosing to state their views against staff flu vaccination anonymously, because they fear backlash from the zealots.

In Alberta last year, only about 55 per cent of health-care workers received a flu shot. The stated target for the coming flu season is for 80 per cent of staff to be vaccinated, with the help of strategies such as the use of flu shot buttons worn on lapels, and the designation of "flu champions" who will encourage colleagues. Such approaches are not really new, and history suggests that they will fall short, in which case the legislation of mandatory staff vaccination, as is done in British Columbia, will be the logical next step.

What are the facts underlying this controversy?

At least one key point is not debated. The flu shot is only about 60 per cent effective in preventing influenza, and that effectiveness can vary somewhat depending on the characteristics of each year's strain. Estimates of influenza deaths each year are challenging to derive, because many people (especially the elderly and those with chronic illnesses) become sick and die due to influenza without the virus being pinpointed as the cause of death. Yet no one disputes that it kills thousands each year.

More controversial is how differently the proponents and detractors are interpreting the existing research evidence. Remarkably, the two sides are looking at the very same primary clinical studies, but then drawing opposing conclusions. The proponents of mandatory staff vaccination point to significantly lower rates of flu-like illness and death from all causes in the primary studies. The detractors, meanwhile, reject those two outcomes as not being linked tightly enough to the flu, and look instead for a higher burden of proof – lower rates of lab-proven influenza, and deaths due to pneumonia. Those harder-to-prove endpoints do trend toward lower rates in health-care facilities with mandatory staff vaccination, but the differences are not statistically significant.

The key nuance in this debate is that absence of airtight proof of benefit does not equate to airtight proof that there is absence of benefit. This sounds like a play on words, but it is far from that.

Given what we know about staff vaccination – i.e., definite suggestion of benefit in the primary studies despite, yes, some lingering questions – should we be ceasing the practice of health-care provider vaccination altogether? And should we reverse legislation and regulations in jurisdictions and hospitals that dictate mandatory vaccination of the health-care work force? Or should we instead point to the existing primary research studies and suggest that the burden of proof around mandatory staff flu shots is currently misplaced, and that it should instead be placed squarely onto the shoulders of the detractors? Without firm proof that mandatory staff vaccination is useless or even harmful, the widespread vaccination of health-care workers should not only be expected, but demanded by all those who enter the doors of a hospital in the upcoming flu season.

Who, then, are those scary public health professionals and infection control folks who use paternalistic scare tactics to force an unwanted intervention upon health-care providers? And why are they undermining the individual rights of those health-care providers in doing so? It seems that the motivation of those advocating for vaccination lies in their acknowledged duty to protect the safety of vulnerable patients. They undoubtedly understand that health-care providers do have individual rights, but also recognize that those rights end when they might bring harm to others. Further, the majority of those who support mandatory staff vaccination do not receive funding from vaccine-makers, as has been insinuated by some critics. They are not a sinister bunch. They are simply committed individuals who wish to create a safer environment in Canadian hospitals. The public should expect no less.

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