Published 28 October 2008, doi:10.1136/bmj.a2140
Cite this as: BMJ 2008;337:a2140

Head to Head

Should influenza immunisation be mandatory for healthcare workers? No

¹ Department of Infectious Diseases, Children’s Hospital at Westmead, Westmead, NSW, 2145, Australia, ² University of Sydney, NSW, Australia, ³ National Centre for Immunisation Research and Surveillance, Children’s Hospital at Westmead

Charles Helms and Philip Polgreen (doi:10.1136/bmj.a2142) believe mandatory immunisation is necessary to achieve good uptake, but David Isaacs and Julie Leask argue that it infringes autonomy and could backfire

Healthcare workers should be immunised against influenza, for their own protection and to protect their patients against influenza. The issue is whether it is ethical and good practice to make immunisation mandatory.

John Stuart Mill, the British philosopher, famously wrote: "The only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others."¹ This statement of what we now call the principle of autonomy, or a person’s right to choose, invalidates any argument that we should force healthcare workers to be immunised for their own sake.²

The state sometimes exerts benign paternalism to coerce personal choice. Examples are the mandatory use of seat belts or of motorcycle helmets, where the infringement of autonomy is justified by the effect on public health, and where the intervention poses little or no harm to the individual and has been proved to save lives. But it is not clear that this applies to immunisation of healthcare workers. For mandatory immunisation to be acceptable it would have to be effective, not harmful, feasible, and have no alternative.

There is good evidence that patients are vulnerable to nosocomial influenza. Immunising healthcare workers who care for institutionalised elderly people protects the elderly against influenza^{3 4} and may even prevent deaths,⁴ although the benefit is greatest in elderly people who have not been immunised.³ However, there is virtually no published evidence that immunising healthcare workers protects other patient groups. Immunising carers ought to protect immunocompromised patients who, like elderly people, have an impaired immune response. A literature search, however, found only one observational study in which nosocomial influenza was reduced on a bone marrow transplant unit after a campaign to improve infection control measures and staff immunisation rates.⁵ The relative contribution of immunisation could not be elucidated.⁵

Potential for harm

Some argue that the severity of influenza in high risk patients, high rates of influenza in healthcare workers, and poor compliance with voluntary programmes are sufficient grounds to make annual immunisation mandatory.⁶

Mandatory immunisation might be justified if it was benign. Although the physical harms from influenza vaccine are generally minor, there are potential psychosocial harms. Mandatory immunisation infringes civil liberty and autonomy. Society commonly recognises the right of people to bodily integrity.⁷ Vaccines are invasive, transgressing the traditional boundary of the skin, so there is greater infringement of liberty than from other public health mandates which infringe autonomy, such as helmets or seatbelts. In addition, if those who do not comply face dismissal, this infringes a person’s freedom to work and ensure financial security.

Mandatory immunisation may alienate many staff and damage morale. Mandatory immunisation devalues staff by treating them as objects, not people. Furthermore, the message that healthcare workers have to be compelled to be immunised will galvanise and provide ammunition to opponents of immunisation. It risks polarising healthcare workers and producing a backlash with opposite consequences to those intended.

Consequences

The term mandatory implies sanctions for non-compliance. Poland and colleagues argued for religious and medical exemptions with the option of an informed refusal.⁸ It could be argued, however, that immunisation is not truly mandatory if you can opt out. We know of two examples of more draconian sanctions.

In 2004, the Virginia Mason Medical Center introduced mandatory influenza immunisation for healthcare workers. The initial penalty for non-compliance was dismissal, but the nurses’ union made a successful legal challenge. The hospital agreed to religious or medical exemptions, but unimmunised staff had to wear masks during the influenza season.⁹ Immunisation rates rose from 56% to 96%, showing that the policy is feasible. Nevertheless, over 600 nurses protested, and the harm to morale was incalculable.¹⁰

In 2007, New South Wales Department of Health introduced mandatory immunisation against various infectious diseases (not yet including influenza) for healthcare workers in a wide range of patient care areas.¹¹ There are no exemptions, and those who do not comply are offered redeployment. The feasibility and acceptability of this policy is untested.

Persuasion not coercion

Immunisation of healthcare workers has some parallels with childhood immunisation. We have argued that compulsory childhood immunisation is not justifiable if high levels of immunisation can be achieved without compulsion.¹² Many countries achieve childhood immunisation rates above 95% without mandates,¹² illustrating that well resourced immunisation programmes can succeed. Immunisation is more highly valued by a public persuaded of its benefits, not coerced.

The majority of healthcare workers recognise that influenza immunisation is safe and effective.⁸ Can we persuade them to be immunised? Over 75% of nurses were immunised in a programme in British Columbia recently, and convenience was critical for uptake.¹³

We advocate administrative commitment to foster a culture of immunisation in healthcare facilities and stress the need to immunise patients at high risk from influenza. We advocate programmes, using incentives, publicity, ready availability, and feedback to educate healthcare workers about the personal benefit and the benefits to their patients.^{14 15}

Mandatory immunisation would be justifiable only if comprehensive measures to win hearts and minds and to make immunisation part of the organisation’s culture were unsuccessful. Even then, mandatory immunisation could be justified only for workers caring for elderly and perhaps immunocompromised patients. We argue that mandatory influenza immunisation of all healthcare workers is an excessive infringement on autonomy relative to its potential benefits.

Cite this as: BMJ 2008;337:a2140

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Competing interests: None declared.

References

1. Mill JS. On liberty. In: Mineka FE, Lindley DN, eds. The collected works of John Stuart Mill. Vol 15. The later letters of John Stuart Mill 1849-1873, part II (1856). Toronto: University of Toronto Press, 1972.
2. Wynia MK. Mandating vaccination: what counts as a mandate in public health and when should they be used? Am J Bioethics 2007;7:2-6.[CrossRef]
3. Thomas RE, Jefferson T, Demicheli V, Rivetti D. Influenza vaccination for healthcare workers who work with the elderly. Cochrane Database Syst Rev 2006;3:CD005187.[Medline]
4. Hayward AC, Harling R, Wetten S, Johnson AM, Munro S, Smedley J, et al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial. BMJ 2006;333:1241.[Abstract/Free Full Text]
5. Weinstock DM, Eagan J, Malak SA, Rogers M, Wallace H, Kiehn TE, et al. Control of influenza A on a bone marrow transplant unit. Infect Control Hosp Epidemiol 2000;21:730-2.[CrossRef][Web of Science][Medline]
6. Poland GA, Tosh P, Jacobson RM. Requiring influenza vaccination for health care workers: seven truths we must accept. Vaccine 2005;23:2251-5.[CrossRef][Web of Science][Medline]
7. Asveld L. Mass-vaccination programmes and the value of respect for autonomy. Bioethics 2008;22:245-57.
8. Poland GA, Ofstead CL, Tucker SJ, Beebe TJ. Receptivity to mandatory influenza vaccination policies for healthcare workers among registered nurses working on inpatient units. Infect Control Hosp Epidemiol 2008;29:170-3.[CrossRef][Web of Science][Medline]
9. Rusk J. Mandatory flu shots boost health care worker immunization rate at Virginia Mason. Infectious Disease News 2006 Mar. www.infectiousdiseasenews.com/200603/mandatory.asp.
10. Nurses outraged by Virginia Mason Medical Center’s mandatory flu vaccination policy. 21 Sep 2004. http://goliath.ecnext.com/coms2/summary_0199-777565_ITM.
11. NSW Health. Occupational assessment, screening, and vaccination against specified infectious diseases. www.health.nsw.gov.au/ohs_vaccination/index.html.
12. Isaacs D, Kilham HA, Marshall H. Should routine childhood immunizations be compulsory? J Paediatr Child Health 2004;40:392-6.[CrossRef][Web of Science][Medline]
13. Norton SP, Scheifele DW, Bettinger JA, West RM. Influenza vaccination in paediatric nurses: cross-sectional study of coverage, refusal, and factors in acceptance. Vaccine 2008;26:2942-8.[CrossRef][Web of Science][Medline]
14. Salgado CD, Giannetta ET, Hayden FG, Farr BM. Preventing nosocomial influenza by improving the vaccine acceptance rate of clinicians. Infect Control Hosp Epidemiol 2004;25:923-8.[CrossRef][Web of Science][Medline]
15. McCullers JA, Speck KM, Williams BF, Liang H, Mirro J Jr. Increased influenza vaccination of healthcare workers at a pediatric cancer hospital: results of a comprehensive influenza vaccination campaign. Infect Control Hosp Epidemiol 2006;27:77-9.[CrossRef][Web of Science][Medline]

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