Influenza vaccination for health care workers: towards a workable and effective standard.

Introduction In an average health care facility, more than half of employed health care workers, such as nurses, do not receive an annual influenza vaccination. (1) If one of these nurses were to contract the influenza virus, she could be contagious for one to four days before symptoms began to appear, during which time she would likely continue to carry out her duties as a health care worker. (2) During the course of a day, this nurse might have direct physical contact with 13 patients. (3) Over two days, then, more than 25 patients could be exposed to the influenza virus as a result of being treated by the nurse. Out of these exposed patients, many could be chronically ill or elderly, and therefore particularly susceptible to complications caused by the influenza virus. It is possible that some vulnerable patients could die as a result of this exposure. And the effects of exposure could greatly increase in spread and severity in a situation of influenza pandemic. (4) In an attempt to avoid such a scenario and to protect patients, many current health care facility policies require that unvaccinated health care workers be sent home without pay upon identification of an influenza outbreak. However, such an approach is problematic, due to the epidemiology of the spread of the influenza virus. During the incubation period, a person can pass on the virus while not yet exhibiting characteristic symptoms. This makes it very likely that a health care worker could pass on an infection before realizing he is sick and removing himself from patient contact, even with immediate exclusion upon appearance of symptoms. This fact, combined with diagnostic delays in identifying influenza infections, means that by the time an outbreak is recognized, the virus would already have spread to several patients. (5) Sporadic infections may also occur, not triggering an outbreak scenario, but spreading influenza from a single health care worker to a patient, or between health care workers and then to a patient. Another approach to protecting patients from the influenza virus could be more effective. Pre-exposure immunization is the most efficient method of preventing annual outbreaks of influenza, and thus is the best method of reducing related morbidity and mortality. (6) However, vaccine coverage amongst health care workers, including both those providing direct patient care as well as those providing more indirect health services, is currently alarmingly poor. Studies of health care workers in long-term care facilities and hospitals show influenza vaccination coverage rates of 26-61%, (7) an unsatisfactorily and, many say, unacceptably low range. Reasons given for refusing the influenza vaccine include the belief that it is either ineffective or unnecessary, a perceived lack of susceptibility, concern about adverse reactions, and personal beliefs against vaccination. (8) The unfounded attribution of influenza symptoms to the vaccine also continues to persist. (9) These concerns suggest that there is insufficient knowledge about the vaccine's effectiveness and side effects, and about the potential risk of transmission to patients, indicating a failure of educational campaigns to adequately target and alleviate the concerns of employees. (10) What policy course would do best to address this perception of inadequacy in current hospital safety regulations? The failure of education programs to improve voluntary hospital worker immunization rates has led to calls for mandatory influenza immunization policies. These policies would have the effect of increasing patient health and safety, and at the same time saving costs and reducing worker illness and absenteeism. However, health care workers have been resistant, and the legality of such an option remains uncertain. We will discuss two broad legal issues surrounding this question. First, would such a policy be acceptable under the Canadian Charter of Rights of Freedoms, specifically under s. …

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