Mandatory Influenza Immunization for Health Care Workers: A Recent Policy Change
by Angela Wignall, RN
In 2012, the Government of British Columbia implemented a mandatory influenza immunization program for healthcare workers. This public health policy implemented a requirement for healthcare workers to either receive the influenza immunization each year or wear a mask while in patient care areas during flu season. Compliance with this policy included self-reporting on immunization status. In addition, the policy provided opportunities for employers to pursue punitive action against healthcare workers who choose not to receive the influenza immunization and elected not to wear a mask. Until recently, punitive action against healthcare works could include loss of work hours and potentially termination of employment.
From the outset, this policy was contentious. By 2013, arbitration was underway examining the legality of such a policy. Unions such as the Health Sciences Association (HSA), Hospital Employees Union (HEU), and the BC Nurses Union (BCNU) launched grievances against the policy. The policy remains contentious today with continued advocacy from unions and other groups against mandatory influenza immunization for healthcare workers.
In December 2019, the Office of the Provincial Health Officer in collaboration with the Health Employers Association of BC (HEABC) announced a change to the mandatory influenza immunization for healthcare workers policy. While the policy of immunize or mask remains, healthcare workers will no longer face disciplinary action for their choice. This policy change signals a willingness to take a more collaborative approach to this issue. It has also brought the issue of mandatory immunization front and centre once again. There are many arguments that come up when public health policies such as mandatory immunization are debated. Are flu vaccines necessary every year? Is the evidence even reliable? Why would nurses choose not to get an immunization when their job is to protect other people? Are nurses promoting an 'anti-vax' point of view?
Nurses are not just care providers; we are leaders in healthcare. Our practice is based on evidence and a disciplinary knowledge that prepares us to address health issues at the individual, community, and population level. We have an important role to play in considering the questions around and the evidence for mandatory influenza immunization for healthcare workers. So let's look at these questions through the eyes of a nurse.
Are flu vaccines necessary every year? Is the evidence even reliable?
The evidence for influenza immunization is unequivocal: immunization reduces the transmission, severity, and incidence of influenza. A Cochrane systematic review of evidence, the gold standard for research evidence on a health topic, showed that immunization for influenza is an evidence-based public health intervention. In addition to research evidence, influenza surveillance reports collected across many countries have shown that influenza incidence and mortality go down when influenza immunization is introduced.
Other questions about the evidence for influenza immunization have been raised. For example, some research has shown that repeated exposure to immunization results in a reduced antibody response, making repeated, year-on-year immunization less useful than initial immunization. In plain language, the first time you get your shot, your body responds well but the next time you get your shot, your body does not respond quite as well. Given that healthcare workers are asked to get an immunization every year, this research raises questions about the benefit of annual immunization. However, there are benefits to year-on-year immunizations that outweigh the evidence of reduced antibody response.
Influenza vaccines are different every year. Every year, the World Health Organization identifies influenza strains that are likely to appear in the northern and southern hemispheres. Then the Biologics and Genetic Therapies Directorate in Health Canada oversees the regulation of new influenza vaccines including the safety, efficacy, and quality of these products each and every year. Variability of the vaccine is an important part of successfully targeting the circulating strains and enabling a significant enough immune response to provide protection. We also know that because the influenza virus changes quickly as people become immune to existing strains, identification of the right strains and building a unique product every year is what makes the influenza vaccine work as well as it does. Even if the match is not perfect or if our antibody response is lower when we receive the vaccine a second or third time, an influenza immunization provides more protection than doing nothing.
We have come a long way by bringing the evidence for influenza into a public health policy. That is the first step for any public health intervention. Now we have the privilege of getting better and better by studying and refining our approach. This includes further research into how immunizations are used year-on-year, ideal immunization frequency, and other questions that are part of making a good public health policy even better.
Why would nurses choose not to get an immunization when their job is to protect other people?
Nursing in Canada is guided by standards and codes of ethics. For example, the Canadian Nurses Association's Code of Ethics for Registered Nurses sets the national standards for ethical practice as a Registered Nurse. Promoting health and well-being, respecting informed decision making, and being accountable are examples of the ethical principles of nursing that intersect with the question of mandatory immunization policies.
Immunization is the most effective means of preventing illness and promoting health. The World Health Organization estimates that immunization prevents up to three million deaths globally per year. No other intervention in the history of modern healthcare has saved as many lives and prevented disability as effectively as vaccines have. When it comes to promoting health, nursing knows that immunization is one of the most important things we can do.
Nursing also knows that people have the right to choose to decline healthcare interventions, even when we believe the intervention is important. A core function of nursing is to advocate for informed consent, which includes the right to refuse. Every day, nurses put aside their personal beliefs and values to support patients in making health choices. Our patient rely on us to be their advocate and to support their health choices in the unique way that only nurses can. And nurses understand that with the right to choose comes accountability for that choice. When healthcare workers choose not to receive an influenza immunization, they are exercising their right to refuse, a principle supported by nursing in our standards and our ethics. To ensure we are accountable for our choice, we self-report our choice so that healthcare employers can make good decisions during outbreaks. Our expectation is that just like patients we will not be punished for exercising our right to refuse.
The new policy change aligns with nursing standards and ethics including balancing our responsibility to the public and our right as individuals to refuse an intervention. It extends the same care to ourselves as we extend to those in our care. The policy change also acknowledges that nurses possess the professional judgement and ethical accountability required to make good choices that balance protecting the public with our rights as individuals.
<2>What about a nurse's right to bodily autonomy?
It may sound silly to say but nurses are people. Just like everyone else, nurses have fundamental human rights that include the right to bodily autonomy. Bodily autonomy is every person's right to decide what happens to their own bodies. It means that we have a right to decide what happens to our bodies without any external influence or coercion. In philosophy and in law, mandated medical interventions violate the sovereignty we have over our own bodies. So how does this fundamental human right square up against mandated immunizations programs for healthcare workers? What gives governments and healthcare agencies the right to violate this principle at the individual level to protect people at the population level?
To answer this question we need to turn to philosophy. The idea of meeting the greatest good by sacrificing what is good for the individual is what philosophers call utilitarianism. J.S. Mill, one of the philosophers who first wrote about utilitarianism, noted, “The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others”. Utilitarianism tells us that actions are philosophically and morally permissible if they benefit the majority of people. In other words, the wellness of the whole outweighs the desires of the individual. Utilitarianism also teaches us that the “rightness” of any action can only be weighed by its effects. This means that if the effect of influenza immunization of healthcare workers is reduced disease burden in the population, the “rightness” of immunizing healthcare workers is justified.
It is important to note that in all arbitration and legal challenges to the policy of mandatory influenza immunization for health workers in BC, the policy has been found to be legal. Examining the philosophical basis by which government can exercise the authority to overrule individual bodily autonomy for population health helps us understand why mandatory influenza immunization of healthcare workers is not only legal but can also be seen as the right thing to do.
Are nurses just becoming anti-vaxxers?
Many people who choose not to receive immunizations do so because they have questions about the issues we have already touched on. Labelling people anti-vaxxers is a political act, an othering of those who do not share the established position on an issue. It is divisive and it drives away those we need to reach the most. It does not improve our immunization rates, address the very real concerns that folks who are hesitant to immunize have, or improve the health of our populations. We cannot achieve our public health goals of reducing disease burden, increasing population immunity, and prolonging wellness in long life without the full participation of and engagement with those who are hesitant to receive vaccines. Compassionate, respectful communication is a cornerstone of our code of ethics as nurses and this principle extends into every conversation, including those about immunization.
Research tells us that strongest predictor of vaccine compliance is trust. Good news! Nurses are experts in building relationships of trust. That means we are just the people to be at the forefront of immunization advocacy. We possess immunology knowledge, practice experience, expertise in relational practice, and we are the country's most trusted professional group. No other group is as well positioned to really move the needle on immunization than nurses. So instead of taking up divisive anti-vaxxer language, nurses invest in each other and our patients, building the trust required to promote health and wellness.
Good for nurses, good for patients.
From many different perspectives, the recent policy change on mandatory influenza immunization for healthcare workers is a good move for nurses and a good move for patients in my opinion. By eliminating the punitive nature of the policy, our provincial health leaders have demonstrated a willingness to engage healthcare workers as collaborators in relationships of cooperation and trust, the very conditions required to improve immunization uptake.
Nurses know that the evidence supports influenza immunization and that we have an ethical responsibility to promote health and protect those under our care. Nurses also have the unique skills and relationships of trust to engage with those questioning immunization and support their informed decision-making. This policy change signals an opportunity for nurses to lead in influenza immunization holistically and with heart, in the spirit of evidence-based caring that is the hallmark of who we are as people and as a profession.
Canadian Nurses Association. (2015). Framework for the practice of Registered Nurses in Canada.
Canadian Nurses Association. (2017). Code of ethics for Registered Nurses.
Demicheli, V., Jefferson, T., Ferroni, E., Rivetti, A., Di Pietrantonj, C. (2018). Vaccines for preventing influenza in healthy adults.
Grzybowski, A., Patryn, R.K., Sak, J., & Zagaja, A. (2017). Vaccination refusal: Autonomy and permitted coercion. Pathology of Global Health, 111(4), 200–205. doi: 10.1080/20477724.2017.1322261
Gaglani, M., Spencer, S., Ball, S., Song, J., Naleway, A., Henkle, E., Bozeman, S., Reynolds, S., Sessions, W., Hancock, K., & Thompson, M. (2014). Antibody response to Influenza A(H1N1)pdm09 among healthcare personnel receiving trivalent inactivated vaccine: Effect of prior monovalent inactivated vaccine. The Journal of Infectious Diseases, 209(11), 1705–1714. doi: 10.1093/infdis/jit825
Nabeshima, S., Kashiwagi, K., Murata, M., Kanamoto, Y., Furuyso, N, & Hayashi, J. (2007). Antibody response to influenza vaccine in adults vaccinated with identical vaccine strains in consecutive years. Journal of Medical Virology, 79(3), 320-325. doi: 10.1002/jmv.20801
Sasaki, S., He, X.S., Homes, T.H., Dekker, C.L., Kemble, G.W., Arvin, A.M., & Greenberg, H.B. (2008). Influence of prior influenza vaccination on antibody and B-cell responses. PloS One, 3(8), e2975. doi: 10.1371/journal.pone.0002975.
World Health Organization. (2019). Immunization.
Angela Wignall, RN, BA, BSN, MA
Angela is a Registered Nurse in Victoria, BC. She has worked as a perinatal and public health nurse, supporting the health and wellness of families and communities across Vancouver Island. Angela currently works in policy and governance in the Office of the Chief Nursing Officer at Island Health. She is proud to serve as the Island region Councillor on the RN Council at NNPBC.