In an editorial published in this week's issue, the journal said hospital workers ought to be vaccinated to safeguard frail, elderly patients whose immune systems are so weakened they don't get much protection from a flu shot themselves.
"We would like individual hospitals to think about taking the initiative," said Dr. Ken Flegel, senior associate editor and a general internal medicine specialist at Montreal's McGill University Health Centre.
Flegel acknowledged there will likely be pushback from health-care workers, the majority of whom do not get a flu shot.
"I don't want anyone to make me do something I don't believe in or I don't agree to do to my body," he said.
"I think that's a sort of fundamental right. On the other hand, I think the hospital has to say 'That's fine by us but don't come near our patients because you're a hazard to our patients.'"
In recent years there has been a growing movement towards requiring health-care workers to take a flu shot, especially in the United States. Earlier this year British Columbia became the first Canadian jurisdiction to require health-care workers to be vaccinated against the flu.
The B.C. policy applies to hospital workers, staff of long-term care homes and community-based health-care workers. It does not cover doctors in private practice. Health-care workers who forgo a flu shot will have to wear a mask on the job from Dec. 1 to the end of March.
Dr. Perry Kendall, the province's chief medical officer of health, said health-care worker vaccination rates — which were never high — have been dropping since 2007.
"If we really think it will make a difference, why do we keep on sitting on the fence and accepting declining levels? It either is important enough to really do it or it isn't," Kendall said.
Health-care unions, which had supported B.C.'s efforts to raise flu shot rates among members, were not happy about the new policy.
"They would rather it is a voluntary program and so would I, frankly. But that just hasn't worked," Kendall said.
The call to make flu shots mandatory comes at a time when serious questions are being asked about how effective flu vaccine actually is. And some of the studies the journal editorial cites in making its case are among those that have been called into question.
It suggests, for instance, that flu vaccine is about 86 per cent effective at preventing flu when the strains in the shot are well matched to circulating viruses. But the study cited as the source of that information doesn't actually make that claim. Flegel said he got the number from another study, which credited the study Flegel cited.
A recent comprehensive review of influenza vaccine written by the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota said the scientific literature on flu vaccine is littered with mistakes — studies that misconstrue what previous research has found or which have design flaws.
The result has been an over-estimation of how much protection current flu vaccines can offer, the CIDRAP report said.
In the last couple of years many expert groups have quietly toned down their language on flu shots, lowering the efficacy estimates to 50 to 70 per cent from the 70 to 90 per cent that was previously claimed.
(It should be noted the studies that assess efficacy are typically done in healthy adults, the people whose immune systems are most likely to respond well to a flu shot. That means those efficacy estimates are a best-case scenario.)
Michael Osterholm, senior author of the CIDRAP flu vaccine report, said public health officials need to be careful not to over sell flu vaccine.
"I fully support the vaccination of health-care workers. But we must be held to a standard of science that we expect anyone who opposes vaccination to also be held to," he said.
Flegel acknowledged that may be a problem. "We probably have been too enthusiastic about the protection rate available from the flu vaccine," he said after learning of the problem in his citations.
But he said even if the vaccine offers only 50 per cent protection, minimizing the risk that health-care workers sick with the flu will pass it to their vulnerable patients makes sense.
The fact that the vaccine doesn't work as well as people would like can actually be used as an argument for requiring health-care workers to get flu shots, said Dr. Kumanan Wilson, a Canada Research Chair in health policy at the Ottawa Hospital Research Institute.
Wilson, who researches vaccine acceptance issues, recently co-wrote an article exploring the issue of mandatory influenza vaccination for health-care workers in the publication Health Law Journal.
"The fact that the vaccine is not so good actually necessitates a high percentage of health-care workers getting the vaccine in order to create some level of herd immunity," Wilson said in an interview.
"So as long as it has some effectiveness, a reasonable level of effectiveness, you could use that as an argument 'This is why we have to mandate everybody get it.'"
Still, Wilson said requiring workers to take a flu shot isn't something hospitals or governments should do lightly. "Because people will perceive it as a major infringement on their liberty. It's actually putting a needle into someone. So you really need to be careful how you proceed with this."
Wilson said mandatory flu shot programs should include commitments from the authorities making the policy that they'll review emerging scientific data on the safety and efficacy of flu vaccine on an ongoing basis.
As well, he said, authorities should commit to studying whether the program is actually working. They should also monitor for any vaccine-induced side-effects and commit to compensate any health-care worker who sustains a health injury that can be linked back to the flu shot.
"If you do bring it in, you have to do it respectfully and showing that you understand the concerns of health-care workers," said Wilson, who noted that he supports the idea of vaccinating health-care workers against influenza.
"If you don't do that, then it comes across, I think, as a bit heavy handed."