In a commentary published in this week's issue of the Canadian Medical Association Journal, Dr. Michael Gardam argues that making the vaccine mandatory could lead to legal challenges that may not be winnable, given the modest efficacy of the vaccine.
Gardam, who is pro-vaccine and who gets a flu shot annually, is essentially arguing that this is not a hill worth dying for.
"Any sort of policy decision where you're going to make a vaccine mandatory is going to be an uphill battle, right? It's going to be a real fight," said Gardam, who is head of infection control at Toronto's University Health Network.
"And so you have to decide if you're going to make that fight, is this vaccine worth it to make that fight? And I personally don't think it is."
The commentary was swiftly rebutted by influenza vaccine proponents, who countered that it's faulty logic to link the fact that the vaccine could be better with the question of whether mandatory flu shot policies for health-care workers are legitimate.
"The premise of a relationship between those two things just doesn't make sense," said Dr. Allison McGeer, head of infection control at Toronto's Mount Sinai Hospital and a vocal advocate for mandatory flu shot policies for health-care workers.
"Yes, influenza vaccine is only 60 per cent effective. Yes, we very clearly need better influenza vaccines, because despite fairly widespread use of a vaccine that's 60 per cent effective there's still a lot of morbidity and mortality" — illness and death — "due to influenza.
"The fact that we need a better vaccine does not mean that our current vaccines are not useful. We need better treatments for cancer too, but we're not going to stop treating people for cancer because our treatments are not perfect."
The commentary and the heated discussion that will surely follow its publication flow from an evolving debate within infectious diseases circles over flu shots.
One of the only tools available to combat influenza, flu vaccine used to be thought to be between 70 and 90 per cent effective at preventing illness in healthy adults, though less effective at protecting the elderly and young children.
But in recent years, the efficacy estimate has taken a big step back, with the U.S. Centers for Disease Control now suggesting the vaccine protects about 50 to 70 per cent of healthy adults who get a shot.
Some infectious diseases experts have rallied to the vaccine's defence, arguing that 50 to 70 per cent protection is still sizable. But others see support for the existing vaccines as undermining efforts to push the pharmaceutical industry towards finding ways to make better flu vaccine — products that last longer and protect against more strains of the always-changing virus.
Gardam said that given the efficacy of the current vaccines he's not sure courts would side with hospitals or provinces that decided to require their health-care workers be vaccinated against influenza. And losing this type of fight could be used by the anti-vaccination movement, he warned.
Dr. Perry Kendall, British Columbia's chief medical officer of health, disagreed with Gardam's position. For Kendall, this issue comes down to ethics. Health-care workers have an ethical responsibility to take the steps available to them to reduce the chance they'll infect their patients with the flu, he said.
"I think everybody would agree that we'd like to have a better vaccine. I'm not convinced, however, that because the vaccine is less effective than we'd like, that it still doesn't offer benefits, particularly to vulnerable patients. The benefits are maybe less than we'd like to see, but they are still benefits," said Kendall.
British Columbia passed a controversial policy requiring health-care workers to get a flu shot or wear masks at work during flu season. But the provincial nurses' union protested and the province announced a compromise last fall, saying that while it wasn't rescinding the policy, for the time being it wouldn't penalize workers who didn't follow it.
Gardam noted Ontario lost a similar battle a number of years ago, backing down on a demand that paramedics and emergency response workers get vaccinated.
"I'm not anti-vaccine," he insisted. "I think there's a line you cross when you make something mandatory that you better damn well make sure what you're doing is really going to have an impact because you're taking away people's rights to choose one way or the other. And you're also setting yourself up for a battle."
McGeer said she understands the concern about doing away with choice. But she said in the U.S., where 20 per cent of health-care facilities now require health-care providers to get flu shots, there hasn't been a backlash.
Said McGeer: "The American experience with mandatory (flu vaccination) is that it is not a hill you die on. It's a hill that actually vanishes when you start climbing it."
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