Mandatory flu vaccination policies, including those that require unvaccinated workers wear masks, have become increasingly common at hospitals. Indeed, Central Oregon’s own hospitals implemented such a policy in December.
A new study suggests such policies offer far less protection to patients than has been touted in research.
Researchers in Canada, Australia and France analyzed four studies commonly cited to support such policies. They found each dramatically overestimated the number of patient deaths prevented, and concluded the research to date is inadequate to ethically support such policies.
Dr. Gaston De Serres, the lead author of the study, published in January in the journal PLOS ONE, is a medical epidemiologist with the Quebec Public Health Institute and an epidemiology professor at Laval University in Quebec City. He said in an interview that mandatory flu vaccination policies are based on ideology, not science.
“If you’re mandating immunization of people to protect someone else, the quality of scientific evidence you need is really high,” he said, “and at the present time, what our article says is we’re not with good evidence or moderate evidence that it works. We are with literally the most flimsy evidence that it may have an effect.”
St. Charles Health System’s flu mask policy took effect Dec. 1. It requires any workers who are not vaccinated to wear masks throughout its hospitals, clinics and offices. The union that represents nurses in Oregon filed a formal complaint over the policy to the National Labor Relations Board, claiming it violates their health privacy and should have been hashed out in collective bargaining.
‘It doesn’t work’
The studies, all of which took place in long-term care facilities, failed to account for outside factors that likely contributed to the patient illnesses and deaths deemed to be influenza-related, the PLOS ONE study found.
The authors determined, for example, that about 90 percent of the illnesses and deaths a prominent 2006 study said were prevented by health care worker vaccination could not be explained by the vaccinations.
That study, published in the in the British Medical Journal, concluded that one patient life is saved for every eight long-term care workers who get vaccinated, a statistic the study said also applies to hospitals.
Extrapolating that to the roughly 1.7 million people who work in long-term care facilities in the U.S. would result in 212,500 patient deaths prevented in those facilities every year, a number that well exceeds the total estimated number of annual flu deaths in the U.S., the PLOS ONE study found. An estimated 4,600 Americans died from the flu in 2014, according to the Centers for Disease Control and Prevention.
Further extrapolating that to the roughly 5.5 million hospital workers in the U.S. would mean an additional 687,500 patient deaths would be prevented annually through health care worker vaccinations, more than the deaths estimated to have occurred during the 1918 Spanish influenza pandemic.
“These numbers, they do not jibe,” De Serres said. “It doesn’t work.”
Striving for a better vaccine
Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy and a leading voice on infectious disease, said the four studies analyzed have long been a point of contention, but they’ve never been scrutinized at this level.
Osterholm, who was not involved in the PLOS ONE study, said the new research shows what little evidence is available to show whether health care worker vaccination reduces patient illnesses and deaths.
Without that, Osterholm said it’s difficult to justify mandatory masks for unvaccinated workers.
“We have an obligation upon ourselves to hold ourselves to a standard that our policies will be based on good science,” he said. “At this point, to me, I can still recommend getting vaccinated because it’s the best tool we have, but surely, the data do not support at this point that it makes a substantial difference in transmission to patients and other colleagues.”
That said, both Osterholm and De Serres agree individuals should be vaccinated — even though some years it’s less than 50 percent effective — they just don’t think there’s enough evidence to justify forcing people to do so.
“Because we have such an inadequate flu vaccine from an effectiveness standpoint, coming up with these mandatory and punitive policies really flies in the face of the science,” Osterholm said.
This all underscores something Osterholm has argued for years: We need a better flu vaccine. Public health agencies for years have breathlessly touted the vaccine as being highly effective, which has seemingly negated the need for new ones, according to a 2012 report on the subject Osterholm co-authored.
“Why would anybody spend billions of dollars to try to get new and better flu vaccines?” he said. “We, are in a sense, a victim of our own message.”
Conflicts of interest
Four of the PLOS ONE study’s authors provided expert testimony, paid or unpaid, for legal cases against mandatory vaccination policies, the study notes.
De Serres testified on behalf of the Ontario Nurses Association in its case against a mandatory flu vaccination policy.
Dr. Rebecca Sherer, St. Charles’ medical director of infection prevention and control, said that shows they have an inherent bias on the subject.
“That is an important point to realize about this article,” she said.
Sherer also took issue with the article’s emphasis on flu deaths prevented without emphasizing the associated hardships for those who survive. People who catch the flu from health care workers could have prolonged hospital stays, they may need additional medications and might see higher bills. Some research has even linked the flu to heart attacks.
“They’re kind of missing the point here,” she said. “The risk of dying from influenza if you’re a patient or a person is not significantly high. It’s less than 1 percent. But there is a huge associated morbidity to acquiring influenza.”
In issuing its policy, St. Charles pointed to the CDC’s goal of getting 90 percent of the country’s health care workers vaccinated for the flu by 2020. While there are no fines currently associated with the CDC’s vaccination goals, it’s “very likely” there will be in the future, said Lisa Goodman, a St. Charles spokeswoman.
During last year’s flu season, 77 percent of St. Charles’ employees were vaccinated for the flu. Since the new policy took effect, that’s jumped to 90 percent.
Dr. Ellie Sukerman, an assistant professor of infectious diseases at Oregon Health & Science University, emphasized that the PLOS ONE study doesn’t show zero benefit to health care worker vaccination, it just suggests more research should be done.
Personally, Sukerman said she thinks it’s a good patient safety measure.
“I think it’s a pretty common policy,” she said, “and certainly in line with, I think, the goal of all health care providers of doing no harm to patients.”
‘Embarrassing and belittling’
Similar policies at OHSU, Providence and PeaceHealth hospitals require unvaccinated employees wear masks in or near patient care areas. St. Charles takes that one step further in that it extends hospitalwide.
John Nangle, ONA’s bargaining unit chair for St. Charles Bend and an emergency department nurse at the hospital, said nurses would be open to more such “progressive” policies. Since Dec. 1, he said nurses have been threatened with discipline for not wearing masks.
“It’s been very embarrassing for some folks and extremely belittling to wear a mask,” he said. “Some people are unable to get the vaccination due to various health care reasons.”
NLRB documents show the board has determined in previous cases that flu vaccination policies are mandatory subjects of collective bargaining, as the ONA asserts in its complaint. However, the board has rejected several previous grievances from unions over policies similar to St. Charles’ because management rights clauses in their contracts effectively waived their rights to negotiate such policies. A representative with the NLRB declined to comment for this article.
ONA’s agreement with St. Charles Bend has a management rights clause, but it’s unclear whether it will hinder the group’s case. The final sentence of that clause reads, “The employer will bargain over any decisions regarding changes in the working conditions of employees.”
— Reporter: 541-383-0304,