Doctors Shouldn’t Get Fired for Skipping the Flu Shot

In healthcare, it's that time of year again. What begins as a slow trickle of email reminders from hospital administrators regarding mandatory flu vaccinations inevitably becomes a deluge. These messages provide locations and times for staff to enthusiastically line up and fulfill their annual commitment to patient care.

As the days turn to weeks and physicians such as myself become delinquent, the friendly reminders turn into threatening rebukes in large, bold font. Soon, the hospital's administrators compel action and we surrender our arms to nurses and their large vaccine-filled needles. All of this is done to achieve a bright sticker bearing the words "I got my flu shot for you" to display on our ID cards and reassure our patients that we're not ironic vectors of disease.

For Ahmed Khan, a cardiology fellow at the University of Maryland Medical Center, this process has been a yearly occurrence since his initial entry into medicine as a student. "While the sheer number of these reminders could be frustrating, I felt it was simply part of an institutional strategy to increase rates of vaccination," he says.

And the coercion has been effective. According to the CDC's 2014-15 data, more healthcare workers got the flu shot when their employers required it (85.8 percent) or recommended it (68.4 percent). Those left to their own volition pursued vaccination markedly less (43.4 percent).

For those who refuse due to ethical or scientific reservations, there are penalties. In addition to potentially being fired or losing income, work privileges are lost and physicians lose access to information systems, which prevents them from accessing patient records, conducting research, and billing for their medical services.

And let's face it, patients have also come to expect doctors to adhere to the same medical advice they dispense. The faintest cough or hint of congestion has elicited inquires about my vaccination status. Even in the absence of symptoms, some patients have sought to ensure that I hadn't somehow evaded the flu vaccine.

But the research that supports this mandatory flu vaccination dogma is flawed as doctors and other healthcare workers are not the definite transmitters of contagion that they've been suggested to be. To deny healthcare personnel their right to informed consent for a medical procedure with documented risks on the basis of such a fallacy is unconscionable—in a setting where evidence-based medicine should reign, we should have a choice.

Given the absence of hard and substantial evidence that not getting a flu shot could hurt the patients, there should not be penalty for healthcare staff who refuse to get the flu vaccination. It's a fundamental individual right to refuse unwanted medical treatment, especially one that has (in rare cases) been associated with causing infection, allergic reaction or Guillain-Barré Syndrome (GBS), which is an autoimmune disorder that can lead to paralysis.

A study published earlier this year concluded that the pursuit of compulsory flu vaccinations lacks "a solid empirical underpinning." It also found that "the impression that unvaccinated healthcare workers place their patients at great influenza peril is greatly exaggerated." It was a critical analysis of the four trials most frequently cited to buttress the case for mandatory vaccinations. Importantly, it noted that all the previous data has been collected from exclusively long-term care facilities (LTCFs) and nursing homes and thus may not have applicability to staff in acute care hospitals or other healthcare settings.

These previous trials also reported an outsized threat which appears highly implausible. A 2006 study from Britain concluded that for every eight healthcare workers vaccinated for influenza in LTCFs, one resident death could be prevented. If this is applied to America's 1.7 million workers in LTCFs, 212,500 flu deaths should be averted. If this is generalized to the country's 5.5 million hospital workers, 687,500 lives should be spared, which is more than the 675,000 that perished from the Spanish flu pandemic in 1918.

While this sounds great, deaths from the flu never ascend to such astronomical heights. According to CDC estimates, flu deaths of all ages range from 3,000 to 49,000 yearly. In 2014, 4,605 individuals died from the flu.

More realistically, according to the 2017 analysis, at least 6,000 to 32,000 hospital workers would need to be vaccinated in order to avert a single patient death. Importantly, mortality rates from the flu were in precipitous decline even prior to the call for mass immunization campaigns, decreasing from 30 to 40 cases per 100,000 people in the mid-1930s to less than five cases per 100,000 people from the 1950s onwards.

There are no promises with the flu vaccine. About 85 percent of flu-like illness is caused not by the flu but by any of approximately 200 viral and bacterial pathogens which are unscathed by the vaccine. The ability of the annual injection to prevent the flu also varies, with vaccine effectiveness fluctuating from 60 percent in 2010-2011 to 23 percent in 2014-2015.

Because of the lack of evidence for proven transmission, even groups like the Occupational Safety and Health Administration (OSHA) have voiced their opposition to compulsory vaccination of healthcare workers. They note that "there is insufficient evidence for the federal government to promote mandatory influenza vaccination programs that may result in employment termination."

Speaking to STAT News, Gaston De Serres, the lead author of the study, emphasized the need to keep vaccination voluntary and to remain cognizant of its limitations. "I take it myself. The reason why I do that is I continue to have the impression that it could work. But it's one thing to say: 'Okay, on a voluntary basis, you get the vaccine despite all its weaknesses,' and it's another thing to say, 'If you don't get it, you get fired.'"

In the end, this is not a case against the flu vaccine. Most doctors and healthcare workers, including myself, will continue to annually heed their hospital emails because of a perceived benefit despite the lack of data. When necessary, we'll also wear masks and gloves. But like our patients, we should be guaranteed the basic right to informed consent in regards to flu vaccination, which is clearly no panacea.

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