Mandatory vaccination
=====================

* Keith F. Woeltje
* Hilary M. Babcock

We read with interest the *CMAJ* commentary by Gardam and Lemieux.1 Although we agree that a better influenza vaccine is needed, we disagree that this precludes maximizing the use of the current vaccine.

As the authors noted, a recent meta-analysis found vaccination of health care workers was associated with significant reductions in nonspecific adverse patient outcomes.2 They also noted that determining which deaths are attributable to influenza is difficult. Given this, nonspecific measures such as influenza-like illness and all-cause mortality are valid measures that may be less likely to miss indirect associations between influenza and mortality.

Vaccine efficacy is higher in healthy health care workers than in frail patients. A 55%–70% efficacy rate is far better than the 0% efficacy of not being vaccinated. Additionally, quoted efficacy rates are often misinterpreted. If 100 health care workers are vaccinated, 55 to 70 of them will be protected. With only half vaccinated, 27 to 35 will be protected, which leaves 65 to 73 vulnerable to infection and potentially spreading influenza to their patients. Which health care worker would you prefer provide care to your loved one?

In 2008, we at BJC HealthCare, in St. Louis, Missouri, started requiring annual influenza vaccination as a condition of employment.3 The decision was based on evidence that vaccination of health care workers could protect patients, and that despite substantial efforts made over more than a decade, more than a quarter of our health care workers were not vaccinated.4 For the past 5 years, our vaccination rates have remained at about 98%.

We are confident that in the future there will be better efficacy of cleaning products for *Clostridium difficile*, better gloves to protect patients and health care workers during surgery, and more rapidly effective antibiotics to prevent postoperative infections. While anticipating those advancements, we should not stop thoroughly cleaning patients’ rooms, using gloves during surgical procedures, and administering perioperative antibiotics in a timely manner.

While waiting for better tools, we should use all tools currently available to protect our patients now.

## References

1.  Gardam M, Lemieux C. Mandatory influenza vaccination? First we need a better vaccine. CMAJ 2013; 185:639–40.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxODUvOC82MzkiO3M6NDoiYXRvbSI7czoyMzoiL2NtYWovMTg1LzExLzk4My4yLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  Thomas RE, Jefferson T, Lasserson TJ. Influenza vaccination for healthcare workers who work with the elderly. Cochrane Database Syst Rev 2010; (2):CD005187.
    
    

3.  Babcock HM, Gemeinhart N, Jones M, et al. Mandatory influenza vaccination of health care workers: translating policy to practice. Clin Infect Dis 2010; 50:459–64.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiY2lkIjtzOjU6InJlc2lkIjtzOjg6IjUwLzQvNDU5IjtzOjQ6ImF0b20iO3M6MjM6Ii9jbWFqLzE4NS8xMS85ODMuMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

4.  Ajenjo MC, Woeltje KF, Babcock HM, et al. Influenza vaccination among healthcare workers: ten-year experience of a large healthcare organization. Infect Control Hosp Epidemiol 2010;31:233–40.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1086/650449&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=20055666&link_type=MED&atom=%2Fcmaj%2F185%2F11%2F983.2.atom)