Source: http://www.cmaj.ca/node/33625.full.print
Timestamp: 2019-04-26 00:25:25+00:00

Document:
Although much has been written about the evidence that the vaccination of health care workers against influenza improves patient outcomes3,4,7 and about the ethics of mandating vaccination,9,10 there is much less published information on aspects of implementation of such policies.
We provide a brief review of the literature regarding the impact of such policies on the vaccination rates among health care workers and their attitudes toward mandated influenza vaccination, and we review key Canadian legal cases.
Policies requiring vaccination against influenza as a condition of service were first introduced in Ontario long-term care facilities in 1998: unvaccinated employees were required to take antiviral prophylaxis or remain off work during influenza outbreaks in their facilities (“may not work during facility outbreak” policies). Such policies were extended to acute care hospitals in Ontario in 2000 and have since been adopted by health care facilities in other jurisdictions across Canada.
More recently, an increasing number of acute care hospitals in the United States have implemented policies requiring influenza vaccination as a condition of service. Generally, these policies either require vaccination as a condition of employment (vaccination-required policies) or offer workers the choice of either being vaccinated or wearing a mask during periods of influenza activity (vaccinate-or-mask policies). Such policies typically include students, volunteers and contractors as well as employees.
In Canada, as of May 2014, at least one nursing home has a vaccination-required policy. All health authorities in British Columbia and one in New Brunswick and 13 hospitals in Ontario have recently implemented vaccinate-or-mask policies.
Table 1 summarizes the available data about the different types of condition-of-service policies and the associated vaccination rates among health care workers.
Although there may be growing support for condition-of-service policies among health care workers, this does not make such policies legal. In Canada, policies requiring influenza vaccination as a condition of service must comply with employment law, human rights codes and the Canadian Charter of Rights and Freedoms (Table 2).
To comply with employment law, a policy that applies to unionized employees must be consistent with the collective agreements between employers and labour unions. Policies must be a reasonable exercise of management rights, which, among other things, requires the policy to be connected to the employer’s legitimate business interests. In this case, the relevant business interest lies in protecting patient health and safety.
Most cases considering the lawfulness of condition-of-service policies for influenza vaccination are grievances by unionized employees arguing that these policies violate the collective agreement because they violate the employee’s bodily integrity, autonomy and privacy. In contrast, health care employers have argued that these policies are substantially connected to their interest in protecting patients from a real and significant safety risk44,51 and that they provide a “choice with consequences”: an employee can choose not to be vaccinated at the risk of being off work (either temporarily or permanently) or being required to wear a mask. The arbitrators who have considered these grievances have generally taken a balancing of interests approach,44 weighing the individual rights of employees against the consequences for patients.
Condition-of-service policies must also comply with provincial human rights codes, which prohibit discrimination in employment based on disability or creed (among other grounds). Canadian courts have endorsed a multidimensional definition of “disability,” which may be real or perceived and which emphasizes human dignity, respect and the right to equality.52 Although there has been no case to date, a court might conclude that a condition-of-service vaccination policy must exempt individuals who have a medical contraindication to influenza vaccination.
With respect to “creed,” this is defined in Ontario as “a set of sincerely held religious beliefs or practices which need not be based on the edicts of an established church or particular denomination.”53 The Human Rights Tribunal of Ontario, which enforces The Ontario Human Rights Code, recently considered a case in which a paramedic argued that his employer discriminated against him by refusing to schedule him until he was vaccinated.50 The tribunal concluded that the employee’s refusal to receive the influenza vaccination was based not on creed but rather on a general objection to immunization. Although the applicant in that case did not satisfy the legal standard, it is likely that condition-of-service vaccination policies must permit exemptions that accommodate religious beliefs and practices.
In cases to date, it has been argued that two sections of the charter may be violated by condition-of-service vaccination policies: the right to liberty and security of the person (section 7), and the right to freedom of expression (section 2b). The right to security of the person has been interpreted by courts as protecting an individual’s physical integrity and a person’s right to make choices concerning his or her own body.56,57 The right to liberty, which has been considered less frequently in the health care context, has been interpreted as including the power to make personal and autonomous decisions with respect to one’s health care.58 The right to freedom of expression has been interpreted to include the right “to say nothing or not to say certain things.”59 These individual rights are not unlimited. The rights to liberty and security of the person can be breached if to do so is consistent with the “principles of fundamental justice.” Both of these rights and the right to freedom of expression may also be breached where it can be shown that the breach is reasonable and justified in accordance with section 1 of the charter.
Vaccinate-or-mask policies for influenza vaccination in health care organizations result in substantial increases in the vaccination rates among health care workers, are supported by most health care workers and, based on decisions to date, are likely to be found to be in compliance with Canadian law. Although vaccination-required policies have been upheld by arbitrators, employers who opt for more intrusive policies should carefully consider whether the details of such a policy maximize patient safety while impairing the charter rights of health care workers as little as possible. Physicians and employers should work together to find the best means to improve vaccination rates and protect both patients and providers from influenza.
Most North American health care workers who have responded to recent surveys are in favour of condition-of-service influenza vaccination policies.
In most Canadian legal cases, arbitrators have weighed the individual rights of employees against the consequences of nonimmunization on patients and have decided in favour of patient safety.
To comply with the Canadian Charter of Rights and Freedoms, employers will need to carefully consider the details of any condition-of-service policy.
Competing interests: Allison McGeer has received funding from Sanofi-Pasteur, Novartis and GlaxoSmithKline for influenza vaccine–related research activities. No other competing interests were declared.
Contributions: Allison McGeer and Vanessa Gruben conceived the idea for this commentary. Reed Siemieniuk conducted the literature reviews. All authors contributed to the drafting and revising of the manuscript, and approved the final version submitted for publication.
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