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Volume 33, 12 Issues, 2023
  Short Communication     May 2023  

Mandatory Influenza Immunisation for Healthcare Workers

By Munazza Saleem1,2


  1. Faculty of Health Disciplines, Athabasca University, University Drive, Athabasca, Canada
  2. Liaquat University of Medical and Health Sciences, Jamshoro, Sindh, Pakistan
doi: 10.29271/jcpsp.2023.05.590

Healthcare workers (HCWs) are at increased risk of contracting and spreading influenza, especially in annual outbreaks. To achieve a high level of health, this matter can be potentially solved with the implementation of mandatory flu vaccination policies. Despite ample evidence of vaccine effectiveness in reducing sickness, hospital visits, and even deaths, there is resistance to mandatory immunization among HCWs. The purpose of this communication is to present the rationale as to why the influenza vaccine should be mandatory among HCWs and to extract its practical and scholarly significance. The article has been organised to highlight the advantages of immunisation for HCWs, recognise the consequences of non-immunization, and resolve the myths associated with the flu vaccine. Finally, the stance and recommendations of several health agencies around the world on mandating the influenza vaccine for HCWs have been incorporated, with relevant literature evidence consolidated to support the narratives.

Key Words: Influenza, Vaccination, Health policy, Healthcare workers' vaccine, Mandatory vaccine.

The influenza viruses are most prevalent during the fall and winter, but the victims of flu can be diagnosed year-round by HCWs.1 Influenza occurs all over the world and is ranked among the top ten leading causes of death. There are usually one billion cases of flu reported around the globe annually, resulting in 12,000 to 500,000 deaths.2 The consequences of influenza are usually underrated by the general population. From mild to moderate symptoms, influenza can be a significant health threat, specifically to vulnerable individuals, including children, the elderly, immunocompromised individuals, and pregnant women.3 An annual flu vaccine is identified as the best way to protect against influenza and alleviate its adverse consequences and potentially serious complications.1,2 Furthermore, inoculating HCW is considered an effective measure to reduce the transmission of illness in the community.3 Although the literature is abundant with substantial evidence to support this fact, immunising or mandating the vaccine for frontline HCWs has still been a matter of debate in recent years. This paper attempts to briefly address why HCWs should be prompted to accept influenza vaccination; moreover, it elaborates on how the adoption of a government-mandated vaccination policy for HCWs is a potential solution to this problem. 

The World Health Organisation (WHO) ranked HCWs on the highest priority list for the flu vaccine, considering them at risk.2 It is estimated that 20% of HCWs are sick annually due to the flu.1 HCWs have first-hand patient contact and can swiftly catch influenza disease from patients and coworkers who are sick with the flu, especially since they are at the highest risk when there is an outbreak within hospitals and long-term care facilities. The large body of evidence recommends that influenza vaccination reduces the risk of influenza illness by 40% to 60%.1 The vaccine prevents HCWs from becoming victims and acquiring the flu; moreover, it restricts secondary infections among HCWs' households.1 Besides that, it also reduces patient morbidity and mortality, which eventually improves patients' outcomes and enhances their quality of life.4 The negative repercussions associated with influenza can impose a visible economic burden on the community. Several studies indicate that influenza outbreaks can result in increased healthcare costs, reduced productivity, societal disturbance, and an increase in workplace absences that can cost billions of dollars each year.3,5

The reactions to the flu vaccine are mostly mild and transient, which should not be a rationale for avoiding the vaccine. The most common side effects of the influenza vaccine are redness and swelling at the site of injection, which usually disappear in a few days. Serious adverse effects like allergic reactions, Guillain-Barré syndrome (17/100,000), and Oculo-respiratory syndrome (2/100,000) are rare following immunisation.2 Thimerosal is an ethyl mercury- based preservative used in multi-dose vials to prevent germs, bacteria, and/or fungi from contaminating the vaccine. Thimerosal, concerning influenza vaccines that have been used safely in vaccines since the 1930s, has also been a topic of debate in recent years.1 The type of mercury linked to nervous system damage is methyl mercury, while thimerosal is an ethyl mercury compound.1 Flu vaccines, however, are also offered as single-dose, pre-filled syringes or in a nasal spray that does not contain thimerosal for those who are concerned about its side effects.1

As per the code of ethics for healthcare personnel, every patient has a right to receive safe, compassionate, competent, and ethical care.1,3 There are groups of people contraindicated from receiving the vaccination, including babies less than six months of age, people who have had an anaphylactic reaction to a prior dose of influenza vaccine, or individuals who are too old or immunocompromised and cannot acquire immunity following a vaccine.1,3 To protect them sufficiently, it is essential to have people around them immunised, particularly HCWs. It is the foremost duty of HCWs to promote health and prevent the patient from harm. Therefore, it can be implied that an unimmunised HCW who has direct contact with sick or vulnerable patients has a “failure to perform their duty of care.”4 Although the autonomy of the HCWs comes into conflict with the best interests of the patient in mandating the flu vaccine, the priority should be the patient first.4 Moreover, there is always an exception for those who have a medical contraindication or have a strong cultural or religious belief regarding influenza vaccination.3 It is generally believed that HCW vaccination is the foundation of flu prevention.1 The idea of seasonal influenza vaccination was first introduced to HCWs in 1984 by the Advisory Committee on Immunization Practices. Widespread support for influenza vaccination of healthcare workers exists among HCWs and patient caregivers. In a sample of HCPs in the United States, nearly 60% advocated that HCPs should be required to be vaccinated for seasonal influenza.6 According to a cross-sectional survey of parents and guardians of hospitalised children, 88% believed that HCP should be vaccinated, and 76% believed that vaccination should be required. Furthermore, the immunisation of HCWs against influenza improves patient outcomes.6 Recent studies suggest that increasing public trust, improving patient safety, and empowering the workforce are a few additional advantages of mandating immunisation in HCWs.3,4

Taking the lead, the Centre for Diseases Control (CDC) and the Government of Canada recommended that frontline HCWs receive seasonal and any pandemic flu vaccination.1 This has also been endorsed by the Infectious Diseases Society of America (IDSA), the Society for Healthcare Epidemiology of America (SHEA), and the American Academy of Pediatrics (AAP). Due to the claimed benefits of this mandatory influenza immunisation program, many provinces and states around the world have recently implemented vaccination or mask policies for their HCWs. Even though mandating the influenza vaccine at the workplace counts toward an extra cost to health care. However, considering absenteeism, the possible cause of spreading the disease further, and the necessary medical care for treating the illness of HCWs, suggest influenza vaccination program can be a cost-effective strategy.5

Considering the rationale associated with influenza vaccination among HCWs, it is apparent that the flu vaccine is an effective measure to provide high-quality patient care. It enhances patient safety, achieves a high-grade level of health, and limits the possible adverse repercussions of influenza in the community. Through legislation, specialised education, and frameworks, the concept of mandating influenza immunisation and the condition of service among HCWs appears to be promising in meeting the health care needs of any community. Therefore, it can be safely deduced that the policies for mandating flu immunisations for HCWs are essential in creating viable and sustainable health care to deliver the best level of health and maintain the overall well-being of people in the community.

There is no competing interest associated with this manuscript.

MS: Original idea. Substantial contributions to the conception and design of the work. Drafting the work and revising it critically for important intellectual content. Proofreading and editing. Final approval of the version to be published.


  1. Seasonal Influenza Vaccination Resources for Health Professionals. [Internet]. [Cited 2022 Oct.2]. Available from:
  2. How to implement seasonal influenza vaccination of health workers [Internet]. [Cited 2022 Oct.2]. Available from:
  3. Goktas O, Can FE, Yakar B, Ercan I, Akalin EH. Seasonal influenza vaccine awareness and factors affecting vaccination in Turkish Society. Pak J Med Sci 2022; 38 (4Part-II):893. doi: 10.12669/pjms.38.4.4915.
  4. Cortes-Penfield N. Mandatory influenza vaccination for health care workers as the new standard of care: A matter of patient safety and nonmaleficent practice. Am J Public Health 2014; 104(11):2060-5. doi: 10.2105/AJPH.2013. 301514. 
  5. Yang J, Jit M, Leung KS, Zheng YM, Feng LZ, Wang LP, et al. The economic burden of influenza-associated outpatient visits and hospitalizations in China: A retrospective survey. Infect Dis Poverty 2015; 4:44. doi: 10.1186/s40249-015- 0077-6.
  6. Maurer J, Harris KM, Black CL, Euler GL. Support for seasonal influenza vaccination requirements among US healthcare personnel. Infect Control Hosp Epidemiol 2012; 33(3):213-21. doi: 10.1086/664056.