With flu season coming in like a lion, many healthcare organizations and some states have taken the controversial step of making the flu vaccine mandatory for healthcare employees. Back in October, Rhode Island became the first state in the nation to require influenza vaccination for all healthcare workers, including doctors, nurses, hospital employees and even temporary workers and volunteers working in hospitals, nursing homes and other healthcare facilities.

Workers who refuse to be immunized or who cannot receive the vaccine for documented medical reasons must wear a surgical mask for each patient contact during any “period when flu is widespread,” as declared by the state health director.

Other states are following suit, including Colorado and Ohio. Many individual hospitals are now making seasonal flu vaccination a condition of employment, leading to disciplinary action or termination for noncompliance. Some unvaccinated employees have even been required to take leaves of absence during the flu season, which generally runs from October through May and often peaks in February.

The Controversy

These new requirements have drawn mixed reactions from the various unions, associations and professional organizations representing healthcare workers. Some organizations have come out in favor of compulsory flu shots, including the American Medical Association and the American Nurses Association, which supports mandates if they are adopted at the state level, affect all hospitals and allow for exceptions on medical or religious grounds.

A list of these organizations, as well as a state-by-state listing of healthcare organizations’ individual flu vaccine policies, can be found on the Immunization Action Coalition’s website,

However, not all professional organizations unequivocally support mandatory vaccination or requiring unvaccinated employees to wear facemasks. Among those raising objections are the American Federation of Labor and Congress of Industrial Organizations (AFL-CIO); the American Federation of Teachers; the American Federation of State, County and Municipal Employees; the Association of American Physicians and Surgeons; and the National Nurses United, to name a few.

The National Vaccine Information Center, a vaccine watchdog group, has created a list of the numerous organizations that take exception to the mandates. The list can be found on the NVIC website at

The Scarlet Letter

As you might expect, some of the strongest opposition to mandatory vaccination has come from the nurses and employees who have been terminated for noncompliance.

One recent termination was that of a board-certified holistic nurse in Missouri. According to media reports and interviews with the nurse herself, she received an exemption on religious grounds, after which the hospital (per its policy) required that she wear a facemask when in direct contact with patients — which she frequently was, since she worked as an admission nurse.

The nurse complained that the mask made it difficult to perform her assigned duties and often required her to explain to patients that she was not contagious. She eventually informed her superiors that she would no longer wear a facemask, arguing that doing so compelled her to share private information beyond what was necessary to provide patient care; she compared it to being forced to wear a scarlet letter. Hospital officials responded by terminating her for contravening hospital policy.

That nurse is not alone in claiming that hospital policies requiring facemasks for unvaccinated personnel are punitive. Eight nurses in Indiana who were fired on similar grounds also claim that such policies are coercive and castigatory.

Opposing Sides

Bring up the subject of mandatory vaccination and you’re likely to encounter people with strong opinions on both sides, each with their own set of facts, arguments and dogma. Ironically, in this debate, both supporters and opponents cite many of the exact same statistics: that the efficacy of the flu vaccine is only around 62 percent and facemasks are only 60 to 80 percent effective against the flu because most masks don’t make a complete seal over the face.

It is true that with viruses like influenza, which mutate constantly, vaccination does not provide long-term protection and is effective only against certain strains. Each year’s flu vaccine is designed to counter whichever strain the experts predict will be the most prevalent during flu season. Add to that the fact that this year’s influenza has a nasty habit of surviving for extended periods of time outside the body and one could reasonably argue that measures like aggressive hand-washing and keeping surfaces sanitized are as effective against the flu as vaccination or facemasks.

However, just because vaccination is not 100 percent effective doesn’t mean that it is not worthwhile. I grew up in an era when polio, diphtheria and other nasty bugs killed or maimed entire generations. I can still recall my relatives’ stories of the 1918 flu pandemic, which devastated families, towns and nations. While living in San Antonio, Texas, in the ‘60s, I cared for far too many children who were dying because they had not been vaccinated for diphtheria or had not received the required booster shots. On one occasion in the ‘70s, my children’s schools were nearly emptied by a flu that spread throughout the South following an unseasonable cold spell. As a military family, we accepted our shots without question, particularly since we never knew where our next assignment might be.

The Rules of the Game

I have kept abreast of all the arguments on mandatory vaccination and I fall strongly on the pro-vaccination side. Health emergencies like the one recently declared in Boston show us just how devastating a flu epidemic can be. Since someone with influenza may be contagious before presenting symptoms (and for up to a week afterwards), vaccinating healthcare workers only makes sense.

As a nurse, if a hospital has a clearly delineated, hospital-wide policy mandating vaccination for employees, I see no reason to object so long as that policy is presented at the time of employment (or in a timely fashion) and includes a reasonable opt-out provision.

Wearing a facemask during flu season as an alternative does not seem overly onerous. As nurses, we are expected to take many special precautions to protect our patients, their families and their visitors: We constantly wash our hands, we glove before and between patient contacts, we give up our acrylic nails and so on. Do we object? Of course not. The vaccination requirement is no different.

Even Lewis Maltby, president of the National Workrights Institute (a spin-off of the American Civil Liberties Union), admits that patient health must take precedence over the rights of healthcare workers.

Of course, that doesn’t mean that nurses can’t or shouldn’t take an active role in advocating for reasonable alternatives. Mandates like these are based on the best information available at the time. As new studies are released, it’s possible that the current rules will be modified or even rescinded. Input from nurses could help to shape future policies.

As the vaccine debate continues, the best course of action for nurses is to make sure that you’re well aware of your workplace’s policies, including any alternative measures your employer may demand if you opt out.