Flu Shot or Mask?

[Nurse Beth]

Recently at the nurse's station at work, I was talking with Lisa. Lisa was wearing a surgical mask. To keep her job, she has to wear a mask until flu season is over because she declined to get a flu vaccination this year.

I asked how it felt to wear a mask for 12 hours. She said, "Well...it's kinda claustrophobic, but I'm getting used to it. What's really weird is people keep asking me to repeat myself.. It's like they can't hear me if they can't see my lips moving. And when I smile at patients, I have to try really hard to smile with my eyes."

Position Statements

The American Nurses Association (ANA), the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP), a CDC panel of medical and public health experts that advises on vaccine use, all align in recommending flu vaccines for healthcare workers with allowable exceptions for religious and/or medical reasons.

National Nurses United (NNU) opposes mandatory flu shots as fostering an atmosphere of distrust. Likewise, they oppose masking on the basis of stigmatizing the individual.

Masking: the Science

The influenza virus is transmitted by direct contact, large droplet spray (like a sneeze or cough, distance of about 3 feet), and by aerosolization (smaller particle aerosols).

The rationale for masking is that unvaccinated asymptomatic persons can shed the influenza virus for 24 hours before symptoms appear and up to 5 days after the onset of illness. However, minimal data regarding aerosol shedding and infectiousness of aerosol particulates exist.

The effectiveness of N95 respirator masks in preventing transmission of airborne viruses has been shown but the results of studies on the efficacy of surgical masks are mixed.

Many surgical masks are not certified as protective against respiratory infections and are loose fitting. There are no clear guidelines on how frequently surgical masks should be changed.

According to the CDC, there are no definitive studies to show that surgical masks worn by health-care workers reduce influenza transmission.

Legislation

State law, state Departments of Health, and county health officers have the authority to mandate flu shots and/or masks. For example, California state law (Health & Safety Code §1288.7 / Cal OSHA §5199) requires either flu vaccination or the signing of a declination statement for all acute care hospital workers and most health-care personnel, including clinic and office-based staff.

Additionally, many county health officers in California mandate that health care workers either receive an annual flu vaccine or wear a mask during the flu season.

Employee Rights

Many acute care facilities have adopted coercive "flu shot or mask" policies. In some cases, healthcare workers have been fired for refusing to be vaccinated.

Legally, most employers can require flu shots as a condition of employment as most employees work under an "at-will" work agreement.

However, the research used by employers to justify mandating flu vaccines for healthcare workers may be flawed and insufficient. Four such studies cited by employers were conducted in long-term care facilities and have not been proven to be generalizable to acute care settings.

Ethics

The ANA maintains vaccination is a public health concern and nurses should role model illness prevention through immunization. Nurses have a responsibility to not place their patients at risk.

Vaccination is for the greater good, but individual rights must also be considered. Sometimes the ethical principle of preventing harm is in direct conflict with the ethical principle of autonomy.

Protective or Punitive?

When I see a co-worker wearing a surgical mask I cringe a little. My core values of justice and fairness are triggered. Is this really about protecting patients based on robust evidence or is this about shaming the nurse?

I believe in doing what is best for the greatest good but I also believe in autonomy. It comes down to personal rights versus social responsibility. I am pro-vaccination but stop short of supporting "flu shot or mask" policies.

For me, it would take irrefutable evidence of patient benefit to justify overriding personal rights and I don't believe we have that.

The rush to disregard individual freedom over scanty evidence concerns me more than the thought of Lisa not wearing a surgical mask.

Do you believe nurses should be required to get mandatory flu shots or mask? Why or why not? I'd love to hear your view.

More thought-provoking articles by Nurse Beth:

Ageism in Nursing is Real

Why Do Nurses Quit?

References

Booth, C. M., Clayton, M., Crook, B., & Gawn, J. M. (2013). Effectiveness of surgical masks against influenza bioaerosols. Journal of Hospital Infection, 84(1), 22-26.

CDC. Interim Guidance for the Use of Masks to Control Influenza Transmission.2009. Accessed January 2017 Interim Guidance for the Use of Masks to Control Influenza Transmission

| Health Professionals | Seasonal Influenza (Flu)

Serres, G., Skowronski, D., Gardam, M., Lemieux, C., Yassi, A., Patrick, D., Krajden, M., Loeb, M., Colignon, P., Carrat, F. 2017. Influenza Vaccination of Healthcare Workers: Critical Analysis of the Evidence for Patient Benefit Underpinning Policies of Enforcement. PLOS.org. accessed January 2017 Influenza Vaccination of Healthcare Workers: Critical Analysis of the Evidence for Patient Benefit Underpinning Policies of Enforcement

[mrl3fnp]

Part of advocating for our patients is doing everything we can to protect them. They don't get the choice of being in our facilities, we do. If you're allergic, that's one thing, but if you're just trying to avoid the shot because it's uncomfortable, you are not upholding your end of the contact. I get sick for a couple days every time I get vaccinated. Still not the flu, which sent me to the ER the last time I got it, years ago.

Do you think it's moral to receive a flu shot knowing it only protects you against 3 or maybe 4 strains of influenza while leaving your patients at risk for the transmission of 100s if not 1000s of other strains of influenza from your direct contact with them? In contrast, if a nurse refuses the flu shot and wears a mask, evidence has shown that they are doing more to protect their patients from the transmission of influenza than you! So who is actually more moral and who is actually advocating more for their patients? Arguing that those who do not wish to inject themselves with potentially harmful substances are somehow not your moral equivalent has no value because it is not supported by evidence.

[mrl3fnp]

It is true that we are susceptible to influenza virus, however those that are immunized each year may be significantly less susceptible. Nothing is absolute.

Do you have any unbiased research supporting your opinion of less susceptibility? In contrast, there have been many unbiased studies in the last few years showing undeniably that mask wearing significantly reduces the risk of viral transmission. I'm not sure what your education level is, but statistical power and bias are factors that need to be considered when your patients are trusting you with their life.

[mrl3fnp]

Wow...THAT is some Biblical scholarship! Here I've been wasting my time reading Calvin.

You know what hazardous chemical I don't wish to get into my children's bodies? Tetorifice toxin.

An honest question I have, is would anyone be so anti-vax if we lived in a time or place where tetorifice or polio or Spanish Flu was a clear and present danger? And why aren't they a clear and present danger, in the industrialized world in 2017? Hmmm...

That's probably skating toward the edge of on-topic, but I had to say it.

If someone's conscience condemns their actions is it moral, or even more importantly a sin to carry out that action? To some with moral convictions, it is better to die than to condemn oneself through their own action. I would recommend more tolerance for those with religious objections.

[BostonFNP, APRN]

Do you think it's moral to receive a flu shot knowing it only protects you against 3 or maybe 4 strains of influenza while leaving your patients at risk for the transmission of 100s if not 1000s of other strains of influenza from your direct contact with them?

'

Excellent example of a perfect solution fallacy: if the vaccine isn't 100% effective then it is useless.

No, the vaccine can't protect against millions of possible subtype and antigen groups of influenza A or B nor does it protect at all against influenza C virus nor a host of other respiratory viruses that cause flu-like symptoms (and complications). However, influenza pandemics are nearly always caused by type A, and only three subtypes (H1, H2, H3) commonly cause disease in humans. Influenza vaccine effectiveness is considerably less than that of other vaccines, however, the adjusted vaccine efficacy is in the 50% range most years, which is significant when considering pandemic disease spread. The vaccine itself carries very little risk of serious adverse reaction.

[BostonFNP, APRN]

Do you have any unbiased research supporting your opinion of less susceptibility? In contrast, there have been many unbiased studies in the last few years showing undeniably that mask wearing significantly reduces the risk of viral transmission. I'm not sure what your education level is, but statistical power and bias are factors that need to be considered when your patients are trusting you with their life.

"15.6% of unvaccinated participants versus 9.9% of vaccinated participants developed ILI symptoms, whilst only 2.4% and 1.1%, respectively, developed laboratory-confirmed influenza"

Demicheli, V., Di Pietrantonj, C., Jefferson, T., Rivetti, A., & Rivetti, D. (2007). Vaccines for preventing influenza in healthy adults. The Cochrane Library.

[Libby1987]

Requiring a mask is a civil rights' violation? A personal freedom violation? People want to decline the flu vac as part of their personal freedoms, of course. But a mask? That's like dress code, I can't wear sleeveless tops exposing my armpits if I'm providing patient care when there's no evidence proving any negative impact. I could win in court and retain my civil right to wear or not wear what I want?

I call BS on any nurse winning a case against a requirement to wear a mask at work.

[mrl3fnp]

Nurses HIPAA rights are being violated......Not only must we divulge private healthcare information to our employer as a condition of employment but many nurses are also labeled by the color of their name tags as to whether they received a flu shot or not.

[Horseshoe, BSN, RN]

Nurses HIPAA rights are being violated......Not only must we divulge private healthcare information to our employer as a condition of employment but many nurses are also labeled by the color of their name tags as to whether they received a flu shot or not.

If you agree to wear a mask or colored name tag vs. quitting your job, YOU are the one revealing your status. No HIPAA violation whatsoever in that scenario.

[mrl3fnp]

"15.6% of unvaccinated participants versus 9.9% of vaccinated participants developed ILI symptoms, whilst only 2.4% and 1.1%, respectively, developed laboratory-confirmed influenza"

Demicheli, V., Di Pietrantonj, C., Jefferson, T., Rivetti, A., & Rivetti, D. (2007). Vaccines for preventing influenza in healthy adults. The Cochrane Library.

Thank you for making my point........Jefferson, T. owns shares in Glaxo SmithKline and received consultancy fees from Sanofi Synthelabo and Roche.

Jefferson, T. designed the update, wrote the protocol, applied inclusion criteria, extracted data, and wrote the final report.

[mrl3fnp]

If you agree to wear a mask or colored name tag vs. quitting your job, YOU are the one revealing your status. No HIPAA violation whatsoever in that scenario.

Have you been paying attention? I am an advocate for everyone wearing a mask, flu shot or not. What I am not an advocate for are nurses being marginalized by peers or policy that requires identification of private healthcare choices, especially when that identification doesn't lead to better healthcare outcomes for my patients.

[Horseshoe, BSN, RN]

Have you been paying attention? I am an advocate for everyone wearing a mask, flu shot or not. What I am not an advocate for are nurses being marginalized by peers or policy that requires identification of private healthcare choices, especially when that identification doesn't lead to better healthcare outcomes for my patients.

I really don't care what you advocate for. I am addressing your comment that requiring nurses who won't vaccinate to wear a mask or a certain name tag is a HIPAA violation. It is not.

[BostonFNP, APRN]

Thank you for making my point........Jefferson, T. owns shares in Glaxo SmithKline and received consultancy fees from Sanofi Synthelabo and Roche.

Jefferson, T. designed the update, wrote the protocol, applied inclusion criteria, extracted data, and wrote the final report.

You do realize that Tom Jefferson is one of the most vocal scientists AGAINST the influenza vaccine right?

Cite your source on Tom owning GSK stock. Also, doesn't GSK make Tamiflu? Would he not benefit from having more flu?