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]

the adjusted vaccine efficacy is in the 50% range most years

Do you have any unbiased research supporting your opinion?

Just a note on professionalism, it's not intellectually honest nor does it promote further discussion by taking out of context what a poster said when you are replying to the post.

[BostonFNP, APRN]

Do you have any unbiased research supporting your opinion?

Just a note on professionalism, it's not intellectually honest nor does it promote further discussion by taking out of context what a poster said when you are replying to the post.

I have lots of peer-reviewed, multinational studies. I would be happy to list a dozen. Will you list a dozen of your sources please.

[mrl3fnp]

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.

Wearing a mask is not a HIPAA violation. An employer requesting employee health records is not a HIPAA violation. An employer requiring an employee to divulge private healthcare information to the general public is a HIPAA violation. You are wrong.

[Horseshoe, BSN, RN]

Wearing a mask is not a HIPAA violation. An employer requesting employee health records is not a HIPAA violation. An employer requiring an employee to divulge private healthcare information to the general public is a HIPAA violation. You are wrong.

If the employee is the one divulging healthcare information, by definition there has been no HIPAA violation. The fact that the employee is doing this as a requirement of employment is irrelevant, as the employee is perfectly free to work elsewhere. If she agrees to the conditions (whether or not she likes them), SHE is agreeing to share her status.

[Wuzzie]

Wearing a mask is not a HIPAA violation. An employer requesting employee health records is not a HIPAA violation. An employer requiring an employee to divulge private healthcare information to the general public is a HIPAA violation. You are wrong.

Not to stir the pot but how exactly does the general public differentiate between a nurse wearing a mask because her lack of vaccination requires her to do so versus another who is masking because they have a cold vs one who masks in the presence of something malodorous? Given the multiple situations where a mask may be worn I fail to see how it could possibly be a HIPAA violation unless the hospital also brands the nurse in some fashion to indicate the purpose of the mask.

[mrl3fnp]

I have lots of peer-reviewed, multinational studies. I would be happy to list a dozen. Will you list a dozen of your sources please.

Most American studies showing the efficacy of the flu vaccination are weak, biased, and financially corrupted by influencing interests. In contrast, non-American studies showing the ineffectiveness and counterproductiveness of the flu vaccination and that it increases the risk of the transmission of influenza never get published in American Journals.....Why is that?

[mrl3fnp]

I am an advocate of everyone wearing a mask, flu shot or not.

[mrl3fnp]

Bottom line......it is passive aggressive harassment. Policies that require an employee to identify differently than their peers, especially when it doesn't improve healthcare outcomes for patients is creating a hostile work environment solely based on their beliefs or religious convictions. It's the equivalent of requiring certain employees to use a different bathroom or drinking fountain because of their color.

[BostonFNP, APRN]

Most American studies showing the efficacy of the flu vaccination are weak, biased, and financially corrupted by influencing interests. In contrast, non-American studies showing the ineffectiveness and counterproductiveness of the flu vaccination and that it increases the risk of the transmission of influenza never get published in American Journals.....Why is that?

I don't know why that is, you didn't cite any sources. If they are not getting published at all I would say the most obvious reason is that they lacked scientific vigor.

Cite some so we can evaluate.

[mrl3fnp]

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?

The source is your source.

[mrl3fnp]

I don't know why that is, you didn't cite any sources. If they are not getting published at all I would say the most obvious reason is that they lacked scientific vigor.

Cite some so we can evaluate.

How can we have a productive discussion if you continue to ignore my questions and deflect? I am still waiting for you to provide me with unbiased and uncorrupted evidence that shows the flu shot to be more efficacious than mask-wearing.

[NurseSpeedy, ADN, LPN, RN]

While I advocate getting the flu shot when able and have gotten one every year myself for the past seven seasons (whether mandated or not), I think the mask thing is a bit overkill, especially since the vaccine itself is only approximately 50% effective. In my 15 years in the field I have been diagnosed positive with influenza 4 times. Every single positive result was AFTER I had the vaccine. Only one of those times even had the possibility of being job related (no positive confirmed patient). Now, since I had the flu four times with the shot and zero (as far as I know) without it, I was more of a "pre-symptomatic" risk to my patients while being compliant with the flu vaccine than I was before I started getting it annually.