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

[BostonFNP, APRN]

(rigor)

Keep going - I'm enjoying this exchange. :)

Vigor. Rigor. Turgor. That's my 7th grade education.

[mrl3fnp]

More sources, less opinions. Can you cite the trial comparing mask use to influenza vaccine in preventing confirmed influenza?

bin‐Reza, F., Lopez Chavarrias, V., Nicoll, A., & Chamberland, M. E. (2012). The use of masks and respirators to prevent transmission of influenza: a systematic review of the scientific evidence. Influenza and other respiratory viruses, 6(4), 257-267.

Thank you once again for making my point about bias and financial corruption.......

The European Centre for Disease Prevention and Control (ECDC) is the European equivalent to America's CDC and those conducting the research work for the ECDC. Consequently, there is a strong potential for bias and financial corruption influencing the conclusions……….

With that being said, did you even read the literature? The researchers stated very specifically why they concluded that there is not a relationship between mask-wearing and the transmission of the influenza virus. Because of data limitations. So to post this research as if it proves a point isn't being intellectually honest……….

Underpowered study; no exposure data; compliance self-reported; no confirmatory laboratory testing. Hard to generalise findings given lack of control arm. Incomplete assessment of compliance and lack of detailed descriptions of exposures. Underpowered pilot study; some index cases wore masks in control and hand hygiene arms; difficulty in starting the intervention quickly may have underestimated its true effect. Compliance low: 45% (21%) of index cases (HH contacts) wore mask often/always. Control and hand hygiene arms ‘contaminated' as some index cases wore masks; delay in starting intervention quickly may have underestimated its true effect. Adherence low: 49% (26%) of index cases (HH contacts) wore mask often/always. Cannot distinguish relative contributions of hand hygiene and mask as they were combined. Underpowered to detect differences between 2 interventions; low level of self-reported adherence (21% of contacts in the surgical mask and respirator arms wore mask often/always). Interval between index case's symptom onset and start of intervention not stated; if delayed may have underestimated true effect of intervention.Hard to generalise given limited age group and specialised setting. Study underpowered to detect small reductions in ILI across arms and the relative contributions of hand hygiene and masks.Poor self-reported compliance with mask use: 22 (50%) of 44 HHs reporting ILI used masks within 48 hours of episode onset; average of 2 (range 0–9) masks/day/ILI episode used. Limited power to detect differences amongst 3 groups; some use of hand sanitiser in control group in response to media reports about methicillin-resistant Staphylococcus aureus.Monitored and self-reported compliance good (68–76%) in the 3 arms; however, monitoring by HCWs' supervisors not optimal method. Limited power to detect differences amongst 3 groups as observed attack rates low. Authors note 46% probability of incorrectly finding one significant difference. Despite stratified randomisation, mask group comprised of only level 3 (most sophisticated) hospitals. Hard to generalise beyond unique study population. Detailed data on potential exposures and information on community levels of influenza not provided.Possible recall bias as questionnaire survey conducted 4 months after outbreak; limited data on frequency and type of exposures to SARS patients.No serological testing of controls; reporting bias possible.Possible recall bias; exposures imprecisely quantified; no serological testing of controls.Possible reporting bias as interview conducted 7 months after outbreak; nature of exposures to SARS not specified; community exposures not assessed.No serological testing of controls; reporting bias possible as interviews conducted a month after cases identified; community exposures not assessed.Small sample size; no serological testing of the controls; limited recall of precise exposure data; no assessment of community/household exposures.Likely misclassification because no laboratory testing for most cases and no testing of controls; non-specific questions about exposures and potential protective measures.Likely misclassification because no laboratory testing for most cases and no testing of controls; lack of information about community exposures; recall and self-selection bias possible.Underpowered study; recall bias possible; community exposure not explored; no serological testing of controls.

[BostonFNP, APRN]

Thank you once again for making my point about bias and financial corruption.......

Your point hasn't been made; you have provided zero evidence perhaps aside for conspiracy theory.

The European Centre for Disease Prevention and Control (ECDC) is the European equivalent to America's CDC and those conducting the research work for the ECDC. Consequently, there is a strong potential for bias and financial corruption influencing the conclusions……….

So to post this research as if it proves a point isn't being intellectually honest……….

Again, cite your evidence that there is any financial corruption or bias by the ECDC or CDC in this peer-reviewed study.

I don't think many people will be surprised that you have once again posted a slew of opinions as if they are fact without citing a single source. You want to talk about intellectual honesty? Then why don't you cite your source on this statement you made a few posts prior that mask-wearing is "more efficacious compared to the flu shot".

[mrl3fnp]

More sources, less opinions. Can you cite the trial comparing mask use to influenza vaccine in preventing confirmed influenza?

Unbiased studies with no financial corruption................

Dionne, Brett, Culbreath, and Mercier (2016) concluded that once the rate of influenza-vaccinated healthcare workers reaches about 50%, there is no further reduction in the rate of patients with hospital-acquired influenza.” At a certain point, you don't have a real return on vaccination for reducing nosocomial flu, and we should look to things like hand-washing, better screening of patients, surgical masks, and better isolation precautions." During the five flu seasons from 2010 to 2015, there was a significant increase in the rate of vaccinated healthcare workers at the University of New Mexico Health Sciences Center.” However, the rate of hospital-acquired influenza - defined as infections diagnosed at least 48 hours after admission in patients who presented to the hospital without influenza-like symptoms in the previous 24 hours - plateaued once about half the healthcare personnel were vaccinated” (Dionne, Brett, Culbreath, & Mercier, 2016).

Dionne B, Brett M, Culbreath K, Mercier RC. (2016). Limited Effect of Healthcare Worker Influenza Vaccination Rates on the Incidence of Nosocomial Influenza Infections. Infection Control Hospital Epidemiology, 37(7). 840–844. Retrieved from DOI: Potential Ceiling Effect of Healthcare Worker Influenza Vaccination on the Incidence of Nosocomial Influenza Infection | Infection Control & Hospital Epidemiology | Cambridge Core

[mrl3fnp]

More sources, less opinions. Can you cite the trial comparing mask use to influenza vaccine in preventing confirmed influenza?

bin‐Reza, F., Lopez Chavarrias, V., Nicoll, A., & Chamberland, M. E. (2012). The use of masks and respirators to prevent transmission of influenza: a systematic review of the scientific evidence. Influenza and other respiratory viruses, 6(4), 257-267.

There much more data in the literature and many more conclusions in the discussion……………….

Policies of enforced HCW influenza vaccination are gaining popularity in North America, bolstered primarily by four cRCTs broadly interpreted to prove substantial patient benefit. Our analyses, however, show that these policies lack a solid empirical underpinning. Although RCTs represent the gold-standard study design for assessing interventions, unblinded cRCTs are at greater risk of bias and where their conclusions appear implausible caution is required in their interpretation, particularly if used to guide policies that abrogate individual rights. In that regard, each of the four cRCTs used to champion compulsory HCW influenza vaccination policies reports patient benefits that are mathematically impossible under any reasonable hypothesis of indirect vaccine effect. Whereas it is assumed on the basis of these studies that unvaccinated HCWs place their patients at great influenza peril, we show through detailed critique and numerical recalibration that these impressions are exaggerated” (De Serres et al., 2017)

Cluster RCTs are at greater risk of bias to explain findings than trials with individual randomization. As highlighted by the Cochrane group, the cRCTs showing patient benefit through increased HCW vaccination in LTCFs suffered multiple methodological issues including failure to conceal group allocation (i.e. blinding), poor performance in increasing HCW vaccine coverage, insufficient power to assess specific influenza outcomes and the possible influence of selection bias. None of the trials provided information on other co-interventions such as hand washing, quarantining, or requesting/requiring HCWs with ILI to stay home or mask. Education and other promotional efforts delivered as part of a program to increase voluntary vaccination within intervention sites may have simultaneously enhanced awareness of and compliance with these other more broadly protective practices, which may have then confounded or compounded the vaccine effects” (De Serres et al., 2017)

Supporters of compulsory policies have cited other studies, including an additional cRCT conducted by Riphagen-Dalhuisen et al in acute care facilities. The main objective of that trial, however, was to assess whether a multi-faceted intervention could increase HCW influenza vaccine coverage. Influenza illness in patients was only assessed as a secondary outcome, without standardized surveillance and based only upon retrospective assessment through computerized discharge notes. The authors reported a significant 50% reduction in the combined outcome of pneumonia and/or influenza among patients in the department of medicine despite just 8% difference in HCW vaccine coverage between the intervention and control groups. As per above, it is not possible to attribute this magnitude of reduction in patient outcome to such minimal change in HCW vaccine uptake, particularly since many pneumonias do not have influenza as a root cause and are not preventable by influenza vaccine, directly or indirectly” The US CDC review also considered four observational studies that have reported indirect patient benefit through HCW influenza vaccination. These observational studies are even more susceptible to bias: each reports percentage reductions (three of four in relation to ILI) that substantially exceed increments in vaccine coverage and are irreconcilable with the principle of dilution” (De Serres et al., 2017)

De Serres, G., Skowronski, D. M., Ward, B. J., Gardam, M., Lemieux, C., Yassi, A., . . . Carrat, F. (2017). Influenza Vaccination of Healthcare Workers: Critical Analysis of the Evidence for Patient Benefit Underpinning Policies of Enforcement. Public Library of Science, 12(1). doi:10.1371/journal.pone.0163586

[mrl3fnp]

More sources, less opinions. Can you cite the trial comparing mask use to influenza vaccine in preventing confirmed influenza?

bin‐Reza, F., Lopez Chavarrias, V., Nicoll, A., & Chamberland, M. E. (2012). The use of masks and respirators to prevent transmission of influenza: a systematic review of the scientific evidence. Influenza and other respiratory viruses, 6(4), 257-267.

A 2008 study published in the International Journal of Infectious Diseases concluded that when used correctly, masks are highly effective in preventing the spread of viral infections. Family members of children with flu-like illnesses who used the masks properly were 80 percent less likely to be diagnosed with the illness. Surprisingly, the difference between types of masks used was insignificant.

Another study published in the Annals of Internal Medicine reported similar results. Researchers looked at 400 people who had the flu. They found that family members reduced their risk of getting the flu by 70 percent when they washed their hands often and wore surgical masks.

Other studies found promising results outside of the household. For example, one such study was conducted by a team of researchers from the University of Michigan on more than 1,000 students living in residence halls. They assigned the student to groups: those who wore masks, those who wore masks and practiced hand hygiene, and those who did neither. The results showed that those who wore masks in residence halls and practiced good handwashing reduced their risk of flu-like illness by an astonishing 75 percent (Story & Cherney, 2015).

I have yet to see an unbiased and financially uncorrupt influenza vaccination study showing the effectiveness at reducing the risk of spreading influenza comparable to that of wearing a mask. If health care facilities were really concerned about patient health and reducing the spread of hospital-acquired influenza why do they not implement a mandatory mask wearing policy for everyone? Especially when the flu vaccination is so controversial and so many health care workers have legitimate objections.

[mrl3fnp]

More sources, less opinions. Can you cite the trial comparing mask use to influenza vaccine in preventing confirmed influenza?

bin‐Reza, F., Lopez Chavarrias, V., Nicoll, A., & Chamberland, M. E. (2012). The use of masks and respirators to prevent transmission of influenza: a systematic review of the scientific evidence. Influenza and other respiratory viruses, 6(4), 257-267.

These are the biased, financially corrupt, exaggerated, and mathematically impossible studies the CDC uses to influence hospitals to implement policies that mandate forced influenza vaccinations on health care workers at the risk of getting fired if they do not comply.

A 2014 study* showed that flu vaccine reduced children's risk of flu-related pediatric intensive care unit (PICU) admission by 74% during flu seasons from 2010-2012.

Financial support. This work was supported by funding from the US Centers for Disease Control and Prevention to Abt Associates, Inc, Cambridge, MA (contract 200-2010-F33396).

Potential conflicts of interest. J. F. has received travel support from Sanofi for an unrelated project.

Another study published in the summer of 2016 showed that people 50 years and older who got a flu vaccine reduced their risk of getting hospitalized from flu by 57%.

Financial support. This work was supported by the CDC.

Potential conflicts of interest. W. S. reports receiving fees for serving on a data safety monitoring board from Merck and Pfizer and consulting fees from Novavax and Genentech.

Flu vaccination is an important preventive tool for people with chronic health conditions. Vaccination was associated with lower rates of some cardiac events among people with heart disease, especially among those who had a cardiac event in the past year.

Collaborator. Solvay Pharmaceuticals, which was sold to Abbott Laboratories in 2009 and is a large manufacturer of the flu vaccine.

Flu vaccination also has been shown to be associated with reduced hospitalizations among people with diabetes (79%) and chronic lung disease (52%)

Date. Evidence-based practice should not rely on out-of-date data from 1997. Do you have any up-to-date studies???

Vaccination helps protect women during and after pregnancy. Getting vaccinated can also protect a baby after birth from flu. (Mom passes antibodies onto the developing baby during her pregnancy.) o A study that looked at flu vaccine effectiveness in pregnant women found that vaccination reduced the risk of flu associated acute respiratory infection by about one half

Financial support. This work was supported by the CDC (contract 200-2010-F-33132 to Abt Associates Inc).

Another study found that babies of women who got a flu vaccine during their pregnancy were about one-third less likely to get sick with flu than babies of unvaccinated women. This protective benefit was observed for up to four months after birth.

Financial support. Bill & Melinda Gates Foundation. (BMGF provides hundreds of millions of dollars each year to vaccines industries, GMO technologies, and sterilization technologies. BMGF is also a huge global depopulation advocate who is currently being sued by the Indian Government for vaccine-related fraud and the killing and injuring of 100s of girls between the ages of 9-15 during HPV trials).

[BostonFNP, APRN]

De Serres, G., Skowronski, D. M., Ward, B. J., Gardam, M., Lemieux, C., Yassi, A., . . . Carrat, F. (2017). Influenza Vaccination of Healthcare Workers: Critical Analysis of the Evidence for Patient Benefit Underpinning Policies of Enforcement. Public Library of Science, 12(1). doi:10.1371/journal.pone.0163586

This is an interesting critical review of a small portion of extant RCT data. From a quick read, I think some concerns raised are valid ones. I am not sure I can fully back the authors assumption that just because clinical values are greater than mathematically predicted values that means the clinical values are the result of bias in a non-blinded study design; that being said I am not an epidemiologist by training so I really can comment on the validity of the authors prediction calculations and the assumptions made to calculate them. They superficially seem reasonable, but again (at least for now) clinical data for me trumps calculated-predicted data.

[BostonFNP, APRN]

These are the biased, financially corrupt, exaggerated, and mathematically impossible studies the CDC uses to influence hospitals to implement policies that mandate forced influenza vaccinations on health care workers at the risk of getting fired if they do not comply.

Again, disclosed information about one or more authors does not invalidate a study. In example, the study you just cited was funded in part by the Ontario Nurses Association, which strongly opposes mandatory vaccination of nurses and was in a concurrent legal battle regarding it.

[BostonFNP, APRN]

I have yet to see an unbiased and financially uncorrupt influenza vaccination study showing the effectiveness at reducing the risk of spreading influenza comparable to that of wearing a mask. If health care facilities were really concerned about patient health and reducing the spread of hospital-acquired influenza why do they not implement a mandatory mask wearing policy for everyone? Especially when the flu vaccination is so controversial and so many health care workers have legitimate objections.

You haven't seen a "unbiased and financially uncurrupt" influenza vaccination study because you chose to call every study that is at odds with your point of view both of those things. Ironically, while calling the extant data biased, you so excellently demonstrate the confirmation bias that is ripe through the pseudoscience movement. Your arguments use the same logical fallacies that we see all the time from anti-vaxxers, including this ad hominem about author disclosures (thankfully the term "shill" has yet to be played). Tell us, do you support other vaccines?

I don't inherently disagree with you that if a hospital system truly wanted to prevent disease spread there are potentially better/boarder ways to accomplish that, and I do think there are other factors at play. Truth be told I think that the influenza vaccine has the least amount of supporting data when compared to other vaccines.

[BostonFNP, APRN]

Dionne B, Brett M, Culbreath K, Mercier RC. (2016). Limited Effect of Healthcare Worker Influenza Vaccination Rates on the Incidence of Nosocomial Influenza Infections. Infection Control Hospital Epidemiology, 37(7). 840–844. Retrieved from DOI: Potential Ceiling Effect of Healthcare Worker Influenza Vaccination on the Incidence of Nosocomial Influenza Infection | Infection Control & Hospital Epidemiology | Cambridge Core

I don't disagree with this study, which showed increasing influenza vaccination rates initially decreased influenza rates by nearly 50% prior to plateauing and maintaining the reduced rate. I think we all understand there is a ceiling that is less than 100%.

What this is not is a citation to a study showing mask use superior to influenza vaccine in the reduction of lab-confirmed influenza virus.

[Horseshoe, BSN, RN]

You haven't seen a "unbiased and financially uncurrupt" influenza vaccination study because you chose to call every study that is at odds with your point of view both of those things

I do understand the frustration with the efficacy of the influenza vaccine. Some years it has really missed the mark. I fully admit to having blown it off a few times here and there (I've never been required to get the vaccine by any healthcare employer). But I must agree with this part of your post.