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

[Skippingtowork]

Not true! talk to a civil rights attorney. Many nurses have won the case against a mandate. The nurses I know of actually were fired, brought suit on the hospitals and won a great deal of money. We are not research subjects and neither are the patients, unless consent is willingly obtained. I have a compact, California, and Minnesota active license. My refusals and physician documentation is always honored! It is your right to refuse any medical intervention that you do not believe or consent to. There are many that are allergic to the vaccines and as previously stated enough paid out to these families that have been injured and lost loved ones. I will advocate for any pt or co worker that can not receive or will not consent. A close friend healthy of 22 who never took the vaccine died after she was mandated by the hospital to have the flu vaccine. That was one tragedy to many for her loved ones friends and myself to ever question another again!

But they can make you wear a mask! It is not a violation of your civil rights. Would you like a TB patient to start talking about their civil rights? Or what about the person with chicken pox who calls you up to "do lunch?"

The flu vaccine does not cause the flu. It is not a live vaccine. Ill feelings are caused by the body mounting a response. The first year I got the vaccine I felt ill for three weeks, along with my two co-workers, but never had the flu. I just don't understand the reference to sepsis. Where did the sepsis come from? What was the pathogen? Unfortunately, I have seen children die from the flu. It is heartbreaking. The vaccine will not protect you from all strains, but it's better than nothing.

[Meigsfla]

I didn't read the previous comments. After the legal case in Canada where nurses won a case against this it has me wondering about it here in the US. Basically Nurses in Canada faught the hospital claiming forgoing the flu shot and wearing a mask indicates to patients and staff that you did not receive the shot. This is a violation of privacy and or hippa and therefore against the law. Now the nurses can make their own decision and not have to wear a mask if the nurse decides not to get the shot. It's like asking a Nurse to wear a sticker indicating if they have hiv or hep c it's private information! I think if nurses banded together and got a lawyer there could be a case made here on this issue.

[Skippingtowork]

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.

Don't even go there. That's a deep and very dirty dive to the bottom. Do you think the people who experienced this would consider the two scenarios comparible?

[Feelgood RN]

So I've read many of these replies, but not all. I will admit to being a new nurse still. I cannot figure out where all this sepsis is coming from? Is it from the vaccine? Is it from getting the vaccination? Is it because people are getting the flu after receiving the flu shot and thinking it's not the flu?

Many of the examples I've read are like "my "healthy" young friend was fine then they got the vaccine and now they're dead after it was mandated." So the mandation caused the vaccine to give them sepsis? Or they got the flu after the vaccine and didn't think it was the flu so they didn't see a doctor? I mean, these people are nurses right, because they were mandated, yet somehow they got sepsis...from the flu...because they didn't know they had it? I don't get it.

I didn't refuse any of the vaccinations I had to receive for nursing school and I don't refuse the flu shot or TB testing. I'm in a profession where flu and TB and Hep are all hazards of the job and I want to protect myself. On the same hand these vaccinations help protect my patients THROUGH me and help increase the standard of care because I can be at work and not sick. Maybe the flu vaccine will work one year and not the next, so what. Not getting the flu shot is like not wearing a hard hat on a construction site because it makes you look stupid. Saying "I'm not wearing that hat because my friend Joe never wore one and the day he did a 2 ton block of cement was dropped on him and he died and it didn't protect him at all" is ridiculous. If your friend had not gotten the flu shot, wouldn't they have gotten sepsis anyway...you know because they would have gotten the flu? Saying "You can't make me wear that hat because It looks dumb and I don't wanna and that's my right" is legitimate, but if your job says...well you have to, and OSHA says...well you have to and you signed a form saying yes I'll work for you then well...tough luck. Wear a mask or find a job that doesn't require you to wear one without a flu shot.

Also apparently there are nurses that need education on the signs/symptoms of the flu because if they're getting to the point of sepsis and dying because they got the flu shot then they missed important class time somewhere.

[Skippingtowork]

So I've read many of these replies, but not all. I will admit to being a new nurse still. I cannot figure out where all this sepsis is coming from? Is it from the vaccine? Is it from getting the vaccination? Is it because people are getting the flu after receiving the flu shot and thinking it's not the flu?

Many of the examples I've read are like "my "healthy" young friend was fine then they got the vaccine and now they're dead after it was mandated." So the mandation caused the vaccine to give them sepsis? Or they got the flu after the vaccine and didn't think it was the flu so they didn't see a doctor? I mean, these people are nurses right, because they were mandated, yet somehow they got sepsis...from the flu...because they didn't know they had it? I don't get it.

I didn't refuse any of the vaccinations I had to receive for nursing school and I don't refuse the flu shot or TB testing. I'm in a profession where flu and TB and Hep are all hazards of the job and I want to protect myself. On the same hand these vaccinations help protect my patients THROUGH me and help increase the standard of care because I can be at work and not sick. Maybe the flu vaccine will work one year and not the next, so what. Not getting the flu shot is like not wearing a hard hat on a construction site because it makes you look stupid. Saying "I'm not wearing that hat because my friend Joe never wore one and the day he did a 2 ton block of cement was dropped on him and he died and it didn't protect him at all" is ridiculous. If your friend had not gotten the flu shot, wouldn't they have gotten sepsis anyway...you know because they would have gotten the flu? Saying "You can't make me wear that hat because It looks dumb and I don't wanna and that's my right" is legitimate, but if your job says...well you have to, and OSHA says...well you have to and you signed a form saying yes I'll work for you then well...tough luck. Wear a mask or find a job that doesn't require you to wear one without a flu shot.

Also apparently there are nurses that need education on the signs/symptoms of the flu because if they're getting to the point of sepsis and dying because they got the flu shot then they missed important class time somewhere.

Are you sure you're a new nurse. You are very articulate and thoughtful. You almost remind me of my hero - Judge Judy:)

[blondy2061h, MSN, 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.

HIPAA doesn't apply to employers. Contrary to popular belief HIPAA does not apply to all medical history. Only history you have with providers HIPAA applies to.

[choirgirl]

In England, we are 'encouraged' to have the flu vaccination, but no-one is forced, and no-one is forced to wear a mask. We wear masks, aprons and gloves on an individual case basis, ie; if the patient has a productive cough that they are not containing, (not using/unable to use tissues etc to contain the droplets, and then dispose of the tissues). Or, if there are more than one patient in a bay of 4 patients who contract flu, then we mask and glove as a matter of course, and close off that bay to prevent movement of patients, and minimise staff. The hospital I work at swabs patients for the flu virus as soon as symptoms occur, and once confirmed they are isolated to a room on their own and treated with Tamiflu. Many nurses and other health care professionals have not had the flu vaccine, particularly in view of the fact that, although the strain of flu most prevalent and most likely to hit is how the vaccine is developed, that doesn't stop you contracting any other viral strands that are out there. I believe personally that excellent infection control methods can be just as effective, and I would like to see some evidence to back this up. I would also like to point out that many of the patients treated in hospital for flu and flu related illness have had the flu vaccination in that 6 month prior to them getting symptoms. In 30 years of nursing, I have had the flu twice, and not had an injection.

[Chaya, ASN, RN]

Not true! talk to a civil rights attorney. Many nurses have won the case against a mandate. The nurses I know of actually were fired, brought suit on the hospitals and won a great deal of money. We are not research subjects and neither are the patients, unless consent is willingly obtained. I have a compact, California, and Minnesota active license. My refusals and physician documentation is always honored! It is your right to refuse any medical intervention that you do not believe or consent to. There are many that are allergic to the vaccines and as previously stated enough paid out to these families that have been injured and lost loved ones. I will advocate for any pt or co worker that can not receive or will not consent. A close friend healthy of 22 who never took the vaccine died after she was mandated by the hospital to have the flu vaccine. That was one tragedy to many for her loved ones friends and myself to ever question another again!

First, condolences on the loss of your friend.

I think it important to focus on actual evidence so far as possible for the sake of clarity. (How quickly these discussions become polarized beyond the point where any communication is possible).

What was listed as her diagnosis/ actual cause of death? Was there an allergic reaction specifically to the vaccine or were there other contributing conditions? Death in a healthy 22 year should be questioned! The hope would be to learn from this tragedy to prevent others. To do this we must gather as much information as we can and examine it objectively and from all angles.

If there is shown to be a clear link to the flu vaccine, is there a specific population group who should not take it, or is is truly risky for everyone? Statistically, do the mass benefits outweigh the risks?

If her death was directly related to receiving the dose of vaccine, what were the specific circumstances? Causality must be established and may not be the immediately obvious. Because if the cause of her death is not what we assume we are seeing, the actual killer remains at large to continue to cause illness and claim lives.

[aflahe00]

I never liked being forced into it I didn't feel like it was right but I did it. I don't have any reason to refuse it and it's not worth it to me. Unless you have an allergy or have had an adverse reaction in the past then just do it, it's what's best for both you and your patients.

[Feelgood RN]

I've been working for going on 9 months so I consider myself a new nurse still, but new does not mean young >

I have been blessed/cursed with the ability to see arguments of both sides and being able to judge with minimal bias. My wife hates it especially when she's having an argument with her family/friends, she thinks I should be an arbitrator if I leave nursing.

Anyway I appreciate the comment and hopefully mine worked with some people.

[canigraduate]

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.

Or that they are non-American articles not submitted to American journals.

The original question asking why non-American articles aren't published in American journals was self-answering, I thought.

[Cheyenne RN,BSHS]

I have to share a recent article on this topic. I have had an opinion that much of the vaccination-mask push is more hype than outright fact. I would appreciate any input from others. I included the link and a few sentences directly from the article.

Mandatory flu shot policies may be based on flawed research, study suggests

Mandatory flu shot policies may be based on flawed research, study suggests

Written by Heather Punke February 01, 2017 |

While the CDC urges everyone to get a flu shot, some hospitals take it a step further and mandate employees to get a flu shot or face possible termination. These mandatory flu shot policies are rooted in the belief the shot protects both workers and patients from the virus. However, a study published in PLOS says the policies may be built on faulty research. "The impression that unvaccinated [healthcare workers] place their patients at great influenza peril is exaggerated," according to the study.