Flu Shot or Mask?

Many healthcare facilities are requiring nurses to either get an influenza vaccination or wear a mask for the entirety of flu season. What do you think about this policy? Nurses General Nursing Article

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

Specializes in Adult Internal Medicine.
I couldn't find anything on a 100% crew Boston, but I was able to find a CDC article that had a crew on a small naval ship and 99% compliance which I think they may have been talking about. It's in my last post.

Yeah and that one showed that 25 of 102 crew members sought care for ILI of which only 18 were LCIV in the setting of 99% vaccination rate (and only 17/ of the 18 were vaccinated). If you consider a VE of about 60% this seems like the vaccine was fairly effective in preventing illness in the majority of the crew. The strain appeared to be a good match that season, so it is interesting that 17 vaccinated people got LCIV, however they were all vaccinated via either intradermal or mist, not IM.

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.

We have access to international journals. When you do research, it's all available. If the journal is reputable, it's available to any and everyone.

I am on page 8 of the comments. I have not yet seen anyone address the possibility of masking the patients. If, in fact, the true goal is to protect the patients, why wouldn't you mask them? It seems silly, out of the box, but think about it. I am not making light of this hot issue, but simply putting another thought out there.

I am on page 8 of the comments. I have not yet seen anyone address the possibility of masking the patients. If, in fact, the true goal is to protect the patients, why wouldn't you mask them? It seems silly, out of the box, but think about it. I am not making light of this hot issue, but simply putting another thought out there.

Look at how indignant people get over being "forced" to wear a mask for employment. How do you imagine a sick patient would feel at such a request? If we take out of the mix of patients those who wear O2, those who have NG tubes or other issue affecting their face, I still have trouble picturing the average patient who is sick enough to be in the hospital putting up with being masked so their nursing staff doesn't have to!

First, patients are not ONLY in the hospital setting. Second, there are a great number of patients in the hospital NOT on O2, NG, bipap etc that would be able to use a mask. I don't mean so the nurses don't have to. I mean, if the real issue is keeping the patient from getting the flu, and the mask decreases the spread, why wouldn't you do EVERYTHING to protect them? As far as how a sick patient would feel...how do you think a sick patient feels getting a nosocomial infection? I know it's far fetched and not ever going to happen. My comment is in response to the point of visitors not being screened and not required to wear masks.

First, patients are not ONLY in the hospital setting. Second, there are a great number of patients in the hospital NOT on O2, NG, bipap etc that would be able to use a mask. I don't mean so the nurses don't have to. I mean, if the real issue is keeping the patient from getting the flu, and the mask decreases the spread, why wouldn't you do EVERYTHING to protect them? As far as how a sick patient would feel...how do you think a sick patient feels getting a nosocomial infection? I know it's far fetched and not ever going to happen. My comment is in response to the point of visitors not being screened and not required to wear masks.

Ok, I see your point. If I'm being asked what I think about that as a viable option to help prevent transmission of infection, I'd have to answer that I don't think it's a realistic one. Yes, it's out of the box, but my personal opinion is that there would be a mega-resistance to that suggestion. Let's face it, people have the option now of wearing a mask whenever they like (talking about inpatients, ones that have those mask dispensing boxes on the wall of their rooms). And they don't.

You're right, not all patients are located in hospitals. If you mean patients who walk into outpatient settings I still have a hard time picturing them being ok with putting on a mask for the duration of their visit. Some may even be insulted, as in "I came here for an infection of my toe and you want me to wear a mask like some kind of leper??"

I suppose if everything were perfect and everyone always kept the public's best interests in mind we wouldn't even have to have discussions or debates about whether or not to vaccinate and whether or not to wear a mask. We all just what we think we need to do to survive each season!

I was thinking the same thing!

My mom works in a NICU and rarely floats outside the unit because she is part of the transport team. She is also allergic--like anaphylactic allergic--to the flu shot. She has to wear a mask every shift for the extent of flu season, even if there's no current outbreak in our area. The rationale is that she could have been exposed while out in the public and could still bring it into the NICU and infect the babies. The flip side, however, is that none of the adult visitors are required to wear a mask unless they have recently been sick or been around someone who's been sick.

One of the managers said my mom "contaminated [a] baby" when she forgot to put her mask on once, despite the fact she was asymptomatic and had not been around anyone who was. So, the random person from who-knows-where that claims to not be sick is okay to be around the babies without a mask, but a nurse who only works in the NICU is suddenly Typhoid Mary because she can't get a flu shot?

I got a flu shot back in the mid 90's, when they first came out. I had an extremely severe reaction that landed me in the emergency room the same evening I received the shot. They kept telling me that it was impossible for the reaction to have been from the flu shot, which, I know, was totally untrue. I did not ever have a flu shot after that, and when I told my doctor or employer why I decline the flu shot, I would hear (repeatedly) that it is impossible to get a reaction from the flu shot. I KNOW IT IS POSSIBLE TO HAVE A REACTION FROM THE FLU SHOT, BECAUSE IT HAPPENED TO ME!! I never could figure out why I reacted to that shot, until many years later...........

I started wearing contact lenses in the summer between 8th and 9th grade (I wore glasses as a kid, and when I went into high school I wanted to participate in sports, but couldn't because my glasses kept getting knocked off my face). Within the first few days of wearing soft contact lenses, my eyeballs turned bright red, like 2 little cherry tomatoes. They didn't hurt, didn't itch---they were just fiery red. Back then, there weren't 15 different kinds of contact lens solutions to choose from, like there are today---there were only one or two---and my eye doctor said that I was allergic to the preservative in the contact lens solutions, so I would have to make my own saline solution from these little salt tablets & distilled water, which I did for many years. I never had a problem with my eyes turning red from the homemade saline solution. The eye doctor never said the name of the preservative, and I was too young to know better than to ask what the name of it was----I was just elated that I didn't have to wear glasses anymore & could play sports in school.

So, years went by---I was working as a CRNA and not getting a flu shot every year, but no big deal was made about it (employers didn't start making a fuss about it until the DOH/CDC/FDA came out & practically threatened the public that they'd die without having an annual flu shot). It was when I first got a computer, with the advent of the internet, that I found out what the culprit was that caused the severe reaction I had to the flu shot.

What was the preservative in the contact lens solution that turned my eyes red? THIMEROSAL.

What is the preservative in the flu vaccine? THIMEROSAL.

It wasn't until much later, in the mid-2000's, that I found out that thimerosal was used as the preservative in the flu vaccine. That is what I had the reaction to!!! Imagine being allergic to thimerosal in contact lens solution, that is only used topically & which caused me eyeballs to look like ripe tomatoes as a 14 year old, and then having thimerosal injected systemically into my body!!!! When I did some research on thimerosal, I was shocked to find out that it is a mercury-based preservative that can be neurotoxic and cause severe reactions in people that are allergic to it. Thimerosal is put in multi-dose vials to drive down the cost of vaccines, so a new vial doesn't have to be opened for every person, and a doctor's office can buy a couple of large vials & give hundreds of shots from one single vial, so they make more money. Thimerosal is the agent blamed for autism, since it was present in all childhood vaccines until 1999, when the FDA told all vaccine manufacturers to remove it from childhood vaccines. No drug company or the FDA ever said that there was a direct link between autism & thimerosal, yet ironically the FDA told drug companies to remove it from childhood vaccines as a "precautionary measure". Thimerosal is a neurotoxin, for goodness' sake!!! If mercury wasn't dangerous, then why aren't mercury thermometers sold anymore, and why aren't dentists filling teeth with mercury amalgam fillings anymore? Thimerosal is nearly 50% mercury.

For many years, when flu season rolled around & my employer was mandating all staff to get flu shots & I declined, trying to explain that I had a severe reaction that landed me in the hospital the first time I had a flu shot, and repeatedly being told that "You can't have a reaction to the flu shot", it ended up in a tit-for-tat argument. I ended up winning, because i was not, under any circumstances, getting a flu shot that contained thimerosal.

Then, I found out that preservative-free, single-dose vials of flu vaccine had been manufactured for people like me that were allergic to thimerosal. (I guess it took that long for the wizards in R&D at the pharmaceutical companies to figure out that THERE WERE PEOPLE OUT THERE THAT WERE ALLERGIC TO THIS NEUROTOXIN, and that it would be wise to manufacture preservative free, single dose vials of flu vaccine.) And, so---guess what? When flu season rolled around, and my employer started hounding everybody about getting a flu shot, I declined the "regular" flu vaccine that got pulled out of a multi dose vial that was preserved with thimerosal, but said that I would consent to receiving the flu vaccine that was a preservative-free, single-dose injection---to the tune of $550/vial---and all of a sudden, my employer was okay with me declining the vaccine that had thimerosal in it because they did not want to pony up $550 for a single-dose, preservative-free vial of flu vaccine just for me. AND, I was not mandated to wear a mask, either. My acceptance & consent to receive a flu vaccine that was appropriate for me, as a single-dose, preservative-free injection, in light of my allergy to thimerosal, and my employer's refusal to provide the $550 injection, apparently changed the rules----funny how that happens, isn't it? I asked a friend of mine that is an attorney, and he said that if an employer mandates its employees to take a flu shot, it is their responsibility to provide the appropriate medication for every employee that they are mandating to get the shot, and if an employee tells them that they are allergic to an ingredient in the "standard" flu vaccine, they must make the vaccine that the employee can take available, no matter what the cost because the employee is not refusing the flu shot altogether. If there is an alternative vaccine available for someone that cannot take the "regular" kind, it must be made available or the mandate is null & void. The employer cannot mandate me to have a "regular" flu shot if I have a history of a reaction & allergy to the preservative, and their refusal to provide me with the $550 dose is not a "refusal" by me. If they don't want to supply it, then they cannot make me wear a mask because the decision was not mine, it was theirs when they did not want to purchase the preservative-free, single-dose vial for me.

So, when flu season rolls around, and my employer does the usual yearly flu shot routine, I always decline & I never have a problem. I guess when an employer doesn't want to shell out any $$$ to validate the mandates they lay on their employees, the mandates disappear..............

The funny thing is that even doctor's offices do not stock the preservative-free, single-dose vials for people with an allergy to thimerosal. I asked my PCP last year about it---after he told me that I should have a flu shot---and then he dropped the entire subject when I told him that I needed the preservative-free, single-dose vial. He didn't have it, and he would lose money if he ordered it, because my insurance would not reimburse him the entire cost of the shot. All of a sudden, I didn't need a flu shot anymore. Funny how that happens, isn't it?

I also find it quite amusing that there is no real evidence that flimsy surgical masks prevent the transmission of the flu. Everything I've read says "It may help", which means nothing. Also, a nurse wears the same mask from room to room, from patient to patient---whatever gets on the front of the mask during a 8, 10 or 12 hour shift is being carried into all of the rooms & presented all of those patients.

I am not a big believer of vaccines. I think the recent vaccine "madness" is just something that pharmaceutical companies made the FDA do in order to make more money. The think the chicken pox vaccine is ridiculous---it is a normal childhood disease that does not KILL anyone. The hepatitis vaccine is good to have if you are exposed regularly in hi-risk situations, like health care workers----but a 24-hour old newborn whose parents do not have hep B and who have absolutely NO RISK of contracting the virus do not need it. Unless someone will be traveling to poor areas in third world countries where the water is not treated/filtered, hepatitis A is unnecessary. Rotavirus vaccine is totally unnecessary. The shingles vaccine is only 66% effective, so why would you even bother getting it? (For that matter, the flu vaccine never has a very high effectiveness rate---one year it had a 7% effectiveness rate---my mother got the shot & got so sick on Christmas Day, she had the flu for 2.5 weeks and it took her another 2.5 to recover from it because she was so sick. So much for the flu shot that year.) I am not a believer in vaccines for diseases that have essentially no risk for further health problems. Diseases that can cause paralysis, like polio, or other long term complications such as sterility or meningitis like mumps can cause, justify getting the vaccine. Most of the diseases nowadays that vaccines are being given for are not dangerous---why not let a person's own immune system fight it so their inherent immune system get stronger, instead of artificially (and ineffectively) introducing agents that don't allow an individual's immune system to develop naturally? The CDC & FDA are in the pockets of big pharma, and all you have to do is follow the money if you want to know why something is being done.

The one disease that requires a vaccine for is Lyme disease. Lyme disease, if left undiagnosed/untreated, can cause some nasty long-term effects. There is a vaccine for dogs--it is a 2-step vaccine, with a booster---and I don't understand why there isn't a Lyme disease vaccine for humans. Then again, big pharma is making a killing from Lyme disease & the long term effects, so there is no incentive for them to come out with any vaccine for it. Follow the money, folks.

My facility banned the mask. All workers must get flu ahot or lose tbeir job.😕

Specializes in Public Health, TB.

I got my flu vaccine at a local pharmacy this year. It was a single-dose, pre-filled syringe. It cost me $40. And I did not get the flu. I have gotten yearly flu shots for at least the last 10 years, and never got the flu. I have, however seen people die from the flu, including a 30 year old co worker.

Multiple studies have demonstrated that autism rates have continued to rise since the removal of thimerosal from childhood diseases.

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