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

[LadysSolo]

My allergic reaction was widespread localized, my entire arm becomes flaming red. After the second bad reaction to the TB test, the ID MD where I worked said "no more," I was at risk of anaphylaxis the next time. And after the flu vaccine did the same thing, he said "no more" to that one too, said too high a risk of anaphylaxis with the next one. He said it might not be the next one, but it might be and not worth the risk. He was the only one who could stop the annual TB test. So they did "signs and symptoms" in employee health because annual chest x-rays are also a bad idea.

[PopcornRN36]

LadysSolo - yes, annual chest x-ray is not necessary/nor a good idea re repetitive x-ray exposure. Annual signs & symptoms sheet is standard. If you go for a new job and they require TB testing, ask for an IGRA , either the Quantiferon Gold or Tspot (simple blood test so no exposure to the PPD).

[PopcornRN36]

First off the influenza virus mutates and every year the developers of the vaccine "guess" as to how the virus will mutate. In studies of adults in long term care facilities the vaccine was shown to only have a 1% efficacy rate.

Kimtimp - Re the efficacy of flu vaccinations within LTC facilities - I'm wondering if these people are being given the regular Quadrivalent/Trivalent vaccinations or the high-dose for over 65 vaccination (which includes 180 micrograms (mcg) of influenza virus hemagglutinin HA - 4 x the amount than the regular vaccination) and adjuvants since the immune system of the elderly can be impaired/sluggish in producing an antibody response? The High-Dose is more expensive and some LTC may not be administering them (I've seen this done especially when an outside company comes in to administer them during a flu clinic).

You are correct that the flu viruses mutate - antigenic shift pandemics (i.e. H1N1 & sub-type H3N2) and the antigenic drifts of Type B viruses). It's a challenge for the CDC/FDA in trying to determine which strains will be addressed when making vaccinations for the upcoming flu season:

'More than 100 national influenza centers in over 100 countries conduct year-round surveillance for influenza. This involves receiving and testing thousands of influenza virus samples from patients. The laboratories send representative viruses to five World Health Organization (WHO) Collaborating Centers for Reference and Research on Influenza, which are located in the following places:

• Atlanta, Georgia, USA (Centers for Disease Control and Prevention, CDC);
  
• London, United Kingdom (The Francis Crick Institute);
  
• Melbourne, Australia (Victoria Infectious Diseases Reference Laboratory);
  
• Tokyo, Japan (National Institute for Infectious Diseases); and
  
• Beijing, China (National Institute for Viral Disease Control and Prevention).
  

Twice a year, the World Health Organization (WHO) organizes a consultation with the Directors of the WHO Collaborating Centers, essential regulatory laboratories and representatives of key national laboratories and academies. They review the results of surveillance, laboratory, and clinical studies, and the availability of vaccine viruses and make recommendations on the composition of the influenza vaccine. These meetings take place in February for selection of the upcoming Northern Hemisphere's seasonal influenza vaccine and in September for the Southern Hemisphere's vaccine. WHO recommends specific vaccine viruses for inclusion in influenza vaccines, but then each country makes their own decision about which viruses should be included in influenza vaccines licensed in their country.

In the United States, the Food and Drug Administration (FDA) makes the final decision about vaccine viruses for influenza vaccines to be sold in the U.S. Information about circulation of influenza viruses and available vaccine viruses is summarized and presented to an advisory committee of the FDA in February each year for the U.S. decision about which viruses to include in the upcoming season's vaccine.'

It's not perfect, but I do believe earnest attempts are made.

[rntonp1day]

I think the worst situation I've seen with this is nurses not being required to get the flu shot or wear masks either one in pediatric offices or family care clinics. Infants under 6 months are not able to get the flu shot at all, but they have to go into the offices to get regular checkups and other immunizations on schedule. They are very highly at risk from complications of the flu, yet the staff is not required to at least try to protect them by doing the right thing. Hep B is required in most medical facilities as well as MMR and Varicella, so what is the big deal about a vaccine once a year? Premature babies with undeveloped lungs, infants up to 6 months of age, and the elderly are at the greatest risk here. I know I have to get this vaccine every year, but it does not bother me one bit because I know I'm protecting people by doing it. Yes, there are some seasons when they get the strain wrong, who cares? It doesn't hurt you, it can only help if it happens to be right.

[PopcornRN36]

I rarely post, but I did a couple of times on this thread. The last comment I made came up with a message when I went to submit, 'This post to be reviewed....(message quickly disappeared prior to my being able to read the rest of it). Seems like my comment was finally posted. Not sure why...for what reasons are comments reviewed/not posted? Mine, I believe, was completely benign, polite, and professional.

[canoehead, BSN, RN]

It's a sign of real knowledge if you can argue your opponents' side and respect their point of view. Name calling, and declaring that they are unfit to practice won't change minds or allow them to hear your information.

[tnbutterfly - Mary, BSN]

COMMUNITY MANAGER NOTE

Several rude, attacking, and divisive posts have been deleted. This is a controversial topic, however if you cannot maintain a level of professionalism while discussing this subject, please refrain from commenting.

Thank you for you cooperation.

Carry on with the great discussion. Thank you Beth for submitting this article!!

[LovingLife123]

Just a question for some people refusing the vaccine. Many if you say, well I got the flu once and I have refused ever since, that doesn't make sense to me and I'm wondering the reasoning behind that?

We all know there are many strains of the flu and the flu shot is a guess based off of what is going around Southeast Asia the year before. But it will protect you from that particular strain. I'm just not understanding the reasoning of not at least trying to protect your patients. Especially those that could die from the flu. Those that can't be vaccinated. I find it hard to understand a nurse who doesn't want to protect their patients.

I feel if you don't vaccinate, you should wear a mask. It's about protecting our patients, not about civil rights or the fact you got the flu once. I got H1N1 years ago. It doesn't stop me from getting vaccinated.

I also agree that when you start the name calling such as sheep, you lose all credibility. I'm also curious to the national committee one poster sits on. I would like to know the specific research you have done and your results. You can link the peer reviewed, study.

[trwells97]

I declined the flu shot this year (chemo plus virus, contraindicated in my case,) but I will likely continue to decline in upcoming years (several reasons - I am not anti-vaxx, but believe we vaccinate too much). We had a large breakout this year and for about 2 weeks I chose to wear a mask, changed it when it became dirty or roughened along the outside. I did have a short cold with a fever, cough, congestion that lasted about 2-3 days with persistent nasal issues afterward. A doctor asked me if I got tested, nope, symptoms were mild, don't want tamiflu (prefer to let my body handle it if I can.) You just have to go with with​what you know. Wearing a mask can protect you, honestly why wouldn't you use a droplet approved mask? (Surgical mask is not approved, I don't support that.)

[GM2RN]

I think the worst situation I've seen with this is nurses not being required to get the flu shot or wear masks either one in pediatric offices or family care clinics. Infants under 6 months are not able to get the flu shot at all, but they have to go into the offices to get regular checkups and other immunizations on schedule. They are very highly at risk from complications of the flu, yet the staff is not required to at least try to protect them by doing the right thing. Hep B is required in most medical facilities as well as MMR and Varicella, so what is the big deal about a vaccine once a year? Premature babies with undeveloped lungs, infants up to 6 months of age, and the elderly are at the greatest risk here. I know I have to get this vaccine every year, but it does not bother me one bit because I know I'm protecting people by doing it. Yes, there are some seasons when they get the strain wrong, who cares? It doesn't hurt you, it can only help if it happens to be right.

This assumes that the flu vaccine is 100% effective for those who receive it. You are willing to force healthy, asymptomatic nurses to wear a mask, who will likely never get or transmit the flu, just because they didn't get the vaccine, but you neglect the fact that those who are vaccinated can still get the flu and they can also potentially transmit it through shedding after receiving the vaccine. You cannot be selective in this. Either everyone wears a mask, including all patients as they are not without risk, or no one wears a mask unless they are symptomatic.

[GM2RN]

It's a sign of real knowledge if you can argue your opponents' side and respect their point of view. Name calling, and declaring that they are unfit to practice won't change minds or allow them to hear your information.

Exactly!

[NotAllWhoWandeRN, ASN, RN]

Oh you have a choice, it's a civil rights violation to mandate!

With my employer, you'd be enjoying your "civil rights" at home on the sofa. If you don't have an acceptable (to them) reason to refuse, refusing means termination.