Are Masks a Good Alternative to Flu Shots for Healthcare Workers?

At some hospitals, it's vaccinate or be fired

  • by Contributing Writer, MedPage Today

Physicians and other healthcare workers who refuse influenza immunization at 535-bed Children's Hospital of Philadelphia can't work in patient care.

"If you don't want to get the vaccine, you have two weeks of unpaid leave to think about it, and if you still don't want to get it, you're fired," said Paul Offit, MD, CHOP's Chief of Infectious Diseases and Director of the Vaccine Education Center.

There's no provision to let workers wear a mask instead, like many healthcare facilities allow, because he said, "masks aren't particularly effective."

CHOP makes exceptions only for a very few workers with documented medical contraindications. But even they don't have to wear a mask.

To Mask or Not

As healthcare organizations rush to comply with new federal immunization reporting requirements for their workers, many infection control experts are questioning the mask option, saying it's an inefficient, ineffective, and dehumanizing alternative to immunization, one that gives workers an excuse not to get their annual flu vaccines.

Mask mandates are "a silly half-way measure that really doesn't serve any useful purpose other than to identify a person as a healthcare worker who is choosing not to get vaccinated -- selfishly," Offit said. "You might as well wear a scarlet letter for all the good it does."

Why are masks ineffective? For starters, they're only 60% effective in blocking viral particles, about the same efficacy rate as the vaccine in a good year. But the real problem is the inconsistency in both use and fitting of the mask to the face.

"Sometimes healthcare workers wear the masks below their chin or below their nose. After awhile it gets wet and therefore permeable," Offit said. "It's not tight fitting so you can still breathe in and out along the side, and small droplets can spread."

Around the country, however, what to do with the unvaccinated healthcare worker remains controversial. Organizations with mask mandates -- from community clinics to skilled nursing and long-term care facilities and hospitals -- are realizing that enforcing mask wearing for the unimmunized is impossible without embarrassing colleagues and disrupting routines.

Priya Sampathkumar MD, chair of immunization and infection control committees at the Mayo Clinic said Mayo facilities in Jacksonville, Rochester and Scottsdale do not require the roughly 9% of workers who refuse the vaccine to mask.

"They're difficult to wear for several hours at a time," Sampathkumar said. The discomfort prompts workers "to remove them, and not put them back on. I don't think they forget; I think they deliberately don't put them on again."

Enforcement also would be a constant struggle, she said. "Managers' time would be spent walking around to make sure everyone without the correct sticker has a mask on -- that's a waste of resources that could be used somewhere else."

Requiring masks may also violate the Health Insurance Portability and Accountability Act by indirectly releasing protected health information, Sampathkumar said. "Some patients can't receive the flu vaccine for medical reasons, so by making them wear a mask, you're marking those people, or unfairly singling them out."

The Stay Home Solution

Instead, the Mayo Clinic's system-wide policy urges workers to "stay home when they're sick, and make sure they're washing their hands before touching a patient or leaving a patient room," Sampathkumar said.

"Taking a punitive approach when employees don't comply with one element of good practice may not be working in the patient's best interest."

The national average for vaccine refusal by hospital workers is 18%, and some hospitals report they have reduced the refusal rate to 10%, but other hospitals' have lagged.

During last year's flu season, roughly 30% of the hospital workforce in New Jersey, Florida, and Alaska declined vaccination, according to Medicare's Hospital Compare database. For 966 of the nation's 3,662 hospitals reporting, one in four or more of their workers declined, and for 140, half or more said no.

Some hospitals have exceptionally low rates. For example, 95% of the workers at Jefferson County Hospital in Fayette, Miss., 88% at Lakeside Medical Center in Belle Glade, Fla., and 87% at Florence Hospital in Florence, Ariz. declined last year.

For hospitals with low vaccination rates but strict mask enforcement, a lot of patients would wake up to personnel wearing masks, and that might be frightening to patients who are severely ill or cognitively impaired.

"It could be very scary," said Sampathkumar.

"I'm not sure that anyone has ever proven that wearing a mask cuts down on influenza transmission," she said. Transmission could happen even with vaccinated employees, "because the vaccine efficacy varies from year to year and is never anywhere near 100%," she said.

But mask mandates are now enforced in several states and localities. In many California counties, for example, public health officers now require that healthcare workers in nearly all settings but physicians' practices get vaccinated or else "wear a mask for the duration of the influenza season (Nov. 1 to March 31) while in contact with patients or working in patient care areas." Physician practices are strongly urged to follow suit.

Deborah Wexler, MD, of the Immunization Action Coalition, also noted the wide variation in influenza vaccines policies, even for those listed on IAC's Honor Roll of healthcare organizations that said they employ some "significant intervention" for employees who decline the vaccine.

The list represents only those who asked to be named, and is not a complete list of healthcare organizations with such policies, she emphasized. But even among these organizations with focused immunization initiatives, policy language varies.

For example, some organizations allow workers to opt out of vaccination if they have a religious belief or a religious reason while others don't.

Religious Exemptions?

At 1,400-bed Greenville Health System in Greenville, S.C., workers at their two hospitals must demonstrate "a sincerely held religious belief or practice." They submit a petition for an exemption, and get that approved by human resources officials who engage in a discussion with the employee "over what their religious qualm to getting the vaccine is," said the system's infectious disease expert, J. William Kelly, MD. They can't just check a box that they don't believe in the vaccine, he said.

But how each organization defines a religious belief is often unclear, Wexler said. "I don't think there's any real religious exemption against vaccination in any real organized religion, whatsoever, that precludes you from being vaccinated," Wexler said.

Nancy Gemeinhart, RN, MHA, program director for BJC HealthCare, a 12-hospital system in Missouri and Illinois with 26,000 workers, said there are some religions that bar influenza vaccination, such as the Church of Universal Knowledge and some factions of other religions. Nevertheless, the few religious exemptions that BJC grants are for 1 year only, Gemeinhart said. "And we don't accept philosophical belief objections. Employees have to provide a statement why vaccination is against their religion."

For Banner Health, a 29-hospital system with 47,000 employees in seven states, workers are required to get immunized, or they can wear a mask if they're granted an exemption for religious or medical reasons.

So, how does such a large organization like Banner define a legitimate religious reason?

Joan Ivaska, Banner's senior director of infection prevention, replied in an e-mail that "to our knowledge, there is no religious tenet that precludes influenza immunization." Banner's policy therefore specifies any "theistic beliefs as well as nontheistic moral or ethical beliefs as to what is right and wrong, which are sincerely held with the strength of traditional religious views."

Workers can submit a religious exemption request form. "We do not inquire as to religious or personal belief since it doesn't really matter as far as the EEOC (Equal Employment Opportunity Commission) is concerned," Ivaska said.

Other variations include how close to a patient an unimmunized healthcare worker must be when the mask requirement kicks in. Some hospitals say it's within 6 feet of a patient. Some say 6 feet of a patient care area. Still others don't specify any distance, thus covering the entire property.

Some hospitals require vaccine documentation of vendors and contractors entering the building while some don't. Some organizations mandate immunization for students, clerical, and janitorial personnel, and even pastors, while others don't.

Neosho Memorial Regional Medical Center in Chanute, Kansas requires workers who decline for medical, religious or personal to wear "a bright pink badge to help others identify them (helps maintain compliance for mask wearing in ALL areas of the hospital.)"

Other organizations, like Frisbie Memorial Hospital in Rochester, N.H., designate its immunized workers with a sticker on their ID badges.

The American Hospital Association encourages all workers to get annual flu vaccines, but there's no clear solution for what hospitals should do if they won't, said Nancy Foster, the AHA's vice president for quality and patient safety.

"There are no clear data telling us what the second best alternative would be," she said. "Do they get more rigorous about telling people to stay home if they're under the weather? Do they move people from patient contact to other areas of the hospital? Without clear evidence of a second strong alternate policy, we're not advising them what that alternative should be."

Foster acknowledged that for many hospitals with high rates of vaccine refusal, transfer to nonpatient care areas is not a practical solution. "If it's a third of your workforce, you wouldn't have enough administrative jobs for that," she said.

National Nurses United, a labor organization representing 186,000 nurses, "highly recommends that nurses get all their vaccinations," said Bonnie Castillo, director of NNU's Registered Nurse Response Network. But policies about what hospitals should do with those who refuse "are all over the map. It's a mishmash. And there's no enforcement mechanism."

NNU vehemently opposes vaccination or masking as a condition of employment because of the potential to be punitive, she said.

"What we're seeing is that there are very coercive measures, including requiring masks, which have no scientific basis for preventing the spread of the flu, and instead give a false sense of security ... and a sense of mistrust," she said.

"If we in the healthcare and science communities are spreading bogus science on one hand, how do we expect to be credible on any other topic of infectious disease, or worker and patient protection? You have to be consistent."

A more sensible option, she said, is for hospitals and other healthcare settings to relax their strict limits on sick days so that when nurses do feel ill, they can stay home without financial consequence.

For Offit, a focus on getting all healthcare workers immunized is really the only solution to keeping patients safe from infection. One must remember that patients' lives are at stake, he said.

"Healthcare workers have a responsibility to their patients, and it is not their inalienable right to catch and transmit a potentially fatal infection. It's not their right to not be vaccinated," Offit said.

Several years ago, a child with cancer "came into this hospital for care, but caught the influenza virus in this hospital and died from it," he said. "She no doubt caught it from us."