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The Lack of Evidence for Vaccinate Or Mask Policies

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The Lack of Evidence for Vaccinate Or Mask Policies point Cover up: The lack of evidence for vaccinate or mask policies Vaccinate or mask is an incoherent policy. Given its inconsistent enforcement and lack of universal application of basic infection control principles, the policy cannot be shown to confer any benefit to patients, and should be discontinued. Will Offley, RN hen a public health policy concern, determining that there is lit- Inconsistent application is put into effect to reduce tle if any evidence that infected indi- In 2015 James Hayes addressed these W a risk to patients, best viduals shed significant amounts of issues in an arbitration between the practice calls for evidence that the influenza virus in the 24-hour asymp- Ontario Nurses’ Association and the risk actually exists, consistent appli- tomatic period following infection.2 Ontario Hospital Association con- cation of the policy, and an assess- cerning that province’s vaccinate or ment of whether the policy achieves A policy without evidence mask policy. In striking down the its stated goals. Failure to meet these The reality is that no provincial statis- policy, Hayes posed the question, “If criteria indicates the need to recon- tics are kept on nosocomial influenza hospital authorities were convinced sider the policy. infections. The BC Centre for Disease about the utility of masks for the pur- In 2012 British Columbia insti- Control has acknowledged that it does pose alleged, why not mask every- tuted a mandatory vaccinate or mask not maintain records on the incidence one?”9 He dismissed the arguments policy for all health care staff who of hospital-acquired influenza, stating of the expert witnesses who provid- receive an influenza vaccination. The that “we are unable to differentiate ed testimony defending the compul- policy’s stated purpose was “to pre- between nosocomial and community- sory policy, stating that they did not vent transmission [of influenza] from acquired cases (a positive lab report explain “to my satisfaction, or to my them to their patients.”1 was sufficient for provincial report- understanding, why masking should This vaccinate or mask policy ing)” (electronic communication not be required generally if the risk is not based on evidence, but on an from Lisa Kwindt, BC Centre for Dis- of [health care worker] transmission assumption that hospital-acquired ease Control, 11 January 2016). Nor is as serious as they maintain and if influenza is a significant threat to does the Vancouver Coastal Health masks actually serve as an effective patients. It is predicated on the Authority,3 Providence Health Care,4 intervention.”9 24-hour period in which a person can the Interior Health Authority,5 the Vaccination and immunity are be infected with the influenza virus Northern Health Authority,6 the Pro- not the same thing. There are many but remain asymptomatic. However, vincial Health Services Authority,7 ways an individual may be infected recent studies have challenged this or the Fraser Health Authority8 keep with influenza despite having had such records. Without these data, the the annual vaccination. As an exam- Mr Offley is an RN working in the emer- vaccinate or mask policy is, in effect, ple, many infections occurred in the gency department of Vancouver General based on assumptions and guesswork, 2014–15 flu season when there was Hospital. The views expressed in this ar- not evidence. There is no proof of a a mismatch between the vaccine and ticle are his own and do not represent the threat to patient safety; nor is there the circulating H3N2 virus, which positions of the Vancouver Coastal Health a means to establish a baseline. In resulted in a vaccine efficiency in Authority or Vancouver General Hospital. short, there is no way of measuring Canada of –8%.10 Considering that the effectiveness of the policy. the 2014–15 vaccine offered virtually This article has been peer reviewed. Continued on page 556 554 BC MEDICAL JOURNAL VOL. 58 NO. 10, DECEMBER 2016 bcmj.org point Continued from page 554 the rights of health care workers to ent policy. Given its inconsistent and no protection to the influenza strain informed consent and medical confi- selective enforcement and its lack of circulating in Canada, it would be rea- dentiality. The policy simply obliter- universal application of basic infec- sonable to expect that a policy consis- ates the rights of health care workers tion control principles, it is clear that tent with the stated goals would have without discussion and without even the policy cannot be shown to confer immediately been enforced—one that acknowledging it is doing so. And any benefit to patients. It should be required all health care workers to don with what justification? Where is the discontinued. masks regardless of their vaccination threat to our patients? status. No such action was taken. The stated policy is intended to References The current policy is also incon- promote patient safety. But many of 1. BC influenza prevention policy: A discus- sistent in its scope. The rationale for its proponents do not appear to be- sion of the evidence. Vancouver, BC: Pro- compulsory masking of nonvacci- lieve that compulsory masking is an vincial Health Services Authority; 2013; nated health care workers makes no effective method of preventing influ- p. 15. sense whatsoever from the stand- enza transmission. For example, in the 2. Patrozou E, Mermel L. Does influenza point of infection control unless all Ontario arbitration, Dr Bonnie Henry, transmission occur from asymptomatic other nonvaccinated individuals are BC’s deputy provincial health officer, infection or prior to symptom onset? Pub- obliged to don masks as well. Visi- while defending mandatory masking lic Health Rep 2009; 124:193-196. tors and family members are at the policies, admitted that “there’s not a 3. Vancouver Coastal Health Authority, FOI bedside of patients for far longer peri- lot of evidence to support mask use.”9 application 2015-F-117, 15 January 2016. ods of time than health care workers. Dr Allison McGeer, epidemiologist 4. Providence Health Care, FOI application They engage in more intimate con- and flu vaccine researcher, also testi- F15-029, 30 November 2015. tact (e.g., kissing, holding hands). fied in support of mandatory masking 5. Interior Health Authority, FOI application They are also, as a rule, far less like- policies, but stated “there’s quite a 50-IH-2015-2016, 7 January 2016. ly to engage in proper handwashing limited literature concerning the ef- 6. Northern Health Authority, FOI application and cough etiquette than are health fectiveness of masks in prevention NH-2016-0207, 17 March 2016. care workers. Yet Vancouver Coastal transmission.”9 Even the BC Minis- 7. Provincial Health Services Authority, FOI Health Authority made it clear early try of Health’s own policy documents application PHSA 0090-15, 4 February on that the vaccinate or mask policy concede that masks don’t work, re- 2016. would not be enforced with visitors, markably stating that “the [vaccinate 8. Fraser Health Authority, FOI application, but would be on the honor system or mask] policy will not be amended 1-788-FOI, 11 January 2016. instead.11 to require vaccinated staff to wear 9. In the Matter of an Arbitration between As well, physicians, residents, and masks because there is no strong Sault Area Hospital and Ontario Hospital medical students are often seen with- evidence to support universal mask- Association and Ontario Nurses’ Associa- out masks in flu season. As it is ex- ing as a preventative measure in the tion, Re: ‘Vaccinate or Mask’ Policy. Ac- tremely unlikely that there this group presence of pronounced vaccine mis- cessed 18 October 2016. ona.org/docu would have a 99%+ vaccination rate, match and in the absence of an out- ments/File/onanews/OHA_SaultArea it appears incontestable that the policy break.”12 HospitalONAAWARD_20151028.pdf is not being enforced equally for this Also at issue is the practical matter 10. Skowronski DM, Chambers C, Sabaiduc category among health care workers. of wearing masks. It appears that co- S, et al. Interim estimates of 2014/15 vac- Infection control measures are ercion is at the heart of the vaccinate cine effectiveness against influenza meaningless if they are not consistent, or mask policy. Masks are extremely A(H3N2) from Canada’s Sentinel Physi- and the vaccinate or mask policy is uncomfortable to wear for 12 hours cian Surveillance Network. Euro Surveill utterly inconsistent. And if the mask- a day continuously over a 4-month 2015;20:ii=21022. ing policy has been implemented in period. In addition, the requirement 11. Lindsay B. BC health officials issue flu such a partial, patchwork, and incon- to mask serves to put psychological shot reminder. Vancouver Sun. 30 No- sistent way, the question arises—what pressure on staff to comply and get vember 2015. is its actual purpose? a flu shot through the very real peer 12. Vancouver Coastal Health Authority. Influ- pressure and disapproval many expe- enza Control Program Frequently Asked Patients vs health rience from some of their co-workers. Questions. 3 November 2015. Accessed care workers 18 October 2016. vch.ca/media/FAQ_ Another key concern with the cur- Summary Influenza_Vaccine_Provincial_November rent policy is the imbalance between Judged by its professed goals, vac- _%203_2015(1).pdf. the rights of patients to safe care and cinate or mask is an utterly incoher- 556 BC MEDICAL JOURNAL VOL. 58 NO. 10, DECEMBER 2016 bcmj.org counterpoint Immunize or mask: A choice to protect patients in BC The policy is an evidence-supported, systematically implemented, and ethically defensible program that has improved influenza vaccine coverage among health care workers and improved protection for our vulnerable patients. Bonnie Henry, MD, MPH, FRCPC Perry Kendall, OBC, MD, FRCPC he BC health care worker in- those they care for, and they do many seasons).23,24 Nonetheless the fluenza protection policy is an work while sick and may transmit great majority of infectious disease evidence-supported, system- influenza while asymptomatically specialists and influenza experts con- T 10.
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