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Home , Arbitration, Bonnie Henry, Primum non nocere

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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 , the policy cannot be shown to confer any benefit to patients, and should be discontinued.

Will Offley, RN

hen a 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 between the practice calls for evidence that the influenza virus in the 24-hour asymp- 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 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

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Continued from page 554 the rights of health care workers to ent policy. Given its inconsistent and no protection to the influenza strain 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? . 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 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 , 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. atically implemented, and ethically shedding virus. tinue to recommend that people get defensible program that has success- The BC policy recognizes that vaccinated against influenza if they fully improved influenza vaccine health care workers have the right to are at higher risk of severe influenza coverage among health care workers refuse vaccination and provides them or complications from influenza or if in the province and, as a result, im- the option to wear surgical masks in they are in contact with higher-risk proved protection for our vulnerable patient care areas during influenza individuals. patients. In response to Mr Offley’s season when influenza is circulating While a universal vaccination critique of the policy, we present the in our communities. There is evi- and mask policy might be the logi- following evidence. dence that masking will reduce influ- cal approach in the face of vaccine First, the policy is supported by enza virus transmission,11-22 and while and circulating virus uncertainty, the the majority of health care workers in the body of evidence is not as robust BC policy seeks a balance of protec- BC, according to a recent survey, and as that supporting influenza immuni- tion of the health care worker and the has been upheld as reasonable at arbi- zation, it is at least as strong as that patient without posing undue hard- tration in BC.1 The policy is, in fact, supporting hand washing in the pre- ship on health care workers. As Mr predicated on several factors: vention of nosocomial transmission. Offley observes, “masks are extreme- · The universal recommendation that Where evidence is lacking (as de- ly uncomfortable to wear for 12 hours health care workers receive annual scribed in testimony to the arbitrator a day continuously over a 4-month vaccination against influenza.2,3 in Ontario that Mr Offley quotes) is period.” · The failure in Canada of voluntary on the issue of whether there is any Consistent application of the pol- programs to achieve anything close additional benefit to an individual icy in BC has been recognized since to high coverage levels.4 wearing a mask over and above im- its inception as a very important fea- · The evidence that high vaccine cov- munization. ture and considerable resources are erage provides patient/resident pro- It is recognized that the current spent on this. That some unvaccinat- tection.5-9 technology for making influenza vac- ed health care workers may seek to · The fact that health care workers cines produces less than optimal effec- subvert the program by inferentially can and do transmit influenza to tive antigens. The continuing annual claiming vaccination status by not drift in viral antigens is challenging wearing a mask is regrettable, but Dr Henry is Deputy Provincial Health Of- and does result in varying degrees of fortunately it is not a characteristic ficer, British Columbia. Dr Perry Kendall is protection from year to year (from the of the overwhelming majority of our Provincial Health Officer, British Columbia. low of 13% in 2014–15 to over 80% professionals. in 2010–11 in Canada with an accept- Vaccinate or mask is a coherent This article has been peer reviewed. ed average of 60% protection over Continued on page 557

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Continued from page 555 personnel on morbidity and mortality Pulm Drug Deliv 2013;26:131-137. policy based on the time-proven among patients: Systematic review and 15. Harnish DA, Heimbuch BK, Husband M, ethical grading of evidence. Clin Infec Dis 2014; et al. Challenge of N95 filtering facepiece (first, do no harm). 58:50-57. respirators with viable H1N1 influenza 10. Bryce E, Embree J, Evans G, et al. Manda- aerosols. Infect Control Hosp Epidemiol References tory influenza immunization of healthcare 2013;34:494-499. 1. Influenza control program policy griev- workers. Ottawa, ON: Association of 16. Loeb M, Dafoe N, Mahony J, et al. Sur- ance award. Vancouver: 2013. Accessed Medical Microbiology and Infectious Dis- gical mask vs N95 respirator for pre- 19 May 2016. Archived by WebCite at ease Canada; 2012. venting influenza among health care www.webcitation.org/6hdfTFm0d. workers: A randomized trial. JAMA 2. National Advisory Committee on Immuni- 2009;302:1865-1871. zation (NACI). Statement on seasonal in- 17. Cowling BJ, Chan KH, Fang VJ, et al. Face- fluenza vaccine for 2015-2016. Public masks and hand hygiene to prevent influ- Health Agency of Canada, 2016. www enza transmission in households: A .phac-aspc.gc.ca/naci-ccni/flu-2015 There is evidence cluster randomized trial. Ann Intern Med -grippe-eng.php#ii. that masking will 2009;151:437-446. 3. Talbot TR, Babcock H, Caplan AL, et al. reduce influenza virus 18. Aiello AE, Perez V, Coulborn RM, et al. Revised SHEA position paper: Influenza Facemasks, hand hygiene, and influenza transmission, and while vaccination of healthcare personnel. In- among young adults: A randomized inter- fect Control Hosp Epidemiol 2010;30: the body of evidence is vention trial. PLoS One 2012;7:e29744. 987-995. not as robust as that doi: 10.1371/journal.pone.0029744. 4. Lam P-P, Chambers LW, Pierrynowski supporting influenza 19. Simmerman JM, Suntarattiwong P, Levy MacDougall DM, et al. Seasonal influenza immunization, it is at J, et al. Findings from a household ran- vaccination campaigns for health care least as strong as that domized controlled trial of hand washing personnel: Systematic review. CMAJ and face masks to reduce influenza trans- supporting hand 2010;182:E542-E548. doi:10.1503/cmaj mission in Bangkok, Thailand. Influenza .091304. washing in the Other Resp Viruses 2011;5:256-267. 5. Potter J, Stott DJ, Roberts M, et al. Influ- prevention of 20. Suess T, Remschmidt C, Schink SB, et al. enza vaccination of health care workers in nosocomial The role of facemasks and hand hygiene long-term-care hospitals reduces the mor- transmission. in the prevention of influenza transmis- tality of elderly patients. J Infect Dis 1997; sion in households: Results from a cluster 175:1-6. doi:10.1093/infdis/175.1.1. randomised trial; Berlin, Germany, 2009- 6. Carman WF, Elder AG, Wallace LA, et al. 2011. BMC Infect Dis 2012;12:26. Effects of influenza vaccination of health- 21. Cowling BJ, Zhou Y, Ip DK, et al. Face care workers on mortality of elderly peo- masks to prevent transmission of influ- ple in long-term care: A randomised con- 11. Milton DK, Fabian MP, Cowling BJ, et al. enza virus: A systematic review. Epide- trolled trial. Lancet 2000;355:93-97. Influenza virus aerosols in human exhaled miol Infect 2010;138:449-456. doi:10.1016/S0140-6736(99)05190-9. breath: Particle size, culturability, and ef- 22. Bin-Reza F, Lopez Chavarrias V, Nicoll A, 7. Hayward AC, Harling R, Wetten S, et al. fect of surgical masks. PLoS Pathog 2013. et al. The use of masks and respirators to Effectiveness of an influenza vaccine pro- Accessed 27 October 2016. http://dx.doi. prevent transmission of influenza: A sys- gramme for care home staff to prevent org/10.1371/journal.ppat.1003205. tematic review of the scientific evidence. , morbidity, and health use 12. Johnson DF, Druce JD, Birch C, et al. A Influenza Other Resp Viruses 2012;6: among residents: Cluster randomised quantitative assessment of the efficacy of 257-267. controlled trial. BMJ 2006;333:1241. surgical and N95 masks to filter influenza 23. Jefferson T, Di Pietrantonj C, Al-Ansary doi:10.1136/bmj.39010.581354.55. virus in patients with acute influenza infec- LA, et al. Vaccines for preventing influenza 8. Lemaitre M, Meret T, Rothan-Tondeur M, tion. Clin Infect Dis 2009;49:275-277. in the elderly. Cochrane Database Syst et al. Effect of influenza vaccination of 13. Makison Booth C, Clayton M, Crook B, Rev 2010;17:CD004876. doi: 10.1002/ nursing home staff on mortality of resi- et al. Effectiveness of surgical masks 14651858.CD004876.pub3. dents: A cluster-randomized trial. J Am against influenza bioaerosols. J Hosp In- 24. Osterholm MT, Kelley NS, Sommer A, Geriatr Soc 2009;57:1580-1586. doi:10. fect 2013;84:22-26. et al. Efficacy and effectiveness of influ- 1111/j.1532-5415.2009.02402.x. 14. Mansour MM, Smaldone GC. Respiratory enza vaccines: A systematic review and 9. Ahmed F, Lindley MC, Allred N, et al. Ef- source control versus receiver protection: meta-analysis. Lancet Infect Dis 2012;12: fect of influenza vaccination of health care Impact of facemask fit. J Aerosol Med 36-44.

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