Questions arise over vaccine-or-mask rules
It quickly becomes obvious how ridiculous it is’
Get the flu vaccine or wear a mask during flu season. That ultimatum is becoming increasingly commonplace in the nation’s hospitals. But it still leaves employee health professionals with a number of questions: Just who should be covered by the policy? And when or where do they need to wear the masks?
Hospitals have taken a variety of approaches to masking policies that encourage employees to roll up their sleeves for the flu vaccine. Some use stickers on ID badges to identify employees who did or didn’t receive the vaccine. (The unvaccinated don’t get a smiley face.) Others rely on supervisors to track the need for mask-wearing and the usual human resources procedures if employees don’t comply.
Some hospitals require the masking when employees are within a certain number of feet of a patient — such as 50 feet. Others require unvaccinated employees to wear a mask anywhere in the hospital. Many of the policies include contract workers, such as physicians, and volunteers.
The Centers for Disease Control and Prevention does not have any recommendations on implementing a policy of masking unvaccinated health care workers because there is no data on such programs, says David Kuhar, MD, medical officer with the CDC’s Division of Healthcare Quality Promotion. "There’s not really an evidence base to review to come up with recommendations. This is simply a matter of expert opinion," he says.
The unpredictability of influenza and variability in the effectiveness of the vaccine add to the infection control questions, says William Schaffner, MD, chairman of the Vanderbilt University Department of Preventive Medicine and an infectious disease expert. It is reasonable for hospitals to establish policies that work best for them, with the ultimate goal of maximizing vaccination, he says. "I think they’re going to be looking for practical solutions that can be implemented and that are workable," he says.
Achieve the highest protection’
Vaccine-or-mask policies have become popular because they are very effective at raising influenza vaccination rates without resorting to threats of termination. For example, Methodist Health System in Omaha, NE, allows employees to decline for any reason after they receive education on influenza and the value of the vaccine.
Anyone who has not been vaccinated must wear a mask during flu season while they are in the hospital hallways or patient care areas. (Break rooms and the cafeteria are excluded.) Hospital infection control determines the dates of the flu season, says Sue Davis, MS, BSN, RN, CCRN, NE-BC, Service Leader for the hospital’s Learning Center & Employee Health.
Methodist Health System adopted the policy in response to an American Hospital Association policy advocating vaccine-or-mask policies "to achieve the highest possible level of protection." Other hospitals in the area had already adopted mandatory vaccination policies, Davis says. "It’s a community standard here," she says.
Last year, the masking period began in December. But because the outpatient clinic sees the first flu patients, the official flu season began there on Oct. 15 and lasted until April 30. Signs on the hospital entrance alert patients that some employees may be wearing masks because they are unable to have the flu vaccine. Patients with respiratory symptoms also are asked to wear a mask, Davis says.
When the policy first began, some employees vented their frustration. But vaccination rates also shot up, from the 70s to 95%.
Little infection control benefit?
Yet some hospitals are bucking this trend toward vaccine-or-mask policies as they question the infection control rationale.
Hospitals feel pressured to show very high vaccination rates without threatening to fire employees, says Melanie Swift, MD, medical director of the Vanderbilt Occupational Health Clinic. But the policies inadvertently raise other issues if their stated goal is patient protection, she says.
"This kind of policy puts you on a slippery slope," she says. "You then have no justification not to mask for early epidemics before you’ve got a vaccine, for any novel strain of flu, when vaccine is delayed in a year, or any year that surveillance shows a poor match [between the vaccine and the prevailing strains].
"If you try to follow it as a logical patient safety intervention, it quickly becomes obvious how ridiculous it is," she says.
Swift also expresses concern about the breach of privacy of the employees’ medical information. Patients, visitors, co-workers and supervisors are all aware of the employees’ vaccination status, and some of those unvaccinated employees have a medical condition that precludes vaccination, she notes.
Marshfield (WI) Clinic has taken a strong stand for vaccination, while bypassing the masking mandates. At Marshfield, all recommended vaccines are a condition of employment, including measles, mumps, rubella, varicella, pertussis, influenza and hepatitis B.
People with religious or medical exemptions are evaluated on a case-by-case basis, and some unvaccinated employees may be transferred out of patient care areas, says Bruce E. Cunha, RN, MS, COHN-S, manager of Employee Health and Safety. However, unvaccinated employees are not asked to wear a mask.
"We do not feel it provides a significant improvement in infection control to be warranted," Cunha says. "I really question how many of these facilities are actually enforcing it."
Marshfield tells employees to stay home if they feel sick, but if they return to work and still have some respiratory symptoms, they must wear a mask while caring for patients, he says. "Regardless of whether you’ve been vaccinated or not [against influenza], if you have symptoms you wear a mask," he says.