When a public health policy is put into effect to reduce a risk to patients, best practice calls for evidence that the risk actually exists, consistent application of the policy, and an assessment of whether the policy achieves its stated goals. Failure to meet these criteria indicates the need to reconsider the policy. 

In 2012 British Columbia instituted a mandatory vaccinate or mask policy for all health care staff who receive an influenza vaccination. The policy’s stated purpose was “to prevent transmission [of influenza] from them to their patients.”[1]

This vaccinate or mask policy is not based on evidence, but on an assumption that hospital-acquired influenza is a significant threat to patients. It is predicated on the 24-hour period in which a person can be infected with the influenza virus but remain asymptomatic. However, recent studies have challenged this concern, determining that there is little if any evidence that infected individuals shed significant amounts of influenza virus in the 24-hour asymptomatic period following infection.[2]

A policy without evidence
The reality is that no provincial statistics are kept on nosocomial influenza infections. The BC Centre for Disease Control has acknowledged that it does not maintain records on the incidence of hospital-acquired influenza, stating that “we are unable to differentiate between nosocomial and community-acquired cases (a positive lab report was sufficient for provincial reporting)” (electronic communication from Lisa Kwindt, BC Centre for Disease Control, 11 January 2016). Nor does the Vancouver Coastal Health Authority,[3] Providence Health Care,[4] the Interior Health Authority,[5] the Northern Health Authority,[6] the Provincial Health Services Authority,[7] or the Fraser Health Authority[8] keep such records. Without these data, the vaccinate or mask policy is, in effect, based on assumptions and guesswork, not evidence. There is no proof of a threat to patient safety; nor is there a means to establish a baseline. In short, there is no way of measuring the effectiveness of the policy. 

Inconsistent application
In 2015 James Hayes addressed these issues in an arbitration between the Ontario Nurses’ Association and the Ontario Hospital Association concerning that province’s vaccinate or mask policy. In striking down the policy, Hayes posed the question, “If hospital authorities were convinced about the utility of masks for the purpose alleged, why not mask everyone?”[9] He dismissed the arguments of the expert witnesses who provided testimony defending the compulsory policy, stating that they did not explain “to my satisfaction, or to my understanding, why masking should not be required generally if the risk of [health care worker] transmission is as serious as they maintain and if masks actually serve as an effective intervention.”[9]

Vaccination and immunity are not the same thing. There are many ways an individual may be infected with influenza despite having had the annual vaccination. As an example, many infections occurred in the 2014–15 flu season when there was a mismatch between the vaccine and the circulating H3N2 virus, which resulted in a vaccine efficiency in Canada of –8%.[10] Considering that the 2014–15 vaccine offered virtually no protection to the influenza strain circulating in Canada, it would be reasonable to expect that a policy consistent with the stated goals would have immediately been enforced—one that required all health care workers to don masks regardless of their vaccination status. No such action was taken.

The current policy is also inconsistent in its scope. The rationale for compulsory masking of nonvaccinated health care workers makes no sense whatsoever from the standpoint of infection control unless all other nonvaccinated individuals are obliged to don masks as well. Visitors and family members are at the bedside of patients for far longer periods of time than health care workers. They engage in more intimate contact (e.g., kissing, holding hands). They are also, as a rule, far less likely to engage in proper handwashing and cough etiquette than are health care workers. Yet Vancouver Coastal Health Authority made it clear early on that the vaccinate or mask policy would not be enforced with visitors, but would be on the honor system instead.[11]

As well, physicians, residents, and medical students are often seen without masks in flu season. As it is extremely unlikely that there this group would have a 99%+ vaccination rate, it appears incontestable that the policy is not being enforced equally for this category among health care workers.

Infection control measures are meaningless if they are not consistent, and the vaccinate or mask policy is utterly inconsistent. And if the masking policy has been implemented in such a partial, patchwork, and inconsistent way, the question arises—what is its actual purpose?

Patients vs health care workers
Another key concern with the current policy is the imbalance between the rights of patients to safe care and the rights of health care workers to informed consent and medical confidentiality. The policy simply obliterates the rights of health care workers without discussion and without even acknowledging it is doing so. And with what justification? Where is the threat to our patients?

The stated policy is intended to promote patient safety. But many of its proponents do not appear to believe that compulsory masking is an effective method of preventing influenza transmission. For example, in the Ontario arbitration, Dr Bonnie Henry, BC’s deputy provincial health officer, while defending mandatory masking policies, admitted that “there’s not a lot of evidence to support mask use.”[9] Dr Allison McGeer, epidemiologist and flu vaccine researcher, also testified in support of mandatory masking policies, but stated “there’s quite a limited literature concerning the effectiveness of masks in prevention transmission.”[9] Even the BC Ministry of Health’s own policy documents concede that masks don’t work, remarkably stating that “the [vaccinate or mask] policy will not be amended to require vaccinated staff to wear masks because there is no strong evidence to support universal masking as a preventative measure in the presence of pronounced vaccine mismatch and in the absence of an outbreak.”[12]

Also at issue is the practical matter of wearing masks. It appears that coercion is at the heart of the vaccinate or mask policy. Masks are extremely uncomfortable to wear for 12 hours a day continuously over a 4-month period. In addition, the requirement to mask serves to put psychological pressure on staff to comply and get a flu shot through the very real peer pressure and disapproval many experience from some of their co-workers. 

Summary
Judged by its professed goals, vaccinate or mask is an utterly incoherent policy. Given its inconsistent and selective enforcement and its lack of universal application of basic infection control principles, it is clear that the policy cannot be shown to confer any benefit to patients. It should be discontinued.

hidden

This article has been peer reviewed.

References

1.    BC influenza prevention policy: A discussion of the evidence. Vancouver, BC: Provincial Health Services Authority; 2013; p. 15.
2.    Patrozou E, Mermel L. Does influenza transmission occur from asymptomatic infection or prior to symptom onset? Public Health Rep 2009; 124:193-196.
3.    Vancouver Coastal Health Authority, FOI application 2015-F-117, 15 January 2016.
4.    Providence Health Care, FOI application F15-029, 30 November 2015.
5.    Interior Health Authority, FOI application 50-IH-2015-2016, 7 January 2016.
6.    Northern Health Authority, FOI application NH-2016-0207, 17 March 2016.
7.    Provincial Health Services Authority, FOI application PHSA 0090-15, 4 February 2016. 
8.    Fraser Health Authority, FOI application, 1-788-FOI, 11 January 2016. 
9.    In the Matter of an Arbitration between Sault Area Hospital and Ontario Hospital Association and Ontario Nurses’ Association, Re: ‘Vaccinate or Mask’ Policy. Accessed 18 October 2016. ona.org/documents/File/onanews/OHA_SaultAreaHospitalONAAWARD_20151028.pdf
10.    Skowronski DM, Chambers C, Sabaiduc S, et al. Interim estimates of 2014/15 vaccine effectiveness against influenza A(H3N2) from Canada’s Sentinel Physician Surveillance Network. Euro Surveill 2015;20:ii=21022.
11.    Lindsay B. BC health officials issue flu shot reminder. Vancouver Sun. 30 November 2015.
12.    Vancouver Coastal Health Authority. Influenza Control Program Frequently Asked Questions. 3 November 2015. Accessed 18 October 2016. vch.ca/media/FAQ_Influenza_Vaccine_Provincial_November_%203_2015(1).pdf.

hidden

Mr Offley is an RN working in the emergency department of Vancouver General Hospital. The views expressed in this article are his own and do not represent the positions of the Vancouver Coastal Health Authority or Vancouver General Hospital.