When San Diego County workers involved in patient care refuse to get flu vaccinations, their only option is to wear a white surgical mask — from the time they clock into the hospital to the time they leave — if they want to keep their jobs.
That’s the mandate from the county public health department issued last Nov. 4. It applies to workers in “all licensed acute care hospitals, skilled nursing facilities, long-term care facilities, ambulatory and community clinics and ambulance providers.”
Many health professionals believe that wearing masks is more effective than not wearing them because they do contain viral particles that could spread from a cough or sneeze as far as 20 feet.
But evidence is sparse that even when worn correctly, masks prevent transmission of influenza from a health care worker to a patient, according to the Centers for Disease Control and Prevention. “No studies have definitively shown that mask use by either infectious patients or health-care personnel prevents influenza transmission,” the CDC says.
The masks can impair communication, especially for those hard of hearing, are uncomfortable and can be scary for some patients. Health care workers may take them off and forget to put them back on.
Despite policies at each health care setting that encourage workers to remind each other about the policy, colleagues may be loath to call out unmasked, unimmunized co-workers — who can be easily spotted because they don’t have a special sticker on their name tag.
Health care workers are allowed to take off the masks in break rooms and cafeterias, when they take a sip of coffee or water, and — intentionally or not — sometimes leave them, or misplace them. For some, they are a poor fit.
That’s why some health care organizations around the country don’t require masks for their unimmunized workers.
The Mayo Clinic's two hospitals in Rochester, Minn., for example, do not require their use for their 32,000 health care workers, even for those who aren't vaccinated, which is about 8 or 9 percent of the eligible workforce.
“It's just not practical; it's counterproductive,” said Dr. Priya Sampathkumar, chair of Mayo's immunization and infection control committees, who called the mask “a scarlet letter.”
“You get hot under the masks, patients can't understand what you're saying sometimes, so you do take them off. They're not patient friendly, and they can be scary to patients.”
Wearing masks “is hard to enforce,” Sampathkumar said. Calling out a co-worker for not wearing a mask may in effect identify the person as having a certain medical condition, which could disclose protected medical information.
Instead, Mayo strongly urges employees to get immunized and encourages them to stay home when they're getting sick.
“Masks are only worn by personnel who are having symptoms and must be at work, or because the patient has an illness that could be transmitted, not because of your vaccination status,” Sampathkumar said.
But in San Diego, Scripps Mercy Hospital’s infectious disease specialist, Dr. Nancy Crum-Cianflone, said they are better than nothing.
“There are legitimate arguments against policies requiring masks (for unimmunized health care workers),” she said. “But there are a lot more legitimate arguments for it.”
Bottom line, she said, is that health care workers “who don’t have a legitimate reason for not getting them are getting vaccinated at much higher rates.”
For her, masks are extremely uncomfortable.
“Personally,” she continued, “I would go crazy wearing one. You feel like — well, you’re not exactly suffocating, but — you feel like you’re not getting enough air.”
She added that “it’s a moral obligation for health care providers to do everything we can to protect our patients and do no harm.”
And if you really can’t get vaccinated, “then you should put on a mask.”
Dr. Thomas R. Talbot, chief epidemiologist at Vanderbilt University School of Medicine in Nashville, Tenn., and a leader with the Society of Healthcare Epidemiology of America, shared his view that masks are a good thing, although enforcement is problematic.
With the masks, “you don't eliminate the amount of virus that gets out, but you dramatically reduce the amount,” Talbot said.
He added that there isn't much data that mask wearing prevents infections, because the topic is hard to study. But, he said, it makes sense. We know you can shed virus even before you have symptoms, and the mask can prevent that spread.”
However, he added, “If you say you have to wear a mask if you're not vaccinated, but there's no one coming around to remind people, and have accountability, then you don't have commitment.”
At Vanderbilt, exceptions to getting vaccinated are granted only after a rigorous professional review of the employee's excuse. With an exemption comes a requirement to wear a mask.
Without that exemption, starting this year, the stakes for Vanderbilt’s health care workers rise. Those who refuse will go on unpaid leave, he said, predicting Vanderbilt’s immunization percentages will rise from last year's 92 percent to 98 percent.
Like time-outs before surgery to prevent operations on the wrong body part, “if it's not tracked and followed up, and people held accountable, people aren't going to do it … and any program will fall apart,” Talbot said.
Patient safety is all about a culture of safety, he said.
Workers know they need to stay home when they're starting to feel sick.
“But we know that we as health care workers don't do that very well,” Talbot said. “And some may mistake early symptoms as just an allergy flare up.”
He continued: Unvaccinated healthcare workers “who object to wearing the mask say, 'Oh my God, the mask is scaring patients' and take it off. Well, so is giving them the flu. If you can empower the provider to understand that, you help mitigate that risk.”
