Effect Measure

A Catholic hospital system in Arkansas seems to have come up with an innovative solution to encouraging health care workers be vaccinated while allowing them the autonomy to make their own decision. When we last brought up this question one of our commenters said he’d like to see a button on health care workers that said, “I’m not vaccinated.” St. Vincent hospital system seems to have figured out a way to do this while still protecting both the worker and the patient. The idea is surprisingly simple:

Given the choice between face masks or the seasonal flu vaccine, nearly all 3,200 employees opted for the needle at St. Vincent Health System ? the first hospital in the state known to have required staff to make such a choice.

Only six staffers opted for the mask, said Jon Timmis, the chief strategy officer at St. Vincent, where officials anticipate this year’s flu season will hit harder ? and sooner ? than usual.

“Based on those two factors ? both coming early and the suspicion that it was going to be a heavier flu season based on patients already coming through our emergency department ? we felt that we as a hospital, one, have a responsibility to be on the leading edge of public health,” Timmis said. “But two, (we) need to protect our work force so that if the flu season is as bad as some have anticipated that we have a work force here to take care of patients.”(Jill Zeman Bleed, AP)

Well, he might have added, “Three, we have an ethical responsibility to protect our patients who are on average at higher risk of death and disability if they have the flu,” but this is a pretty innovative plan. It’s the button that says, “I’m not vaccinated” while providing some (possibly minimal) protection for the worker and some (probably a bit more) protection for the patient. And a mask — especially an N95 — are not comfortable to work in for long periods and many settings. Vaccination starts to look better.

Experience is showing that mandatory vaccination for anyone but children, who can’t make their own decisions, has its own adverse effects. Requiring employees to wear a mask is not different than requiring them to wear gloves or a scrub suit. But it allows someone to decline a vaccination, for whatever reason. And it tells the rest of us whom we are dealing with.


  1. #1 Joanna Holland
    October 8, 2009

    I think that’s a fantastic idea. I’m not comfortable with the button idea as I think healthcare workers advertising that they’re unvaccinated may send the wrong message to patients, and it would also “punish” people who have a valid reason for declining that shot (such as egg allergy). This makes logical sense as it’s an alternative way of protecting patients, as well as the unvaccinated staff themselves. Having worn an N95 mask for long periods of time in Toronto during SARS, I can agree that this would make the flu shot look a lot better to a lot of people.

  2. #2 Mark
    October 8, 2009


    I surprised you find this version of manditory vaccination policy acceptable, given your posting a few days ago. This does not provide healthcare workers with a free choice since the “option” of wearing a mask all time has no public health benefit beyond punishing the worker for not choosing to have the flu vaccination. It is meant soley as a “scarlet letter” to force accepting the vaccination. I know of one hospital wear the managers are making jokes about those wearing masks.

    Most of these employers have not thought out these policies well. For example, some policies exclude workers with medical or religous reasons for not getting the vaccination, others do not. Some policies require wearing the mask all the time during a shift, other only with patient contact. The enforcement often mentioned is “not wearing your mask properly at any time is your voluntary resignation”

    In addition, my experience looking at many of these programs of manditory vaccination or masking is that the employers are often ignoring many other aspect of a comphrehensive infection control program for H1N1 contained in the current CDC guidance, including not providing N95 or better respirators, not providing training to staff, not doing proper triage or isolation of known or suspected patients.

    We need our healthcare workers more than ever if this flu season is as difficult as many predict. These policies are not helpful.

  3. #3 Snowy Owl
    October 8, 2009

    I am surprised too after reading your post of few days ago that you accept stigmatization of non-vaccinate HCW, this will backfired, I am convinced, no one like being stigmatized.

    Snowy Owl

  4. #4 Joe
    October 8, 2009

    Considering no vaccine confers 100% immunity…I would imagine…vaccinated or not…health workers would always wear a mask dealing with infectious disease.
    So much for the “Innovative Idea.”

  5. #5 Christina
    October 8, 2009


    As a healthcare worker, I believe that this is a fair solution. The only way that a healthcare worker would be stigmatized while wearing a mask with patients is if he/she chooses to tell the patients, “I have to wear the mask because I don’t want to get vaccinated.” Otherwise, if the patient asks, then he/she could say something like, “I choose to wear a mask to protect both of us during the flu season.” Of course, a patient might wonder why other healthcare workers aren’t wearing masks, but they probably won’t ask. I often wear gloves in situations in which my co-workers don’t, and my patients don’t ask about it. Also, if that hospital system in Arkansas actually has enough N95 masks to make this policy work, at least they are ahead of many workplaces.

    On a slightly different topic, I have a question for Revere. I know you normally, and understandably, don’t like to comment about information that Dr. Henry Niman posts, but I’m very curious regarding your opinion on his most recent posting about people getting infected twice with pandemic H1N1: http://www.recombinomics.com/News/10080901/H1N1_Buffalo_2.html. The anecdotal “evidence” he refers to seems like spurious support for his argument, but I was just wondering what you think about whether reinfection is even possible, and whether the current vaccine (based on the spring version of the virus) might not be as effective now in the fall. Thank you!

  6. #6 Christina
    October 8, 2009

    As an addendum to my above comment, you have to copy and paste the web reference I included, since the period at the end of the link makes the actual link invalid. Sorry about that.

  7. #7 Phila
    October 8, 2009

    no one like being stigmatized.

    I suppose we need to stop making food preparers wear hair nets and funny hats, too. After all, some of them may not feel like it.

  8. #8 SusanC
    October 8, 2009

    I think it’s a fair solution, and carries benefits for everyone…

  9. #9 Mark
    October 8, 2009

    The wearing of the mask in this case is for no positive reason, as wearing gloves or gowns, for healthcare workers or hairnets for food service. Employers and supporters of these policies know that but find that rationale convincing in their PR efforts.

    The sole reason for the masking option is to appear to be allowing workers to chose (needed because of a federal Appeals court decision a few years ago), to punish those who will not take the vaccine and to be a “scarlet letter” to force taking the vaccine. Surgical masks do not provide protection from the flu for patients or the healthcare worker. An infection prevention manager admitted this to me in a conversation a few months ago when this idea was being considered. And the point that key is that most of those advocating this policy are not supporting other policy for good infection prevention program, such as the proper use of N95s when caring for flu patients, proper triage and isolation and training of the healthcare workers to be prepared to deal with H1N1. A good infection control program is more than just vaccinations and handwashing.

  10. #10 Racter
    October 8, 2009

    I wouldn’t want to rely on a surgical mask to protect me (as the wearer) against airborne pathogens — but whether the surgical mask effective in preventing an infectious person from exposing others seems like a different matter altogether. Seems like a no-brainer when you consider the reason we call it a “surgical mask”: for a person undergoing surgery, even a healthy person poses a potential contamination risk; a tiny bit of saliva in the wrong place at the wrong time could have pretty serious consequences — and for a person hospitalized for any one of a thousand reasons, exposure to influenza virus could pose just as serious a threat. Unless you can provide evidence that this is not an effective practice, it seems fair to ask why it should be considered any more unreasonable to require an unvaccinated person to protect vulnerable patients by wearing a mask than it is to require a surgeon to wear a mask while performing surgery?

  11. #11 Mark
    October 8, 2009

    Dear Racter,

    he evidence shows that surgical masks are not as effective as a source control as we’d expect. Research published in the infection control literature cast doubts on their effectiveness. This was reviewed by Dr. Brosseau at the recent IOM meeting on PPE for H1N1. This is a smokescreen used to justify a punative program.

  12. #12 Racter
    October 8, 2009

    I submit that “not as effective as we’d expect” is not the same thing as “not effective”.

    The way I see it, the only thing that can be absolutely guaranteed is that anyone looking for absolute guarantees is setting themselves up for disappointment. It’s about shaving percentiles off of odds.

  13. #13 Mark
    October 8, 2009


    No one approach will be 100% effective. But employers enacting these policies are betting on the vaccine as their main infection control method. They mostly oppose workers using respirators, they are not doing training, not setting up proper triage, isolation and other infection control methods. I support voluntary vaccination programs (which can include 70-80% of all staff if rolled out properly) as one part of an overall IC program. Many healthcare employers (and state and local health departments) have done little to really prepare their faclities for this H1N1 season. Much of their attention has been focused on opposing the reality of airborne transmission, opposing the use of respirators,etc. Where is the outrage over their lack of preparation and their refusal to follow the unified national guidance from the CDC and OSHA?

  14. #14 caia
    October 8, 2009

    My understanding is that surgical masks prevent large droplets from traveling when someone exhales, speaks, or coughs. And since droplets are one of the ways flu is spread, and medical personnel are at least theoretically trained in proper mask hygiene, they may well reduce the risk of an infectious person infecting others.

    And while it may not have anything like 100% effectiveness, ethically it does send the right message: you have the right to take your chances for yourself, but not for your patients (and colleagues, who are also placed at risk by insufficient herd immunity, even if they are vaccinated).

    Your right to cough your germy cough ends at my face, and soforth.

  15. #15 gilmore
    October 9, 2009

    Shouldn’t they all be in masks when being exposed to patients shedding virus. . . Vaccine or not? ? ?

  16. #16 Racter
    October 9, 2009

    I would regard any approach to infection control which relies entirely on one method as poorly conceived, period — but I don’t know that I’m quite ready to accept your observation that vaccination IS widely regarded as THE main infection control method. I don’t disagree that there are other approaches that may be underutilized. But I still don’t see that as being very relevant to the question of whether health care workers should be either vaccinated or masked.

    Resources are always finite, and allocating them in anticipation of an event for which there is essentially no precedent necessarily involves making some judgement calls. Some measures are simple, straightforward, and cost effective. Vaccination is one. Mask-wearing is another. I don’t find gilmore’s suggestion (both) to be overly cautious. I was thinking it would be cool to have a mask that comes pre-printed with the biohazard spider thingy. I figure if things get really hairy, I could wear that sucker to the grocery store. Sigma be damned, by GOD that oughta get me a little distance!

    It would be swell if no one needed to visit a hospital this winter for any reason other than to be treated for influenza, wouldn’t it?

  17. #17 BostonERDoc
    October 9, 2009

    Will be hard to enforce and bordering being discriminatory. Arkansas has a law mandating influenza immunization for all HCWs but individual has opt out option due to religious or moral beliefs without penalty so I smell law suits brewing.

    Unlike the white house, I favor true transparency–encourage all patients to ask the HCW: Are you vaccinated against_____? That way the patient is informed and the HCW is not discriminated against. The pt can then make a decision as to whether or not they want to be treated by the clinician. We now encourage hospitalized pts to ask the clinician: Did you wash your hands before they touch them.

  18. #18 Paula
    October 9, 2009

    BostonERDoc, I understand what you are saying re discrimination, but I wonder if you have ever been a patient in a hospital where you were not known to be a member of the profession. A patient asking any question, let alone a question that a less than progressive practitioner may take as “insulting” or as invasive of her/his prerogatives, may well feel too intimidated and, in point of fact, may indeed experience retaliation, ranging from snide looks to something more serious. Nor are patients always in that “free choice” ideal position to decide “whetehr or not they want to be treated by the clinician”. Perhaps it should not be left to patients to have to remind one that a pandemic may shift a bit the balance among one’s responsibilities and one’s rights.

  19. #19 Phillip Huggan
    October 9, 2009

    3 potential ways of flu spread, we don’t know which are significant:
    1) are aerosol (little drops).
    2) big droplets.
    3) phlegm or mucus membrane fluids on your hand to some surface to someone’s hand to their face.

    A face mask stops #3 cold. Removing or putting it on improperly is a failure mode.
    A face mask probably stops some/most of #2.
    Even for #1, given talking to someone spreads a certain epidemic well (I think from a study of cases in an airport or on a plane…can’t remember if Swine Flu or earlier SARS or something), it probably helps a bit, though removing the mask could spread more the #3 way.

    Just because we don’t kno with 100% certainty how flu spreads doesn’t mean do nothing, as some are suggesting on this thread. Really if there was no human testing I’d see an objection to not being vaccinated. Since there is maybe time to find a new career? I’d object to treating ugly patients on aesthetics grounds if allowed.

  20. #20 revere
    October 9, 2009

    BostonERDoc: It is’t a law. It is hospital policy and they don’t have to enforce it. It’s done. 6 people out of 1000 plus opted for a mask. The rest got vaccinated. By their own choice. You wear a mask in surgery and gloves and scrubs. If you serve food in the cafeteria you wear a hair net. And if hyou aren’t vaccinated you wear a mask. As some have suggested maybe this is worong because maybe everyone should wear a mask. I think this is a better idea. Not foolproff, but at least these fools have masks on and you know who they are.

  21. #21 Tom
    October 11, 2009

    I work at a hospital with a similar policy – vaccine or mask. Our infection control department often works with their counterparts at St Vincent on policy and procedures, so I suspect the policies are actually the same. However, I have not seen the St Vincent policy, and the AP story did not provide any details. We too had the choice to receive the vaccine or wear a mask. However, you could only choose the mask option after you had provided medical or religious reasons for not receiving the vaccine and were approved. Only 6 of 3200 not receiving the vaccine is awesome, and I applaud St Vincent for that. But the choice between vaccine and mask might not have been as straightforward as the AP story implies.

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