On October 24, 2012, we posted about Government’s new influenza protection policy for health workers. The discussion has been ongoing ever since, and several nurses have submitted comments or emailed us with questions about how the new policy will impact them. Not wanting to leave our readers hanging, we asked the Ministry to provide answers to some of the key questions nurses have raised.
1. Could the Association work with government to develop some sort of bibliography that has all the most recent evidence and articles about this important topic?
Yes we can and will. As we work to pull together a more comprehensive list, the Ministry has pointed out that there are some resources currently posted on the Immunize BC website (see http://immunizebc.ca/node/551). ARNBC and the Ministry will continue to work together to develop a list of additional information that supports the discussion. Watch this space for more information.
2. Why did nurses learn about this change in policy through the media? Why wasn’t there a dedicated campaign to inform those who are impacted first?
The Ministry feels it’s unfortunate that some employees learned of this decision through the media, as that was certainly not their intention. Health authorities did communicate to their staff in advance of the public announcement, and health industry unions were sent the policy for review a couple of weeks prior; however, it is likely that some staff were not able to access their employer communication before the media picked up the announcement.
Each health authority is delivering their own comprehensive communications to employees, through things like staff intranets and newsletters, QA sessions with managers or staff, work station screen savers, and the QA documents posted. Every effort is being made to ensure employees have access to the information they need, in a timely way.
3. Does a nurse have to put a mask on when entering the hospital and not take it off until they leave? Are there exceptions? Can a nurse remove their mask in the cafeteria for instance, even though there are patients around? Can a nurse take it off if they are trying to talk to a patient about something personal or emotional? Do nurses have to wear masks if they’re giving a presentation or meeting with their manager?”
Immunize BC has posted information on wearing masks (Influenza Control Policy – wearing masks). The policy speaks to type of mask, where masks are required and when they should be changed. The policy states that: Unvaccinated health care workers are required to wear a mask when in patient care locations. Only areas such as cafeterias and lunch rooms reserved for the consumption of food are exempt. Unvaccinated workers would also not be required to wear a mask in administration-only areas, including a private office, where patients are not present.
4. Was due diligence done to determine why some individuals choose to not have flu shots? Has government exhausted ways to get people to do it voluntarily? Wasn’t a stepped missed – the one where people actually make the effort to not just stick up signs in bathrooms, but to educate, to inform and to provide evidence and education to change that thinking?
Each year, comprehensive education and vaccine encouragement efforts have been made across health authorities, through things like peer immunization champions, contests for staff giveaways (even for things like a vacation getaway and an iPad!) and articles on intranets and in newsletters. Despite every effort having been made to increase voluntary rates, we were still not getting the kind of uptake needed to ensure patients are safe.
5. Does the mask work both ways (i.e., will it prevent an individual from getting sick at the same time it keeps patients from getting sick, or does it just help the patients?)
Yes the masks work both ways. Masks can serve as a method of source control of infected health care workers who may have no or minimal influenza-like illness symptoms. Masks may protect unvaccinated health care workers from as yet unrecognized infected patients, visitors or other health professionals with influenza. However, while mask wearing does likely confer some benefit on the wearer, the primary goal in this policy is to protect patients.
6. How or will this be applied to the dental profession? What about community health nurses or people doing home visits?
The policy applies to all Health Authority employees (unionized and excluded), other credentialed professionals, residents, volunteers, students, contractors, and vendors (collectively, these individuals are referred to as “Covered Individuals”) who attend a patient care area. Any dental professionals covered in the aforementioned group will be expected to adhere to the policy.
A Patient Care Location includes: any building, property, or site owned, leased, rented or operated by a Health Authority where there are patients, residents or clients who are receiving care; and any patient/client/resident home or other location where Covered Individuals interact with the patient/client/resident in the course of his/her work for the Health Authority.
7. If it’s just a hospital policy, isn’t that kind of like brushing only one tooth?
The policy applies to any building, property, or site owned, leased, rented or operated by a Health Authority where there are patients, residents or clients who are receiving care; and any patient/client/resident home or other location where Covered Individuals interact with the patient/client/resident in the course of his/her work for the Health Authority.
8. As a culture we’re too heavily focused on immunizations. Normal, healthy adults should be able to either fight the flu off and if unable to do so will not suffer long term serious consequences as a result of having the flu. Is it really necessary to suggest we’re being remiss if we don’t get a flu shot? Is this really a matter of public health? What about our personal choices, not only nurses but as individuals?
Nearly every professional code of ethics in the health care field – from medicine, to nursing, to pharmacists – outlines that the interests of the patient must come first, and that healthcare workers have a duty to act in the best interests of their patients, and not put them at undue risk of harm. The flu can cause serious illness in those most at risk – including seniors, people with compromised immune systems, respiratory illnesses or a variety of other underlying causes. In other words: many of our patients and long-term care residents.
According to the Public Health Agency of Canada, nationally there are between 2,000 and 8,000 deaths per year from influenza and its complications. Hospitalized patients are frequently more vulnerable to influenza than members of the general population and healthcare workers have been implicated as the source of influenza in healthcare settings (infected individuals are highly contagious and can transmit influenza for 24 hours before they are symptomatic). Vaccination of healthcare workers will reduce their risk of getting influenza and spreading it to patients. The flu vaccine is safe and effective and, when used in conjunction with other infection control practices such as hand washing and remaining home when sick, it is extremely effective at preventing illness.
The policy allows for personal choice - workers have the option to wear a mask if they are unable to be vaccinated, or choose not to.
Government also reminds us that while normal, healthy adults are likely able to fight off infection far better, the point of this policy is to protect patients – people who by definition are NOT healthy. These are the very people who are at risk of serious complications. By protecting yourself from getting sick with as many tools at your disposal as possible – including flu shots – you are protecting your patients who do not have those options available to them.
The provincial news release and backgrounder can be found on the Ministry of Health website (Click to View)
ARNBC's news release on the flu shot issue can be found on our site under News (Click to View)
This is a GREAT followup to the work you've already done on flu shots on your blog. Well done having government actually respond to the questions nurses asked.
Congratulations ARNBC, this is exactly why I come to your website. I consider this one of the most proactive efforts to assist members and ask questions that I've seen.
My colleagues and I have been talking about this ever since the BCNU lodged their grievance and hit the media. We totally disagree with the Union on this. Maybe we didn't like how we found out, but if the evidence says this could save even one patient, then I would be remiss in my practice to not get a shot.
I don't think there are very many nurses who are really angry with this policy. I appreciate ARNBC taking the time to seek out answers from government.
Great press release. Great blogposts. It's about time someone said what most nurses are thinking. We're FINE with this policy. We wish it had been handled a bit better, and I didn't need to learn about it on the 6pm news, but otherwise, it's not a big deal.
Time to accept it and move on to other more important nursing issues like patient overflow, workload, etc.
I don't agree with the new policy at all, and I think it's barberic that they're even considering forcing us to get the shot or be shamed into wearing masks. Plus, can you imagine wearing a mask for 6 months straight. My teeth will fall out.
Even though I don't agree with the policy or ArNBCs positoin on this, I really respect the Association for taking a stance and for checking out questions with government. I think this is a really responsible thing to do. Most nurses would agree with you that this policy is a good one, and since you are the voice for nurses, I think you have made the right choice by supporting it.
If my teeth do fall out maybe I'll write a blog on the dangers of prolonged mask wearing.
I can't believe ARNBC is supporting this ridiculous policy. You say that the evidence is clear, but thats not what the Cochrane Review and other articles have said.
This is a heavy-handed, dictatorial, oppressive policy that will only seek to enrage nurses.
Shame on you.
What I find stunning is that the latest scientific evidence isn’t factored in IF it goes against the usual pro vaccine dogma?
People who contracted the Swine flu and who got the seasonal flu vaccine the year before got more severe symptoms . This has just recently been duplicated in follow up studies. This implies that we are only now realizing that we are not fully aware of the implications of mass flu vaccinations. Read this carefully…why aren’t we considering this new information?
http://www.vancouversun.com/health/Vancouver+researcher+finds+shot+linked+H1N1+illness/7217609/story.html
Why is everyone so focused on one article, the Cochrane piece? A variety of additional, reputable, sources have indicated they feel mandatory shots are necessary. Sources like: Lancet, the Canadian Medical Association Journal, the British Medical Journal. if everyone is so concerned about evidence what about evidence on the other side? Or is all of this fuss just about the Union needing to disagree with everything government does?
Re. The vancouver researcher with the ferret study... Why is the last quote from her in the article, that she hopes this work will not stop people from getting flu shots?
Thank YOU! My question exactly? If evidence goes against the 'expected' pro vaccine evidence, then we should just ignore it? That's insanity!! This is a highly significant flaw in the mandate mantra. A mandate could be endangering not only all the health care workers who have been 'forced' to take the vaccine, but ultimately our patients. We may be unwittingly opening the door to becoming infected with the much more serious H1N1 virus (or some yet unknown virus) and then passing that onto the most vulnerable people. That could put them in much greater danger. Agree?
I'm going to wear the mask...and I'm going to tell ALL who ask why I'm wearing it....recent studies show..etc etc. Be careful what you're asking for Kendall, you may get the exact opposite result you were hoping for.
http://www.cbc.ca/news/yourcommunity/2012/09/how-likely-are-you-to-get-a-flu-shot-this-year.html
Here's another article regarding this new evidence (check below for link) .. If you notice the poll results, these people who are made aware of these new studies are equally divided on whether the 'want' to get the annual flu vaccine or not......Isn't that wonderful that they actually have the option, too bad health care workers don't!
Unfortunately some of the debate on this represents rather a poor state of scientific understanding which does not reflect well on our profession.
1) Animal study findings are not transferable to humans, and this is a common misconception of the media, but professional nurses should really know better. If you examine the evidence pyramid you will find animal and in-vitro studies are down the bottom.
2) Cochrane does not support vaccination? If you look at the list of reviews here: http://summaries.cochrane.org/search/site/influenza%2520immunisation you will find the overall evidence is that vaccination helps in the interruption of person-to-person spread of the influenza virus or prevention of pneumonia. As would be expected there are a couple of reviews that suggests the effectiveness of both drugs for the prevention and treatment of symptoms of influenza are weak, and that there may be side effects in some cases (as with all drugs). However, the overall current evidence is that it is an effective in preventing spread of the virus, and has value in symptom control particularly in children and the elderly.
3) Much of the antipathy towards this appears to arise from arguments about personal
rights and an anti-science/vaccination agenda. Immunization policy is not dogma, it has been well established and demonstrated as good public health policy. Sadly this reflects the well-documented MMR and mumps vaccine controversies in the late 1990’s which were serious cases of bad science that triggered a widespread health scare, of which the ramifications that still seem to be having an effect today. More worryingly bogus medical stories and examples of bad science and pseudoscience still dominate this issue in the media and in pop culture, where anti-vaccination stances have been supported by celebrities such as Charlie Sheen Jim Carrey, and Jenny McCarthy.
If we support evidence-based practice policies, then this one like other current immunization requirements makes sense on the basis of the existing evidence. However, if we want to abandon this and claim professional nurses individual rights override the public-health needs of their patients, or denounce the germ theory of disease as a rationale, it will be the public who lose out.
Thank-you Bernie for this vital reflection on the direction of this debate. Flu immunization is the best public health measure we have to offer in protection of the public, and this debate is now confusing the public as to its efficacy. Nurses are in the position to model health behaviors such as immunization to the public and other health care workers and we must consider how the profession is communicating this responsibility at this time. Of concern is the media interest in a profession divided over the issue, which serves to erode public confidence in the health promotion strategies we have actively promoted and implemented, such as the annual flu immunization.
This debate should not be over the efficacy of a well supported public health measure, but one of how nursing can and should be involved in policy implementation and evaluation. Nurses agree that efffective and equitable health policy is achieved through full and informed engagement of the nursing profession and this should be the focus of our deliberations over the current policy.
http://www.bccdc.ca/util/about/UBCCDC/People/Faculty/DrDanutaSkowronski.htm
Here's a link to Dr. Danuta Skowronski showing her credentials regarding this recent study. Are you saying she's not qualified Mr. Garrett? If so...why?
And should the fear of possibly creating another unfounded anti-vaccine scare dissuade open debate on today's science?
Personally I think that's a very slippery slope! We now see proponents like Kendall appearing to try to gag opposing views by exaggerating scientific findings, mandating compliance, and stigmatizing (via masks) the opposition. This, in my opinion, will only lead to more distrust of vaccines?
I don't think any well informed people who will debate the wonders of vaccines like those for polio or diphtheria. However... this growing plethora of curing countless human ills via vaccinations may yet have unknown consequences. These recent studies seem extremely relevant to this debate, yet media seems hesitant to open up the discussion. Why? Because it contradicts todays pro-vaccine 'dogma'!
Dogma defined..."A principle or set of principles laid down by an authority as incontrovertibly true"
Nurses must recognize that it is impossible to create airtight evidence around a population-based public health policy without implementing and evaluating it. The BC decision to take this step is based on science that is as extensive as any in the public health domain. We recognize that "mandatory" public health policy inevitably has detractors for reasons of individual rights and freedoms. And yet, in our province, we remember the leading voice in public policy debates that our nursing professional association took on such mandatory policy issues as auto seatbelts and bike helmets. Even in the face of vociferous pushback from those who felt such decisions infringed on their right to decide, nurses spoke out strongly and convincingly for the value of these new regulations in preventing unnecessary suffering for individuals and families. In all such processes, as the population health benefits become more clear over time, debate tends to fade. Alternatively, if the benefits of the policy are not as anticipated, revisions and changes can then be informed by current and locally relevant contextual evidence. And that is the process of evidence-based public policy – never an exact scientific “truth,” but a way of approaching practice that we strongly endorse.
My worry is that, by using public media to challenge the quality of the evidence associated with this policy, nurses may be inadvertently triggering a heightened sense of confusion among the general public as to whether flu shots are safe and effective. From my perspective, we need to be strong, clear and consistent with this message, as it will save lives.
At the same time, I do not believe that vocal support for the new policy has to detract from the very real concerns individual nurses may have if they are unwilling or unable to get immunized. As happens with all policy processes, the devil may be in the details. I hope we would all urge health authorities, employers and professional practice leaders to consult directly with nurses at the front lines of practice. So often it is those most closely affected who will come up with creative and workable measures to keep patients safe while preserving the rights and dignity of the professionals. But that’s an argument that should not be front page news if it puts patients at risk by complicating the message about why flu shots are a good idea. The public trusts us for a reason!
"Flegel points to a 2010 study published in the same journal that concluded 55 per cent to 65 per cent of doctors don't get an annual flu shot."
That is from a CBC article...So my next question, would be...why? Why do the majority of Doctors choose NOT to get the flu vaccine? There must be a reason for that statistic and I find it very illogical to claim Doctors are just lazy, misinformed, highly irresponsible, or just too plan stupid to make an informed decision.
So...why? Could it possibly be that they question the science?
Ben Goldacre Ted Talk, (move it ahead half way perhaps), he actually goes on to talk about Tamiflu. The way he ends the..."sunlight is the best disinfectant!" and I agree whole heartedly 🙂
http://www.ted.com/talks/ben_goldacre_battling_bad_science.html
Hi
I don't think I have much to add to the discussion, except I really appreciate the wide variance in opinions that have been shared here. I'm learning a lot from both sides of the debate, and I think it's really healthy to host a conversation like this.
I feel like I will get the flu shot this weekend because that's the best choice for my family and I. But I understand that there are a lot of people who won't want to get it, and I respect that choice too. Tara, I've really appreciated your views on all of this and I'm glad that you've spoken up. Thanks for sharing your thoughts. And thanks to ARNBC for letting this discussion take place on the website. It's really great.
Thanks Lisa,
It sound like you're 'Pro Choice'....as am I !!
An open, unbiased, non coercive discussion on the evidence is what we all need. Wonderful.
🙂
What hasn't been acknowledged is that nurses are already required to have other immunizations in order to enter their profession - Hepatitis B, Tetanus-diptheria and MMR. In fact we are required to prove our titres even. Recently many nurses who work with pregnant women and infants were required to update their pertussis vaccines in response to a local outbreak - in order to protect their patients. Also, nurses are required to have a Tb skin test as part of entry to their schooling and often of employment as well.
Influenza is just another vaccine that we require as people who have chosen to care for the most sick and vulnerable. I'm proud to wear my flu sticker and to tell my patients that I am fully immunized because I care about my health, my family's health, their health and the health of my community.
From a more selfish point of view, when my colleagues are off sick with the flu for 2 or more weeks, the unit may work short (especially during holiday season). It's frustrating that those of us who stay healthy and prevent the flu have to cover for those who didn't. Even if people don't get paid for the sick time, the rest of the team still suffers.
On CBC The National last night (Nov 25) there was a story on influenza and how many people actually die from the flu. At the end of the story they calculate the number - watch and be stunned. Less than 1 % (0.02%)
If you slide it forward until 17:40 mark - the story appears. (only 4 minutes long - ends 21:12)
http://www.cbc.ca/player/News/TV+Shows/The+National/ID/2309263526/
BCNU cites evidence from Cochrane Collaboration which is credible and denounces the utility of the flu shot for health care workers. If there is NO proof that health care workers are the vector how could ARNBC support a policy NOT based on credible evidence. As the link above shows, PHAC is not citing credible facts.
This is a link to a rather long informative post and I have to read it all myself yet...but as this is something not yet covered on this site, I'd thought I'd highlight it.
THE COST in B.C alone is over $18,000,000 per flu season to vaccinate.
Are you frigg'n kidd'n me? With so much needed in the way of research, hospitals, staff...we're spending our tax dollars on mass vaccinations that are backed up by highly flawed statistics!! ....
"This is not a trivial, or inexpensive question. BC already buys 1.1 million doses of vaccines each year to provide to those in the province who want one, at a cost of about $17.5 million. Moving to 95 percent coverage of BC’s health workers (assuming about 110,000 health workers) would cost in the neighbourhood of $1 million more per year."
ooops....link is http://focusonline.ca/?q=node/447 Read it all if you have the time, it's rather good. 🙂
April 20, 2013
Dear Colleagues
Below you will find a copy of a letter we sent several weeks ago to Mr. Graham Whitmarsh, the BC Deputy Health Minister. This letter addresses the concerns we share regarding the current BC influenza policy of compulsory vaccination-or -masking for all provincial health care providers. We are making it public in the hope that it contributes to sparking a discussion as to the shortcomings of the current policy, and in the hope that this discussion can help articulate other measures we can all be taking to reduce the transmission of influenza and influenza-like illnesses. If you agree with the points raised in our letter, we would like to ask that you forward it on to any of your colleagues and co-workers who you believe would be interested in it.
If you would like to be kept in touch with on this issue, we urge you to send us your personal email address, and you will be sent further updates in the future.
We will forward you Mr. Whitmarsh's response when it becomes available.
Yours truly,
Tamara Ballard RN
Christine Davie RN
Tracy Johnson RN
Will Offley RN
John Tino RN
Cindy Vanderbyl RN
Tracy Visser RN
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Mr. Graham Whitmarsh
Deputy Minister of Health
Province of British Columbia
Dear Mr. Whitmarsh,
Last November 30 you sent a letter to the CEO's of B.C.'s six health authorities announcing the temporary suspension of the disciplinary provisions of the province's new influenza policy. Prior to this, health care workers were expected to get the flu vaccination or wear a mask throughout the flu season, and those refusing to do so faced possible disciplinary action up to and including dismissal. Your letter went on to state "I would like to afford health care workers the additional opportunity to voice their opinions on how best to achieve our shared objective.... It is my hope that, through the forthcoming dialogue, we can establish a shared vehicle for moving the policy forward."
We welcome this opportunity for dialogue, and are submitting this letter as an initial contribution in the hope it sparks further contributions from others - the physicians, nurses, therapists, paramedics, support staff and all those involved in providing health care and/or providing the services that make it possible. However, we think this debate needs to be somewhat broader if it is to be a fully productive discussion. It should encompass the content of the influenza policy itself, not just the issues concerning how the policy is to be carried out.
Our opposition to the current flu policy is based above all on the understanding that there is no scientific evidence to indicate that immunizing health care workers against the flu reduces the transmission of influenza to our patients. On September 8, 2010 the Acute Respiratory Infections Group of the Cochrane Collaboration reported on five research studies which "found that vaccinating healthcare workers who look after the elderly in long-term care facilities did not show any effect on the specific outcomes of interest, namely laboratory-proven influenza, pneumonia or deaths from pneumonia...." On the basis of this, the Cochrane Collaboration concluded "there is no evidence that only vaccinating healthcare workers prevents laboratory-proven influenza, pneumonia and death from pneumonia in elderly residents in long-term care facilities." (T. Jefferson and T.J. Lasserton "Influenza Vaccination For Healthcare Workers Who Work With The Elderly, http://ow.lv/fF6bW , emphasis added)
The October 2012 University of Minnesota CIDRAP study arrived at the same conclusion, noting that U.S. policies adopted in 2006 aimed at promoting compulsory influenza vaccinations for health care personnel could provide no compelling scientific evidence that this did actually reduce transmission of the flu from health care staff to patients. (The Compelling Need For Game-Changing Influenza Vaccines, Center for Infectious Disease Research and Policy (CIDRAP), University of Minnesota, October 2012, pp.54-64, online at http://ow.ly/fF6qs)
These findings above completely contradict the stated basis for the flu policy - the presumption that vaccinating healthcare workers will reduce the transmission of flu to our patients.
More than that, we believe the current provincial flu policy fails to reflect the values we believe the health care community should operate on. Specifically, we believe that in addition to being a policy that fails to demonstrate a grounding in scientific evidence, it is coercive rather than persuasive, it constitutes an invasion of privacy, it nullifies informed consent, and it is not even internally consistent.
A coercive policy - We have no objections to the health authorities attempting to persuade employees to receive flu shots, or holding vaccination clinics. We believe that staff who wish to receive vaccinations should be free to do so. Our opposition to the policy is that it is a coercive one, backed up by the threat of future sanctions up to and including termination for those who do not comply. While these measures are temporarily on hold, your letter made it quite clear that this would end by the 2013-14 flu season.
A breach of privacy - The policy requires all staff to wear stickers indicating they have been vaccinated, or else to wear a mask, and in so doing has the effect of requiring staff to publicly disclose private medical information (i.e. whether they have been vaccinated or not).
A nullification of informed consent - All of our clinical practice is based on the premise that a competent patient at all times has the right to make an informed consent to any medical procedure. Requiring health care staff to receive vaccinations or else face termination removes our right to make (or withhold) our consent to an invasive medical procedure.
An internally contradictory policy - In its current form the policy is not even internally consistent. We will provide two examples. First, the policy requires health care staff to produce proof of vaccination or else to put on a mask, but it makes no such requirement for visitors. A second example is that we are being sent different messages around management's expectations in regard to reporting unvaccinated coworkers who are not wearing masks. One document states "you are asked to report this behaviour your supervisor" (Health Care Worker Influenza Control Programme, Questions And Answers, p.8). But another document contradicts that, stating instead "individuals who witness any instances of noncompliance with this policy are required to report the incident of non-compliance immediately to their supervisor." (VCH, Influenza Control Program Policy, p.2., emphasis added)
For all these reasons, we ask that the disciplinary provisions of this policy be withdrawn permanently. We would prefer instead to be discussing all the ways we can contribute to lessening the risk to our patients, whether through more consistent handwashing, improved housekeeping standards, encouraging staff to stay home when sick or any other measure.
We look forward to your response this letter and to continuing this dialogue.
Yours truly,
Tamara Ballard RN
Christine Davie RN
Tracy Johnson RN
Will Offley RN
John Tino RN
Cindy Vanderbyl RN
Tracy Visser RN
I am shocked and a bit disappointed that healthcare workers would resist this. Is the point not to keep patients safe? It's such a small thing to ask in exchange for a life saved. I'm really glad to hear that nurses recognize there might be some value in this.