I Have to Wear a Mask? Unfair!

I recently discovered something that disturbed me a bit, but which I did not find altogether surprising. In December, the Massachusetts Nursing Association (MNA) issued a position statement opposing mandatory masking of health care workers as a means of preventing the spread of influenza. The statement comes as many hospitals in the state are beginning to require that those health care workers who do not get vaccinated against the flu must wear surgical masks to help prevent the transmission of the virus. In some hospitals, refusal to either get vaccinated or wear a mask while at work can result in disciplinary action. This does not seem all that unreasonable, to me, and I've touched on the use of masks before (for example here and here). It is another tool in the fight to make our health care facilities that much safer for patients, so to see an organization representing hundreds of thousands of health care personnel opposing measures that would help achieve that goal simply boggles my mind.

Reading the statement makes me think that the opposition stems mainly from those who do not want to get vaccinated and find that the masks are uncomfortable. Images of petulant teens whinging about the unfairness of it all spring to mind ("Spinach or broccoli for my vegetable? Why can't I just skip the veggies for dinner! It's not fair!"). Of course, the MNA doesn't outright take this approach; it's just the impression I got. And I won't even get into how these policies generally apply to more than just nurses (e.g., all other health care workers, and may even extend to non-employees, such as volunteer greeters and so on).

No, they try to claim that science supports their opposition.

The defining issue is there is no medical evidence that the masking of unvaccinated, healthy nurses prevents the transmission of influenza. The medical evidence shows that surgical masks are designed to prevent dispersion and are not designed to prevent inhalation of airborne particles containing virus, therefore masks would be more effective if placed on people who are coughing or sneezing, whether patients or workers. Masking an asymptomatic nurse is neither preventive in the spread of infection nor appropriate.

I have to admit, this tidbit got me asking what evidence there actually was around whether masks and/or respirators reduce the transmission of influenza. What does the science actually say about whether masking reduces the risk of transmission? I assumed that there had to be some studies looking at this question. Did they find that masks did not help at all? Certainly the MNA has to have done some study of this before publishing their statement.

It turns out that while the evidence is difficult to come by, what research has been done suggests that wearing a mask or an N95 respirator actually can help reduce the risk of influenza transmission. I went digging a bit more for studies looking at the issue and found several showing that wearing some form of mask (surgical mask or respirator) did reduce transmission. One even looked specifically at whether such interventions prevented inhalation of the virus. What did they find? Facial masking, whether a surgical mask or even an ill-fitting N95, blocked entry of the virus!

Here are just a few of the studies I found:

• The use of masks and respirators to prevent transmission of influenza: a systematic review of the scientific evidence by Bin-Reza et al. - Found that data is inconsistent, but evidence suggests that masks, as part of a comprehensive infection control policy, were useful in preventing transmission.
• Physical interventions to interrupt or reduce the spread of respiratory viruses by Jefferson et al. - Found that surgical masks and N95 respirators were the most consistent measures for preventing spread of outbreaks, though noting that N95s could be uncomfortable and irritate the skin.
• Mask-wearing and respiratory infection in healthcare workers in Beijing, China by Yang et al. - Found that mask-wearing and vaccination were effective at preventing respiratory infection in health care workers.
• A cluster randomized clinical trial comparing fit-tested and non-fit-tested N95 respirators to medical masks to prevent respiratory virus infection in health care workers by MacIntyre et al. - Found that masks were better than no masks and that N95s were better than surgical masks at preventing infection.
• The role of facemasks and hand hygiene in the prevention of influenza transmission in households: results from a cluster randomised trial; Berlin, Germany, 2009-2011 by Suess et al. - Found that facemasks can help reduce household transmission of influenza, especially when implemented early on.

So there actually is evidence showing that masks help. From what I found, fit-tested N95 respirators provided the best protection, followed by fitted surgical masks. Loose surgical masks and N95s that did not fit properly were roughly equal in their protection, which was still better than no mask at all.

With evidence like this, what reason could the MNA really have to oppose mandatory masking policies? Perhaps it's just quibbling over the selected subject populations, trying to claim that no studies have used unvaccinated health care workers as the study population. Whether or not that is the case, the important thing to look at is whether masks reduce the risk of transmission, regardless of who wears the mask. Not to mention that even if the MNA is right and masks only prevent the wearer from spreading the illness, by the time symptoms appear and prompt the use of masks, it's already too late. Since the objections thus far don't hold much water, what other reasons are there to oppose mandatory mask policies?

The Massachusetts Nurses Association believes that the practice of mandating a mask is a punitive, coercive way of bullying workers into vaccination to avoid being penalized for failure to reach the required vaccination threshold.

Ah...belief that it's punishment for not vaccinating rather than taking steps to help protect patients. This, it seems, puts things into a somewhat different light. Reading this, the opposition appears to be more about mandatory vaccination policies and far less to do with mandating the wearing of masks. The MNA's opposition to mandatory masks focuses on the comfort of and "fairness" to nurses, rather than on the well-being of the patients they serve.

It's not all bad, though. At least they aren't totally opposed to immunization:

The MNA supports the current voluntary influenza immunization program as directed by the Massachusetts Department of Public Health, which has proven to be highly successful, increasing rates of flu vaccination in health care facilities.

Well, if we can't force health care employees to take appropriate measures like immunization and/or wearing masks or respirators to minimize influenza risk to themselves, their coworkers and, most of all, their patients, what does this Nurses Association recommend?

• Educate all staff about appropriate infection prevention practices.
• Practice good hand hygiene.
• Educate all patients, employees, vendors and visitors about the flu vaccine (VIS).
• Voluntary Flu Vaccination -- The influenza (flu), vaccine is partially protective against three viruses. The published effectiveness rate of this vaccine gives individuals approximately a 50% chance of contracting the flu, but there are other influenza like illnesses (ILI), for which there are no vaccines. This does not mean you should not receive the influenza, vaccine; on the contrary, the current flu vaccine protects against the three viruses that are highly virulent. The vaccine helps protect high risk patients, health care workers and the community.
• Establish and enforce guidelines by Environmental Services (housekeeping and food service staff), to include cleaning surfaces and disinfecting patient rooms. The staff need education on when, where and how to clean to prevent the transmission of influenza.
• Screen patients in the Emergency Department and mask patients who are positive for influenza. After appropriate treatment, they may be well enough to be sent home to recover. If patients require admission, they need an isolation room with appropriate precautions.
• Isolate infected patients in private rooms, with air filters to prevent the spread of infection.
• Restrict visitors and vendors from close patient contact, or have them wear personal protective equipment when visiting a patient.
• Ensure Safe and appropriate RN and support staff levels that allow for proper care of patients and infection control procedures. In fact, inadequate staffing is a major cause of all types of hospital acquired infections. Understaffing of RNs and other staff makes it more difficult to maintain appropriate hand washing and infection control procedures. Cuts in housekeeping staff make it more difficult to maintain sanitary conditions that will prevent the spread of infection in hospitals.
• Create better illness prevention policies! Nurses and health care workers need to be allowed to utilize sick time and stay home if they are ill, as recommended by the Center for Disease Control and Prevention (CDC). Nurses should not be disciplined for taking the time necessary to recover.
• Work with your infection prevention specialist within your facility.

I agree with all of these. But you know what's missing? It's something that I read in the position statement on influenza from a certain organization representing nurses. What was it again. Ah, yes. This (emphasis added):

In order to reduce the death rate from all ILI, hospitals need to implement control measures beyond just influenza vaccination such as hand washing, isolation, gloves, masks and gowns, sick leave policy, environmental controls, ventilation, housekeeping, equipment and visitor controls. A paramount concern is that hospitals provide adequate staffing so that nurses have flexibility and time to gown, glove, mask and hand wash sufficiently as they move between patients.

The MNA of October 13, 2011 seems to think that not only do masks help reduce the risk of infection, but that implementing masks as a control measure is a good thing. What happened in the year and two months since then to change their minds? Why would they go from supporting masking as an infection control measure to taking actions like this:

In response to the masking policies, the MNA/NNU has been demanding to meet with management of facilities considering the policy to try and convince them to take a more balanced approach to flu prevention.  In cases where hospitals have refused to discuss nurses’ concerns, the MNA/NNU has filed grievances, pursued arbitration over the issue (in the case of the policy implemented at Anna Jaques Hospital), and pursued unfair labor practice charges with the National Labor Relations Board.

This week, the MNA/NNU filed a charge against Lawrence General Hospital, which unilaterally changed its policy, moving from a highly successful voluntary masking policy to a mandatory policy.

Oh right.

Maybe the MNA could learn from these books.

Edited to Add: If you feel so inclined, the Massachusetts Nurses Association can be contacted here.