in the matter of an arbitration between: and€¦ · in the matter of an arbitration between: st....

INTHEMATTEROFANARBITRATION

BETWEEN:

St.Michael’sHospitalandTheOntarioHospitalAssociation

and

TheOntarioNurses’Association

Before: WilliamKaplan SoleArbitratorAppearancesForSt.Michael’sHospital&TheOntarioHospitalAssn. RoyC.Filion,QC MelanieD.McNaught GiovannaDiSauro FilionWakelyThorupAngelettiLLP Barristers&SolicitorsFortheOntarioNurses’Association: KateA.Hughes PhilipB.Abbink TylerBoggs CavalluzzoLLP Barristers&SolicitorsThemattersindisputeproceededtoahearinginTorontoonAugust9andOctober31,2016,February3,April6,29,30,May1,June1,2,22,August22,September30,October28,29,andDecember11,2017,April19,21,22,May4,andJuly16,23,2018.

2

Introduction

Summarilystated,thiscaseconcernsthereasonablenessoftheVaccinateorMask

Policy(hereafter“VOMpolicy”)thatwasintroducedatSt.Michael’sHospital

(hereafter“St.Michael’s”)in2014forthe2014-2015fluseasonandwhichhasbeen

inplaceeversince.UndertheVOMpolicy,HealthCareWorkersandthatgroup,of

course,includesnurses(hereafter“HCWs”),whohavenotreceivedtheannual

influenzavaccine,must,duringallormostofthefluseason,wearasurgicalor

proceduralmaskinareaswherepatientsarepresentand/orpatientcareis

delivered.

St.Michael’sisoneofaverysmallnumberofOntariohospitalswithaVOMpolicy:

lessthan10%ofapproximately165hospitals.TheOntarioNurses’Association

(hereafter“theAssociation”)immediatelygrievedtheVOMpolicyineveryhospital

whereitwasintroduced.ItshouldbenotedattheoutsetthattheVOMpolicyhas

nothingtodowithinfluenzaoutbreaksthataregovernedbyanentirelydifferent

protocol,andonethatisnotatissueinthiscase.

ThisisnotthefirstOntariogrievancetakingissuewiththeVOMpolicy.Theparties

appropriatelyrecognizedthatthemattersindisputewerebestdecidedthrougha

leadcaseratherthanthroughmultipleproceedingsattheminorityofhospitals

wherethepolicywasinplace.Accordingly,theAssociationgrievanceattheSault

AreaHospitalwasdesignatedasthatleadcaseandproceededtoalengthyhearing

beforearbitratorJamesK.A.HayesbeginninginOctober2014andendinginJuly

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2015.ArbitratorHayesheardmultipledaysofevidence(replicatedtosomeextent

inthisproceeding)andissuedhisdecision,discussedfurtherbelow,onSeptember

8,2015(hereafter“theHayesAward”).ArbitratorHayesfoundthattheSaultArea

Hospital’sVOMpolicywasinconsistentwiththecollectiveagreementand

unreasonable.Thegrievancewas,accordingly,upheld.

TheHayesAward

IntheSaultAreaHospitalcase(SAH&OHA&ONA,[2015]O.L.A.A.No.339),the

AssociationassertedthattheVOMpolicy,identicalinallmaterialrespectstotheone

contestedhere,wasinconsistentwiththecollectiveagreementandconstitutedan

unreasonableexerciseofmanagementrights.TheAssociation,inthatcase,tookthe

positionthattherewasinsufficientscientificevidencesupportingtheVOMpolicy.

ArbitratorHayesagreed.Heconcludedthattherewas“scant”scientificevidence

supportingtheVOMpolicyandheupheldthegrievance.

Inparticular,ArbitratorHayesdetermined,followinganexhaustivereviewofthe

scientificevidence,andthedetailedandextensivesubmissionsoftheparties,as

follows:

Onthemerits,IsustainthecoreoftheUnionposition.IfindthatthePolicywasintroducedatSAHforthepurposeofdrivingupvaccinationrates.IalsofindthattheweightofscientificevidencesaidtosupporttheVOMPolicyonpatientsafetygroundsisinsufficienttowarranttheimpositionofamask-wearingrequirementforuptosixmonthseveryyear.Absentadequatesupportforthefreestandingpatientsafetypurposealleged,IconcludethatthePolicyoperatestocoerceinfluenzaimmunizationand,thereby,underminesthecollectiveagreementrightofemployeestorefusevaccination.Onalloftheevidence,andforthereasonscanvassedatlengthinthisAward,IconcludethattheVOMPolicyisunreasonable(atpara.13).

4

Accordingly,SaultAreaHospitalimmediatelydiscontinueditsVOMpolicy,asdid

otherhospitals.However,somehospitals,includinganumberofhospitalslikeSt.

Michael’s,didnotdoso,necessitatingthissecondproceeding.Inordertoensure

finality,theOntarioHospitalAssociationandtheAssociationagreedonMarch25,

2016,thattheawardintwoSt.Michael’sVOMpolicygrievanceswouldbebinding

onitandonanumberofotherscheduledhospitals(excepttotheextentthatan

issueraisedbyanotherpolicywasnotaddressed).

InlightoftheMarch25,2016agreement,themattersindisputeproceededtoa

hearingoveranumberofdaysin2016,2017and2018.Thepartiesdidnotagree

aboutmuch,althoughtherewascommongroundthatthecontestedscientific

evidencehadtobeexaminedandthensubjectedtoalegalassessment:didtheVOM

policyviolateand/orconflictwiththecollectiveagreement,andwasitreasonable?

PreliminaryObservations

Somepreliminaryobservationsareappropriatestartingwiththefollowing:St.

Michael’sefforttodistinguishtheHayesawardwasunsuccessful.Thenewevidence

thatwasintroducedintheattempttodosowasnotparticularlyhelpful.Indeed,by

andlarge,thesamepolicy,thesamelegalissues,andsomeoftheverysame

evidencethatwasintroducedinthisproceedinghadearlierbeenputbefore

ArbitratorHayes.Forreasonsthatwillbeelaboratedbelow,andingeneral,thenew

evidencethatwascalledbytheAssociationcorroboratedandreconfirmedthat

whichhadbeenputbeforeArbitratorHayes,whilethatcalledbySt.Michael’swas

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notparticularlypersuasive,andasnotedlater,inthecaseofonereport,hasbeen

completelydisregarded.

VOMatSt.Michael’s–TheTAHSNReport

TheVOMpolicywasbasedonarecommendationdraftedbyaworkinggroupofthe

TorontoAreaHealthSciencesNetwork(hereafter“TAHSN”).TAHSNiscomposedof

13Toronto-areateachinghospitals(andanumberofassociatehospitalmembers).

TheTHASNreportfoundasfollows:

Thereareseveralimportantinfectioncontrolmeasuresthathelptopreventinfluenzatransmission.Theseinclude:restrictingHCWswithsymptomsfromattendingthehospital,goodhandhygienepractices,influenzavaccination,coughetiquette,earlyidentificationandmanagementofinfectedpatients,andappropriateoutbreakmanagementincludingpromptuseofanti-viralmedicationsforunvaccinatedHCWsandexposedpatients.ThewearingoffacemaskscanserveasamethodofsourcecontrolofinfectedHCWswhomayormaynothavesymptoms.MasksmayalsopreventunvaccinatedHCWsfromasyetunrecognizedinfectedpatientsorvisitors.Whileallthesemeasuresarevaluableandshouldbepartofacomprehensivepreventionprogram,vaccinationremainsthecornerstoneofeffortstocontrolinfluenzatransmission.

TheTHASNreportmadeitclearthatvoluntaryeffortstoincreaseinfluenza

immunizationhadfailed–40%to60%uptake“despiterobustinfluenzaeducation

campaigns”–andthatstepswerenecessarytoaddressthatfailureand“to

significantlyimprovehealthcareworkerinfluenzaimmunizationrates.”Thereport

recommendedthatVOMpolicies“bepartofacomprehensivepreventionand

controlprogramaimedatpreventinghospital-acquiredinfluenza….”This

recommendationwasmadeintheadmittedabsenceofdirectevidencethatmask-

wearingHCWsprotectedpatientsfrominfluenza;butonthebasisof“indirect

evidence[that]suggestsitdoes.”Theonlyfairwordstodescribetheevidence

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advancedinsupportofthemaskingcomponentoftheVOMpolicyintheTHASN

report,andinthisproceeding,areinsufficient,inadequate,andcompletely

unpersuasive.

TheCollectiveAgreementItisusefultosetoutcertainprovisionsofthecollectiveagreement:6.05OccupationalHealth&Safety(a)Itisamutualinterestofthepartiestopromotehealthandsafetyinworkplacesandtopreventandreducetheoccurrenceofworkplaceinjuriesandoccupationaldiseases.Thepartiesagreethathealthandsafetyisoftheutmostimportanceandagreetopromotehealthandsafetyandwellnessthroughouttheorganization.

…

*Whenfacedwithoccupationalhealthandsafetydecisions,theHospitalwillnotawaitfullscientificorabsolutecertaintybeforetakingreasonableaction(s)thatreducesriskandprotectsemployees.

…*Theemployeeshalluseorweartheequipment,protectivedevicesorclothingthattheemployerrequirestobeusedorworn[OccupationalHealthandSafetyAct,s.28(1)(b).

…(e)(vi)TheUnionagreestoendeavourtoobtainthefullcooperationofitsmembershipintheobservationofallsafetyrulesandpractices.

…18.07InfluenzaVaccineThepartiesagreethatinfluenzavaccinationsmaybebeneficialforpatientsandnurses.Uponarecommendationpertainingtoafacilityoraspecificallydesignatedarea(s)thereoffromtheMedicalOfficerofHealthorincompliancewithapplicableprovinciallegislation,thefollowingruleswillapply:(a)Nursesshall,subjecttothefollowing,berequiredtobevaccinatedforinfluenza.

7

…

(c)Hospitalsrecognizethatnurseshavetherighttorefuseanyrequiredvaccine.Oneoftheprovisionsofthelocalagreementisalsorelevant:

…theAssociationacknowledgesthatitistheexclusivefunctionoftheHospitalto…makeandenforceandalterfromtimetotimereasonablerulesandregulationstobeobservedbynurses,providedthatsuchrulesandregulationsshallnotbeinconsistentwiththeprovisionsofthisAgreement.

AdditionalPreliminaryObservations

Whateveritsvalue,alabourarbitrationisnotanidealforumbyanyintelligent

measuretoestablishbestpracticesinpublichealth.Inthiscase,a(second)hearing

wasmadenecessarybythecontinuingdivisionofexpertopinion,nottomentionthe

disagreementinsomequarterswiththeoriginalarbitraloutcome.Intheresult,

questionsthatshouldnormallyberesolvedbyexperts–basedonthebestpossible

evidence–mustbedecidedbyadecidedlyinexperttribunalthroughacollective

agreementandlabourlawlens,albeitonethathasbeenexceptionallywellinformed

byathoroughlyarguedcasethatincludedtheevidenceofinternationally

recognizedexperts,orpersonswithsubjectmatterexpertise.

Thereisnoshortageofquestionsrequiringanswers,buttwooftheprincipalones

aretheextenttowhichunvaccinatedHCWsposearisktopatients–ariskof

transmittinginfluenzaespeciallywhentheyareasymptomatic–andwhether

maskingappreciablyreducesthatrisk.

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Theinterestsatissuearesubstantial.Ontheonehand,thereisahospitalpolicy

designedtoensurepatientwell-beingbytakingstepstopreventnosocomial–

hospitalacquired–influenza.IfunvaccinatedHCWsareinfectingpatients,andif

wearingasurgicalorproceduralmaskpreventsthespreadofinfluenza–meaningit

preventsseriousillnessanddeath–thatis,byanyobjectivestandard,areasonable

precautioneveniftheevidenceisnotallin.However,ifthevaccinationitselfisof

questionableutility,andifthemasksareoflimitedvalueinpreventingtransmission

ofinfluenzabyasymptomaticHCWs(symptomaticHCWSshouldnotbeatwork),

thentheentireenterpriseisputintoquestionevenifthemotiveunderlyingthe

policyiscompletelysalutary.

Itisclearandagreedthatinfluenzaisaseriousandlife-threateningillness.Thereis

alsoconsensusaboutotherthings.Ingeneral,theinfluenzavaccineissafeformost

personsandhasa“moderate”effectivenessformuchofthepopulation:upto60%,

(althoughinsomeyearssubstantiallyless,andonceinawhile,vaccinationprovides

virtuallynoprotection).Thevaccinehasnoeffectivenessagainstinfluenza-like

illnesses.Theinfluenzavirusmutatesquickly,requiringannualdevelopmentofa

newvaccine.Vaccineeffectivenessdependsontheclosenessofthematchofthe

strainsinthevaccinetothestrainscirculatingintheseasoninwhichthevaccineis

employed.Forinfluenzatobetransmitted,thevirusmustbebothshedand

transmitted.Contact–directcontactwiththeinfectedperson,orindirectcontact

throughinfectedsurfaces–anddroplets–particlesthattravelballistically–and

aerosol–particlessuspendedintheair–arethelikelymodesoftransmission.

9

Thereisclearlyahealthbenefitinvaccination.Exceptinyearsofacomplete

mismatch,thevaccineprovidessomeprotectionagainstinfluenza.Indeed,the

influenzavaccineisthebestavailableinterventiontopreventinfluenza(although

repeatedannualvaccinationsreducesvaccineefficacyandthisisknownasthe

repeatvaccinationeffect).Effectivenessalsovarieswithageandpopulationgroups.

Thegeneraleffectivenessofthevaccine,i.e.,whetherthevaccineisamatchfor

circulatingstrains,isonlyascertainableoncetheinfluenzaseasonisunderway,

althoughearlyindicationsareavailablefromtheexperienceinthesouthern

hemisphere.Becausethevaccinationprovidesonlypartialprotection,unvaccinated

HCWscontractinfluenzabutsotoodovaccinatedHCWs–thatisobviousgiventhe

effectivenessrate.

Inthebroadestpossibleterms,theissuetobedecided,ontheevidence,iswhethera

VOMpolicyforHCWsisreasonable.Statedsomewhatdifferently,thequestiontobe

answerediswhethertheevidencesupportstheconclusionthattheuseofsurgical

orproceduralmasks,wornbyunvaccinatedHCWsforsomeorallofthefluseason,

actuallyresultsinreductionofharmtopatients?Doesitpreventthetransmissionof

illness?Doesitsavelives?IftheVOMpolicypreventedpatientillnessandsaved

patientlives,itsreasonablenesswouldbedifficulttochallenge.Afterall,preventing

illnessandsavinglivesisthecorepurposeofSt.Michael’sandotherhospitals.Itis

centraltothemission.

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If,ontheotherhand,theevidenceindicatedthatthepolicydidnotachievethis

objective,andifthesciencesaidtosupportitwasunsoundatbest,thenthe

reasonablenessofthepolicywouldbeappropriatelycalledintoquestion.

Thiscasewastriedovermultiplehearingdaysoverthreecalendaryears.The

evidentiaryrecordisextensive:Volumesofscientificarticles–clusterrandomized

controlledtrials(hereafter“cRCTs”),observationalstudies,summaries,critiques,

literaturereviews,meta-analyses,commentaries,etc.andnumerousexpertreports,

morethanonehundredandfiftyexhibitsandthousandsofpagesoftranscript.Two

AssociationmembersalsotestifiedabouttheimpactoftheVOMpolicyonthem:

theirexperienceofbeingcompelledtodonamaskfordays,weeksandmonthson

end.Butattheendoftheday,theevidenceadducedhereleadstotheverysame

conclusionreachedbyArbitratorHayes.Theexhaustiveevidentiaryreviewinthe

Hayesawardneednotberepeated,orasimilarexercisereplicatedhere,although

thekeyevidenceandargumentsmust,ofcourse,beappropriatelyaddressed,and

thisfollows.

PositionoftheParties

OverviewofOntarioNurses’AssociationSubmissions

TheAssociationarguedthattheVOMpolicymustbesetasideforanumberof

reasonsincluding:

1. TheVOMpolicywasinconsistentwithand/orcontrarytothecollective

agreement.

11

2. TheTAHSNreport–thebasisfortheVOMpolicy–wasunreliable.

3. Evidencethatmaskingasasourcecontrolresultsinanymaterialreduction

intransmissionwasscant,anecdotal,and,intheoverall,lacking.

Inarelatedpoint,theAssociationarguedthattheevidenceestablishing

asymptomatictransmission–thatistransmissionbyHCWswhenshedding

viruseitherpriortosymptomonsetorwhenasymptomaticallyinfected–

wasabsent.Therisk,basedontheevidence,theAssociationargued,was

theoreticalorminimalandinsufficienttojustifytheVOMpolicyona

reasonablenessstandard.

Inanyevent,ifmaskingwereeffective,itwouldberequiredofallHCWsin

additiontovaccinationasallHCWscanacquireinfluenzawhethervaccinated

ornot.Theexperienceofmismatchyearsillustratedthispoint.Fromtimeto

timethevaccinefailedtowork–itprovidedlittleor,rarely,noprotection.In

thoseyearslogicdictatedadirectivethateveryonemask.Butthatwas

neitherthepolicynorthepractice.TheVOMpolicywas,inaword,“illogical.”

4. Therewasnoevidenceofaproblem;norwasthereevidencethatthe

“problem”waseffectivelyaddressedbytheVOMpolicy“solution.”

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5. Inallofthesecircumstances,requiringaHCWtowearamaskforeachand

everyshiftforuptosixmonthswasunwarrantedandunjustifiableinlightof

theimpactofdoingso–theimpactonHCWs,nottomentionitsadverse

implicationsforpatientcare.

Inconsistentwithand/orContrarytotheCollectiveAgreement

IntheAssociation’ssubmission,St.Michael’scouldissuerulesandregulations,but

theycouldnotbeinconsistentwithand/orinconflictwiththecollectiveagreement.

However,theVOMpolicydidjustthatbyunderminingandinterferingwiththe

categoricalrightofanursetorefuseanunwantedvaccination.TheVOMpolicywas

unreasonableasitcoercedHCWsintoagreeingtovaccinationbyimposingon

unvaccinatedHCWstheobligationtowearamaskwhenitservednousefulpurpose.

TheTAHSNReportwasUnreliable

ThejustificationfortheVOMpolicywastheTAHSNreport.However,thatreport

citednosubstantiveevidencethatVOMpoliciesreduceinfluenzatransmission,and

thereasonitfailedtodoso,intheAssociation’ssubmission,wasbecausetherewas

nosuchevidence.

TheinitialfocusoftheworkinggroupthatdraftedtheTAHSNreportwason

increasingvaccinationratesanditwentaboutitswork,theAssociationargued,with

thatgoalsquarelyinmind.Indeed,St.Michael’sevidenceestablishedthis,and

specificreferencewasmadetothetestimonyofsomeofitswitnesses.Itwas

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particularlynoteworthytotheAssociationthattheworkinggroupwentoutofits

waytoavoidhearingfromexpertswhodisagreedwithwhattheAssociation

characterizedasapre-determinedoutcome.

TheTAHSNreportsubstantiallyreliedonfourcRCTS:Potter,Carman,Hayward&

Lemaitre(hereafterthe“fourcRCTs”)conductedinlong-termcare(hereafter“LTC”)

facilities(nothospitalsettingslikeSt.Michael’s).ThesefourcRCTSfoundthatthere

wasasubstantialreductioninall-causemortalityinLTCfacilitieswhenHCWswere

vaccinated.Statedinthesimplestterms,thesefourcRCTsconcludedthatwhen

HCWvaccinationratesincreased,patientdeathsdecreased.Additionalevidencewas

citedbySt.Michael’stosupportthefollowingproposition:theriskofinfluenza

outbreaksdecreasedwhentherateofHCWimmunizationincreased.

However,intheAssociation’sview,thefindingsofthefourcRCTswereinapplicable,

implausibleandunreliable(LTCvs.acutecarehospitalsettinglikeSt.Michael’s,all-

causemortalityvs.influenza-causeddeath,etc.),andhadbeenthoroughlyand

conclusivelydebunkedbytheoverwhelmingweightofcrediblescientificevidence.

(DiscussionofthefourcRCTs,itshouldbenoted,occupiedcountlessdaysof

evidenceengagingalloftheexpertsbutone.)

ThefactofthematterwasthattheTAHSNreportcouldnotsurviveseriousscrutiny

givenitsmanifestdeficiencies.Oneexample,theAssociationargued,amply

illustratedthispoint.

14

RelyingonthefourcRCTs,theTAHSNreportstatedthatforevery8HCWs

vaccinated1patientdeathwouldbeprevented.ThisisknownastheNumber

NeededtoVaccinate(hereafter“NNV”).Butwhencarefullyanalyzed,thisnumber

wasnonsensicalandcouldnotbesustained.Infact,StMichael’switnessesreadily

concededlimitationsofthefourcRCTs,whilethosefortheAssociationcompletely

rejectedtheirfindings–theexpertstestifiedthattheywere“controversial,”“low

grade,”and“fundamentallyflawed”–andcouldnotserveascientificfoundationfor

aVOMpolicy.Itwasnotable,theAssociationargued,thattheCollegeofNursesdid

notrequirethatnursesbevaccinated,thattheProvinceofOntariohadnot

designatedinfluenzaformandatoryHCWimmunization,norhadtheProvinceof

Quebec.PublicHealthOntario’sProvincialInfectiousDiseaseAdvisoryCommittee

doesnotrecommendaVOMpolicy(althoughmaskingforsymptomaticindividuals

wasadifferentmatter).

Indeed,theAssociationmadedetailedreferenceinitssubmissionstothemost

compellingcritiquesofthefourcRCTS,includingtheCochraneReview,describedby

theAssociationasuniversallyrespected.It’sfinding,thatthefourcRCTshada“high

riskofbias”andthattherewas“noevidence…thatvaccinatinghealthcareworkers

againstinfluenzaprotectselderlypeopleintheircare,”wasmaterialanddirectlyon

point.

ThisconclusionwassupplementedbyAssociationexpertreportsandpeer-

reviewedpublications,mostnotably“InfluenzaVaccinationofHealthcareWorkers,”

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a2017PlosOnearticlebyAssociationexpertDr.GastonDeSerres(andothers).Dr.

DeSerreswastheprincipalAssociationwitness.HehasanMDandaPhDin

epidemiology.Hisevidence,alongwithotherleadingstudies,e.g.,Osterholm,cast

seriousdoubtonthevalidityofthefourcRCTsandtheirvariousfindings,including

theirapplicabilitytotheacutecarehospitalsetting.

AsDr.Osterholmwrote:“Thefourrandomizedcontrolledtrials…donotprovide

strongevidencetosupportanimpactonpatientmortalitywhenincreasednumbers

ofhealthcareworkersarevaccinated.Infact,twoofthestudiesdonotsupportthis

claim…andtheothertwoonlyweaklysupportit.”

TheDeSerresarticlereachedthefollowingconclusion:

ThefourcRCTs…attributeimplausiblylargereductionsinpatientrisktoHCWvaccination,castingseriousdoubtsontheirvalidity.TheimpressionthatunvaccinatedHCWsplacetheirpatientsatgreatinfluenzaperilisexaggerated.Instead,theHCW-attributableriskandvaccine-preventablefractionbothremainunknownandtheNNVtoachievepatientbenefitstillrequiresbetterunderstanding.AlthoughcurrentscientificdataareinadequatetosupporttheethicalimplementationofenforcedHCWinfluenzavaccination,theydonotrefuteapproachestosupportvoluntaryvaccinationorothermorebroadlyprotectivepractices,suchasstayinghomeormaskingwhenacutelyill.

TherestofthedatareliedonbySt.Michael’s,theAssociationsubmitted,fellfar

shortofmakingacase–andthiswasreviewedindetail.

Insummary,onthispoint,neithertheTAHSNreport,noranyoftheevidence

adducedbySt.Michael’satthehearing,establishedthattheuseofsurgicaland

proceduralmasksbyunvaccinatednursesreducedtheriskoftransmissionof

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influenzatopatientsorledtoareductioninoutbreaks.ArbitratorHayeshad

concluded,giventheabsenceofunderlyingscientificsupport,thattheVOMpolicy

wasmotivatedbyanimproperpurpose:itwas,hefound,acoercivepractice

designedtodriveupvaccinationrates,andtheAssociationurgedmetoreachthe

sameconclusion.

MaskingEffectiveness

Influenzaistransmittedinanumberofways,butprimarilythroughdroplets

emittedbyaninfectedperson.Thevirusdroplethastobeshedandthen

transportedinsufficientamountandcloseenoughtopotentialrecipientstoinfect

them(andevidencewasledthatexploredthisprocessindetail).Thequestiontobe

askedhere,andwhichtheAssociationanswered,waswhetherthesemasks

effectivelypreventinfluenzatransmission:Aretheyaneffectivemeansofsource

control?

Thisanswertothisquestionwas“no,”andtheAssociationpointedtothereportand

evidenceofmaskingexpertProfessorLisaBrosseau.Inherreport,Professor

Brosseaucanvassedalloftherelevantliteratureandwrote:“Itismyopinionthat

thesurgicalmasksrequiredforunvaccinatedstaffatSt.Michael’sHospitalwilloffer

nooraverylowlevelofprotectionfrominfectiousaerosolseitherforthewearer

exposedtonearbypatientsorforpatientsexposedtoaninfectedwearer.”Referring

specificallytosurgicalandproceduralmasks,shetestified:“…noneofthesurgical

masksexhibitedadequatefacialfitcharacteristicstobeconsideredrespiratory

17

protectiondevices.”Inparticular,surgicalandproceduralmasksdidnotprevent

influenzatransmissionbyaninfectedperson:“Inadditiontohavingfiltersthatdo

notperformverywell,thefitofthesemasksonyourfacewillallowalotofleakage

aroundtheside.”

InProfessorBrosseau’sopinion,coughing,sneezingandtalkingproducedawide

rangeofparticles,andindifferentsizes,allofwhichcouldbeinfectious.Thesmaller

particlescouldbypassthefilter,makingitunlikelythatamaskwouldlowertherisk

ofnosocomialinfluenzafromaninfectedHCW.Masksmightpreventorimpede

largedroplets,butthatwasonlyoneofthewaysinwhichinfluenzawas

transmitted.Otherevidence,whichtheAssociationpointedto,supportedthis

conclusionindicatingthattheinfluenzaviruscanbypass/penetratesurgicalmasks.

IntheAssociation’ssubmission(developedfurtherbelow)maskingdidnotstopthe

spreadofinfluenza.Forexample,astheCentersforDiseaseControl(hereafter

“CDC”)observed,“nostudieshavedefinitivelyshownthatmaskuseby…healthcare

personnelpreventsinfluenzatransmission….”Maskswere,asoneofSt.Michael’s

witnessesconceded,“theweakpoint(notmuchdatathattheywork”)and,as

anotheragreed,“therereallyisn’tdataforusingthemaskinawaythatwehave

useditintheVOMpolicy.”Theseadmissionsalone,theAssociationargued,formeda

sufficientfactualandlegalbasistoupholdbothgrievances:theymadethe

Associationcase.

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FortheVOMpolicytosurvivearbitralreview,itcouldnotbearbitrary.Therehadto

beaproblem–nosocomialinfluenzafromunvaccinatedHCWs,andalinkbetweenit

andthesolution:the“ask”,i.e.,wearingthemask.Noelementofthistest–legallyor

factually–theAssociationsubmitted,hadbeenmet.First,therewasverylittle

persuasiveevidenceabouttheexistence,indeed,scopeoftheproblem.Second,even

assuming,forthesakeofargumentthattheevidenceaboutunvaccinatedHCWsasa

sourceofnosocomialinfluenzawasaccurate,theevidenceaboutmaskeffectiveness

asasolutionwasinsufficient,atbest,tosupporttheVOMpolicy.

(ItshouldbenotedthatonJanuary18,2018,St.Michael’samendeditsInfluenza

Prevention&Control&InpatientVaccinationGuidelinebypostingsignsasking

unvaccinatedvisitorstowearamaskwhileinpatientcareareas.Thenewpolicy

wasentirelyvoluntaryandnovisitorisaskedaboutvaccinationstatus.Thisnew

policy,intheAssociation’ssubmission,didverylittletoaddressthelogicalflawsin

theapplicationoftheVOMpolicy.)

AsymptomaticTransmission

Influenzaishighlycontagiousanditcanbetransmittedbyasymptomatic

individuals.TheAssociationdidnotdisputethepossibilityofasymptomatic

transmission.However,theevidenceindicatedthattherateofasymptomatic

transmissionwaslowand“unlikelytobeofclinicalsignificance”astheproduction

ofthevirusandthedevelopmentofsymptomswaslinked.Dataestablishing

asymptomaticinfectionwas,theAssociationargued,extremelylimited–

19

inconclusiveatbest–andcertainlycomingnowherenearestablishingaproblem

requiringasolution.Numerousauthoritieswerereferredtoinsupportofthis

submission.

Moreover,iftherereallywas,asSt.Michael’sasserted,aproblemwith

asymptomatictransmission,andifmaskingreallyworked,thenuniversalmasking

wouldberequiredbecausebothvaccinatedandunvaccinatedHCWscanbecome

infectedwithinfluenzaand,ifinfectedandasymptomatic,cantransmitit(albeit

minimally,atbest).Moreover,familymembers,police,ambulancedriversandmany

otherswhoregularlypassthroughpatientareasofthehospitalarenotrequiredto

vaccinateormask.WhyjustHCWs,theAssociationasked?This,again,illustrated

howillogicaltheVOMpolicyactuallywasandthiswenttotheheart,theAssociation

argued,ofitsunreasonableness.

Onthispoint,theevidencefurtherestablishedthatmaskingprovidedevenless

protectionagainsttransmissionbyasymptomaticindividualsthanthealreadylow

protectiontheyprovidedinthecaseofsymptomaticpersons.Maskingwasnotan

effectivemeansofsourcecontrolingeneral,and,inparticular,inthecaseof

asymptomatictransmission.

MismatchYears

Eveninthebestyear–thebestmatch–theinfluenzavaccinationwasonlypartially

successful(andtheAssociationarguedwasbecomeincreasinglylesssobecauseof

20

therepeatvaccinationeffect).Duringthe2017/2018influenzaseason,forexample,

whenitbecameapparentthattherewasaseriousmismatch–meaningthatthe

vaccinedidnotprovidesignificantprotection–St.Michael’sdidnotimposea

system-widemaskingrequirement.Onanearlieroccasion,the2014/2015influenza

season,thevaccinehadminimaleffectiveness.Inallcircumstances,andinevery

year,bothvaccinatedandunvaccinatedHCWscouldtransmitinfluenzatopatients,

butonlyunvaccinatedindividualswererequiredtomask.

Theonlyconclusionthatcouldbedrawninthesecircumstances,anditwasonethat

theAssociationurgeduponme,wastofindthatthetruepurposeoftheVOMpolicy

wastoincreasevaccinationratesbyofferingupanunpalatablealternative–

wearingclosetouseless,inconvenientandburdensomemasksformonthsonend.

Bydefinition,thiscouldnotbereasonable.

NoEvidenceofaProblem

Forapolicytobefoundtobereasonable,theAssociationargued,andwherethat

policymustbebalancedagainstemployeeinterests,thenthescaleandnatureofthe

issuemustbeknown.Thesolutionmustactuallyaddressareal,notimaginary,

problem.Here,theAssociationsubmitted,therewasnoevidenceoftheburdenof

disease–St.Michael’sexpertshadadmittedasmuch–noevidenceofany

demonstratedneed,andnoevidenceofthedegreetowhichunvaccinatedHCWs

werethecauseofnosocomialinfluenza.Likewise,therewasacompleteabsenceof

21

quantificationoftheamountofinfluenzathatwaspreventablebysurgicaland

proceduralmasks.

Pre-existingInfectionProtectionandControl(IPAC)policiesandpracticesatSt.

Michael’s–whichAssociationcounseldescribed–werenotonlyworkingand

evidence-based,butaccepted.Therewasnoproblemandnoneedforasolution,

especiallythemaskingsolutionthatdidnotwork.Andthatmeantthepolicywas

arbitrary.Inthesefactualcircumstances,theAssociationargued,theVOMpolicy

couldnotbefoundtobereasonable.

AdverseImpactsonHCWsandPatients

Althoughchallenged,theevidencewaslargelyuncontradictedthatwearingsurgical

andproceduralmasksoverthecourseofanentireshiftdayinanddayoutforweeks

andmonthsonendwasextremelyuncomfortableforthenurseandproblematicfor

patientcare,apointestablishedintheevidenceoftwolong-servicenurses.They

testifiedaboutadversereactionstothevaccine,thediscomforttheyexperienced

fromwearingmasksforprolongedperiods,thatwearingthemasksattracted

negativeattention,thatitseemedlikeapunishmentfornotbeingvaccinated,thatit

disturbedpatientswhowereconcernedwhetherthey–theHCWs–wereinfectious,

andthatitfrequentlyinterferedwiththeircare.Theyalsospokeabouttheir

concernsaboutempathyandunderstandingandhowmasksunderminedboth–an

issueraisedinsomeoftheliterature.TheVOMpolicy,inshort,shamedandblamed,

22

andservednolegitimatepurpose,theAssociationargued,otherthantocoerce

HCWstosubmittoinfluenzavaccination.

ConclusiontoAssociationSubmissions

TheonlyconclusionthattheAssociationcoulddraw,whenalltheevidencewas

examined,wasthattheVOMpolicywasnotalegitimateandscientificallybased

employerresponsetoanidentifiedproblemwithareasonableandtargeted

solution.Instead,itwasclearlydesignedfromtheoutsetwithoneobjectiveinmind:

toincreaseinfluenzavaccination.

HCWsweregivenanunacceptable,unjustifiedandunwelcomechoice,anditwas

onethathadclosetozeromedicaljustification,demonstratingitsulteriorpurpose:

drivingupvaccinationratesinthefaceofaclearcollectiveagreemententitlementto

refuseanunwantedvaccine.TheVOMpolicywascontrarytothecollective

agreement,itconflictedwiththecollectiveagreement,anditwasillogicaland

unreasonable.ArbitratorHayeshadconcludeditwascompletelyimproper,andthe

AssociationurgedthatIreachthesameresult.TheAssociationaskedthatbothits

grievancesbeupheldandtheVOMpolicystruck.TheAssociationaskedmeto

remainseizedwiththeimplementationofmyaward.

SubmissionsofSt.Michael’s

InSt.Michael’ssubmission,thecasefortheVOMpolicywasstraightforward:

nosocomialinfluenzacausedseriousillnessandsometimesdeath.HCWscan

23

transmitinfluenzatopatients.VaccinationreducedtheriskofHCWsbecoming

infectedwithinfluenzaand,therefore,reducedtheriskofHCWstransmitting

influenza.Maskswereeffectiveassourcecontrol–theypreventedtransmissionof

influenza.AndmasksservedasareasonablealternativeforHCWswhochosenotto

vaccinate.

OriginoftheVOMpolicyatSt.Michael’s

TheTAHSNworkinggroupthatdraftedtheVOMpolicywasconstitutedtodiscuss

optionsandmakerecommendationsonhowtobestreducenosocomialinfluenza.

Increasingvaccinationrateswastheobviousfirststepbecauseinfluenza

vaccinationprovidedprotection.Buttheeffortwasunsuccessful.Notwithstanding

variousinitiatives,influenzavaccinationratesremainedstatic.Theworkinggroup

exercise,involvingamulti-disciplinaryexpertteam,St.Michael’ssubmitted,took

thetaskseriouslyanddirectedconsiderableresourcestoit.

Inthemeantime,theevidenceindicated–thefourcRCTsinparticular–thatthe

burdenofHCW-associatedinfluenzawassignificant.Oneofthemaincontributorsto

theTAHSNreport,andawitnesscalledbySt.Michael’s,Dr.AllisonMcGeer,testified

asfollows:“Don’tknowthatIcanadequatelyrepresenthoursandhoursof

discussionbutIthinkthatthefocusofthecommitteebecameonwhattheleast

intrusivethingwecoulddo…[to]...providethebestprotectionwecouldgivetothe

patientsinhospitalfrominfluenza.”Dr.McGeerwaslookingforanalternative“to

protectpatientsatthesametimeastryingtobetheleastintrusivetoworkers.”

24

Thatmeantmasking.Therewas,Dr.McGeertestified,andwroteinherreport:

“…evidencethatmasks,especiallywhencombinedwithgoodhygiene,reducethe

riskofinfectiontoexposedpersons;thatis,thattheycanbeexpectedtoconfer

someprotectionagainsthealthcare-associatedinfluenzainunvaccinatedHCWs.”

Indeedtherewasevidencethatmaskingworkedtopreventtransmissionof

influenzaanditwasquitepossiblyas“effectiveasvaccineinprotectingpatients

frominfluenza.”Maskingwasespeciallyimportant,andnecessary,St.Michael’s

argued,assomeinfluenzawastransmittedbyasymptomaticHCWs.TheVOMpolicy

was,therefore,properlyarrivedat:groundedinscientificevidenceandcarefully

calibratedtobalanceinterests.

Allofthis,St.Michael’sargued,hadbeenestablishedintheevidenceofitswitnesses

–internationallyrecognizedexpertsandpersonswithsubjectmatterexpertise–

whoseevidenceSt.Michael’scounselcarefullyandcomprehensivelyreviewed.The

TAHSNreportwasnotuncriticallyaccepted.Itsfindingswerecarefullyreviewedby

epidemiologistDr.MatthewMuller,St.Michael’sDirectorofInfectionPrevention

andControl.

AsDr.Mullertestified,“whenIsawtheresults…itreallyincreasedmyurgencyabout

thefactthat…perhapstosomeextentwehadbeencomplacent…andthoughtthat,if

theseinterventionscansavepatientlivesinthemannerthatwasdemonstratedin

thoseclusterrandomizedtrials,thisissomethingweshouldbetakingadifferent

approachtothisproblemandweshouldhavestartedyesterdayessentially.”Dr.

25

MullerconsideredthedifferencesinLTCfacilitiesandacutehospitalsandtook

noticeofthebiologicalplausibilityofHCWvaccinationreducinginfluenzaamong

inpatients.Hewasalsopersuadedbysomeoftheconclusionsreachedinsomeof

theotherliteratureincludingbyAhmedetal;indicatingthatHCWvaccination“can

enhancepatientsafety.”

Dr.Mullerwasnotinfavourofamandatoryvaccinationprogram–althoughhe

understoodthattheonlyguaranteedmethodofsubstantiallyincreasinginfluenza

vaccinationwasbymakingitaconditionofservice–normativeintheUnitedStates.

Heunderstoodthatacompromiseposition–VOM–hadachievedsomesuccessin

BritishColumbia–meaningthatvaccinationrateshadincreased–anddetermined

thatitwasbothausefulandappropriatecompromiseforSt.Michael’s.Hisresearch

satisfiedhimthatmaskswereagoodmeansofsourcecontrolandcouldinterrupt

influenzatransmission.Simplyput,“bywearingamask,unvaccinatedhealthcare

workerswillprotectpatientsfrominfluenza,giventheprovenabilityofmasksto

containsecretions,bypreventingtransmissionofinfluenzafromhealthcare

workerswithasymptomaticorsubclinicalillnesswhoaresheddingvirus,andfrom

healthcareworkerswhocontinuetoworkdespitesignificantsymptomsof

influenza.”

Accordingly,Dr.MullerrecommendedthatSt.Michael’sadoptaVOMpolicy,anda

widespreadandcollegialprocesswasthenundertakenwherethepolicywas

26

presentedanddiscussed:“…wefeltthatboththevaccineandthemaskwould

protectpatients.”

TheVOMpolicyinPractice

Itwas,St.Michael’sinsisted,entirelyuptoindividualHCWstodecidewhetherto

vaccinateormask,andnothingintheadministrationofthepolicy–discussedinthe

evidenceandsubmissions–couldbefairlydescribedasintrusiveorcoercive.HCWs

atSt.Michael’s,forexample,werenotrequiredtomaskfortheentireseasonbut

onlythatpartoftheperiodwheninfluenzaactivitywasthemostsignificant(on

averageabout10weeksayear).

St.Michael’srejectedtheevidenceofthenurseswhotestifiedaboutdifficultiesin

wearingthemaskaswellastheassertedconcernsaboutinterferencewithpatient

care.ItnotedthatnoHCWhasbeendisciplinedfornon-compliance.Intermsof

mismatchyears,whiletimingwasproblematical–themismatchmaynotbeevident

untillaterintheinfluenzaseason–theamendedVOMpolicyallowsSt.Michael’sto

requireuniversalmasking,ifneedbe.Anamendmenttoarelatedpolicy,referredto

above,invitesunvaccinatedvisitorstothehospitaltowearmasks.

Justification

Muchoftheevidence,St.Michael’sargued,wasacceptedandnon-controversial.

HCWscanbeinfectedwithinfluenza.HCWscantransmitinfluenzatotheirpatients.

Influenzacausesseriousillnessanddeath.Nosocomialinfluenzaisaserious

27

problem,andonethatmustbeaddressedevenifprecisenumbersofpatients

infectedbyunvaccinatedHCWsisnotreadilyascertainable.

Attheveryleast,thefourcRCTsprovidedevidenceoftheproblemandpointedthe

waytoasolution.Vaccinationwasthefirststep.Associationwitnesses

acknowledgedasmuch–itprotectedHCWsfrominfluenza.Althoughnotperfect,it

wasthebestprotectionavailable.Andeveninmismatchyears,exceptintherare

andextremecaseofacompletemismatch,vaccinationsprovidesomeprotection,

andthatisobviouslybetterthannoprotection.ButifanHCWdecidedagainst

vaccination,thenVOMwasareasonablealternative,onethatconferredprotection

againstnosocomialinfluenza.

ThefourcRCTs

ThefourcRCTs,followedbyafifth,referredtoastheDutchRCT,unambiguously

established,inSt.Michael’sview,thatvaccinatingHCWsagainstinfluenzaprotected

patients.WhiletheCochraneReviewtookissuewiththefourcRCTs,andfoundthat

theeffectsizewastoobigtobereal,thatcriticismwas,St.Michael’sargued,

unfounded.Dr.McGeerrebuttedtheCochraneReview,anditsfindingthattherewas

“noevidence”thatvaccinatinghealthcareworkersprotectspatientsintheircarein

herappendixtotheTAHSNreportandinherevidenceintheseproceedings:“There

issubstantialevidenceincreasingvaccinationratesinhealthcareworkersresultsin

reducedmortalityduringinfluenzaseasonintheresidentstheycarefor.”

28

Otherswhohadlookedintoit,andreferencewasmadetovariousstudies,

concurred:influenzavaccinationcananddoesenhancepatientsafety,apointwhich,

St.Michael’snoted,theAssociationexpertsdidnotdispute.Equallyimportant,Dr.

DeSerres’sconclusionsinthePlosOnearticlehadbeenthoroughlyrebuttedbySt.

Michael’sexpertDr.RekaGustafson.St.Michael’surgedmetoadoptherevidence

andconcludelikewise.AdditionaldatathatSt.Michael’sreviewed–forexample,

someobservationalstudies–supportedtheVOMpolicy.

AsymptomaticTransmission

Peopletransmitinfluenzabeforetheyknowtheyaresick.Theextentof

asymptomatictransmissionisdifficulttoestablish,buttheweightoftheevidence,

nevertheless,St.Michael’sargued,isthatitoccurs.Itisalsothecasethatsome

HCWs,eventhoughitwascontrarytoestablishedpolicy,workwhilesick

(presenteeism).InSt.Michael’sview,thiswasanotherreasontorequire

unvaccinatedHCWStomask:itprotectedpatients.

Masking

InSt.Michael’ssubmission,maskspreventunvaccinatedHCWsfromtransmitting

influenza.Italsoprotectedthemfromacquiringit.Whiletherewasnotalotof

evidencedemonstratingtheefficacyofmaskingassourcecontrol,whattherewas–

andSt.Michael’sreviewedanumberofstudies–establishedthatmaskingworked.

29

StandardofCare

ThemedicaldatasupportedHCWimmunizationbutsotoo,increasingly,didthe

standardofcare,andthiswasespeciallyimportantinanacutecareinstitutionlike

St.Michael’s,wherethepatientpopulationwasparticularlyvulnerable.TheCDC

recommendedit.Canada’sNationalAdvisoryCommitteeonImmunization

describedHCWinfluenzavaccinationas“anessentialcomponentofthestandardof

care.”TheProvincialInfectiousDiseasesAdvisoryCommitteeofPublicHealth

OntariorecommendedthatinfluenzavaccinationbeaconditionofHCW

employment.Otherorganizationsindicatingsupportofonekindoranother

includedtheOntarioMedicalAssociation,TorontoPublicHealth,theCanadian

NursesAssociationandtheRegisteredNursesAssociationofOntario.Standardsof

care,St.Michael’sargued,matter,andtherewaslittlequestionthatinfluenza

vaccinationwasappropriateandapproved.

NotInconsistentwithorContrarytotheCollectiveAgreement

InSt.Michael’ssubmission,therewasnoinconsistencybetweentheVOMpolicyand

thecollectiveagreement,anditwasdefinitelynotcontrarytoanycollective

agreementprovision.TheVOMpolicygaveeffecttotheparties’sharedobligationto

providethebestpossiblecareandhealthprotectionforpatients.Itwasbasedon

goodevidence–andinhealthandsafetymattersabsolutescientificcertaintywas

notapreconditiontotakingstepstoreduceriskstoprotectHCWsandpatients.St.

Michael’swaswellwithinitsnegotiatedrightstorequireHCWstowearprotective

equipment.

30

Thepartiesagreedthattheinfluenzavaccinemaybebeneficialforpatientsand

HCWs–theysaidsointhecollectiveagreement–andthisexpressedtheirshared

viewthatitwasanappropriatemedicalinterventionandestablishedthattheVOM

policywasnotonlycollectiveagreement-compliantbutreasonable.Andperhaps

mostimportantlyofall,Article18.07(c)wasnotimpactedbecausetheinfluenza

vaccinewasnot“required”.Noonewasorderedtotakethevaccine.Noonewas

disciplinedfornottakingthevaccine.Therewasnoinconsistency,inSt.Michael’s

view,betweenapolicythatallowsHCWsachoicebetweenvaccinationandmasking

andcollectiveagreementprovisionswherethepartiesagreethatvaccinationmay

bebeneficialforHCWsandpatients.

VOMPolicyReasonable

TheVOMpolicyprovidedHCWswithachoice:theycouldelectbetweentwo

meaningfuloptions.Theycouldvaccinateortheycouldmask.Offeringachoice,St.

Michael’sargued,wastheexactoppositeofcoercionandexemplified

reasonableness.Allchoicewassubjecttoinfluence,butSt.Michael’spreferencefor

vaccinationdidnotaffectthevoluntarinessofthedecisionbeingmade.Thechoice

maybedifficult,butitwasstillachoice.ThatwasthefindingofArbitratorDiebolt’s

inHealthEmployersAssn.ofB.C.(2013)237LAC(4th)1(“theDieboltAward”).

31

TheDieboltAward

AVOMpolicywasintroducedinBritishColumbiaaftereffortstoincreasevoluntary

influenzavaccinationrateswereunsuccessful.Itwasgrieved.ArbitratorDiebolt

foundthatprogramsthatincreasedHCWinfluenzaimmunizationwerereasonable:

Pausinghere,inmyview,thefactsthat:(1)influenzacanbeaserious,evenfatal,disease;(2)thatimmunizationreducestheprobabilityofcontractingthedisease,and(3)thatimmunizationofhealthcareworkersreducestransmissionofinfluenzatopatientsallmilitatestronglyinfavourofaconclusionthatanimmunizationprogramthatincreasestherateofhealthcareimmunizationisareasonablepolicy(atpara.205).Thatleftoutstandingthecontestedpolicy:VOM.ArbitratorDieboltacceptedthe

evidencethathadbeenledthatVOMpoliciesincreaseimmunizationrates.Healso

acceptedthatmaskingprovided“somepatientprotection”(atpara.208).

Thatsaid,itwouldbetroublingiftheonlypurposeoreffectofthePolicy’smaskingcomponentweretomotivatehealthcareworkerstoimmunize.Inthatevent,maskingwouldonlybeacoercivetool.Onalltheevidence,however,Iampersuadedthatmaskinghasapatientsafetypurposeandeffectandalsoanaccommodativepurposeforhealthcareworkerswhoconscientiouslyobjecttoimmunization(atpara.207).

Accordingly,ArbitratorDieboltupheldtheVOMpolicyanddismissedthegrievance,

andthisresult,forthesereasons,wasurgeduponmeinthiscase.

Speakingofarbitralresults,St.Michael’sarguedthattheHayesAwardnotbe

followed.Asindicatedattheoutset,IhaveconcludedthattheHayesAward,inits

mostmaterialrespects,isonallfourswiththiscase.Thatbeingsaid,therearesome

differencesworthpointingout,especiallyastheygotoArbitratorHayes

characterizingthepolicyascoerciveasaprincipalbasisforhisdeterminationthat

theVOMpolicywasunreasonable(incontrasttothefindinghere).

32

TheSaultAreaHospitalseta100%targetvaccinationrate.NotargetwassetatSt.

Michael’s.TheSaultAreaHospitalrequiredVOMduringtheentireinfluenzaseason.

St.Michael’srequiresitonlyduringthemostactivephase.SaultAreaHospital

actuallyimplementeditsVOMpolicythemonthbeforetheTAHSNreportbecame

effective.St.Michael’shadanepidemiologistonstaffwhotookthetimetostudyit

andconsultwithcolleagues.St.Michael’scounselalsopointedtosomedifferences

intheevidenceoftheHCWswhotestifiedintheSaultAreaHospitalcaseandthe

oneswhotestifiedinthisproceedingandsuggestedthattherewasnoevidencein

thiscaseofanythingthatcouldberemotelydescribedascoercive.Forallthese

reasons,andothers,St.Michael’sarguedthattheHayesAwardcouldnotandshould

notbefollowed.Certainly,therewasnobasistoadoptthataward’sprincipalfinding

thattheVOMpolicyinplaceattheSaultAreaHospitalwascoerciveandthatmasks

werecastastheconsequencefornon-compliance.

ConclusiontoSaintMichael’sSubmissions

TheVOMpolicyhadonegoal:puttingpatientsfirst.Itwasgroundedintheevidence,

evidencethatestablishedthatencouragingandincreasingHCWvaccinationrates

reducednosocomialinfluenza.Experienceelsewhereindicatedthatvaccination

ratesriseinresponsetointroductionofaVOMpolicy,andthatadditionalprotection

wasobtainedbyrequiringunvaccinatedHCWstowearmasks.

Ultimately,therewasnofinalanswerinscience,butnoreasontowaitforbetter

evidenceortheperfectstudy.Doingnothingwasnotasatisfactoryresponsewhen

33

activestepscouldandshouldbetakentopromotepatientwelfare.ThefourcRCTS,

andtheotherevidenceSt.Michael’sreliedupon,mightnotproduceexact

quantitativeresultsthatcouldbeextrapolatedacrossanentirehealthcaresystem,

butintotalconvincinglyestablishedthatinfluenzatransmissionwasreducedwhen

HCWsvaccinate.Theburdenofpreventablediseasewasaddressedbyencouraging

influenzavaccinationandbyrequiringmaskingforthoseHCWswhochosenotto

takeadvantageofthevaccine.Bothprovidedprotectionagainstnosocomial

influenzainfection,aclearlydesirablegoal.Andbothdidsoinareasonableand

lawfulmannerthatappropriatelybalancedallinterests.St.Michael’saskedthatthe

grievancesbedismissed.

Decision

Havingcarefullyconsideredtheevidenceandargumentsoftheparties,Iamofthe

viewthatthegrievancesmustbeallowed.TheVOMpolicy–unilaterallydeveloped

andimplementedbySt.Michael’s–comesdirectlywithinarbitralpurview.

Forthereasonsthatfollow,theVOMpolicyisinconsistentwithandcontrarytothe

collectiveagreementanditisalsounreasonable.

GeneralObservations

Theevidenceestablishesthat,moreorless,andotherthantherarecaseofa

completemismatchyear,influenzavaccinationprovidessome–varying–degreeof

protection.Itmakessense,therefore,thathospitalssuchasSt.Michael’swouldwant

toencourageinfluenzavaccinationasitisaxiomaticthatifonedoesnotcontract

34

influenzaonecannotpassiton.Itishardlysurprising,inthesecircumstances,that

thereisageneralconsensusinthemedicalestablishmentinfavourofinfluenza

vaccination.Thepartieshave,however,agreedthatHCWscanrefuseanunwanted

vaccination.AndasDr.Mullerandotherstestified,individualshaveallsortsof

reasonstodoso,thelegitimacyofwhichhasnotbeenbroughtintoquestion.Indeed,

influenzavaccinationisnotrequiredbySt.Michael’s.

TheVOMpolicy,however,failsforanumberofreasons:Thereisinsufficient

evidenceofaproblemtobeaddressed–nosocomialinfluenzatransmittedby

unvaccinatedHCWs.Thereisinsufficientevidencethatasymptomaticorpre-

symptomatictransmissionisasignificantsourceofinfection.Andthereis

insufficientevidencethatmaskingpreventsthespreadofinfluenza.

Inthefaceofallofthis,the“ask”thatHCWswearamaskfortheirentireshiftfor

possiblymonthsonendwhenentirelyfreeofsymptomsiscompletelyunreasonable

andiscontrarytothecollectiveagreement.

Ingeneral,wheremattersofpatientsafetyareconcerned,cautionisinorder,and

appropriate.Bettertobesafethansorry.Tobesure,oneneednotawaitallthe

evidencebeforetakingappropriatesteps.Norisitnecessarytoawaitperfect

evidence.Vaccinationsarethebesttoolintheboxtoprotectagainstinfluenza.A

policyencouragingHCWstovaccinatemakesobvioussense(asdoesencouraging

35

handwashinghygiene,anddiscouragingpeoplefromcomingtoworkwhentheyare

sick).However,theVOMpolicyfailsforanumberofreasonsassetoutbelow.

Beforeturningtothereasonswhythegrievanceshavebeenupheld,oneassertion

needstobeputtorest.TheVOMpolicy,forallofitsdeficiencies,doesnotfail

becauseitiscoercive.Thatsubmissioniscompletelyrejected.

NotCoercive

ItiscorrectthatSt.Michael’sHCWsarenotrequiredtosubmittotheannual

influenzavaccination.Buttheirrighttorefusethevaccineisinterferedwithbyan

unreasonablepolicy.However,unliketheHayesAward,Icannotconcludethatthe

VOMpolicyiscoercive.Thisfindingrequireselaboration.

IntheHayesAward,theevidenceclearlyestablishedthattheSaultAreaHospital

determinedthattherewasaproblem–lowinfluenzavaccinationrates–andwent

aboutdevisingasolutiontoaddressthatproblem.Theminutesofahospital

meetingheldonJanuary30,2013sayitall:“Needtodeterminethemostaggressive

stancethatwecantake…toeithermandatestafftocomply,orimposeconsequences

(i.e.masksthattheywouldbechargedfor)”(atpara.52).Quiteclearly,thesolution

totheproblemattheSaultAreaHospitalhadnothingtodowithusingmasksto

preventtransmissionandeverythingtodowithusingthethreatofmasking,and

chargingHCWsforthem,toincreasevaccinationrates.

36

Whenanarbitrarilysetvoluntaryimmunizationgoalfailedtobereached,theSault

AreaHospitalimplementeditspolicy.Littleornoattentionwaspaidtoevidence

aboutmaskingefficacyinpreventingnosocomialinfluenza.Rather,whenthecarrot

ofencouragingvoluntaryvaccinationfailed,thedecisionwasmadetoturntothe

stick,andthatwasimposingamaskingobligationonunvaccinatedHCWsasa

punitiveandcoercivemeasure.

Moreover,atSaultAreaHospitaltheVOMpolicywaspursuednotwithstanding

concernsraisedbyseniormedicalstaff.Ifthetargetimmunizationrateof70%was

notachieved,theVOMpolicywouldfollow.Anditwasnot,anditdid.Thetargetof

70%wasanarbitrarynumberinandofitself.Theobjective–increasingHCW

influenzavaccination–wasthere,andhere,entirelylegitimate,butthemeans

employedtheretoachievethatobjectivewashighlycolourable,asArbitratorHayes

found.ThesituationatSt.Michael’s–thebackstory–iscompletelydifferent.

Inmyview,theevidenceisabsolutelyclearthatthedecisiontointroducetheVOM

policyatSt.Michael’swasmadeinpursuitofentirelyreasonableobjectives:to

increasevaccinationlevelsandtherebypreventnosocomialinfluenzabasedona

good-faithbeliefthatthefourcRCTsestablishedapersuasivelinkbetween

increasedHCWinfluenzavaccinationandreducedmorbidityandmortality,andthat

maskingwasareasonablealternative,providingsomeprotectionforpatientswhen

HCWsdeclinedinfluenzavaccination.Thatwas,inanutshell,thereasonsthat

informedthedecisionthatwasmade.

37

WhileArbitratorHayesconcludedonthelocation-specificevidencebeforehimthat

maskingwasintendedtocoerceSaultAreaHospitalHCWstovaccinate,Idonot

reachthesameconclusion.IconcludethatSt.Michael’sintroducedanddefendedits

policybecauseitbelievedittobeintheinterestofpatients.IacceptDr.Muller’s

evidenceonthispoint:

…IcansaycategoricallythatitwasnevermyintentiontoshameorblameanyonebyimplementingthistypeofpolicyatSt.Mikes.IwouldgofurtherandsaythatonthedifferentcommitteesandgroupsthatI’vesatatwherethepolicywasdevelopedorpresentedorrefined,everyeffortwasmadetoavoidshamingorblaming,andtheintentionofthepolicywasalwaysfocusedonpatientandstaffsafety.So,Icansaythatabsolutely.Ithinkthatthemaskwasselectedbecauseofourbeliefthatitaffordssomeprotectionagainstinfluenza,bothtothepersonwearingthemaskandthepeoplearoundthepersonwearingthemask.So,again,itactsasapieceofpersonalprotectiveequipmentthatprotectsthepersonbutit’salsoaformofsourcecontrol.So,ifthatpersonweretohaveasymptomaticfluordevelopmildsymptomsoffluwhichtheydon’trecognizeortohavemoresignificantsymptomswhichtheychoosetoignore,forwhateverreason,thatthiscouldprotectthepeoplearoundthem.AndIthinkwewantedtopresenthealthcareworkerswitharealchoicewhichmeansbothchoiceshadtobeabletoprotectpatientsfromflu,althoughourpreferencethroughallofthiswastohavemorehealthcareworkersvaccinated.So,thebestevidenceforvaccinatinghealthcareworkers,wehavethefourclusterrandomizedtrialsaswellastheotherevidencethatwe’vegoneoverindetail.Wedon’thavefourclusterrandomizedtrialsofmaskingbutwehaveIthinksoundbiologicrationaleandsomestudydatashowingthatmasksshouldbeeffective….So,bygivinghealthcareworkerstwochoices,oneisthevaccineandoneisthemask,itmeansthateveryhealthcareworkercanmaketheirowndecision…

St.Michael’sapprovedtheVOMpolicybecausevaccinationsdo(imperfectly)work

andthereforereduceinfluenzaincidence.Encouragingvaccinationisagoodthing.

Maskingmaynotprovideperfectprotectionbutitisbetterthannothing.Taken

together,St.Michael’sconcludedthatitcoulddealwithaproblem–nosocomial

38

influenza–anddosoinameasuredandbalancedfashion.Thereisnoevidenceof

coercion.

Thereisalsonoevidencethatmaskingwasidentifiedasapunishmentorstigmato

encouragevaccination.Nevertheless,theVOMpolicydoesimpingeonthecollective

agreement,assetoutabove,andfailsthereasonablenesstest.Actingingoodfaithis

notenoughalonetoestablishthataunilateralemployerpolicyisreasonablewhere,

ashere,itisinconsistentwiththecollectiveagreementandwhereitsitsonashaky

evidentiaryfoundation.

TheReasonablenessTest

NoonedisputesthatSt.Michael’shastherightandresponsibilitytotake

appropriateprecautionstoprotectthehealthandsafetyofpatients.Butinthiscase,

thestepstaken–theVOMpolicy–aresubjecttoareasonablenesstest.

Asisprovidedinthejurisprudence,anddealingwithonlytherelevantpartsofwhat

iscommonlyreferredtoasKVP((1965)16LAC73),arbitratorsmustapplytheir

labourrelationsexpertise,considercontextanddecidewhetheracontestedpolicy

strikesareasonablebalance.Inreachingaconclusion,amongthefactorstobe

consideredisthenatureoftheinterestsatstake,whethertherearelessintrusive

meansavailabletoachievetheobjective,andtheimpactoftheparticularpolicyon

employees.Thepolicymustalsonotbeinconsistentwithorcontrarytothe

collectiveagreement.

39

AVOMpolicycannotbeupheldsimplybecauseitissupportedbygoodfaithand

someevidence.Tosatisfyareasonablenesstest,objectiveevidenceisrequiredofa

realproblemthatwillbeaddressedbyaspecificsolution.Andwhentheevidenceis

examined,thesefactualandlegalelementsareabsent.Forthereasonsthatfollow,I

amlefttoconcludethattheVOMpolicyviolates,andisinconsistent,withthe

collectiveagreement,andisunreasonable.

InsufficientEvidenceofaProblem

AusefulstartingpointistheTAHSNreport.Itis,afterall,thebasisoftheVOM

policy.However,itcannotberelieduponbecausetheevidenceitcitesas

justificationinsupportoftheVOMpolicydoesnotwithstandseriousscrutiny.Iam

referring,ofcourse,andinthemain,tothefourcRCTs.

AsDr.DeSerresputit,“thefourcRCTs…attributeimplausiblylargereductionsin

patientrisktoHCWvaccination,castingseriousdoubtsontheirvalidity.(Notably,

Dr.DeSerresisinfavourofinfluenzavaccination–herecommendsitandis

annuallyvaccinated.)Otherpersuasiveevidence–forexample,theCochrane

Review,generallyunderstoodtopresentthehighestqualityofanalysis,supports

thisconclusion.

St.Michael’scalledDr.GustafsontorebutDr.DeSerres’sexpertevidenceand

publications.However,shewasnotanepidemiologist,andaddedvirtuallynothing

tothediscussionofvaccineefficacy,asymptomatictransmission,maskingassource

40

control,ortoprotectthewearer,andminimalindirectevidenceabouttheburdenof

nosocomialinfluenzainacutecare.HercriticismsofDr.DeSerrres’sworkand

conclusionsfellshort;theywereentirelyunpersuasive.

ThesuggestionthatunvaccinatedHCWsplacepatientsatgreatinfluenzaperilis,as

Dr.DeSerrestestified,exaggerated.Forexample,theTAHSNreportadoptsthe

findingofoneofthefourcRCTSandconcludesthatforevery8HCWsvaccinated,1

patientlifecouldbesaved.Ifthiswereactuallytrue,itwouldbehardtodisagree

withanassertionofanoverwhelmingpublichealthinterestinpromotinginfluenza

vaccination.Butitisnottrue,forthereasonsexplainedintheextremelydetailed

andpersuasiveevidenceofDr.DeSerres,alsoassetoutinhisreport,andinhisPlos

Onearticle.Iaccepthisconclusionthattheassertionof8/1NNVis“preposterous.”I

accepthisevidencethatthefourcRCTsprovideimpossibleresultsfrom

methodologicallyflawedstudiesthatcannotbereasonablyextrapolatedandapplied

toanacutecarehospitalsetting.Dr.McGeerconcededthatNNVof8/1was

incorrect.Itwas,anotherSt.Michael’switnesswrote,“acatchyphrase,”butitisnot

asupportableone.Obviously,andevenassumingtherewaspersuasivedataonthe

NNV,maskingplaysnoroleintheNNV.

TotheextentthatthefourcRCTshavevalue,theirvalueissurelylimitedtosome

extentbythefactthattheyariseinLTC,notinamajoracutecarehospitalwitha

constantflowofpersonnelandvisitors.Also,areductioninall-causemortality

cannotbeattributedtoahighervaccinationrate.Influenzavaccinesprotectagainst

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influenza,notallcausesofdeath,anditislogicallyunpersuasivetosuggestthatan

influenzavaccinehasamuchwiderreach.ThefourcRCTsprovideresultsthatreally

aretoogoodtobetrue.AsDr.McGeerwroteinonearticle,“vaccineefficacyis

limited,andconsiderablemorbidityandmortalityoccurseveninvaccinated

persons.”

Thefactis,notwithstandingallofthestudies,thatnoonecanaccuratelyreporton

howmuch,ifany,nosocomialinfluenzaiscausedbyunmaskedorunvaccinated

HCWs.

Itisappropriateheretocommentaboutsomeoftheothernewmedicalevidence

(otherthanGustafson,discussedabove)reliedonbySt.Michael’s.Thenewmedical

evidence,uponcarefulexamination,washardlynewatalland/orsubjecttoserious

limitationsand/orofquestionablerelevance–“smallerbricks”,asoneoftheSt.

Michael’switnessesacknowledged.Moreseriously,someoftheexpertevidence

advancedbySt.Michael’swasparticularlyproblematicandactuallyinconsistent

withthemostbasicacademicnorms.

Itwouldservenousefulpurposetoparticularizethisevidenceindetailotherthan

toobservethattwooftheprincipalexpertsadvancedbySt.Michael’sputforwardin

theirjointreportpropositionswithoutevidentiarysupport,whichwascertainly

troubling,butmakingmattersworse,someofwhattheywrotewassimplyincorrect.

Ontoomanyoccasionstheirnotedcitationsstoodfortheexactoppositeofthepoint

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beingmade–“Iamgoingtoagreewithyouthatthisisnotthebestreference…”–or,

consideredmostfavourably,completelyoverstatedthepropositionbeingadvanced.

Thereweretoomanyapologieswhenerrorswerebroughttotheirattention.Asone

ofthesewitnessestestified,“wemayhavebeensloppy….”Everyonemakes

mistakes,butthiswentbeyondthepale.Icompletelydisregardtheirreport.

AsthefirststepinestablishingthattheVOMpolicyisreasonable,St.Michael’shad

toestablishthatvaccinationreducedtransmissionand/orthatunvaccinatedHCWs

putpatientsatagreaterriskofcontractinginfluenza.Ithasnotmetthisevidentiary

burden.

ThereisnoquestionthatHCWshaveanobligationtodowhattheycantoprotect

theirpatientsfromnosocomialinfluenza.Andthereisnoquestionthatinfluenza

vaccinationprovidessomeprotectionexceptinthosecircumstanceswhenit

providesnoorlittleprotection.However,ontheevidenceledinthisproceeding,the

burdenofdiseasepresentedbyunvaccinatedHCWsisabsent.

Vaccinationobviouslyreducessomeinfluenzatransmission–exceptincomplete

mismatchyears.Butitsefficacyvaries,andeveryyearbothvaccinatedand

unvaccinatedHCWscantransmitinfluenzawhilebothasymptomaticand

symptomatic.Buttheactualextenttowhichinfluenzavaccinationreduces

transmissionisopentoquestionanddebate.AsDr.MichaelGardamwroteinhis

report,weare“onlyabletosaywithcertaintythatinfluenzatransmissionoccurs

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fromclosecontactwithinfectedindividuals.Therelativeparticularsofwhatthis

means…wereunknown.”

Asonestudyindicated,mandatoryinfluenzavaccinationofHCWsisof“uncertain

clinicalimpact.”Inanotherstudy,ahospitalachieveda97%influenzavaccination

ratebutexperiencednoreductioninsickleave.Anotherstudynoted,“wecannotsay

forcertainwhethertherewasachangeduetoinfluenzavaccination.”Anecdotal

evidencewaspresentedthatinfluenzaoutbreakscanoccurinhighlyvaccinatedand

isolatedpopulations.Needlesstosay,thereareotherstudiesindicatingtheexact

opposite.Onbalance,though,thecaseestablishingalinkbetweenvaccinationand

preventionofnosocomialinfluenzawasnotmade.

Itisalsonoteworthythatthereislittleevidenceofanypositiveimpactonpatient

careoutcomesasaresultoftheVOMpolicy.Bothpriortoandafterintroductionof

thepolicy,St.Michael’sexperienced,andcontinuestoexperience,influenza

outbreaks.Inparticular,therewasoneinfluenzaoutbreakbeforetheVOMpolicy

wasintroduced–in2011–andtherehavebeenseveralsince.TheVOMpolicy,as

earliernoted,wasupheldinBritishColumbia,butevidencefromthatjurisdiction

suggeststhatitdoesnotachievethestatedobjective.SeeBritishColumbiaInfluenza

SurveillanceBulletin,2014-15,No.21.

ThefourcRCTsarecontroversial;sotooarethestudiestakingissuewiththem.

Eventhosestudiesandreviewssupportingvaccinationreportthatthequalityof

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evidencethatHCWvaccinationreducesmortalityandinfluenzacasesinpatientsof

healthcarefacilitiesis“moderateandlow.”Attheendoftheday,theevidencedoes

notsupportthepropositionthatnosocomialinfluenzaisassociatedwith

unvaccinatedHCWs–theevidencesimplydoesnotdemonstratethatthereisa

specificburdenofdiseaseassociatedwithunvaccinatedHCWs

Whilereasonableeffortstoreduceriskinpublichealthneednotawaitscientific

certainty,thefactofthematteristhattheextentoftheproblemisunknown;wedo

notknowtheburdenofdiseasefornosocomialinfluenza,andwedonotknowwhat

proportioniscausedbyHCWs,vaccinatedornot.WealsodonotknowNNV.Wedo

knowthatitisnot8/1,thenumbercitedintheTAHSNreport.Allofthisevidence–

reallyabsenceofevidence–goestotheheartofreasonableness.

Inanyevent,evenassumingforthesakeofargumentthattherewasadequateor

sufficientevidencethatvaccinationpreventedorsignificantlyreducednosocomial

influenza,theVOMpolicystillfailsforanumberofreasons,beginningwiththefact

thattheevidencedoesnotsupportmaskingassourcecontrolforunvaccinated

HCWs,therebyputtingthepolicy’sreasonablenessdirectlyintoquestion.

Masking–NotaSolution

Thereisnopersuasiveevidenceestablishingaconclusiverelationshipbetweenthe

useofsurgicalandproceduralmasksandprotectionagainstinfluenzatransmission.

Thelogicalflawsinthepolicyarediscussedbelow.

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St.Michael’sdidnotcallamaskingexpert,andurgedmetorejecttheevidenceof

theexpertcalledbytheAssociation.However,thepreponderanceofthemasking

evidenceiscompelling–surgicalandproceduralmasksareextremelylimitedin

termsofsourcecontrol:theydonotpreventthetransmissionoftheinfluenzavirus.

Thetwomasksintroducedintoevidenceclearlydemonstratewhythatwouldbethe

case.Whatprotectiontheyprovideisself-evidentlylimitedbytheirconstruction

andhowtheysitonahumanface.

IacceptProfessorBrosseau’sevidence.Sheisanexpertonmasking.St.Michael’s

attemptedtodiscreditherbecauseofheradvocacyforworkers:“Iaminterestedin

protectingworkers,”shetestified.Andthereisnothinginthat,inmyview,that

undermineshertestimonyandexpertreportinanyway:bothwereevidence-based,

convincingandcorroborated.

Thebin-Rezasystemicreviewconcludedasfollows:“Noneofthestudiesestablished

aconclusiverelationshipbetweenmask/respiratoruseandprotectionagainst

influenzatransmission.”Dr.Gardamagreed:“Theuseofsurgicalorprocedural

masksisneitheraviablenorscientificallysupportedalternative.”Andfurthermore:

“theevidencesupportingpeoplewearingamaskduringfluseasonisfarflimsier

thanthefourclusterrandomizedcontrolledtrialssupportinginfluenza

vaccination….”Toquoteoneofthescientificarticles,thestudiessupportingtheuse

ofmasksassourcecontrolare“underpowered.”Asanotherstudyconcluded,“there

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islittlegoodqualityevidencetosupportsurgicalmasksasaneffectiveinfection

protectionmeasure….”

Yetanotherstudyobserved:“thereisalackofsubstantialevidencetosupportclams

thatface-masksprotecteitherpatientorsurgeonfrominfectiouscontamination.”

TheCDCiscategorical:“Nostudieshavedefinitivelyshownthatmaskusebyeither

infectiouspatientsorhealth-carepersonnelpreventsinfluenzatransmission.”As

theCDCalsostated,“whileafacemaskmaybeeffectiveinblockingsplashesand

large-particledroplets,afacemask,bydesign,doesnotfilterorblockverysmall

particlesintheairthatmaybetransmittedbycoughs,sneezesorcertainmedical

procedures.”Asanotherstudyindicated,“overall,theevidencetoinformpolicieson

maskuseinHCWsispoor,withasmallnumberofstudiesthatispronetoreporting

biasesandlackofstatisticalpower.”

Thebestcaseformaskingisasfollows:Thereis“ongoingdebate”aboutthe

effectivenessofsurgicalandproceduralmasksasrespiratoryprotectiondevices.

Theevidenceinfavourofmaskingismostly“preliminary.”Or,thereis“some”

evidencethatsurgicalandproceduralmasks“may”reducesheddingandthe

concentrationoftheinfluenzavirusintheairandenvironmentaroundthewearer

(withquestionsaboutactualtransmissionbeingentirelyanothermatter).Butthe

factofthematteris,becauseof“leakage,”surgicalmasksdonotexhibit“adequate

filterperformanceandfacialfitcharacteristicstobeconsideredrespiratory

protectiondevices.”

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Onbalance,andafterthemostthoroughreviewofallofthetestimony,studiesand

reportstenderedinthisproceeding,andwiththegreatestofrespecttoan

accomplishedandrespectedresearcherandphysician,Icannotconcludethatthe

evidencecomesevenclosetoestablishingthatmaskingmaybeas“effectiveas

vaccineinprotectingpatientsfrominfluenza.”

Maskingistheacknowledgedandacceptedstandardofcarewhentendingtoan

infectedpatient,buttheexpertevidenceindicatesthatitisoflimitedvalueto

anyoneasamethodofsourcecontrol,particularlyincaseofanasymptomaticHCW.

Thefactthatthereissomeevidence,forexample,thatmaskingcanprevent

transmissionoflargedroplets–unlikelyinasymptomatictransmission–isnot

enoughtoconferreasonablenessonthepolicy.Littleevidence–negligibleevidence

–cannotserveasthejustificationforthispolicy,allthingsconsidered,especially

sincethemaskingpartoftheVOMpolicyisnotuniversalizedinmismatchorbad

matchyears.The“ask”issignificant,butthebenefitissolimitedthattheformer

cannotbalancethelatter.Independentofanyotherfindinginthisaward,theVOM

policyfailsonareasonablenessbasisforthesereasonsalone.

AsymptomaticTransmissionOverstated

TheargumentwasadvancedbySt.Michael’sthatmaskingwasespeciallyimportant

toreducetheriskofnosocomialinfluenzabyasymptomaticorpre-symptomatic

HCWs.Atbest,theevidenceindicatesthatasymptomatictransmissionisnota

significantfactorinnosocomialinfluenza.AsDr.Mullertestified,asymptomatic

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transmissioncouldnotberuledout,but“thelikelihoodoftransmissionis

dramaticallyhigherwhenyou’recoughingorsneezing.”Thereis,nevertheless,some

evidencethatmaskingcanpreventtransmissionoflargedroplets.However,inthe

samewaythatthereisnocrediblequantificationoftheburdenofdisease

attributabletounvaccinatedHCWs,thereisnocrediblequantificationoftherateof

infectionthatmightoccurintheasymptomaticperiod.

Thedegreetowhichasymptomaticindividualstransmitinfluenzatoothersis,more

orless,unknown:“Silentspreaders…maybelessimportantinthespreadof

influenzaepidemicsthanpreviouslythought.”AsDr.EleniPatrozouconcluded

followinghersystemicreview:“Basedontheavailableliterature,wefoundthat

thereisscant,ifany,evidencethatasymptomaticorpre-symptomaticindividuals

playanimportantroleininfluenzatransmission.”AsDr.DeSerreswrote,“The

evidencethatpre-symptomaticorasymptomaticinfectionscontributesubstantially

toinfluenzatransmissionremainsscant.”

Ingeneral,secretionandsymptomsareparallel,oftenrisinguponalogarithmic

curve.Carratandothershavedemonstratedthatasymptomatictransmissionis

unlikelytobeofclinicalsignificance.AsCarratobserved,“viralshedding,the

surrogatemarkerofinfectiousness,wasofmoderateduration,anditsdynamics

largelyoverlappedthoseofsystemicsymptoms….”BestPPEpracticesindicatethat

individualsberequiredtowearprotectiveequipmentwhenitisnecessaryand

appropriateforthemtodoso,andVOMwhileasymptomaticwouldnotmeetthis

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test.Symptomaticindividuals,problemswithpresenteeismaside,shouldnotbeat

work(andthepoliciesrequiringthisshouldbevigorouslyenforced).Moreover,and

torepeat,ifmaskingreallydidpreventasymptomatictransmission,theonlylogical

conclusionthatshouldbedrawn,givengeneralvaccineeffectiveness,isthat

everyoneshouldmaskallthetimeduringtheinfluenzaseason,whethervaccinated

ornot.

Themasking“ask”issignificant,butthebenefitissolimitedthattheformercannot

balancethelatter.TwonursestestifiedabouttheimpactoftheVOMpolicyonthem

andtheirpatients.Iaccepttheirevidence,whichwascorroboratedinsomeofthe

literature.Forexample,Dr.PriyaSampathkumar,ChairoftheMayoClinic’s

ImmunizationandControlCommittee,hasobserved,“yougethotunderthemasks,

patientscan’tunderstandwhatyou’resayingsometimes…theyarenotpatient

friendly,andtheycanbescarytopatients.”TheMayoClinicdoesnotrequireits

32,000HCWstomaskifunvaccinated–approximately8or9percentoftheeligible

workforce.InfectiousHCWsaretoldtostayhomewhentheyaregettingsick,and

whentheyaresick.Thereisnoevidencebeforemethatcouldleadmetofind,as

wasthecasewithArbitratorDiebolt,thatwearingamaskisaccommodative.

Onbalance,Iampersuadedbytheevidenceandaccepttheconclusionoftheexperts

thatthereis,indeed,scantevidenceofasymptomaticnosocomialinfluenza

transmission.Itisunlikelytobeofclinicalsignificance.Accordingly,requiring

unvaccinatedHCWstowearsurgicalorproceduralmasks–notwithstandingthe

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inherentillogicalityofitall–isunreasonable,andso,therefore,isthepolicy

compellingit.

IllogicalandUnsustainable

Influenzaishighlycontagious.Hospitalpatientsarehighlyvulnerable.Theseare

reasonstoencouragevaccination–generallyregardedassafeandalmostalways

providingsomedegreeofprotection.However,bothvaccinatedandunvaccinated

HCWscantransmititandasymptomatictransmissioncanoccur.Ifdonninga

surgicalorproceduralmaskprovidedprotection,theconclusionshouldbe

inevitablethateveryoneshouldmask–atleastuntilavaccinewithonehundred

percenteffectiveness,orclosetoit,becomesavailable.Thatisnot,however,

requiredillustratinghowillogicaltheVOMpolicyactuallyis.

Attheveryleast,incompletemismatchyears,theonlylogicalapplicationofthe

VOMpolicywouldrequireeveryonetomask,asthevaccineconfersnoorlittle

protection–buteventhatisnotdone.Inyearsofacompletemismatch,ora

generallyineffectivevaccine,St.Michael’sdidnotrequireallHCWstomask.Ifthe

vaccinewereineffective,orexceptionallyofalmostnovalue,andifmasking

providedprotection,thelogicalinferencewouldbethatallHCWsshoulddonmasks

becausevaccinatedHCWswouldbeatleastassusceptibletoinfluenzaas

unvaccinatedHCWs.Buttheywerenotrequiredtodoso,leadingtotheirresistible

conclusionthatthepolicyisillogicalandmakesnosense–theexactoppositeofit

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beingreasonable.Thereareanumberofcollateralreasonsthatsupportthis

conclusion.

InJanuary2018,St.Michael’sbeganaskingunvaccinatedvisitorstomask,butits

effortsinthisregard–noquestionsareaskedaboutvisitorvaccinationstatus–are

hardlymuscular.Unvaccinatedvisitorslogicallypresentthesamerisk,andpossibly

agreaterone,thanunvaccinatedHCWs.Ifmaskingistrulyeffectiveassource

control,howcanitbethattheytooarenotrequiredtomask?Theanswertothis

questionrevealsthatthemaskingpartofthepolicyis,asoneSt.Michael’switness

admitted,“weak.”AsDr.Mulleralsotestified,“there’sfarmoreevidencesupporting

influenzavaccinationitselftoprotectusfromflutransmissionthanthereisfora

mask.”TorequireonlyunvaccinatedHCWstomaskinthecaseofacomplete

mismatch,orinayearwhenthevaccineisofmarginalutility,issimplybizarreand

completelyinconsistentwithanynotionofreasonableness.

TheVOMpolicyisalsounderminedbyrealquestionsofenforcement.Assumingan

averageSt.Michael’svaccinationrateof70%,approximately30%ofHCWs,one

wouldexpect,wouldbewearingmasksatonepointoranother.However,asDr.

Mullertestified,“yououghttosee30percentofpeoplewearingamask…peoplefelt

wedidn’tsee30percentofpeople….”AsDr.Mullerexplained,differencesin

vaccinationratesbetweenfull-,part-timeandcasualemployeesmayprovidesome

explanation,butoneisleftwiththeirresistibleinferencethatonthemaskingsideof

theequation,enforcementwasnotahospitalpriority.ClinicalHCWswork

throughoutthehospital,andthepolicyisexpansiveinitsgeographicscope,

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meaningthatonewouldexpectthatifthepolicywereenforcedunvaccinatedHCWs

wouldweartheirmasksvirtuallynon-stopandwould,therefore,behighlyvisible.

AndIcanonlyconcludethatallofthisbuttressestheevidence–andatleasttacit

understanding–aboutthetrueeffectivenessofmasksassourcecontrol.

Inconsistentwithand/orContrarytotheCollectiveAgreement

Thecollectiveagreementisclear:Article18.07(c)states:“Hospitalsrecognizethat

nurseshavetherighttorefuseanyrequiredvaccine.”Thatrightiscategoricalbut

theVOMpolicy,Ifind,interfereswiththeexerciseofthatright.Accordingly,andto

thislimitedextent,thereisabreach,butitisonethatisparticularlymade

meaningfulbythefactthattheVOMpolicyitselfisunreasonable.Takentogether–a

collectiveagreementbreach–bothcentralandlocal–andanunreasonablepolicy–

thegrievancesmustsucceed.

Conclusion

Itwasnotedattheoutsetthatthiscasewas,inlargemeasure,arepeatoftheone

putbeforeArbitratorHayes.Itisnot,therefore,surprisingthatthereisanidentical

outcome.Ultimately,IagreewithArbitratorHayes:“Thereisscantscientific

evidenceconcerningasymptomatictransmission,and,also,scantscientificevidence

oftheuseofmasksinreducingthetransmissionofthevirustopatients”(atpara.

329).Tobesure,thereisanotherauthorityonpoint,andthedecisioninthatcase

deservesrespect.Butitwasadifferentcasewithacompletelydifferentevidentiary

focus.Itisnotaresultthatcanbefollowed.

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Oneday,aninfluenzavaccinelikeMMRmaybedeveloped,onethatiscloseto100%

effective.ToparaphraseDr.Gardam,ifabettervaccineandmorerobustliterature

aboutinfluenza-specificpatientoutcomeswereavailable,theentiremattermightbe

appropriatelyrevisited.Forthetimebeing,however,thecasefortheVOMpolicy

failsandthegrievancesallowed.IfindSt.Michael’sVOMpolicycontrarytothe

collectiveagreementandunreasonable.St.Michael’sisrequired,immediately,to

rescinditsVOMpolicy.Iremainseizedwithrespecttotheimplementationofthis

award.

DATEDatTorontothis6thdayofSeptember2018.“WilliamKaplan”WilliamKaplan,SoleArbitrator