in the matter of an arbitration between: and€¦ · in the matter of an arbitration between: st....
TRANSCRIPT
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
3
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
5
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
6
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.
8
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.
10
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.”
12
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
13
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,”
15
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
16
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.
18
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
41
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
42
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
43
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
44
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.
45
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
46
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.”
47
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
48
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
49
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
50
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
51
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,
52
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.
53
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