Family Webicine

By Rod Moser, PA, PhD

You don’t see very many people in the U.S. voluntarily wearing surgical masks in public, but that is not true in Japan. Twenty years ago, when my wife and I traveled to Japan to visit our former exchange students, we were shocked at the number of people on Tokyo’s crowded subways who were wearing surgical masks. At first I thought the mask-wearers were protecting themselves from airborne germs, but was told that the mask-wearer was the one who was ill and protecting others. In Mexico City a year or so ago, it seemed like the entire population was donning masks for fear of the H1N1 virus that originated in this country.

You want surgeons to be wearing masks. Hospitals are contaminated enough, so you don’t want your heart surgeon sneezing into your open chest. Personally, I have worn masks in the office on those days where I am one of the working ill. I should have stayed home, but the idea of inconveniencing 30-40 patients was not appealing to me. So, on went the mask.

When you come in wearing a mask, it does not go unnoticed. It is important to explain why you are wearing a mask today. Most people are grateful for the hygienic gesture.  Like hand-washing, it is best to do it in front of the patient (so they know you did it), and again after the patient is examined (so they know you are not just washing your hands after them). Personally, I hate wearing masks. They are hot and humid, and as a bearded man, the seal is not really very good. If you have to cough or blow your nose, you will need to change your mask. Wearing a mask is still better than inadvertently coughing or sneezing on a baby, though. Incidentally, if you suddenly sneeze in the air, contaminated droplets can travel three feet or more, contaminating any surfaces in their path.

Masks look silly. One pediatrician in my office always wears a surgical mask when he is quasi-ill so that he does not infect any of his little patients. The infants and babies, who instinctively look for smiles, must be terribly confused about this, so one day I drew a big smile on the outside of his mask. Unfortunately, he looked even sillier, but in a pediatric office where children are often frightened, silly can be good.

The studies are conflicting, but if you had to weigh them for a consensus, masks may be very helpful, assuming they are the proper type and worn correctly. Influenza viruses are very tiny and can penetrate around and through improper masks. Viruses can also enter the body via the eyes, so unless you are also wearing eye protection, surgical masks only offer partial protection.

The influenza vaccine, although not perfect, is the best defense, but there are many people who refuse the flu vaccine for a variety of reasons. If the person has a history of a severe (allergic) reaction to influenza vaccine in the past, it may be best not to receive it again. Allergic reactions are rare.  People who claim they got the flu from the vaccine are mistaken – the flu vaccine is biologically incapable of causing the flu. They may have been exposed to the flu while standing in line, but not by getting the vaccine. Because flu viruses can rapidly change after the vaccine has been manufactured, the efficacy of the vaccine varies from year to year, so a past experience does not automatically imply future responses.

A medical assistant in a neighboring practice refused to get the flu vaccine this year. Twice in the past, she had a reactivation of her herpes simplex (cold sores/fever blisters) immediately after the flu shot. Although this is not a commonly reported reaction, it is theoretically possible, and she did not want to risk a third, painful outbreak.

Because she refused the flu vaccine, she is required by office policy to wear a surgical mask at all times when in the office for the next six months. She was even informed that she had to leave the building to have lunch. Unless you actually have the flu, you are not contagious, so this policy is really to protect her. However, we have not seen one lab-confirmed case of influenza yet this year, and again, a person can contract the flu from other than respiratory droplets that enter the nose or mouth. She could just as easily get the flu from touching a contaminated surface and rubbing her eyes. Perhaps the policy is just designed to be punitive.

Influenza cases are coming, of course, but she may still be partially protected from last year’s vaccine, which is identical to this year’s. I am not sure of the wisdom of this policy, since the mask is really not the panacea of protection.  She is reluctantly wearing the mask because she needs her job.

My wife, also a medical provider in our office, just got her flu vaccine yesterday. The flu vaccine always gives her a sore arm, so she avoids it up to the last minute. Our office would have made her wear a mask too, if she did not get it. I got my flu vaccine earlier in the year.

The bottom line is that there is no conclusive evidence that the mandatory use of surgical masks by those who provide patient care during flu season is worth the expense and hassle. However, combined with other hygiene procedures, like through hand-washing (not just those gestures for show) and surface sanitation, masks are likely to offer a better defense than nothing.

What do you do to protect yourself and others during cold and flu season? Share your tips in the comments below or in our Cold and Flu Community.