PROVIDENCE, R.I. (AP) — Rhode Island’s health director says the flu is now widespread in the state, a declaration that triggers a requirement that unvaccinated health workers must wear masks when having contact with patients.

Department of Health Director Michael Fine announced his decision Wednesday. He says vaccination is the best defense against the flu, and says that health care workers who haven’t been vaccinated can protect their patients by wearing masks.

In 2012 a union representing health care workers challenged the policy in court, saying there was no evidence it worked to prevent the spread of the flu. The lawsuit was later withdrawn.

The state says there have been 51 hospitalizations in Rhode Island related to the flu so far this season.

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