Mandatory vaccination for healthcare workers – Exploring issues, challenges and supports

RNAO has lead the advocacy for mandatory COVID-19 vaccination for healthcare workers in Ontario. Drawing on experts, in this article we explore the issues and challenges involved and the way forward.

Provincial and territorial governments in Canada should institute mandatory COVID-19 vaccination for health care workers that cut across all public and private settings, argues an article in the Canadian Medical Association Journal. As frontline workers, those in healthcare are both at increased risk of contracting the virus and of transmitting it. The authors argue that an effective vaccine provided to all healthcare workers in Canada would protect both the health workforce and patients, reducing the overall burden of COVID-19 on services and ensuring adequate qualified personnel to ensure people’s health needs are met through the pandemic. They also point to other advantages of mandatory vaccinations:  the expense and difficulty of procuring PPE [editor: as well as that of ongoing COVID-19 testing] and, pragmatically, whether PPE is used appropriately to effectively reduce the risk of acquiring SARS-CoV-2 infection for both healthcare workers and their patients.

The authors call on provincial and territorial governments to set clear rules for vaccination of health care workers across public and private settings and not to leave this task to individual employers. They also address the legality of these mandates. Legality would likely be determined via labour law that considers the “reasonableness” of the employer’s directive, such as what happened with case law related to mandatory influenza vaccination. In 2019, nurses in B.C. won a case against mandatory vaccination policies at their workplaces, making vaccination a matter of individual choice. However, COVID-19 is not influenza. Given the severity of the global pandemic, the authors suggest it is unlikely that challenges to a government mandate would be successful. The authors believe that a challenge under the Canadian Charter of Rights and Freedoms would likely not succeed if provisions were made for those who could not receive the vaccination due to underlying health issues or for those who object to vaccination on religious or conscientious objection grounds.

This article was published in February 2021. Since it was published, I will argue that five developments strengthen the conclusions of the study. One is the growing evidence about the outstanding effectiveness of the COVID-19 vaccines rolled out in Canada in preventing serious illness and hospitalization (much higher than the effectiveness of the typical influenza vaccine). Second, there is mounting evidence that vaccines reduce transmission of the virus (although they do not eliminate it). Third, the deployment of the vaccines and the minuscule rate of serious side effects across millions of individuals has reinforced their safety profile. Fourth is the arrival of new variants, such as delta, that are more transmissible and dangerous and that target those who are unvaccinated. And fifth, we are experiencing a major health human resources crisis – especially in nursing – that makes COVID-19-related absences from work more challenging to replace. Thus, from a legal perspective, the health reward from mandating the vaccine and the risk from remaining unvaccinated have both increased. In short, the “reasonableness” test for mandating vaccines has strengthened.

Many jurisdictions, organizations and coalitions are raising the question of mandatory vaccination for healthcare workers. Hospitals and other healthcare facilities should require employees to be vaccinated against COVID-19, argues a consensus statement by the Society for Healthcare Epidemiology of America (SHEA) and six other leading U.S. organizations representing medical professionals working in infectious diseases, infection prevention, pharmacy, pediatrics, and long-term care. The paper specifies exemption for those with medical contraindications and some other circumstances in compliance with federal and state laws. The guidelines issued by the coalition — which include recommendations for engaging wary employees, navigating regulations and how to enforce a mandatory coronavirus vaccination policy — were crafted by a team of nearly 30 experts during the past two months. This is a move supported by infectious-disease expert Anthony S. Fauci, who suggested that “there should be more mandates” at the local level to curb virus spread.

Enacting a mandatory vaccination policy encourages the vast majority of the workers to take the vaccine, but it also raises resistance from a small number of opposers. That has been the experience of Houston Methodist, a large U.S. hospital system that announced April 1 to staffers they would need to be vaccinated to keep their jobs. While 24,974 workers are now vaccinated, about 150 workers resigned or were fired for refusing to do so. Last month, a federal district court judge dismissed a lawsuit brought by one of those employees, Jennifer Bridges, a former nurse who alleged the policy was unlawful and forced staffers to be “guinea pigs” for vaccines that had not gone through the full Food and Drug Administration approval process.

A paper in the BMJ journal assesses the British and international experience implementing mandatory vaccination for healthcare workers. Here is a summary:

• Public Health England’s 2019-20 report on seasonal influenza vaccines revealed that one in four healthcare workers did not get a flu vaccine. And there are indications that roughly the same proportion of people are wary of having covid-19 vaccines.
• The UK government will make covid vaccination mandatory for home care staff starting in October 2021, and is considering whether to extend the policy to NHS staff. Advocates argue that it is not dissimilar to hepatitis B vaccination, which is required by some hospital trusts. But such policies have never been tested legally. Trusts ask staff to receive the hepatitis B vaccine but, in practice, those who don’t are simply taken off duties that could expose them to the disease.
• In Italy, the government introduced in March a requirement for health workers, including pharmacists, to be vaccinated before treating patients. Serbia is considering a similar stance. “The aim of the measure is to protect as much as possible both medical and paramedical staff and those who are in environments that may be more exposed to the risk of infection,” the Italian government said in a statement. Those who refuse face suspension without pay for the rest of the year. The government moved after clusters of hospital infections were linked to unvaccinated staff and is designed to combat an endemic anti-vaccination movement in the country.
• Saudi Arabia has taken perhaps the hardest line: no jab, no job. In May, its government said employees in the public, private, and non-profit sectors must be vaccinated before they can return to work.
• Most countries are, however, yet to tackle the difficult question and, among those that have, policies differ in terms of the types of workers, situations, and strictness in insisting on vaccination.
• In Moscow, two million people in public facing jobs, including frontline health workers, have been told they must be vaccinated by the city’s mayor after a spike in cases. Businesses will be monitored to make sure they comply – at least 60% of employees must have a first dose by 15 July or firms risking being fined.
• Ireland hasn’t ruled out making covid-19 vaccination mandatory for health workers, but the country’s health regulator called it the “most intrusive step” that should only be considered if the risk to patients from unvaccinated health staff was high because of increased community transmission. Some hospital trusts in Ireland have already sent staff who refuse to be vaccinated home on full pay to avoid them being close to patients.

In recent days, France and Greece have announced that vaccinations will be mandatory for healthcare workers. On July 12 French president Emmanuel Macron announced that mandatory vaccination would apply to anyone who comes into contact with vulnerable people, including doctors, nurses, office staff, and volunteers. They must be fully vaccinated against the coronavirus by 15 September or will risk not being paid. He added that from 21 July anyone wanting to visit a theatre, cinema, sports venue, or festival involving an audience of more than 50 people would need to show a pass proving that they were either fully vaccinated or had tested negative. From August 1st this requirement will extend to cafes, bars, restaurants, shopping malls, and long distance trains. After his announcement almost a million people, most of them under 35, booked their vaccination. In Greece the prime minister, Kyriakos Mitsotakis, announced that nursing home staff needed to get vaccinated immediately, while healthcare workers would have to be vaccinated from September 1st.

Experts agree that simply imposing a mandate to vaccinate is not enough. There must be accompanying policies to promote, facilitate and encourage vaccination. An article focuses on the Australian mandate for COVID-19 vaccination for residential aged-care workers, with the aim to ensure all aged-care staff have received their first dose by mid-September. The author identifies several actions and policies to support implementation:

• More on-site vaccination at workplaces as opposed to seeking vaccination appointments via mass clinics. In this sector, the delivery of vaccination is complicated by variations in staff working hours. Providing the vaccine at their place of work can potentially address issues around access to vaccination.
• Seeing coworkers getting vaccinated may help build confidence in those who are sitting on the fence. Workplace provision of vaccination plays an important part in the decision to immunise among aged-care workers, with higher vaccination rates in facilities providing on-site vaccination.
• Support conversations within the facilities to ensure staff members understand why the shift in policy has occurred, to address any misinformation and to support them to take up the vaccine.
• As English may be a second language for a portion of workers, efforts are required to ensure information sheets and booking systems are available in other languages.
• Be mindful to adopt best practice to support engagement with vaccine services for people from culturally and linguistically diverse communities.
• Support in booking appointments for workers who may have limited computer skills.

The author identifies leave time (paid time off) to take the vaccine as an important factor. It is essential to ensure aged-care workers can take time off if needed to access off-site vaccination appointments, and to recover if they experience any adverse reactions.