Mandates and other questions about vaccination of health care workers

ACP Hospitalist recently spoke to infectious diseases and ethics expert Janet A. Jokela, MD, MPH, FACP, about how health care systems should handle getting their staff vaccinated against COVID-19.

With the availability of vaccines against SARS-CoV-2 appearing imminent, many questions have arisen about how they'll be implemented. The CDC's Advisory Committee on Immunization Practices voted on Dec. 1 to prioritize vaccination of health care workers, but does that mean health care workers will be required to get a vaccine, by either their governments or their employers?

For thoughts on this and related questions, ACP Hospitalist recently spoke to Janet A. Jokela, MD, MPH, FACP, an infectious diseases physician and professor of clinical medicine at University of Illinois College of Medicine at Urbana-Champaign, as well as an ACP Regent and Chair of the College's Ethics, Professionalism, and Human Rights Committee.

Q: What are your thoughts on whether hospitals should mandate COVID-19 vaccines for their staff?

A: Vaccine mandates for health care workers are not new and have been in place for many years, such as vaccines for measles and hepatitis B. New vaccine mandates have become more common over recent years, especially with the flu vaccine. With COVID-19 vaccines, we may well end up in the same place down the road. But I think right now, in December 2020, it remains premature to think that a vaccine mandate for health care workers would be an effective or good strategy to roll out the vaccine, especially assuming these new vaccines initially receive emergency use authorization.

Q: Is there potential for supply limitations to also affect the decision making about this?

A: Absolutely. The supply is going to trickle out, as we know, and vaccines will not be widely available in the beginning. It's hard to say, but it could be a few months before the vaccine is even available for all health care workers in the United States. Given this, certainly in the beginning, I think it would be difficult, if not impossible, for employers to mandate COVID-19 vaccines for health care workers.

Q: Do you think hospitals will have to prioritize categories of staff for vaccination? How might that work?

A: I think that's happening already. Health care systems are trying to figure out now whom to vaccinate first amongst their staffs. Some of the most high-risk employees—for instance, those working in the emergency room and the ICU and respiratory therapists, for example—I think those may be some of the groups that hospitals will consider offering the vaccine to first.

Q: Do you expect that almost all health care workers would be willing to get a vaccine without a mandate?

A: On average, according to recent surveys, about 20% of health care workers may decline the vaccine. So no, I don't think that all health care workers will rush to get it, however the majority will. … The recently reported high efficacy rates have certainly increased enthusiasm. The question for those of us in public health or leadership roles within our institutions is how to minimize the number that decline, and how to incentivize employees to get vaccinated. I also think it's critically important for health care workers to get vaccinated, in part because we'll set the example for the rest of the country. If health care workers are comfortable getting the vaccine, that sends a powerful message to our patients and the rest of society.

Q: How can leaders convince reluctant health care workers to get the vaccine?

A: I think there are techniques that can be used aside from mandates. … It could be things like using an opt-out policy. This is something that's been shown to be effective with flu vaccines. The default is that yes, everybody will get the vaccine, but if someone intends to opt out, they have to declare why. Another approach could be for leaders, whether in local health systems or across the country, to very publicly get a vaccine. For instance, in 1956, Elvis Presley received his polio vaccine on “The Ed Sullivan Show,” and reportedly rates of polio vaccinations increased significantly after that. It's that kind of leadership, and public health messaging, that will be critical for health care leaders to demonstrate.

Q: There have been reports that reactions to some of the vaccines can be fairly intense and similar to COVID-19 symptoms. What are your thoughts on how hospitals should handle time off for their employees after vaccination if that's necessary?

A: That's a really cutting-edge question. I think all those issues are being considered and worked out almost as we speak, as there aren't clear answers just yet or a lot of data. But I think there will have to be some accommodations for employees who have mild reactions such as fevers and chills that could be suggestive of COVID. That said, reactions like these are proof that the vaccine is working and the immune system is responding appropriately. Hospital systems and clinics will have to develop protocols and vaccination schedules for groups of employees so staff may miss work for a few days if symptoms do develop. It's also important we are careful about scheduling vaccinations, because we don't want all the respiratory therapists, for example, to be out at the same time. We're in new territory here, and that's partly what makes this all so challenging.

Q: Do you think there might eventually be mandatory vaccination of health care workers?

A: I don't think a mandate upfront would be a good direction to go in, because this could incite a backlash, and in turn this could limit the number of people who will eventually sign up. A mandate is heavy handed and it has the potential to send the wrong message, certainly in our current environment and our current culture. … States and employers have the authority now to mandate vaccines. This authority has been used in the past with the smallpox vaccine in Massachusetts in 1905 and measles vaccine in New York City more recently. Down the road, as this all unfolds and after many more people receive the vaccine, that may well be the direction that we end up [going] in.

Q: Might that happen sometime next year?

A: It's too early to say yet. Certainly [for vaccines] approved with the emergency use authorization, I think it would be difficult if not impossible to mandate. Once many more people receive the vaccine and it is fully approved by the FDA, I think mandates will become a more real possibility, and then it would probably vary community to community or hospital to hospital, similar to how the flu vaccine mandates rolled out. Certainly over time that gained momentum, and something similar could happen with COVID-19 vaccines, eventually.

Q: Thanks for your thoughts on this fast-moving issue. Is there anything else you'd add?

A: It's all moving very fast. Who was even talking about vaccine mandates for health care workers just two months ago? But then, when companies announced that their vaccine is 94% effective, this topic has really gained momentum. And I think that's part of the challenge. People feel, I think, a bit unsafe, because of the fast pace and because of the tie to politics. When the president said that the vaccine will come out in time for the elections, that raised a lot of concerns in people's minds that this was being pushed forward for political reasons, and it starts to raise questions about safety. That said, I think there are things that can be done to convey a sense of trust and confidence in the vaccine itself and the integrity of the process. A tremendous amount of education about this is happening now, directed to the public and health professionals both. I am confident that the FDA will not grant emergency use authorization or approve a vaccine until after a careful review of the data is done and it's been demonstrated to be safe and effective. So I think it's critically important for us as health care workers, also for those of us as leaders within our institutions, to set an example for everybody else and get the vaccine.