An Argument for the Mandatory Vaccination of Healthcare Workers

Overview

This paper discusses vaccination mandates specifically in the population of healthcare workers and argues that these mandates are necessary because they restrict individual autonomy for the common good. It starts with an overview of vaccinations as a crucial public health measure, emphasizing their high efficacy with low health risks and few side effects. Then, it transitions to a history of hesitation towards vaccination and the reasons behind this doubt. In order to establish that vaccination mandates should be implemented, this paper then traces the history of vaccine enforcement from smallpox, measles, and others to seasonal flu vaccinations. Next, the attitudes of healthcare workers towards vaccination and mandatory vaccination policies are discussed, as well as current statewide and hospital mandates that exist. The discussion then turns towards mandatory vaccination in the context of COVID-19 and finally builds a case for advocating for mandatory vaccination of healthcare workers, starting with the COVID-19 vaccine.

Introduction

Vaccination is a Crucial Public Health Measure

Vaccination is a vital tool in maintaining the health of a population. Vaccines are instrumental in protecting against a wide variety of communicable diseases. In fact, vaccinations are thought to have prevented more illness and death than any other medical advance in the past century (Field, 2009). Most vaccine-preventable diseases spread rapidly and can be deadly, especially to vulnerable populations such as the immunocompromised and the elderly. Medical experts argue that the most effective way to prevent the transmission of pathogens is to protect a large portion of the population with vaccinations (Von Linstow et al., 2020).

One of the most crucial groups to target for vaccination is the population of healthcare workers. One reason is that healthcare workers are frequently exposed to communicable diseases and these infections pose a threat not only to themselves but their families and patients as well. Multiple studies demonstrated extensive asymptomatic transfer of infections from providers to their patients as well as numerous infections resulting from healthcare workers who continue to work despite being ill (Poland et al., 2005). Hospital-acquired infections pose the greatest risk to many of the groups of people healthcare workers interact with daily; the elderly, the immunocompromised, those who are critically ill, and young children. Documented hospital outbreaks that have been proven to be mitigated by healthcare workers have been detrimental to populations of patients (Poland et al., 2005). Additionally, vaccine-preventable diseases cause a significant loss of work time and increased healthcare costs in the US where healthcare spending is increasingly problematic (Steckel, 2007). The Centers for Disease Control and Prevention (CDC) endorses vaccination of healthcare workers as the most important infection control measure, but vaccine uptake by this population is still insufficient (Steckel, 2007).

Resistance to Vaccination

Vaccinations work best when a significant proportion of a population has been protected against a disease, but not necessarily the entire population. Herd immunity is the phenomenon that occurs when a threshold percentage of a group has been vaccinated and thus a pathogen can no longer maintain itself. Essentially, the majority of people who are vaccinated protect those who are medically unable to receive an inoculation. However, herd immunity is never reached when healthcare workers are only encouraged to become vaccinated (Steckel, 2007). Thus, many hospital administrators are beginning to require the vaccination of their healthcare workers against certain diseases as a requirement for their job.

Vaccination mandates for healthcare workers are highly contentious because there are many reasons why providers are opposed to receiving an injection. Many people are hesitant to receive vaccinations because of the perceived risk of side effects, which, in fact, are statistically improbable. Many others are still skeptical because of research that linked vaccination with the onset of Autism Spectrum Disorder, however, this study has been discredited and redacted (Berman, 2020). Compounding the hesitancy towards receiving a vaccination field by fear of side effects, the issue of autonomy is often cited as a reason for opposing mandatory vaccination (Berman, 2020). People feel that the medical autonomy of healthcare providers should be protected and that employers have no authority in mandating vaccinations (Berman, 2020). However, history and empirical research both support the necessity of reaching the threshold of herd immunity and vaccinating as many healthcare providers as possible. These reasons are sufficient justification for mandatory vaccination policies. In the case of vaccines, it is necessary to restrict the autonomy of healthcare providers and compel them to be vaccinated because of their position that involves protecting the health of their communities. This issue is particularly relevant today with the introduction of the COVID-19 vaccines, which have unsurprisingly been met with hesitancy by groups of healthcare workers.

History of Vaccination Enforcement

Smallpox, Measles, and Others

The spread of vaccine-preventable diseases from healthcare workers to patients and the concept of mandating healthcare worker vaccination are not new phenomena. Healthcare providers have been implicated in outbreaks of measles, rubella, pertussis, and varicella, among others, in patient populations (Von Linstow et al., 2020). As a result of these trends, compulsory vaccination policies have their roots in the early 1900s. In 1905, the Supreme Court in Jacobson v. Massachusetts upheld the state’s authority to pass vaccination laws and penalties for noncompliance (Colgrove & Bayer, 2005). This decision set a precedent for additional vaccination mandates and reinforced the notion that the concern for common welfare may sometimes subordinate individual freedom. However, there have been mixed policies regarding mandatory vaccination since then. With outbreaks of diphtheria in the 1920s, only persuasion was employed to increase vaccination compliance, rather than mandates (Steckel, 2007). In the 1922 case, Zucht v King, the Court extended mandatory vaccination to school-children (Colgrove & Bayer, 2005). In 1965, the New York City health commissioner passed mandating the polio vaccine and it wasn’t until 1981 that all states had mandatory vaccination policies for children in public schools (Colgrove & Bayer, 2005). These measures vastly improved immunization rates, often exceeding 90-95% (Poland et al., 2005). This evidence demonstrates that mandatory vaccination laws, although contested, have been an important factor in controlling the spread of many diseases over the past 100 years.

Influenza

Influenza vaccination is exceptionally important for healthcare professionals. Despite public acceptance that influenza is simply an unfortunate reality of the winter months, the viral illness causes great devastation each year. Influenza is vaccine-preventable, with an inexpensive and safe vaccine that is updated seasonally. The flu is so widespread that 20% of the US population is affected each year and the illness is the sixth leading cause of death among American adults, accounting for 36,000 deaths annually (Steckel, 2007). Even more alarming, up to 500,000 die of influenza worldwide every season. This is especially disheartening because much of this devastation can be attributed to influenza outbreaks in hospitals and long term care facilities (Steckel, 2007). Data has shown that increased influenza vaccination compliance among healthcare workers causes improved patient and employee safety, decreased health expenditures, fewer hospital staffing problems and led to a 40% reduction in all-cause mortality in patients (Poland et al., 2005).

Despite the immense benefits of vaccinating the healthcare worker population, the data on flu vaccination is abysmal. The CDC has been monitoring the vaccination rates of healthcare workers against influenza since 1981 but compliance has been incredibly low and unimproved (Poland et al., 2005). Surveys indicate that less than 40% of healthcare workers receive their seasonal flu vaccination as a part of the voluntary programs that are currently in place in most hospitals (Steckel, 2007). However, influenza vaccination uptake increases to above 95% when mandatory policies are put into place, as evidenced by few employers who have put these sanctions in place (Von Linstow et al., 2020). This is a clear demonstration that mandatory vaccination for influenza among healthcare workers is perhaps the most powerful tool available to combat yearly influenza outbreaks.

Current Vaccination Mandates

Attitudes of Healthcare Workers

In considering the option of mandating healthcare worker influenza vaccination, it is important to understand current attitudes regarding this issue. Healthcare workers’ mindsets towards vaccination are considered one of the most significant barriers to achieving higher rates of immunization (Steckel, 2007). One survey found that the primary reason healthcare workers cite for getting the seasonal flu vaccination is the protection of themselves, but almost all also mentioned protection of patients as a driving force as well (Von Linstow et al., 2020). While most healthcare workers and healthcare students have positive attitudes towards vaccinations, there is a discrepancy between their beliefs about vaccinations and their vaccination status (Kunze & Schweinzer, 2020). That is to say, many people support immunization but fail to get their shot. Additionally, there are those who strongly oppose such mandates and are particularly outspoken about their beliefs. Some workers do not see the necessity of vaccination and others are opposed to the intervention altogether. Only 27% of emergency department staff in one study believed that patients were at great risk of contracting influenza from the staff and others felt that standard precautions, including personal protective equipment, were sufficient in mitigating the risk to patients (Steckel, 2007).

Studies in the US and Austria investigated healthcare workers’ attitudes towards mandatory vaccinations for their demographic. Over 77% favored compulsory vaccination for doctors, however, some only saw these measures as necessary in specific fields and for specific diseases (Kunze & Schweinzer, 2020). Merely 5% of healthcare workers in an Austrian study opposed mandatory vaccinations altogether (Kunze & Schweinzer, 2020). Despite the low prevalence of “antivaxx” doctors, members of this group have been particularly outspoken against employer mandated vaccination laws. They claim that these mandates violate their autonomy to make medical decisions about their bodies themselves. They have even taken legal action with varying levels of success (Hollmeyer et al., 2012). It is evident that while healthcare workers support vaccination as a means of disease control for themselves and their patients, many of their attitudes conflict with their practice, and those who oppose vaccination are adamant about their choices.

Current Mandates and Policies

Next, it is important to investigate current hospital policies regarding vaccinations before arguing for mandatory policies. There is no universal vaccination policy worldwide. The US federal government has not established a vaccination law and it is unclear if it has the authority to do so (Moorthy, 2020). Individual states, hospitals, and other patient care facilities construct their own policies under the international law that allows governments to limit personal liberty to mitigate public health threats (Steckel, 2007). The states have moved toward granting power to compel vaccination of the public. Some states passed a Model State Emergency Health Powers Act which gives the governor power to declare a public health energy and compel vaccination (Moorthy, 2020). However, these measures have yet to be implemented in a real crisis. The states have been more willing to promote and more successful at enforcing mandatory public school vaccination compared to mandatory vaccination of healthcare workers (Moorthy, 2020). In 2009, New York State attempted to mandate seasonal influenza vaccination of all healthcare workers having patient contact, but the proposal was withdrawn after facing lawsuits (Field, 2009).

Hospitals vary in their policies for enforcing mandatory vaccination and dealing with employees who refuse to comply. Currently, some institutions in the US and Europe mandate influenza, pertussis, measles-mumps-rubella, and diphtheria vaccinations in order to maintain employment (Von Linstow et al., 2020). Refusal of vaccination may result in departmental transfer, fines, or termination of employment if no medical or religious exemptions are provided (Von Linstow et al., 2020). The CDC recommends that those refusing vaccination while working in the healthcare setting should sign declination forms. These forms are provided in hope that they will cause further reflection on the choice to refuse vaccination and perhaps change their minds (Steckel, 2007). In 2004, a hospital in West Virginia became the first in the nation to make vaccination a condition of employment (Musumeci, 2021). One study evaluated three US vaccination programs that involved mandatory vaccination against influenza and found that those who were granted an exemption were encouraged to wear additional Personal Protective Equipment (PPE) and less than .25% were fired or quit as a result of these issues (Hollmeyer et al., 2012).

Finally, many healthcare organizations not only encourage vaccination but mandate it for members. For instance, the American Academy of Family Physicians supports mandatory vaccination and those with exceptions must take extra precautions during flu season such as PPE and refrain from direct patient contact (Immunization Action Coalition, 2021). The American Academy of Pediatrics, the American College of Physicians, and the American Hospital Association all endorse requiring influenza vaccination of healthcare workers for the sake of patient safety. This literature shows overwhelming support for mandatory vaccination policies for healthcare workers by experts and administrators.

Mandatory Vaccination in the Context of COVID-19

As the current pandemic continues to evolve, vaccination remains the essential route for returning to pre-pandemic ways of life. Healthcare workers were some of the first people offered the new COVID-19 vaccines as soon as they were approved. Now that vaccination is being opened up to a larger portion of the population, supply will soon exceed demand because many will refuse vaccination. Hesitation toward the COVID-19 vaccination is readily apparent in the media and everyone’s lives, even among populations of healthcare workers. Thus, it is important to investigate healthcare worker vaccination specifically in regards to COVID-19.

On December 3rd, 2021, the CDC published recommendations that the nation’s 21 million healthcare workers should be the first to receive the COVID vaccinations approved for emergency use by the Food and Drug Administration (FDA) (Vestal, 2021). On this very day, there were up to 250,000 cases of COVID-19 confirmed in healthcare personnel with 866 deaths, which emphasizes the importance of haste vaccination of this population (CDC, 2020). As previously mentioned, vaccination of the healthcare workforce is essential because it protects providers, their families, patients, and communities while also protecting the healthcare capacity of a nation (CDC, 2020). However, despite the fact that the FDA granted Emergency Use Authorization to three COVID-19 vaccines after determining that the known benefits outweigh the potential risks, many people have been hesitant (CDC, 2020). One study estimates that more than 40% of Americans indicate that they would not consent to vaccination (Moorthy, 2020).

Healthcare workers are not exempt from this hesitancy. For instance, a survey conducted by the American Nurses Association found that before the initial vaccination rollout, only ⅓ said they would voluntarily take the vaccine, ⅓ said they would decline it, and the remaining ⅓ said they were unsure (Vestal, 2021). Healthcare workers have similar reasons for their hesitancy with the COVID vaccine as the general public. Many expressed heightened concern for the safety and effectiveness because of the short time frame in which the vaccines were developed (Flood et al., 2021). Others believe they should instead rely on the amped-up PPE regulations, although the efficacy of these measures has not yet been evaluated in comparison to the vaccine (Flood et al., 2021). As much as half of the healthcare worker population opposes the concept that governments and institutions have the authority to mandate vaccination in the first place (Flood et al., 2021). Despite this, the nation’s healthcare leaders are confident that American healthcare workers will eventually roll up their sleeves for the COVID-19 vaccination. Dr. Georges Benjamin and Dr. Susan Bailey, presidents of the American Public Health Association and the American Medical Association, respectively, believe that most doctors will eventually voluntarily sign up for vaccination (Vestal, 2021). Despite this positive outlook, there is overwhelming evidence of healthcare workers denying the shot. The Governor of Ohio reported that 60% of the state’s nursing home staff declined the vaccine and at least 30% of New York City healthcare workers have also chosen to forgo vaccination (Robbins, 2021). At a Queens hospital, 16 of 19 respiratory therapists, those who directly work with the most critical coronavirus patients, have declined to get vaccinated (Robbins, 2021). Vaccination rates so low in specific communities are alarming even if herd immunity is reached in the overall population. When the vaccination rate of an enclave drops below the herd immunity threshold, the community is not protected from the spread (Berman, 2020). Thus, pockets of healthcare workers banding together against vaccination is a serious threat to their patients.

At this point, neither state nor federal governments have attempted to mandate COVID-19 vaccination of healthcare workers, although some institutions have done so (Musumeci, 2021). For instance, many universities have implemented mandates for the vaccination of employees and students (Musumeci, 2021). The Houston Methodist Hospital system has set a deadline for vaccination of all its employees, except in the case of medical or religious exemption, or else they will lose their jobs. However, some workers have already spoken out in opposition of this deadline (Troutman, 2021). Other hospital systems indicate that they will not institute mandates until full approval of the vaccinations is instituted by the FDA (Vestal, 2021). Some hospitals are taking the approach of awarding those who are vaccinated. These institutions are offering cash and paid time off bonuses to those who get vaccinated, but the success of these measures has not been supported by research (Robbins, 2021). Politicians in 23 states have proposed legislation to ban employers from requiring COVID vaccination for healthcare workers, but these bills have not gained much support (Quinton, 2021). In fact, guidance from the federal government encourages employers to require vaccinations as long as they accommodate those with legitimate exemptions (Quinton, 2021). As the COVID-19 pandemic drags well into a second year, it is clear that vaccination is a highly contested issue but the most promising way to return to normal.

Human Values Implications for Mandating Healthcare Worker Vaccination

Argument for Restricting Autonomy

Medical autonomy, the right for one to have the freedom to make their own decisions regarding their health and body, is one of the central ethical tenets of medical practice (Steckel, 2007). Autonomy should be upheld in all aspects of medical practice, including for doctors as patients themselves. However, as with all rights and freedoms, situations arise when these freedoms must be limited for the protection of the common good. Conflicts between fundamental human rights and public health are inevitable and there are situations, as with vaccines, where a trade-off between rights and the common good is necessary (Colgrove & Bayer, 2005). Vaccination of healthcare workers is one of these instances where it is important to consider the potential positive impacts of one’s limiting freedom to forgo vaccination. Vaccines are remarkably safe and effective, protecting not just individuals but entire populations by extension of herd immunity. Vaccination produces the immense benefits of improved health and decreased morbidity and mortality while it comes with only mild side effects and low risk of complications (Steckel, 2007). Therefore, it is justifiable to require healthcare workers to receive an inoculation that will protect themselves and their patients and pose little threat to their own well-being.

The argument for mandatory vaccination of healthcare workers can be justified even though it can be seen as restricting their medical autonomy. As demonstrated, states have a history of increasing vaccine compliance in public schools by mandating certain vaccinations as a requirement for attendance (Musumeci, 2021). These laws have not been widely implemented in the healthcare setting, but it is justifiable to use these education laws as precedent for mandates in the health sphere. Additionally, mandatory vaccination laws are beginning to become more and more common since the case of Jacobson v. Massachusetts upheld the authority of compulsory vaccination laws. Few states have passed Model State Emergency Health Powers Acts which allow the governors to compel vaccination in public health emergencies, and COVID-19 is certainly an opportune time for the implementation of this policy (Moorthy, 2020).

Mandating healthcare worker vaccination is also justified as an ethical obligation of healthcare workers. In fact, many healthcare workers agree that vaccination is a moral imperative (Poland et al., 2005). Healthcare professionals, such as doctors who take the Hippocratic Oath, take a vow to do no harm, and interacting with patients without being vaccinated has the potential to do them harm (Field, 2009). Additionally, patients trust to expect that their providers will take every precaution to protect them from getting sicker (Field, 2009). Healthcare providers are expected to keep their patients healthy, and a provider who can serve as a vector for a disease is not upholding this oath.

Some may argue that mandating vaccination is unnecessary because most people are willing to accept vaccination voluntarily. They assert that volunteer programs foster greater cooperation and trust (Von Linstow et al., 2020). However, this is not the case because, in reality, vaccination rates only reach herd immunity levels when mandatory orders are enforced (Hollmeyer et al., 2012). Voluntary programs simply do not result in high, sustained levels of vaccination that are necessary to reach herd immunity (Poland et al., 2005). A comprehensive study of several vaccination intervention programs found that the most successful method for increasing vaccination rates, among the general public and healthcare workers, was to institute a mandate (Hollmeyer et al., 2012). In fact, these programs almost achieved universal coverage. It is clear that while they are not ideal, vaccination mandates for healthcare workers are absolutely necessary.

Conclusion and Justification of Mandatory Vaccination with COVID-19

There has been no other time since the advent of vaccines in which it is most crucial to vaccinate as much of the population as possible as it is now. COVID-19 continues to devastate the world as the grim landmark of 3 million deaths has just been surpassed. As important as masks and social distancing have been to stop the spread, the only way to return to normalcy is to vaccinate the majority of the population. Data shows that the best method of increasing vaccination compliance and stopping the spread of disease, especially in the healthcare setting, is to mandate vaccination. It is important to maintain the autonomy of healthcare workers, but these individuals vowed to protect others and must fulfill this obligation by getting vaccinated. The benefits of enforcing mandatory vaccination simply outweigh the potential costs, except in cases of medical or religious exemption. The government should set regulations for the vaccination of healthcare workers, and individuals in general, across the country to ensure that all individuals develop immunity and are protected from the devastation of COVID-19. It is without a doubt that there will be future pandemics, therefore establishing a system of compulsory vaccination will not only aid in getting out of this pandemic but will set the world up for a better response to the next one, is essential

References

Berman, J. M. (2020). Antivaxxers: How to challenge a misinformed movement. MIT Press.

Center for Disease Control and Prevention. (2020, December 28). The importance of COVID-19 vaccination for healthcare personnel. Center for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/hcp.html

Colgrove, J., & Bayer, R. (2005). Liberty, public health, and the legacy of Jacobson v Massachusetts. American Journal of Public Health, 95(4), 571-576. https://www.doi.org/10.2105/AJPH.2004.055145

Field, R. I. (2009). Mandatory vaccination of healthcare workers: Whose rights should come first. Pharmacy and Therapeutics, 34(11), 615–618.

Flood, C. M., Thomas, B., and Wilson, K. (2021). Mandatory vaccination for health care workers: An analysis of law and policy. Canadian Medical Association Journal, 193(6), 217-220

Hollmeyer, H., Hayden, F., Mounts, A., & Bucholz, U. (2012) Review: interventions to increase influenza vaccination among healthcare workers in hospitals. Influenza and Other Respiratory Viruses, 7(4), 604–621. https://doi.org/10.1111/irv.12002

Immunization Action Coalition. (2019, November 24). Influenza vaccination honor roll. Immunize. https://www.immunize.org/honor-roll/influenza-mandates/

Kunze, U., & Schweinzer, H. (2020). Self-reported vaccination status and attitudes towards mandatory vaccinations for health care workers among medical students. Vaccine 38(35), 5695-5699.

Moorthy, G. (2020). Compulsory COVID-19 vaccination?: Only as a policy of last resort. Voices in Bioethics, 6. https://doi.org/10.7916/vib.v6i.7301.

Musumeci, M.B., & Kates, J. (2021, April 07). Key questions about COVID-19 vaccine mandates. Kaiser Family Foundation. https://www.kff.org/coronavirus-covid-19/issue-brief/key-questions-about-covid-19-vaccine-mandates/

Poland, G. A., Tosh, P, & Jacobson, R. M. (2005). Requiring influenza vaccination for health care workers: Seven truths we must accept. Vaccine, 25(18), 2251-2255.

Quinton, S. (2021, February 23). Bills to block mandatory worker vaccines falter in the states. Pewtrusts. https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2021/02/23/bills-to-block-mandatory-worker-vaccines-falter-in-the-states

Robbins, R., Tavernise, S., & Otterman, S. (2021, January 14). Cash, breakfasts and firings: An all-out push to vaccinate wary medical workers. New York Times. https://www.nytimes.com/2021/01/14/business/covid-vaccine-health-hospitals.html

Steckel, C.M. (2007). Mandatory influenza immunization for health care workers: An ethical discussion. AAOHN Journal, 55(1), 34-9.

Troutman, K. (2021, April 19). Hospital encounters pushback on mandatory vaccine policy: 7 issues to consider before your company requires vaccines. JDSUPRA. https://www.jdsupra.com/legalnews/hospital-encounters-pushback-on-1834518/

Vestal, C. (2020, December 08). Health care workers can decline a covid-19 shot-for now. Pew Charitable Trusts. https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2020/12/08/health-care-workers-can-decline-a-covid-19-shot-for-now

Von Linstow, M.V., Winther, T.N., Eltvedt, A., Nielsen, A. B., Nielsen, A. Y., & Poulsen, A. (2020). Self-reported immunity and opinions on vaccination of hospital personnel among paediatric healthcare workers in Denmark. Vaccine, 38(42), 6570-6577. http://dx.doi.org/10.1016/j.vaccine.2020.08.010