Mandating COVID-19 Vaccination

With the remarkable efficacy of the mRNA vaccines and the newly available one shot, standard refrigeration Janssen (Johnson and Johnson) vaccine, many in long-term care are wondering if healthcare personnel (HCP) should be mandated to receive vaccines.

The case for mandating HCP vaccination is based upon strong ethical principles for the common good and, in healthcare, “primum non nocere” or first do no harm.  Vaccinating HCPs will not only protect the vaccinated individual from getting a severe life-threatening COVID-19 infection, but there is increasing evidence that it may reduce the risk of spreading COVID-19 to the vulnerable older adults who are under their care. This means that vaccinated HCPs are trying not to do harm by lowering their risk of spreading COVID-19 to their residents.  In health care settings, including nursing facilities and increasingly extensive-assistance residential models, there also exists a social contract between the patient or resident and the healthcare provider to safeguard health and heal when possible.  HCPs do not have the right to put their residents at risk.  While not all long-term care residents are as frail or vulnerable as others, the emergence of more contagious, vaccine resistant, and potentially more deadly COVID-19 variants in the community only further increases the value of vaccination, with partial protection against some of the new strains.  

On the other hand, there is the case for opposing mandatory HCP COVID-19 vaccination. Ethical, moral and safety considerations are important to understand. An individual's autonomy or right to choose, religious or moral stances on use of fetal tissue for research, or concerns that these vaccines have only been emergency use authorized (EUA) and are not yet designated as FDA approved are all thoughtful reasons against mandating HCP vaccination.  Mandated vaccination may also inflame historically and culturally-founded concerns of distrust of government, industry, or well-intentioned past policy failures.  

However, oppositional arguments against vaccination that are based upon misinformation are worrisome.  Misinformation is not a valid reason to oppose mandatory HCP vaccination and education inclusive of the scientific support of the vaccine's safety and efficacy is the best way to reduce opposition to the vaccine from misinformation. We now have 3 months (~120 million doses) experience with these vaccines and have found them to be effective and safe without significant new adverse events.

The aforementioned arguments either for or against mandatory vaccination for healthcare workers is compelling however, they are not equally weighted.  It is worth noting that the devastating mortality and morbidity of the COVID-19 disease and the grave harm to society, suggests the importance of efficiently and effectively utilizing our current and future vaccines in combating this disease leading to restoration of societal freedoms for all.  

Organizations that choose to mandate vaccination, should ensure that they have legal backing to do so under Federal, State and local laws.  The Equal Employment Opportunity Commission (EEOC) paved a path for legality by releasing its COVID-19 guidance on December 16, 2020.  In its guidance, the EEOC outlined that with respect to the federal anti-discrimination acts (Americans with Disabilities Act, Title VII of the Civil Rights Act of 1964, and the Genetic Information Nondiscrimination Act) it was legal to exclude non-vaccinated individuals from the workplace.  

So what would I recommend as a physician?  The best change comes from good individual choices and I don’t believe that society is ready to support mandatory vaccinations.  Instead, I would continue to encourage every person who is able to receive the COVID-19 vaccine to do so.  It is notable that the benefits far outweigh the risks that we have seen from vaccination thus far. Based on increasing data, the expectation is that both mRNA vaccines will move from EUA to FDA approved status.  This is an important benchmark of safety and efficacy that we hope will provide more healthcare personnel the reassurance that they are waiting for in order to decide to get vaccinated.

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