key: cord-0857723-jgcv1wf3 authors: Klompas, Michael; Pearson, Madelyn; Morris, Charles title: The Case for Mandating COVID-19 Vaccines for Health Care Workers date: 2021-07-13 journal: Ann Intern Med DOI: 10.7326/m21-2366 sha: 77927207107eadb26e800a16a23d649b3fb51f18 doc_id: 857723 cord_uid: jgcv1wf3 Not all health care workers have been vaccinated against COVID-19, and their reasons are multiple and varied. Some additional health care workers might decide to be vaccinated if the argument for vaccination were sufficiently clear. This article attempts to provide that clarity. Vaccines for SARS-CoV-2 save lives (4) . Health care workers and other essential workers have higher rates of infection than people in other fields (5) . According to the Centers for Disease Control and Prevention, more than 1600 U.S. health care workers have died of COVID-19 thus far. Although it is unclear how many of these infections were acquired in the workplace versus the community, vaccine mandates will prevent infections, severe illness, and deaths in health care workers no matter where they are exposed. Up to two thirds of cases of SARS-CoV-2 infection are attributable to asymptomatic and presymptomatic transmissions. Hospitals have undertaken considerable efforts to stop staff from working while sick, but these policies do not prevent staff with silent infections from coming to work and potentially infecting patients and colleagues. In some cases, staff-to-patient and staff-to-staff transmissions have led to large clusters (6) . Universal masking diminishes this risk, but perfect adherence is not realistic and surgical masks are not perfectly protective; nosocomial transmission despite masks has been well documented (7) . Vaccines, by contrast, provide constant protection without requiring reminders, persuasion, mask-fitting aids, or behavioral changes. We believe that there is an extra onus on health care workers to protect themselves from SARS-CoV-2 in order to protect patients. Health care workers routinely tend to the elderly, ill, and vulnerable, in whom SARS-CoV-2 infection is more likely to be deadly. We cannot rely on patients being vaccinated to prevent nosocomial transmission because some patients cannot get the vaccine, some will decline, and vaccine may not be effective in immunocompromised patients (8) . Vaccinating health care workers, however, helps protect even unvaccinated patients because SARS-CoV-2 vaccines are associated with fewer infections overall, less silent carriage, and less risk for transmission (4, 9) . The estimated effectiveness of influenza vaccines varies by season but generally ranges from 30% to 50%. The 2 messenger RNA vaccines for SARS-CoV-2, by contrast, are more than 90% effective. Notwithstanding the moderate effectiveness of influenza vaccines, randomized trials suggest that vaccinating health care workers in congregate health care settings may decrease patient deaths by 30% (10) . The life-saving effects of vaccinating health care workers against COVID-19 will be that much greater given these vaccines' greater effectiveness against a pathogen that is more common and more deadly than influenza. The SARS-CoV-2 pandemic has had an unprecedented effect on day-to-day operations in health care. Changes include universal masking, daily attestations of health, limitations on visitors, cancellations of surgery and elective admissions, cancellation of in-person meetings and education sessions, cancellation of travel, and much more. Universal vaccination is the pathway to rolling back these disruptions and returning to normal operations. Vaccinating health care workers will help preserve workforce continuity. Workers with influenza are typically allowed to return to work 24 hours after their fever More adults have now been inoculated against SARS-CoV-2 than are typically vaccinated against influenza in a given year. More than 300 million doses of SARS-CoV-2 vaccine have been administered in the United States alone, and more than 65% of U.S. adults have been vaccinated. By contrast, in a typical influenza season only about 150 million to 175 million doses of influenza vaccine are administered and fewer than 50% of adults are immunized. Despite the enormous number of people who have now received SARS-CoV-2 vaccines, serious side effects have been exceedingly rare. We acknowledge that some life-threating adverse effects and deaths have occurred, but the incidence of these complications is vanishingly small, is substantially lower than the risk for complications of COVID-19, and is far outweighed in our opinion by the likelihood of benefit to both health care workers and their patients. Similarly, we believe that these benefits also outweigh the other possible reasons that health care workers may object to vaccination, including fear of postvaccine side effects, concerns about fetal safety, philosophical disagreement, and perceived invulnerability to serious infection. Many organizations contemplating mandating SARS-CoV-2 vaccines are reluctant to move forward while vaccines remain under emergency use authorization. Some are also concerned about legal challenges. As more safety data on the vaccines rapidly accumulate, however, there is every expectation of full approval from the U.S. Food and Drug Administration later this year, and the courts have ruled in favor of health care organizations on the legal challenges that have come forward thus far. Now is the time for organizations to ready themselves to adopt mandatory vaccination policies as soon as full approval is granted. This includes drafting policies, educating employees about vaccine safety and effectiveness, developing strategies to address unvaccinated employees' specific concerns, ensuring easy vaccine access, partnering with employee leaders and unions to make a shared case for universal vaccination, weighing potential exemptions, and foreshadowing the road ahead for all. The Case for Mandating COVID-19 Vaccines for Health Care Workers SARS-CoV-2 antibody prevalence in England following the first peak of the pandemic Comparison of the characteristics, morbidity, and mortality of COVID-19 and seasonal influenza: a nationwide, population-based retrospective cohort study Excess deaths from COVID-19 and other causes in the US BNT162b2 mRNA Covid-19 vaccine in a nationwide mass vaccination setting Risk of hospital admission with coronavirus disease 2019 in healthcare workers and their households: nationwide linkage cohort study COVID-19 outbreak associated with a SARS-CoV-2 R.1 lineage variant in a skilled nursing facility after vaccination program -Kentucky Transmission of SARS-CoV-2 from asymptomatic and presymptomatic individuals in healthcare settings despite medical masks and eye protection Safety and immunogenicity of anti-SARS-CoV-2 messenger RNA vaccines in recipients of solid organ transplants Effect of vaccination on household transmission of SARS-CoV-2 Effect of influenza vaccination of healthcare personnel on morbidity and mortality among patients: systematic review and grading of evidence Current Author Addresses: Dr. Klompas: Department of Population Medicine, 401 Park Drive Author Contributions: Conception and design: M. Klompas, C. Morris. Drafting of the article: M. Klompas, M. Pearson, C. Morris. Critical revision of the article for important intellectual content: M. Klompas, C. Morris. Final approval of the article: M. Klompas