key: cord-0937926-44byhh63
authors: Emanuel, Ezekiel J.; Skorton, David J.
title: Mandating COVID-19 Vaccination for Health Care Workers
date: 2021-07-30
journal: Ann Intern Med
DOI: 10.7326/m21-3150
sha: 763d3e91ad88b068adc3e8c74564090a0dd0bebf
doc_id: 937926
cord_uid: 44byhh63

It is imperative that all 17 million health care workers in the United States be vaccinated against COVID-19. The authors believe that the best way to achieve this is for the workers to choose vaccination, but given the current situation, the authors feel that health care employers should mandate vaccination. A joint statement signed by dozens of health care professional societies and organizations endorses this requirement.

W ith the emergence and spread of the Delta variant, it is clear that we are in a long-term coronavirus war with no quick victories. July 2021 will go down in history as a turning point; it was the time when the United Statesas well as other countries, such as France and Italyadopted the notion of this being equivalent to a war and implemented mandates to ensure social mobilization.

Throughout the coronavirus pandemic, people working in health care and long-term care have defined the frontlines in every important way. More than 15 years before we recognized SARS-CoV-2 as a human pathogen, researchers were doing fundamental work that led to the concept of the mRNA and adenovirus vaccine platforms, which eventuated in the breathtakingly rapid development of effective and safe vaccines. Physicians, nurses, physician assistants, laboratory professionals, and many others worked through the surges in March and April 2020 and the winter of 2021, with no question about their devotion to patients. That is why they are rightly considered heroes. And let us not forget all of the others who work in the health care setting, supporting in myriad ways the work of those providing direct patient care. All who work in health care institutions are health care workers, regardless of their specific job description, and all of us depend on them to contribute to the effective, safe, and compassionate care we expect of our health care institutions.

Unfortunately, when it comes to COVID-19 vaccination rates, health care workers seem to reflect the country. Vaccination rates vary greatly, with 96% of physicians but 55% of nursing home staff, fewer than 50% of nurses, and just 26% of home health aides being fully vaccinated (1) (2) (3) (4) . To prevent the ravages of COVID-19, many more people living in the United States need to be vaccinated. The facts are clear: The U.S. Food and Drug Administration (FDA)-authorized vaccines have been administered to hundreds of millions of people and have been found to prevent severe disease and death. Our fondest hope is that the vaccination rate will increase quickly.

It is imperative that all 17 million health care workers in the United States be vaccinated (5) . The best way to achieve this is for them to choose vaccination. However, in the current situation, health care employers should mandate vaccination. To induce employers to require vaccines, we brought together health care professional societies and organizations to endorse this requirement. The more organizations endorse vaccination mandates, the easier it will be to gain attention and ensure that no single organization will be targeted with malicious attacks, as the American Academy of Pediatrics was when it advocated for mask wearing in classrooms; hence our brief campaign to draft a joint statement and get professional societies and organizations to sign and disseminate it (6) . As of 29 July 2021, 88 organizations had signed, representing all facets of health care: physicians, nurses, pharmacists, physician assistants, nurse practitioners, epidemiologists, public health workers, and long-term care workers (Figure) (6) .

The rationale for requiring vaccines for health care workers is 3-fold (5). First, like any person, health care workers have a general ethical duty to protect others, especially when there is minimal threat to their own wellbeing, and the vaccines have so few adverse effects that there is little risk to a vaccinated person's health.

Second, beyond this general ethical duty, health care workers have a special ethical and professional responsibility to protect others. The objective of the health care professions is to promote the health and well-being of patients and their families, residents of long-term care facilities, and the broader community. Getting vaccinated is one way to achieve this professional objective and protect the health of all of these parties. This responsibility holds not only for physicians, nurses, respiratory therapists, and other health care professionals who take professional oaths or pledges but also for the dietitians, environmental workers, safety officers, clerks, and other support staff at health care facilities. All who choose to work in health care settings-hospitals, urgent care settings, long-term care facilities, physicians' offices-must be committed to putting patients first. During their usual activities, health care workers are likely to interact with patients who are vulnerable to COVID-19, namely elderly adults, children younger than 12 years, and immunocompromised persons. Their work setting confers a special responsibility to not endanger the health of other people.

Third, requiring COVID-19 vaccines for health care workers is not new but is merely an extension of wellestablished practices and policies. Many health care facilities have long required their workers to be vaccinated against influenza, hepatitis B, and other infectious diseases. As a result, health care workers have historically been role models of good health behaviors, particularly vaccination. All of us working shoulder-to-shoulder in health care can embody health practices for the public. Part of our opportunity to have a positive effect is to show the importance of receiving the COVID-19 vaccine-and, indeed, all vaccines.

Having health care employers mandate that their workers be vaccinated is merely realizing this ethical obligation. It is a way of nudging people to do the right thing.

In addition to the ethics of mandating vaccines for health care workers, such mandates are legal. As the U.S. Equal Employment Opportunity Commission and courts have made clear, employers have the right to require vaccination as a condition of employment (7) . This right extends to vaccines under emergency use authorization as well as those that have been fully approved by the FDA.

This article was published at Annals.org on 30 July 2021.

Annals of Internal Medicine © 2021 American College of Physicians 1

IDEAS AND OPINIONS Figure. Joint statement in support of COVID-19 vaccine mandates for all workers in health and long-term care.

This version of the statement was provided by Dr. Emanuel on 29 July 2021 and is reproduced with his permission.

We stand with the growing number of experts and insƟtuƟons that support the requirement for universal vaccinaƟon of health workers. 2,3 While we recognize some workers cannot be vaccinated because of idenƟfied medical reasons and should be exempted from a mandate, they consƟtute a small minority of all workers. Employers should consider any applicable state laws on a case-by-case basis.

ExisƟng COVID-19 vaccine mandates have proven effecƟve. 4,5 Simultaneously, we recognize the historical mistrust of health care insƟtuƟons, including among many in our own health care workforce. We must conƟnue to address workers' concerns, engage with marginalized populaƟons, and work with trusted messengers to improve vaccine acceptance.

As the health care community leads the way in requiring vaccines for our employees, we hope all other employers across the country will follow our lead and implement effecƟve policies to encourage vaccinaƟon. The health and safety of U.S. workers, families, communiƟes, and the naƟon depends on it.

Due to the recent COVID-19 surge and the availability of safe and effecƟve vaccines, our health care organizaƟons and socieƟes advocate that all health care and long-term care employers require their workers to receive the COVID-19 vaccine. This is the logical fulfillment of the ethical commitment of all health care workers to put paƟents as well as residents of long-term care faciliƟes first and take all steps necessary to ensure their health and well-being.

Because of highly contagious variants, including the Delta variant, and significant numbers of unvaccinated people, COVID-19 cases, hospitalizaƟons and deaths are once again rising throughout the United States. 1 VaccinaƟon is the primary way to put the pandemic behind us and avoid the return of stringent public health measures.

Unfortunately, many health care and long-term care personnel remain unvaccinated. As we move towards full FDA approval of the currently available vaccines, all health care workers should get vaccinated for their own health, and to protect their colleagues, families, residents of long-term care faciliƟes and paƟents. This is especially necessary to protect those who are vulnerable, including unvaccinated children and the immunocompromised. Indeed, this is why many health care and long-term care organizaƟons already require vaccinaƟons for influenza, hepaƟƟs B, and pertussis. Finally, we should recognize that mandates increase vaccination rates. After Houston Methodist Hospital required its workers to be vaccinated, 99.5% received the vaccine, with few resigning rather than getting vaccinated (8) . Several companies that own more than 250 long-term care facilities have similarly mandated COVID-19 vaccines. There, too, more than 95% of workers-and, in some cases, 100%-have been vaccinated (9) , and few have quit rather than being vaccinated. Having more workers vaccinated and fewer out recovering from COVID-19 will also lessen the pressure on workers, improving the resilience of our health care workforce.

There are ethical, legal, and practical reasons for health care workers to be vaccinated against COVID-19. This sentiment resonated with all of the health care societies and organizations asked to sign this joint statement; indeed, the rapid affirmation was like a supersaturated liquid producing myriad crystals with the addition of a tiny nidus. Almost everyone recognized that calling for a mandate was the right thing to do for the health care professions, local communities, and the nation as a whole.

After this joint statement was released, it was announced that the U.S. Department of Veterans Affairs will require all of its frontline health workers to be vaccinated against COVID-19; California and New York will mandate vaccines for many state and city employees; many private employers, such as Google, will require vaccination for their employees; and the Biden administration will require federal workers to get vaccinated or be tested weekly (10) . These new government policies and the overwhelming response of the health care community shown in the joint letter give us hope for turning a corner in this war. Please join us. Disclosures: Disclosures can be viewed at www.acponline.org /authors/icmje/ConflictOfInterestForms.do?msNum=M21-3150.

MulƟsociety Statement on COVID-19 VaccinaƟon as a Condit ion of Employment for Healthcare Personnel

AHA Policy Statement on Mandatory COVID-19 VaccinaƟon of Health Care Personnel

CondiƟon of employment': Hospitals in DC, across the naƟon follow Houston Methodist in requiring vaccinat ion for workers. USA Today

More Nursing Homes Are Requiring Staff COVID-19 VaccinaƟons

IDEAS AND OPINIONS Mandating COVID-19 Vaccination for Health Care Workers References

AMA Survey Shows Over 96% of Doctors Fully Vaccinated Against COVID-19

45% of Nursing Home Staff Still Unvaccinated Against COVID-19

COVID-19 Vaccination Rates Are Poor Among Healthcare Workers -How Can We Do Better? Forbes

KFF/Post Survey of Frontline Health Care Workers Finds Nearly Half Remain Unvaccinated [press release

The case for mandating COVID-19 vaccines for health care workers

Accessed at www.ezekielemanuel.com/writing/all-articles/2021/07/26/joint-statement -in-support-of-covid-19-vaccine-mandates-for-all-workers-in-health-and -long-term-care on 28

Equal Employment Opportunity Commission. EEOC Issues Updated COVID-19 Technical Assistance

Order on Dismissal: Jennifer Bridges et al v Houston Methodist Hospital et al (SD Tex 2021)

Accessed at www.mcknightsseniorliving.com /home/news/integracare-reaches-100-percent-staff-covid-vaccinationrate-trilogy-mandates-vaccination on 28

NYC unveil plans to require vaccinations or testing; VA says shots mandatory for medical workers. USA Today

Mandating COVID-19 Vaccination for Health Care Workers IDEAS AND OPINIONS Annals.org Annals of Internal Medicine Current Author Addresses: Dr. Emanuel: Department of Medical Ethics and Health Policy

Critical revision of the article for important intellectual content