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Should hospitals mandate COVID-19 vaccination?

Patrick Boyle, Senior Staff Writer
June 15, 2021

More large health systems are requiring all staff to get vaccinated; others are opting for gentle persuasion. Here are the factors that drive those approaches.

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An employee receives her second dose of a COVID-19 vaccine at Riley Hospital for Children in Indianapolis.
An employee receives her second dose of a COVID-19 vaccine at Riley Hospital for Children in Indianapolis.
Courtesy: Indiana University Health

Marc Boom, MD, doesn’t want to lose 200 workers just because they won’t follow a new rule, but the president and CEO of Houston Methodist will take that chance to reach an aggressive goal: getting every one of the health system’s 26,000 employees vaccinated against COVID-19.

In April, Houston Methodist became the first health system in the country to require all its employees to get fully vaccinated. While most complied, the health system suspended 178 workers without pay for missing the June 7 inoculation deadline.

Boom says the health benefit to patients and staff is worth the battle. “In health care, we are called to do amazing work, and part of that calling is a responsibility to keep patients safe,” he explains. “They put their lives in our hands.”

Suresh Gunasekaran, MBA, agrees about that responsibility — but University of Iowa (UI) Hospitals & Clinics, which he oversees as CEO, does not plan to require vaccinations. With 91% of its 16,500 staff vaccinated, he believes nearly every worker at UI Hospitals & Clinics, based in Iowa City, will get vaccinated without a mandate. 

“We respect employees’ rights to make their own health care decisions,” Gunasekaran notes. “We believe there will be greater acceptance of the vaccines if people are able to make that decision on their own.”

Leaders at hospitals all across the country are weighing the pros and cons of those diametric approaches, especially as vaccination rates flatten nationwide. About a half-dozen health systems have issued vaccination requirements so far and more are expected to follow.

“I don’t hear a lot of confusion over ‘if we’re going to do this,’” Boom says about other hospital leaders he’s spoken with. “It’s, ‘When are we going to do this?’”

Hospitals are cautiously joining a growing number of businesses, including colleges and universities, that require staff and students to get vaccinated. For health systems, the factors to consider include vaccination levels among employees and in the surrounding communities, the need for hospitals to serve as role models in fighting the pandemic, and the effectiveness of vaccine education without mandates.

Flat vaccination rates

A tragedy at a nursing home helped to convince leaders at UofL Health in Louisville, Kentucky, that all its workers need to be vaccinated. Early this year, an unvaccinated staffer brought a variant of the virus that causes COVID-19 into the nursing home in eastern Kentucky, according to an investigation by the Centers for Disease Control and Prevention (CDC). Although most of the health workers and 90% of the residents at the facility were fully vaccinated, the CDC reported that COVID-19 subsequently struck 46 staffers and residents; three of the residents died.

“That demonstrated the risks that patients” and staff are exposed to from unvaccinated people, says Jason Smith, MD, PhD, chief medical officer for UofL Health.

Adding to the concern is that only about half the population of Louisville has been vaccinated, Smith explains, creating uncomfortably high chances that patients and visitors could bring the virus into UofL Health facilities. On June 1, UofL Health announced that all staff must be fully vaccinated by Sept. 1.

Aside from seeing low vaccination rates in some of their communities, many hospital leaders also have seen staff vaccinations level off at about 75%-85% of all workers. “The vaccine campaign has stalled with health care workers” just as it has slowed down with the general population, says Patrick J. Brennan, MD, chief medical officer of the Philadelphia-based University of Pennsylvania Health System (UPHS), which announced in May that its 44,000 employees must be fully vaccinated by Sept. 1. Other hospitals, including the University of Maryland Medical System and Johns Hopkins Health System in Maryland, and the George Washington University Hospital and Children’s National Hospital in Washington, D.C., have followed suit.

Health system leaders say most of the employees who have yet to be vaccinated are waiting for something: for more people they know to get vaccinated and show no severe side effects, for more scientific data about the vaccines’ safety and effectiveness, or for the vaccination process to become more convenient.

But while they wait, some patients are asking if those caring for them have been vaccinated, Brennan notes — and some of those patients have asked to be treated only by those who have, even if that means changing care providers. At Indiana University (IU) Health, based in Indianapolis, a woman “refused to allow her home health care workers to come in” because they weren’t vaccinated, says Paul Calkins, MD, associate chief medical executive.

The revelation that some staff have not been vaccinated can challenge the credibility of a health care system, experts explain. How can medical leaders convince the public that the vaccines are safe — as well as necessary to fight the pandemic — if their employees signal doubts?

“If we’re going to be a leader in the community, we have to stand by the information we’re putting out” by demonstrating total faith in the vaccines, Smith says. 

Science and ethics

Health system leaders began thinking about whether they would eventually issue mandates as soon as the Food and Drug Administration (FDA) approved three vaccines under emergency use authorizations (EUAs) late last year. They wanted to wait for data about adverse side effects and see if that information swayed more people to get the inoculations. 

For many of those leaders, the vaccine safety question has been answered: More than half of the U.S. population (172 million people) has received at least one dose of a COVID-19 vaccine, according to the CDC, with only a few dozen critical side effects confirmed.

“This vaccine was way better than we had any right to expect” in terms of safety and effectiveness, says Calkins at IU Health. “In the name of protecting our patients and staff, it became obvious this [requirement] was a step we needed to take.”

But doubts about safety are a main reason that nearly one-quarter of Americans say they don’t plan to get vaccinated, according to a Gallup poll released last week. More than 100 staffers who joined a lawsuit against Houston Methodist argued that the vaccine requirement subjects employees to “medical experimentation,” but a judge dismissed the suit on June 12, calling the mandate “a choice made to keep staff, patients and their families safer.”

(New guidance from the U.S. Equal Employment Opportunity Commission [EEOC] notes that federal equal employment opportunity laws “do not prevent an employer from requiring all employees physically entering the workplace to be vaccinated for COVID-19.”)

Can a health care worker who is not against vaccines in general still harbor sincere concerns that scientists don’t yet know about all the side effects of these vaccines? Yes, says Ezekiel Emanuel, MD, PhD, professor of medical ethics and health policy at Perelman School of Medicine at the University of Pennsylvania — but those people should not work in health care.

“We don’t force anyone to go into a health care profession,” explains Emanuel, co-author of a New York Times commentary arguing that vaccines should be required for all health care workers. “When you go into medicine, part of what you’re signing up for is, ‘I’m going to put my patients first.’”

While rejecting medical treatment is a matter of individual liberty, he says, people must sometimes yield when that refusal can harm those around them by spreading a severe and potentially fatal disease. “The idea that ‘it’s my body and it affects only me’ is just not true,” he says.

On that principle of protecting patients, staff, and their families, many health care facilities require staff to get flu shots each year. In 2009, the swine flu pandemic prompted some hospitals to institute vaccination mandates for health care workers.

The new COVID-19 vaccination requirements, however, typically cover all workers — even those who do not work in patient care or who are employed by outside companies that provide such services as food preparation and security. That’s because just about everybody working in a health care facility comes within close vicinity of patients, visitors, and colleagues, Boom explains. At UPHS, Brennan adds that “in order to be equitable, we had to require it for everyone. Everyone has the same rules of employment.”

That said, the policies do provide procedures for people to apply for exemptions and deferrals based on medical conditions, religious beliefs, and pregnancy. (The EEOC also covers exemptions in its updated guidance.) 

Other options

Why not wait? At this point, the vast majority of hospitals are doing just that, hoping that several developments will make mandates more palatable or even unnecessary.

One such development would be the FDA granting full approval to any of the three COVID-19 vaccines. That decision might prompt more staff to get inoculated voluntarily while also giving health systems more scientific backup for mandates.

EUAs are granted on a temporary basis for treatments that have been shown to be safe and effective in initial clinical trials when sufficient alternatives do not exist. Full, permanent approvals require companies to collect data on their treatments’ effects on thousands of people over longer periods (typically six months or more). Moderna and Pfizer — the makers of the first two vaccines to be granted EUAs — have applied for full approval, which might come this fall.

Fall is too late for some health leaders. They worry that the cooler weather, reopening of schools, and seasonal retreat of more people back indoors might fuel the spread of the disease.

“We really don’t want to get into the fall respiratory season without getting our people protected” at IU Health, says Calkins. “We’re concerned there could be a fall surge.”

In nearby Iowa, Gunasekaran believes he can avoid a surge within UI Hospitals & Clinics by continuing staff education efforts that include providing extensive data about the vaccines on the institution’s websites, having staff conversations with senior leaders and scientists, and offering vaccines on day, evening, and weekend shifts. With the health system data showing no significant COVID-19 outbreaks among staff, he hopes the voluntary option can get the vaccination rate above the 97% rate for flu shots, which are also voluntary there.

Staff education and communication efforts, along with incentives such as bonuses, have worked to varying degrees at many hospitals ever since the vaccines became available. Last year Houston Methodist announced a $500 Hope Bonus for employees in appreciation of their dedication during the pandemic — on the condition that they get vaccinated.

At the end of this past March, staff vaccinations had flattened after reaching 84%, Boom notes. Since Houston Methodist subsequently issued the vaccine mandate — first for management, then for all staff — the rate has reached over 99%, he says. But dozens of staff have staged public protests against the requirement.

As that experience shows, vaccine mandates will draw strong responses, both pro and con.

“We’ve had very vocal groups both for and against” the mandate at UofL Health, according to Smith. “We’re a microcosm of everything going on around the country right now.”

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