Should vaccination for healthcare workers be mandatory?

Recent studies have reported high efficacy and safety for a number of COVID-19 vaccines for protection against severe disease. Healthcare workers, particularly those in patient-facing roles, are at highest risk of contracting infection due to SARS-CoV-2 virus, having severe outcomes and at risk of spreading the virus to patients and staff. Healthcare workers have been prioritised to receive the COVID-19 vaccine in many countries, including the UK.¹ However, recent reports have suggested low uptake of the COVID-19 vaccine among healthcare workers in UK and the USA. A study from a large NHS Trust in England showed that overall uptake of the vaccine was only 64.5% among healthcare workers with a significantly lower uptake among ethnic minority populations with 58.5% of South Asians and 36.4% of Black individuals having the vaccine compared to 70.9% of White healthcare workers. In the USA, in view of high rates of infections and deaths in patients in institutionalised settings, residents and staff in long-term facilities have been prioritised for vaccination.² However, a recent study reported that among institutionalised facilities, 77.8% of residents were vaccinated but only 37.55% of staff were vaccinated.²

Vaccine hesitancy among healthcare staff is not new and has been reported with influenza vaccine.³ The low uptake, described as vaccine hesitancy, among healthcare workers, is certainly of major concern, including potentially increasing vaccine hesitancy among the general population. There are, however, nuanced differences between vaccine hesitancy and vaccine refusal. Overall, the low uptake in the majority of healthcare workers is due to vaccine hesitancy. Reasons for vaccine hesitancy for the COVID-19 vaccine are complex and include scepticism, low perceived risk, fears about adverse effects, concerns about infertility among young women, tendency to postpone the vaccine until further data are available, concerns that the vaccines have been fast-tracked, cultural and religious beliefs, and general low trust, particularly among ethnic minority populations.^4,5 There has also been increasing mistrust in the healthcare system with ethnic minority healthcare workers being disproportionately impacted by COVID-19 and feeling less protected.^6,7

In view of their high risk, it is not surprising that there are already discussions about making the COVID-19 vaccination mandatory for healthcare workers. A strong case for making any vaccination mandatory (or compulsory) can be made if four conditions are met: there is a grave threat to public health; the vaccine is safe and effective; mandatory vaccination has a superior cost/benefit profile compared with other alternatives; and the level of coercion is proportionate.⁸ There is already a case for some individuals being contractually obligated for the hepatitis B vaccine, particularly healthcare workers in high-risk settings. The government has previously said that COVID-19 vaccines will not be compulsory for healthcare workers⁹; however, recent leaked cabinet documents have revealed that care home workers will be required by law to have a COVID-19 vaccine. It may also be practically and ethically problematic to introduce a mandatory policy, at least initially, and indeed employers could put themselves at risk of discrimination.¹⁰ Mandating vaccination is viewed unfavourably as this does not address many concerns of healthcare workers. Many healthcare organisations do not support mandating vaccination to staff and are totally against staff vaccination being part of staff contracts, terms and conditions of employment or linked to pay.^10,11 So are there more attractive alternatives?

Evidence suggests there are a number of strategies that could improve vaccine uptake without mandating vaccinations. Instead of mandating vaccination, initial approaches should include an open dialogue that addresses specific concerns including sharing information about vaccine safety and efficacy, risk perceptions and perceived need of vaccination, and use of trusted, credible sources. The vaccine should be reoffered as hesitancy is linked with uncertainty of outcomes, which may diminish over time as more people are vaccinated. Perception of support from family and friends is also associated with increased vaccine uptake⁸ and wider community engagement efforts are likely to create opportunities in the wider network of healthcare workers to reduce hesitancy. In addition, supportive workplace policies to address practical barriers such as having vaccinations available onsite, ensuring safety with adequate personal protective equipment, ease of appointments, adequate time to attend vaccination and active promotion by employers may increase vaccine uptake in healthcare workers.

Vaccine hesitancy in healthcare workers could create operational challenges for delivering safe care in health and social care. However, some of these issues are not unsurmountable. For example these individuals can still contribute through working in green zones¹² and having regular lateral flow testing. Remote consultations are also likely to continue, not only during the pandemic but even when we are back to some form of normal working.¹³

A mandatory COVID-19 vaccination programme could be seen as discriminatory and may cause stigmatisation, further loss of trust and overall widen the inequalities already seen during the pandemic. We should at all costs avoid mandatory vaccination of healthcare workers until we get further information on the vaccine that addresses the concerns of healthcare workers.