Are the conditions met to make COVID-19 vaccination mandatory for healthcare professionals?

Historically, epidemics claimed lives of healthcare professionals (HCP) (Plague, Yellow Fever, SARS, Ebola, etc.) [1]. HCPs have been at the front line of the response to the SARS-CoV-2 pandemic. They are both potential victims and spreaders of the infection [2]. During the opening session of the World Health Assembly on May 24, 2021, the general director of the World Health Organization estimated that 115,000 HCPs had lost their lives due to COVID-19 [3]. In May 2021, the French public health agency (Santé publique France, SPF), reported 81,032 COVID-19 cases (and 19 deaths) among HCPs working in healthcare facilities. This evaluation is probably underestimated [4]. Nurses and assistant nurses were the most affected occupational groups. In May 2021, 62,678 nosocomial cases of COVID-19 were identified by SPF, of which 24,048 cases occurred in HCPs [5]. HCPs were identified as the index case in a third of cases. The proportion of infected HCPs in nosocomial clusters has been decreasing since March 2021 [5].

Worldwide, HCPs represent a priority group for COVID-19 vaccination. In France, their intention to get vaccinated against COVID-19 varied across time and across professional categories [6]. On May 18, 2021, SPF reported that 91.7% of HCPs had received one dose of COVID-19 vaccine and 63.4% were fully vaccinated [5]. This proportion of vaccinated HCPs is probably overestimated as other employees of healthcare facilities were vaccinated, but acceptability of COVID-19 vaccines among HCPs does seem to increase. In March 2021, the French National Academy of Medicine stated that COVID-19 vaccine should be mandatory for HCPs [7]. On May 25, 2021, they reiterated their statement and made a decision for mandatory vaccination against COVID-19 for various occupations and activities: HCPs, essential workers, students, travels, etc. [8]. These statements were not endorsed by the authorities at this time. An opinion poll demonstrated that the French general population was favorable to a mandatory vaccine for HCPs (IFOP/Fiducial March 11, 2021). While COVID-19 vaccination is highly recommended for HCPs, and might become required to attend various social events and to travel, it is time to address or re-address the question of a mandatory COVID-19 vaccine in French HCPs.

By making a vaccine mandatory for HCPs, high vaccine coverage in healthcare professionals may be obtained and differences observed between occupational groups may be reduced. Suboptimal vaccine coverage against seasonal influenza, pertussis, measles, and varicella (non-mandatory vaccines in France) has indeed been observed [9]. Moreover, vaccine coverage for recommended vaccines (especially influenza vaccine) is lower in nurses and assistant nurses; no difference is observed in terms of vaccine coverage between occupational groups for mandatory vaccines [9].

In 2016, the French High Council for Public Health (French acronym HCSP) published guidelines on mandatory vaccines for French HCPs. They developed the following framework to recommend the mandatory nature of a vaccine for HCPs: [10] (i) HCPs should be at high risk of the vaccine-preventable disease, and highly exposed to the pathogens; (ii) there should be a transmission risk to patients; (iii) the vaccine should be effective; (iv) the benefit-risk ratio should be favorable for HCPs. In these guidelines, the HCSP considered that these criteria were not fulfilled for the seasonal influenza vaccine. Although they recommended against mandatory influenza vaccine in HCPs, they considered that in a pandemic context and/or if a more effective vaccine became available, this position should be newly discussed.

1. HCPs are at risk of COVID-19

In a meta-analysis with most data collected during the first wave of the pandemic, the prevalence of SARS-CoV-2 infections in HCPs was estimated at 7% ranging from 0.4 to 57% [11]. In the first analysis of the French EPICOV study, the seroprevalence of SARS-CoV-2 was estimated at 11% in HCPs in France in June 2020 versus 4.5% in the general population [12]. This observation confirmed the high burden of COVID-19 in HCPs — at least at the beginning of the pandemic — while HCPs experienced shortage in personal protective equipment. In more recent time, the higher risk of infection among HCPs may be mitigated. However, although COVID-19 in young HCPs had mostly favorable outcomes, long-term consequences such as the prevalence of long COVID in HCPs, remain to be determined.

2. Risk of transmission to patients

Although patients are more often index cases of COVID-19 nosocomial outbreaks, HCPs contribute to the spread of the infection in healthcare settings [5]. Furthermore, there is evidence of SARS-CoV-2 transmission from asymptomatic or presymptomatic individuals [13]. Consequently, HCPs may spread SARS-CoV-2 several days before experiencing symptoms and self-isolating. In addition, HCPs take care of patients with potentially impaired response to COVID-19 vaccines. The French National Authority for Health (French acronym HAS) recommended a cocooning strategy around patients with conditions reducing COVID-19 immunogenicity such as transplant recipients, patients receiving renal replacement therapies, patients with malignancies on chemotherapy inducing lymphopenia, and on anti-CD20 therapy [14]. Unvaccinated HCPs may transmit infections to fully vaccinated immunocompromised patients. However, the risk of transmission to patients is also largely mitigated by universal use of masks, hand hygiene, and precautions in healthcare settings.

3. COVID-19 vaccines are effective

Efficacy of COVID-19 vaccines observed in randomized controlled trials (RCT) was confirmed in real-life settings. COVID-19 vaccines are highly effective to protect individuals against COVID-19, COVID-19 hospitalizations, and deaths [15]. Outcomes in RCT were moderate to severe COVID-19, consequently, at the time of emergency use authorizations, data on a reduction of the transmission risk were lacking. Once again, real-life observations provided impressive results with a BNT162b2 vaccine effectiveness of 85% on both symptomatic and asymptomatic SARS-CoV-2 infections [16]. COVID-19 vaccines also have an impact on SARS-CoV-2 viral load a few days after the first dose and may even reduce contagiousness in vaccinated infected individuals [17]. HCP vaccination is effective to reduce the risk of infection in their household contacts [18].

4. COVID-19 vaccines benefit/risk balance is favorable

On May 18, 2021, more than 1.5 billion of COVID-19 vaccine doses had been administered globally. Despite safety signal for AstraZeneca and Janssen vaccines due to the occurrence of rare thrombotic thrombocytopenic events, the WHO and the European Medicine Agency confirmed that the benefits of these vaccines outweighed the risks. Due to the vaccine roll-out at a pandemic speed, it is reasonable to state that the benefit/risk balance of COVID-19 vaccines is positive in HCPs, even in the youngest, due to their high level of exposure [19], [20].

5. Are there ethical issues related to mandatory COVID-19 vaccine for HCPs?

COVID-19 vaccines have the potential to individually protect HCPs but also to reduce the burden of SARS-CoV-2 infections in healthcare settings. Mandatory vaccination against COVID-19 for HCPs would be an effective way to reach high vaccine coverage but raises ethical issues based on four principles: Beneficence, Non-maleficence, Justice, and Autonomy [21]. Beneficence arguments include: 1) increase in COVID-19 vaccine coverage related to mandatory vaccination will possibly benefit patients, household contacts (now proven), and colleagues of HCPs considering the now proven impact of COVID-19 vaccines on transmission; 2) HCPs may also experience personal benefit from COVID-19 vaccines as COVID-19 vaccines exhibit high efficacy to prevent infection, and since viral circulation remains high. Regarding non-maleficence, a mandatory vaccine program may cause harm to HCPs who would be vaccinated against their will. However, side effects of COVID-19 vaccination are rare (1.4/1000 administered doses), and the frequency of serious adverse events is 3/10,000 administered doses. A mandatory program could also enhance suspicion against vaccines as a whole. This is however uncertain in France as SPF observed an increase in vaccine coverage for non-mandatory vaccines since the extension of mandatory vaccinations to 11 vaccines in infants born after January 1, 2018, and an increase in the proportion of the French population favorable to vaccines in general [22]. Autonomy of HCPs in making decision about COVID-19 vaccination means that HCPs have equal access to evidence. However, COVID-19 is associated with infodemic, and HCPs are also exposed to false and misleading information. Health literacy is critical to identify false and misleading information in the infodemic context [23]. Social gradients were observed in health literacy level, and may contribute to the discrepancies observed in intention to get vaccinated between the various professional categories of HCPs. Equal access to reliable and readable information should be ensured for all HCP categories. If COVID-19 vaccine were to become mandatory for HCPs but not for the general population, HCPs may consider this situation unfair and a source of injustice. On the contrary, while the “COVID Health Pass” (certificate of recent testing, or recent proven SARS-CoV-2 infection, or vaccination) was recently approved to attend large events in France and to travel in Europe, it may appear unfair that HCPs can work in direct contact with vulnerable patients without frequent SARS-CoV-2 testing or without getting the COVID-19 vaccine. On May 5, 2021, a majority (63%) of the French general population was in favor of the “Health Pass” (Elabe/BFM TV).

One question remains unanswered: could mandatory COVID-19 vaccination for HCPs have an impact on their attitudes towards patients’ vaccination and their ability to recommend COVID-19 vaccines? The increase in vaccine coverage (even observed for non-mandatory vaccines) since the introduction of the 11 mandatory vaccines might be in part due to changes in “vaccinators” attitudes.

In conclusion, we believe conditions to recommend mandatory COVID-19 vaccine in HCPs according to the HCSP framework are met. However, ethical issues such as autonomy are not yet fulfilled. Interventions aiming to help HCPs make an evidence-based decision should be prioritized and should address concerns of all HCP professional categories. In addition, incentives may also contribute to increase vaccine coverage in healthcare facilities. Alternatively to mandatory COVID-19 vaccination for all HCPs, the vaccine could only be required for HCPs in direct contact with vulnerable patients for whom evidence of sub-optimal effectiveness of COVID-19 vaccines is available. This would include solid organ transplant recipients, bone marrow transplant recipients, and patients with active malignancies as described in the cocooning strategy [14]. In any case, a mandatory vaccination policy should be associated with adequate training of all HCP categories, aiming to discuss all concerns, with a thorough and transparent evaluation of its effectiveness and safety, and a large and reliable communication on its impact.

Human and animal rights

The authors declare that the work described has been carried out in accordance with the Declaration of Helsinki of the World Medical Association revised in 2013 for experiments involving humans as well as in accordance with the EU Directive 2010/63/EU for animal experiments.

Informed consent and patient details

The authors declare that the work described does not involve patients or volunteers.

Disclosure of interest

The authors declare that they have no competing interest.

Funding

This work did not receive any grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

All authors attest that they meet the current International Committee of Medical Journal Editors (ICMJE) criteria for Authorship.

Contributions of authors

AGB, EBN, and OL performed the literature search.

AGB, EBN, OL wrote the article.