Are vaccine mandates for healthcare workers data-driven?
It’s not as obvious as you think.
Yesterday, my hospital announced that employees will soon be required to be vaccinated against SARS-CoV-2, the virus that causes Covid-19. What took so long? The data, I think. Until recently, we didn’t quite have the information we needed to justify policies like this.
Most people assume that organizations recently announcing employee vaccine mandates—ranging from governments to United Airlines–had been reluctant because so far the vaccines only have “emergency use authorization” rather than full approval from the Food and Drug Administration. But I suspect that the slow march towards workplace mandates likely reflects that until recently, we did not actually know whether healthcare workers truly posed any risk of viral transmission to our patients.
Until recently, we did not actually know whether healthcare workers truly posed any risk of viral transmission to our patients.
In fact, early in the pandemic, a handful of studies suggested that healthcare workers were not at any increased risk of contracting coronavirus. That information was both surprising and reassuring. For those of us working in hospitals, it signaled that we could go to work, wear our personal protective equipment (PPE), and not face any excessive personal danger. We could work on the frontlines of this pandemic, help as many people as possible, and even be called “heroes”—simply for doing the jobs we had signed up to do in the first place. The early data also implied that, as long as we stuck with the fairly intense PPE program that included donning-and-doffing gowns, gloves, masks, and face shields every time we entered and left a patient’s room, we constituted neither a threat to them, nor to our families at home.
Over time, that picture changed. An important study found that healthcare staff working in dedicated Covid-19 units were four times more likely to acquire SARS-CoV-2 than were their colleagues working in other areas of the hospital. Notably, PPE adherence didn’t seem to have a large impact, albeit those data relied on self-reporting, which is notoriously unreliable. Regardless, hospital-acquired infections were occurring more often than in the surrounding communities, and just where you’d expect them: in Covid-19 wards. This meant that that prevalent and heartening narrative—that healthcare workers’ largest risks were not at the hospital but in their communities outside of work—might actually be wrong. Alternatively, maybe that narrative had been true, but was inconsistent or changing over time. For example, one hospital that fended off an outbreak early in the pandemic by way of intense infection control measures later experienced an outbreak. As my friend and collaborator Dr. Carlos del Rio of Emory University noted, a “battle-weary” frontline would all but be expected to slowly let its guard down.
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Enter the vaccines. When clinical trial results first came in, we recognized them as game-changers with respect to decreasing critical illness and death from Covid-19. But remember, we did not immediately know whether the vaccines prevented infection or forward transmission all together. Fortunately, a number of studies began to indicate the good news: vaccinations also decreased rates of all infection—and therefore any chance of spread from the vaccinated. In May, we learned that healthcare workers in Israel were less likely to have either a symptomatic or asymptomatic coronavirus infection after vaccination. While being fully vaccinated seemed to make a difference, another study found that some decreases in infection were notable within just 8 days of the first dose, albeit with far greater decreases after two weeks. In sum, vaccinating healthcare workers now stood to impart a fast and notable decrease in infections happening in healthcare settings.
As the vaccines were rolled out, cases, hospitalizations, and deaths dropped dramatically. As that happened, though, we began hearing of outbreaks connected to unvaccinated healthcare workers who had brought Covid-19 back into nursing homes. Soon, it became clear where the weak links were. A study conducted by the Centers for Disease Control and Prevention found that in nursing homes, doctors and other treating clinicians were the most likely to be vaccinated against Covid-19, at over 75% (that number is now much higher). But vaccination rates among nurses and aides, the very healthcare professionals who tend to spend the most time near patients, was far lower, hovering around 50%. Worse, nursing homes that serve especially vulnerable ZIP codes were found to have lower overall rates of staff vaccination.
We now had the three vital pieces of information that together all but required healthcare organizations to move on vaccine mandates for its workers, from both a public health and ethical perspective. First, healthcare workers were now seen as more likely to become infected than other people in their own communities. Second, the vaccines decreased infection in all recipients, including healthcare workers (though the Delta variant appears to be blunting that effect to some degree), thereby cutting important chains of transmission. Lastly, unvaccinated healthcare workers were linked to outbreaks in healthcare settings. Knowing that some unions might fight a vaccine mandate, employers needed evidence that such policies would protect patients. Finally, they had it.
We now had the three vital pieces of information that together all but required healthcare organizations to move on vaccine mandates for its workers, from both a public health and ethical perspective.
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An argument could be made that companies outside of healthcare do not have the same obligation to their customers. For example, if American Airlines does not want to require its flight attendants and pilots to vaccinate, travelers can vote with their pocketbooks and choose United, which has announced an employee vaccine mandate. But patients being transported to a hospital frequently do not have a choice. Vaccine mandates, then, are less about employers overriding the health decisions of their employees and more about protecting patients.
Indeed, if the vaccines currently approved for use only protected the recipients themselves, a mandate like this would not be necessary, and in fact might be hard to justify. I might reasonably question the judgment of a colleague choosing to forgo “protection without the risk of infection,” given the mountains of data supporting their safety and effectiveness, but that would alone not suffice for justifying a mandate. The relevant question is whether the vaccine prevents forward transmission from healthcare workers to patients. Because we now know that it can and does, allowing unvaccinated healthcare workers to put their patients at risk, especially as breakthrough hospitalizations mount, would be profoundly unethical.
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Would you knowingly seek care at a medical facility without a vaccine mandate for its staff? Please leave your comments below.
References and further reading:
Healthcare workers (pre-vaccine era) were not more likely to acquire infection:
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2769442
Healthcare workers (pre-vaccine era) in Covid-19 units were more likely to acquire infection:
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2782430
Vaccinated healthcare workers are less likely to become infected with SARS-CoV-2:
https://jamanetwork.com/journals/jama/fullarticle/2779853
A single dose makes a big difference in decreasing infections among healthcare workers:
A Covid-19 outbreak is linked to an unvaccinated healthcare worker:
https://www.cdc.gov/mmwr/volumes/70/wr/mm7017e2.htm?s_cid=mm7017e2_w
Nursing home staff vaccination rate varies by role. Facilities with lower rates tend to serve more vulnerable ZIP codes: