June 14th, 2021

The Time for Hospitals to Require COVID-19 Vaccination Among Employees Is Now

Drs. Harry Meyer and Paul Parkman examine the rubella vaccine. National Library of Medicine.

Imagine you work at a hospital.

Patients come and go, admitted through the emergency room, or electively for surgery. Or they arrive for the day — maybe it’s an outpatient visit, or to receive chemotherapy or an infusion of biologic agents, or to undergo various imaging and other tests.

Some of them, of course, have weakened immune systems and won’t be fully protected by the COVID-19 vaccines. Others may not have received the vaccines based on poor access to healthcare or other social determinants.

Now imagine that you, healthcare worker, contracted COVID-19 because you’ve chosen not to be vaccinated. You feel well — in fact you are completely asymptomatic, blithely clicking the NO SYMPTOMS box in your hospital’s entry screen — but you’re in that brief period of being highly contagious.

And, as a result, you are the source of a COVID-19 transmission within the hospital to one or more of these vulnerable patients, and maybe some hospital coworkers (who could also be immunocompromised) as well.

How would that make you feel?

Importantly, the above chilling scenario is anything but hypothetical. An outbreak in a nursing home occured when one of the unvaccinated employees infected multiple residents and other staff. Even though 90% of the residents had been vaccinated, three of them died.

As cases continue to drop in the United States, we might need reminding that this is a highly contagious virus — even more so with the latest variants, which are 50% more transmissible than the original virus from China. Key graphic below, with estimated R0 for the increasingly dominant alpha and delta variants:

There is a solution, of course, one which would make the likelihood of in-hospital transmission to patients much less likely.

Hospitals can institute policies requiring that all employees be vaccinated.

Medical exemptions, of course, would be allowable. Some also would argue that documentation of prior infection would be sufficient — reinfection is rare. I’m fine with both, though do recommend vaccination for people with prior disease.

But what about the limbo “emergency use authorization” status of the vaccines? Shouldn’t we await full FDA approval? According to the U.S. Equal Employment Opportunity Commission, employers may require vaccines for onsite workers as a means of protecting the safety of others despite this status.

This approach of mandatory immunization follows the model of required influenza vaccination (already widely in place nationally), but is arguably much more important — COVID-19 is more lethal than the flu, and the vaccines are more effective. Such a win-win-win for the individual, the hospital, and for public health overall.

As a result, it’s a policy we ID doctors — especially infection preventionists — strongly endorse. That’s why I was ecstatic when hearing that Houston Methodist, Penn Medicine, and Johns Hopkins, among others, all had put such rules in place. Our hospital is considering similar action.

Penn Medicine staff articulated their rationale in a NEJM Perspective, entitled Incentives for Immunity — Strategies for Increasing Covid-19 Vaccine Uptake. They cite a systematic review showing that requiring vaccination for employment is the most effective strategy to increase vaccination rates.

Vaccine requirements have enormous potential to improve public health. We know that school immunization policies here in the United States have kept our outbreaks of vaccine preventable illnesses among children much less common than in other countries, and we’ve actually eliminated one scourge entirely:

With vaccination requirements, more than 90 percent of children are protected against devastating diseases like polio and measles. Through vaccination requirements, smallpox was eradicated from planet Earth.

With the caveat that those interested in the musings of me, an ID doctor, are likely to think similarly, it appears that most agree that this is the way to go — if not now, then after full FDA approval:

But not all agree. More than 100 employees of Houston Methodist sued the hospital, saying that the mandate forced them “to participate in an experimental vaccine trial as a condition for continued employment.”

This is nonsense — getting the vaccine is not participation “in an experimental vaccine trial” — and fortunately a federal judge agrees, and dismissed the lawsuit. I’m hopeful that this action will pave the way for many other healthcare facilities to institute similar policies.

The bottom line is that it is a privilege to be in the position of taking care of patients, and with that privilege comes the responsibility of keeping them as safe as possible.

And that means getting vaccinated.

13 Responses to “The Time for Hospitals to Require COVID-19 Vaccination Among Employees Is Now”

  1. Donald Steinmuller MD says:

    Dr Sax, thank you for your blog that always seems to explain and clarify the best approach to Covid and other infectious diseases. I wish you had been appointed CDC director!
    Thanks for your good work!

  2. Donald M. Pachuta says:

    One of your best – Mandatory is the answer to many problems

    I also enjoyed you again in the Harvard IM Course last week

    Seems you had less jokes than before 🙂

  3. Gordon Huth, MD says:

    I completely agree with you. Healthcare workers have an ethical obligation to be vaccinated against COVID and other infectious diseases, and hospitals have an ethical obligation to mandate those vaccinations.

  4. Sam Stampfer says:

    I would strongly argue against the idea that “reinfection is rare”, and say that even those with prior COVID-19 infection need to be vaccinated if vaccination is being mandated for hospital staff.

    See https://pubmed.ncbi.nlm.nih.gov/33951374/ which is the Novavax COVID-19 vaccine clinical trial that they unluckily ran in South Africa 8/2020-12/2020, just as Beta variant (B.1.351) emerged. One third of the clinical trial participants had pre-existing anti-spike antibodies consistent with prior infection. And yet, for those in the placebo group, pre-existing antibodies from natural infection (with presumed wild-type SARS-CoV-2) did not protect at all against mild and moderate infection with Beta variant (no one got severely infected, probably because the median age in the clinical trial was 28 . . .) Figure 2C if you’re looking at the paper, which is a fascinating read. The scenario you’re trying to prevent is that of a highly-contagious individual with mild or asymptomatic infection, which certainly could include individuals who were originally infected with wild-type virus who then get reinfected with a variant. Thus, prior infection should not be an exception to vaccination.

  5. Roger Kimber says:

    Vaccination is not 100% effective, right? The scenario you outline can (& eventually will- but likely will be suppressed, just like Fauci’s complicity in the bioengineering of COVID 19) occur with an infected & infectious vaccinated worker. Much less likely but NOT impossible.
    There is an alternative: ivermectin once a week @ 0.2 mg/kg dose prophylaxis, which in one Latin American study (cited @ flccc.net) was 100% effective.
    Just like with recalcitrant children, giving people alternatives results in more compliance & less conflict.
    For those w/o children, if Johnny wants to do prohibited A, better to offer B or C, rather than a simple ‘No A’. Same end result w/ more family (workplace) peace.
    Plus, no coercive precedent, which is what the protest & resistance is about for @ least some on the picket lines.
    BTW, I am & have been since January 20th fully vaccinated; just that I believe in civil liberties & the malign effect of power: it corrupts.

    • Peter Bergé, JD, MPA, PA-C Emeritus says:

      I agree that studies should continue in the search for effective alternatives for vaccination of healthcare workers, and that coercive policies should be the last alternative.

      However, I differ on two points:

      1. Requiring vaccination would not set set a precedent, as vaccinations or proof of immunity have been required in hospitals for decades, not to mention testing for TB.

      2. “Civil liberties” are not germane to this article. Civil liberties are a governmental issue. Infection prevention and patient protection in healthcare institutions are not a question of civil liberties even, I would argue, when the institution happens to be run by a governmental agency, although in that situation the issues can and do become intertwined. But this article refers to “hospitals,” not governmental mandates.

      Therefore, as a healthcare policy question, civil liberties are not implicated.

  6. Loretta S says:

    “The bottom line is that it is a privilege to be in the position of taking care of patients, and with that privilege comes the responsibility of keeping them as safe as possible.” Exactly!

  7. J.L. Castillion says:

    I totally agree with your statement in the last line. No healthcare intends to purposely harm someone in his or her care. Forcing someone to take something he /she perceives as potentially unsafe is in my opinion, not the way to go forward in this situation. Let us try counselling, addressing concerns and offering alternatives.

  8. Joshua Q says:

    Thank you Dr Sax, a respected and needed expert voice, for endorsing this sensible but somehow controversial recommendation.

    The evidence of benefit GREATLY outweighs any yet to be seen risk with COVID vaccination.

    I do not generally endorse mandatory therapy on folks. A “once-in-a-century” deadly pandemic is the rare exception that we should fight for.

  9. Margaret Pothier says:

    Dr. Paul Sax has been a leader in evaluating evidence as well as employing common sense regarding vaccination for healthcare workers. I am appalled that the Boston hospitals have not yet required all employees to be vaccinated against SARS-CoV-2. Boston is rightfully considered to be a medical hub of great innovation and healthcare. The Dana Farber Cancer Institute does not require employees to be vaccinated. This is unconscionable considering that the majority of their patients are immunocompromised. Where is the leadership? Dr. Marc Boom CEO of Houston Methodist Hospital is a great leader and his mandate for vaccination as a requirement for employment should be the template followed by other less courageous healthcare administrators.

  10. Jason Anthony Moore says:

    I understand where the author is coming from and the point he is trying to get across but disagree with his choice of words as he makes it sound as if the vaccine is 100% effective when it is not. COVID-19 can still be acquired and transmitted despite being vaccinated.

    The following paragraph could have easily been written as follows:

    Now imagine that you, healthcare worker, contracted COVID-19 DESPITE BEING VACCINATED. You feel well — in fact you are completely asymptomatic, blithely clicking the NO SYMPTOMS box in your hospital’s entry screen — but you’re in that brief period of being highly contagious.

    And, as a result, you are the source of a COVID-19 transmission within the hospital to one or more of these vulnerable patients, and maybe some hospital coworkers (who could also be immunocompromised) as well.

    How would that make you feel?

    I know in either instance that I would feel horrible if I infected someone with COVID-19 no matter the outcome.

  11. John Leung, M.B.,B.S.,F.R.C.S.Ed. says:

    Instead of hard-selling the current vaccines as being “perfectly safe (almost) and any serious. or fatal side effects should be accepted as extremely rare and worthy sacrifice for the good of the whole society,” why not make those vaccines actually safer, with less side effects and more effective at. This will increase the appeal of vaccination to the skeptics and reaffirm the credibility of the vaccination programs.
    A very simple method to achieve such objective is by giving the vaccine intradermally, instead of intramuscularly, but at 1/10 of the standard dose. This has been proven long ago to be more effective and with less systemic side effects than the intramuscular route. It is easier to convince people that giving 1/10 of the standard vaccine dose by the most peripheral route is likely to cause less side effects.
    Objections are (1) we need to do some work testing the intradermal injections on these new vaccines;
    (2) the injection site could be painful (probably not more than the intramuscular site;
    (3) intradermal injection requires a little more dexterity than intramuscular injection – but not much more. In fact some nurses even felt it is much safer because you don’t have to worry about hitting a large blood vessel or nerve;
    (4) this idea might lower the sales volume and profit of big pharmaceutical corporates. But by making the vaccine 10 times cheaper to administer it might become more attractive to under-privileged communities and expanded sales volume with net gain in profit.
    I sincerely look forward to your expert opinion.

  12. ie Rabinovitz says:

    Roll up your left sleeve people; and look for that nasty vaccinia scar. I don’t think anyone asked us if we wished to to take it then; but in those days *everyone* knew some middle aged person scarred for life by the smallpox.

    Yes, my primary school had one of those distinguished pox-survivors: a remarkably hot-tempered, red-faced teacher; of course all presumed he was red-faced because he had a nasty temper. But that was not it. And he wasn’t an ugly fellow; in fact he was “distinguished” — looked a lot like Abe Lincoln. I digress.

    No one asked us; and it is quite probably that the transient vaccinia induced by that inoculation given us was rather on the nasty-side too; but then little kids are always off their feed for one reason or another. In the end however, no one asked our permission; we took it; and the older folks were glad for us.

    For they were the older folks who’d seen what the pox had done to their little brothers or sisters — those little pals of theirs they’d carried memories of their whole lives, the cheerful little girl or boy who’d been always such a good sport, that summer afternoon once, who’d come down with a bit of a fever; then was locked away in the upstairs bedroom; from whence the horrid putrid gauze was brought down four times a day, to the basement wrapped in phenol-impregnated sheets to be boiled; the cheerful little pal who last said, “could you get me one of those cherry-sodas?” but was gone, a hot, glutinous corpse, by the time they got back from the corner druggist; the room stifling in that nauseating carbolic odor and the vague but unmistakable putrid undertone of plasma and pus:

    That’s what they knew they were protecting *us* against and that’s why *everyone*, from little alpha to little Obie to little Billy to little omega — *all* got that nasty scar on the upper left. And if in case the pampered over-educated fools (graduates of the you-tube school for advanced studies) want to have a look, they too can still consult the color plates in any medical text; if they have the courage to see it — the pox — in its full, florid purulent third degree glory.

    Just because in covid disease the clots and thrombi and diffuse alveolar damage are seen only by the pathologist on autopsy does not suffice to sweep the whole matter out of sight and out of mind.

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HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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