Mandating COVID-19 Vaccination for Health Care Workers
Authors: Ezekiel J. Emanuel, David J. Skorton
Journal: Annals of Internal Medicine (2021)

Ideas and Opinions30 July 2021Mandating COVID-19 Vaccination for Health Care WorkersFREEEzekiel J. Emanuel, MD, PhD and David J. Skorton, MDEzekiel J. Emanuel, MD, PhDUniversity of Pennsylvania, Philadelphia, Pennsylvania (E.J.E.)Search for more papers by this author and David J. Skorton, MDAssociation of American Medical Colleges, Washington, DC (D.J.S.).Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M21-3150 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail With the emergence and spread of the Delta variant, it is clear that we are in a long-term coronavirus war with no quick victories. July 2021 will go down in history as a turning point; it was the time when the United States—as well as other countries, such as France and Italy—adopted the notion of this being equivalent to a war and implemented mandates to ensure social mobilization.Throughout the coronavirus pandemic, people working in health care and long-term care have defined the frontlines in every important way. More than 15 years before we recognized SARS-CoV-2 as a human pathogen, researchers were doing fundamental work that led to the concept of the mRNA and adenovirus vaccine platforms, which eventuated in the breathtakingly rapid development of effective and safe vaccines. Physicians, nurses, physician assistants, laboratory professionals, and many others worked through the surges in March and April 2020 and the winter of 2021, with no question about their devotion to patients. That is why they are rightly considered heroes. And let us not forget all of the others who work in the health care setting, supporting in myriad ways the work of those providing direct patient care. All who work in health care institutions are health care workers, regardless of their specific job description, and all of us depend on them to contribute to the effective, safe, and compassionate care we expect of our health care institutions.Unfortunately, when it comes to COVID-19 vaccination rates, health care workers seem to reflect the country. Vaccination rates vary greatly, with 96% of physicians but 55% of nursing home staff, fewer than 50% of nurses, and just 26% of home health aides being fully vaccinated (1–4). To prevent the ravages of COVID-19, many more people living in the United States need to be vaccinated. The facts are clear: The U.S. Food and Drug Administration (FDA)–authorized vaccines have been administered to hundreds of millions of people and have been found to prevent severe disease and death. Our fondest hope is that the vaccination rate will increase quickly.It is imperative that all 17 million health care workers in the United States be vaccinated (5). The best way to achieve this is for them to choose vaccination. However, in the current situation, health care employers should mandate vaccination. To induce employers to require vaccines, we brought together health care professional societies and organizations to endorse this requirement. The more organizations endorse vaccination mandates, the easier it will be to gain attention and ensure that no single organization will be targeted with malicious attacks, as the American Academy of Pediatrics was when it advocated for mask wearing in classrooms; hence our brief campaign to draft a joint statement and get professional societies and organizations to sign and disseminate it (6). As of 29 July 2021, 88 organizations had signed, representing all facets of health care: physicians, nurses, pharmacists, physician assistants, nurse practitioners, epidemiologists, public health workers, and long-term care workers (Figure) (6).Figure. Joint statement in support of COVID-19 vaccine mandates for all workers in health and long-term care. Download figure Download PowerPoint The rationale for requiring vaccines for health care workers is 3-fold (5). First, like any person, health care workers have a general ethical duty to protect others, especially when there is minimal threat to their own well-being, and the vaccines have so few adverse effects that there is little risk to a vaccinated person's health.Second, beyond this general ethical duty, health care workers have a special ethical and professional responsibility to protect others. The objective of the health care professions is to promote the health and well-being of patients and their families, residents of long-term care facilities, and the broader community. Getting vaccinated is one way to achieve this professional objective and protect the health of all of these parties. This responsibility holds not only for physicians, nurses, respiratory therapists, and other health care professionals who take professional oaths or pledges but also for the dietitians, environmental workers, safety officers, clerks, and other support staff at health care facilities. All who choose to work in health care settings—hospitals, urgent care settings, long-term care facilities, physicians' offices—must be committed to putting patients first. During their usual activities, health care workers are likely to interact with patients who are vulnerable to COVID-19, namely elderly adults, children younger than 12 years, and immunocompromised persons. Their work setting confers a special responsibility to not endanger the health of other people.Third, requiring COVID-19 vaccines for health care workers is not new but is merely an extension of well-established practices and policies. Many health care facilities have long required their workers to be vaccinated against influenza, hepatitis B, and other infectious diseases. As a result, health care workers have historically been role models of good health behaviors, particularly vaccination. All of us working shoulder-to-shoulder in health care can embody health practices for the public. Part of our opportunity to have a positive effect is to show the importance of receiving the COVID-19 vaccine—and, indeed, all vaccines.Having health care employers mandate that their workers be vaccinated is merely realizing this ethical obligation. It is a way of nudging people to do the right thing.In addition to the ethics of mandating vaccines for health care workers, such mandates are legal. As the U.S. Equal Employment Opportunity Commission and courts have made clear, employers have the right to require vaccination as a condition of employment (7). This right extends to vaccines under emergency use authorization as well as those that have been fully approved by the FDA.Finally, we should recognize that mandates increase vaccination rates. After Houston Methodist Hospital required its workers to be vaccinated, 99.5% received the vaccine, with few resigning rather than getting vaccinated (8). Several companies that own more than 250 long-term care facilities have similarly mandated COVID-19 vaccines. There, too, more than 95% of workers—and, in some cases, 100%—have been vaccinated (9), and few have quit rather than being vaccinated. Having more workers vaccinated and fewer out recovering from COVID-19 will also lessen the pressure on workers, improving the resilience of our health care workforce.There are ethical, legal, and practical reasons for health care workers to be vaccinated against COVID-19. This sentiment resonated with all of the health care societies and organizations asked to sign this joint statement; indeed, the rapid affirmation was like a supersaturated liquid producing myriad crystals with the addition of a tiny nidus. Almost everyone recognized that calling for a mandate was the right thing to do for the health care professions, local communities, and the nation as a whole.After this joint statement was released, it was announced that the U.S. Department of Veterans Affairs will require all of its frontline health workers to be vaccinated against COVID-19; California and New York will mandate vaccines for many state and city employees; many private employers, such as Google, will require vaccination for their employees; and the Biden administration will require federal workers to get vaccinated or be tested weekly (10). These new government policies and the overwhelming response of the health care community shown in the joint letter give us hope for turning a corner in this war. Please join us.References1. American Medical Association. AMA Survey Shows Over 96% of Doctors Fully Vaccinated Against COVID-19 [press release]. 11 June 2021. Accessed at www.ama-assn.org/press-center/press-releases/ama-survey-shows-over-96-doctors-fully-vaccinated-against-covid-19 on 28 July 2021. Google Scholar2. Paulin E. 45% of Nursing Home Staff Still Unvaccinated Against COVID-19. AARP. 25 June 2021. Accessed at www.aarp.org/caregiving/health/info-2021/nursing-home-staff-still-unvaccinated-for-covid.html on 28 July 2021. Google Scholar3. Stone J. COVID-19 Vaccination Rates Are Poor Among Healthcare Workers – How Can We Do Better? Forbes. 28 June 2021. Accessed at www.forbes.com/sites/judystone/2021/06/28/covid19-vaccination-rates-are-poor-among-healthcare-workershow-can-we-do-better/?sh=5de7d758589e on 28 July 2021. Google Scholar4. Kaiser Family Foundation. KFF/Post Survey of Frontline Health Care Workers Finds Nearly Half Remain Unvaccinated [press release]. 19 March 2021. Accessed at www.kff.org/coronavirus-covid-19/press-release/kff-post-survey-of-frontline-health-care-workers-finds-nearly-half-remain-unvaccinated on 28 July 2021. Google Scholar5. Klompas M, Pearson M, Morris C. The case for mandating COVID-19 vaccines for health care workers [Editorial]. Ann Intern Med. 2021;174:1305-7. [PMID:34251905] doi:10.7326/M21-2366 LinkGoogle Scholar6. Joint Statement in Support of COVID-19 Vaccine Mandates for All Workers in Health and Long-Term Care. 26 July 2021. Accessed at www.ezekielemanuel.com/writing/all-articles/2021/07/26/joint-statement-in-support-of-covid-19-vaccine-mandates-for-all-workers-in-health-and-long-term-care on 28 July 2021. Google Scholar7. U.S. Equal Employment Opportunity Commission. EEOC Issues Updated COVID-19 Technical Assistance [press release]. 28 May 2021. Accessed at www.eeoc.gov/newsroom/eeoc-issues-updated-covid-19-technical-assistance on 28 July 2021. Google Scholar8. Order on Dismissal: Jennifer Bridges et al v Houston Methodist Hospital et al (SD Tex 2021). Google Scholar9. Bonvissuto K. IntegraCare reaches 100 percent staff COVID vaccination rate; Trilogy mandates vaccination. McKnight's Senior Living. 22 June 2021. Accessed at www.mcknightsseniorliving.com/home/news/integracare-reaches-100-percent-staff-covid-vaccination-rate-trilogy-mandates-vaccination on 28 July 2021. Google Scholar10. Aspegren E, Miller RW, Bacon J, et al. California, NYC unveil plans to require vaccinations or testing; VA says shots mandatory for medical workers. USA Today. 26 July 2021. Accessed at www.usatoday.com/story/news/health/2021/07/26/covid-vaccine-variants-masks-cdc/8087573002 on 28 July 2021. Google Scholar Comments 0 Comments Sign In to Submit A Comment Kristy MormanPA-C, Optum/UHG30 July 2021 Mandates needed I applaud ACP and all the other organizations who have called for mandated vaccines of health workers and appreciate the rationale so wisely laid out here. We know the vaccine to be safe and effective. As a PA-C and an immunocompromised individual, when I myself go to a health care facility, I want to feel safe knowing that everyone I encounter is vaccinated; unfortunately, I have no way of knowing that (apart from asking everyone, which they can decline to answer). Mandates for healthcare workers are necessary to protect the most vulnerable and help curb the spread. I completely agree that if one has chosen to work in healthcare--a field which, by definition, promotes health--they should be vaccinated. I hope my organization and others will quickly join the VA and others in mandating vaccines. John Ryan MDFlorida Internal Medicine30 July 2021 "Heroes Work Here" That's the sign on the medical office building I work in. Has always been true -- but even more so for the past 16 months, when we have served our often very ill and always very frightened patients with our time, fortune, health and some of us, our lives. Why? Because our nature and ethical principles as healing professionals leads us into the fight, not sheltering from it. So let's all roll up our sleeves and finish this. Richard OblerActive ER MD31 July 2021 Groupthink Many points are right, but some are wrong. Why should the mandate for vaccines extend to emergency use authorization? And if our patients refuse vaccines, which should protect them almost fully against death or hospitalization, why then force the rest of us? And I am fully vaccinated myself. We need to protect the rights of those of our colleagues who for one reason or another don't want to get the vaccine. They have rights too. We should not allow these organizations to take away all our rights. And our patients are well enough protected just with simple masking and so forth. Richard Paul Junghans, PhD, MDBoston University19 August 2021 Comment Whereas vaccinating everyone in health care settings makes sense, there is a nuance to this situation with vaccine-averse people that can be exploited to everyone’s benefit. Let’s say 50% are vaccinated and we want to get to 100%. We provide incentives, we threaten their jobs, and in general try to shame people as health care troglodytes to get their vaccinations done. I want to appeal to the science, not politics, not morality, not expediency. That is, let us find the population that is truly at risk and reduce the focus to this subset. The population at risk are those who have neither been vaccinated nor infected. So far, public health agencies have chosen to ignore prior infectees and treated them the same as the susceptible population. This is a gross error and a missed opportunity. In general, the consensus view is that natural immunity that arises from exposure to all viral proteins is superior to vaccine immunity with exposure to one viral protein. https://www.chop.edu/centers-programs/vaccine-education-center/vaccine-safety/immune-system-and-health Unfortunately, there is an abiding bias against the study of “natural immunity” from prior infection with covid-19 that is as mystifying as it is exasperating and that only benefits Pfizer et al profits selling more doses. Any honest, critical and objective valuation ranks natural immunity as good or likely better than the best of the vaccines. See https://www.youtube.com/watch?v=3Upjjm7QUjA. For example, in the recent outbreak in a high exposure setting with miners in French Guiana, among 25 fully vaccinated, 15 were infected for a case rate of 60% breakthrough infection. Among all prior infectees, the re-infection rate was 0/6 (0%). The superiority of prior infection over vaccination was highly significant (p = 0.0177, Fisher exact test). See https://pubmed.ncbi.nlm.nih.gov/34289335/. Accordingly, I propose that all prior infectees be designated the same as vaccinated. From April 2021, CDC data estimated 40% of the adult population was previously infected, with a much higher likely prevalence among front-line workers whom we disproportionately target with mandatory vaccination – whether in health care or other job classifications. The impact? If we exempt prior infectees, this legitimately reduces the at-risk group from 50% down to 30% or 20%, much more manageable numbers. Any prior positive PCR, antigen or antibody test exempts them. Not everyone has proof of prior infection. But offering antibody testing to non-vaccinated employees will inform, and if positive, they are exempted. This has the further benefit of engaging the employee in his or her own health choices, and more likely to be agreeable to vaccination when offered after a negative test. If we follow the science and avoid aggressive -- even classist – mandates that selectively impact the poorer economic classes with these threats, then this proposal to treat prior infectees as vaccinated is an easy choice, respectful without caprice or arbitrariness, and it follows the science, not politics. In this case, I predict this proposal will increase vaccine participation while also decreasing the social strains. Author, Article, and Disclosure InformationAuthors: Ezekiel J. Emanuel, MD, PhD; David J. Skorton, MDAffiliations: University of Pennsylvania, Philadelphia, Pennsylvania (E.J.E.)Association of American Medical Colleges, Washington, DC (D.J.S.).Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-3150.Corresponding Author: Ezekiel J. Emanuel, MD, PhD, Department of Medical Ethics and Health Policy, University of Pennsylvania, 423 Guardian Drive, Blockley Hall, Philadelphia, PA 19104; e-mail, mehpchair@upenn.edu.Current Author Addresses: Dr. Emanuel: Department of Medical Ethics and Health Policy, University of Pennsylvania, 423 Guardian Drive, Blockley Hall, Philadelphia, PA 19104.Dr. Skorton: Association of American Medical Colleges, 3114 Q Street NW, Washington, DC 20007.Author Contributions: Analysis and interpretation of the data: D.J. Skorton.Drafting of the article: E.J. Emanuel.Critical revision of the article for important intellectual content: E.J. Emanuel, D.J. Skorton.Final approval of the article: E.J. Emanuel, D.J. Skorton.Administrative, technical, or logistic support: E.J. Emanuel.This article was published at Annals.org on 30 July 2021. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byConsidering a COVID-19 vaccine mandate for pediatric kidney transplant candidatesAvoidable intensive care unit resource use and costs of unvaccinated patients with COVID-19: a historical population-based cohort studyMandatory COVID-19 vaccination for healthcare personnel in the era of new SARS-CoV-2 variants“I Would Rather Take the Vaccine Than Undergo Weekly Testing”: Correlates of Health Workers’ Support for COVID-19 Vaccine MandatesStrategies to Address COVID-19 Vaccine Hesitancy Among Ohio Nursing Home StaffPay-for-performance incentives for health worker vaccination: looking under the hoodBarriers to SARS-CoV-2 Testing among U.S. Employers in the COVID-19 Pandemic: A Qualitative Analysis Conducted January through April 2021Decisions to Choose COVID-19 Vaccination by Health Care Workers in a Southern California Safety Net Medical Center Vary by Sociodemographic FactorsEthical Issues in Kidney Transplant and Donation During COVID-19 PandemicCOVID ‐19 infection and the broader impacts of the pandemic on healthcare workersVaccine mandates need a clear rationale to identify which exemptions are appropriateImpact of COVID-19 vaccine-associated side effects on health care worker absenteeism and future booster vaccinationAugust 2021 and the Delta variant: is mandatory vaccination of individuals against SARS-CoV-2 acceptable?Agosto 2021 y la variante Delta: ¿es aceptable obligar a las personas a vacunarse contra el SARS-CoV-2?Attitudes and Determinants of Mandatory Vaccination against COVID-19 among the General Population of Cyprus: A Nationwide Cross-Sectional StudyLong-term adverse events of three COVID-19 vaccines as reported by vaccinated physicians and dentists, a study from Jordan and Saudi Arabia September 2021Volume 174, Issue 9 Page: 1308-1310 Keywords COVID-19 Health care Health care facilities Health care policy Health care providers Long-term care Prevention, policy, and public health Safety Vaccines ePublished: 30 July 2021 Issue Published: September 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...