This Briefing Note was completed by the Evidence Synthesis Unit (Research, Analysis and Evaluation Branch, Ministry of Health).
To examine mandatory COVID-19 vaccination policies for health care workers (HCWs), including the impacts on vaccination rates and unintended consequences.
- A study (July 31, 2021) from the University of Pennsylvania found that a mandatory COVID-19 vaccine policy, along with frequent and personalized outreach, resulted in high staff vaccination rates and minimal staff turnover in one community nursing home. Fewer than half of the staff were vaccinated prior to the policy. The facility reached 100% compliance with the policy, with 18 people who chose to resign and seven people who were exempt or on a leave of absence.
- A review (April 26, 2021) reported that 12 of 30 (40%) European countries currently have mandatory vaccination policies, however they are highly heterogeneous in their requirements, target groups, sanctions, and penalties. Overall, there is evidence that mandatory vaccination policies (from 2010-20) increases vaccine uptake over time in HCWs; but impacts on rates vary by setting and immunization programs.
- Government-Implemented COVID-19 Vaccine Mandates (Internationally): Australia, England, Iceland, Italy, France, Greece, Hungary, Turkmenistan, Moscow, Quebec, Prince Edward Island, and some jurisdictions in the US (Department of Veterans Affairs, California, Massachusetts, New York City, New Jersey, Oregon, and Washington) have mandates.
- Types of HCWs: Ranges from all HCWs in any setting, LTC settings only, employees across different sectors (including health), and all adults.
- Exemptions: Some jurisdictions allow exemptions for religious or qualifying medical reasons.
- Non-Compliance Consequences: Staff have a set deadline to be fully vaccinated, or otherwise face fines, reassignment to other low-risk duties, suspension without pay, or termination in some jurisdictions, while others require masking or one to three COVID-19 tests per week.
- Vaccination Rates: Information was only identified about vaccination rates just before implementation of COVID-19 mandates in England, Italy, and Australia, where significant portions of the HCW population remain unvaccinated.
- Unintended Consequences: These include a petition against the mandate (England), several court challenges (Italy), and workplaces struggling to re-staff positions vacated by those who refused vaccination (Moscow).
- Employer-Implemented COVID-19 Vaccine Mandates (US): Health facilities in the US have mandates, including Mayo Clinic Health System (Mayo), Indiana University Health, North Carolina’s Duke University Health System and UNC Health, University of Pennsylvania Health System, Texas Houston Methodist (Methodist), and several LTC operators.
- Types of HCWs: All employees working at all of the identified health facilities.
- Exemptions: Some facilities allow exemptions for religious or qualifying medical reasons.
- Non-Compliance Consequences: Unvaccinated employees could face suspension without pay or termination at Methodist, or have to complete education modules, wear masks, and physically distance at Mayo.
- Vaccination Rates: Vaccine mandates have increased vaccination rates among staff, ranging from 72% to 100%, in some of the identified health facilities, with few staff having quit or been terminated rather than being vaccinated.
- Unintended Consequences: At Methodist, 117 employees sued the hospital over its mandate, but it was dismissed by a federal judge; it is currently being appealed.
Ministry of Health guidance strongly recommends COVID-19 vaccination for HCWs, but it is voluntary. An employer may choose to create their own policies regarding mandatory staff immunization.
Mandatory vaccine policies likely increase vaccination rates, but responding to potential negative impacts on individual HCWs and wider public perceptions should also be considered.
This section below lists and describes scientific evidence and jurisdictional experiences regarding mandatory COVID-19 vaccination policies for health care workers (HCWs), including the unintended consequences and expected/reported outcomes relating to vaccination rates before/after such policies are implemented.
Please refer to the following previously completed Evidence Synthesis Briefing Notes for other relevant information on the topics of interest:
- 66. Evidence Synthesis Briefing Note on Guidance and Jurisdictional Evidence Regarding the Use of Vaccine Passports (June 16, 2021)
- 67. Evidence Synthesis Briefing Note on COVID-19 Immunization Policies for Hospitals and Health Care Workers (June 8, 2021)
Support for Mandatory COVID-19 Vaccination Policies
- A Canadian study (Feb 8, 2021) recommended that provincial governments should put in place rules for mandatory vaccination of HCWs across all public and private settings, and should not leave this to the discretion of individual employers. The rationale for this is that vaccination will protect individual HCWs, and the patients for whom they care, from acquiring SARS-CoV-2, reducing the overall burden of COVID-19 on services, and ensuring adequate personnel to minister to people’s health needs through the pandemic.
- If individual employers were to require vaccination among their staff, the legality of these mandates would likely be determined via labour law that considers the “reasonableness” of the employer’s directive, as is evident from case law related to mandatory influenza vaccination.
- Government mandates for the vaccination of HCWs may be challenged under the Canadian Charter of Rights and Freedoms, but these challenges, on the extant evidence, likely will not succeed if provisions are made for those who cannot receive the vaccination because of underlying health issues and for those who object to vaccination on bona fide religious or conscientious objection grounds.
- Challengers may argue that HCWs have the right to wear personal protective equipment (PPE) in lieu of receiving vaccination, which means that governments must support vaccine surveillance and keep abreast of emerging evidence of the effectiveness and safety of the various SARS-CoV-2 vaccines relative to evidence of the effectiveness of PPE in reducing transmission of SARS-CoV-2.
Impact of Mandatory Vaccination Policies on Vaccination Rates for COVID-19
- A preprint study (Jul 31, 2021) from researchers at the University of Pennsylvania found that a COVID-19 vaccine condition of employment (COE) policy, in combination with frequent and personalized outreach, resulted in high staff vaccination rates and minimal staff turnover in one community nursing home. Fewer than half of the staff were vaccinated prior to the decision to pursue a vaccine COE on February 9, 2021, which was supported by executive leadership and nursing home staff to protect the health and safety of each other and their residents. By May 1, 2021, a total of 221 of the 246 (89.8%) nursing home staff members received a COVID-19 vaccination. The facility reached 100% compliance with the policy, with 18 people who chose to resign and seven people who were exempt or on a leave of absence.
Impact of Mandatory Vaccination Policies on Vaccination Rates for Other Diseases
- A review (Apr 26, 2021) examined the health, political, and ethical aspects of mandatory vaccination laws in Europe, which are the responsibility of member states. Out of 30 European Union/European Economic Area countries, 12 (40%) currently have mandatory vaccination policies in place, including Italy, France, and Germany which passed new laws on mandatory vaccination, respectively in, 2017, 2018, and 2020. However, the laws are highly heterogeneous in their requirements, target groups, sanctions, and penalties. A review of the literature also found evidence that mandatory vaccination policies (from 2010-20) increases vaccine uptake over time in children, adolescents, and HCWs; however, impacts on rates vary by setting and immunization programs. Limited and inconclusive evidence is available on the impact of mandatory vaccination policies on norms’ acceptance and attitudes towards vaccinations.
Government-Implemented COVID-19 Vaccine Mandates (Internationally)
- Australia, England, Iceland, Italy, France, Greece, Hungary, Turkmenistan, some jurisdictions in the US (Department of Veterans Affairs, California, Massachusetts, New York City, New Jersey, Oregon, and Washington), and Russia (Moscow and other cities) have implemented mandatory COVID-19 vaccine policies to address low vaccination rates, the spread of the Delta variant, and rebounds in outbreaks in health settings.
- Settings and Types of HCWs:
- All Types of HCWs (including those in hospitals and high-risk congregate settings such as long-term care [LTC] facilities, homeless shelters, and jails): Iceland, Italy, France, Greece, Hungary, the US Department of Veteran Affairs, California, New York City, New Jersey, and Oregon.
- HCWs in LTC Settings Only: Australia, Massachusetts, and England.
- Employees across Sectors (e.g., health, retail, transportation, government): Washington, Moscow, and other local governments in Russia.
- Adults: Turkmenistan is the first country to legally require all residents over 18 years of age to be vaccinated against coronavirus.
- Exemptions: Exemptions are allowed for religious or qualifying medical reasons in California, Massachusetts, and Washington, and only for medical reasons in Iceland.
- Non-Compliance Consequences: Employees have a set deadline to be fully vaccinated, or otherwise face fines, reassignment to other low-risk duties, suspension without pay, or termination in England, Iceland, France, Greece, and Moscow. California, New York City, New Jersey, and Oregon require once- or twice-weekly testing for HCWs who refuse vaccination. California also requires unvaccinated HCWs to wear masks in health facilities.
- Oversight: Health facility and business operators in California, England, and Moscow must maintain records of vaccination, exemption statuses, and/or test results of exempt workers.
- Vaccination Rates: Information was only identified about vaccination rates just before implementation of mandatory COVID-19 vaccination policies in three jurisdictions:
- England: As of July 8, 2021, 85% of 1,378,502 HCWs had received both doses of vaccine, leaving 209,422 not fully protected.
- Italy: As of April 1, 2021, about one in 10,000 medical staff is refusing to be vaccinated, and greater reluctance is seen among less skilled HCWs in health facilities and care homes.
- Australia: As of June 25, 2021, two-thirds of LTC staff have yet to be vaccinated.
- Unintended Consequences: A petition against the vaccine mandate has attracted more than 72,000 signatures in England, several court challenges were launched by those who do not want to get vaccinated in Italy, and some workplaces are struggling to re-staff positions vacated by those who refused vaccination in Moscow. No further details were identified about these issues.
- Settings and Types of HCWs:
- As of July 29, 2021, 10 US states have enacted 11 laws with prohibitions on COVID-19 vaccine mandates.
Employer-Implemented COVID-19 Vaccine Mandates (US)
- A US commentary (Jul 30, 2021) on mandating COVID-19 vaccination for HCWs noted that vaccination rates vary greatly across the country: 96% of physicians, 55% of nursing home staff, fewer than 50% of nurses, and 26% of home health aides have been fully vaccinated.
- As of March 25, 2021, the Food and Drug Administration (FDA) does not mandate vaccination under Emergency Use Authorizations (EUA). However, whether a state, local government, or employer, may require or mandate COVID-19 vaccination is a matter of state or other applicable law. If an employer requires employees to provide proof that they have received a COVID-19 vaccination from a pharmacy or their own health care provider, the employer cannot mandate that the employee provide any medical information as part of the proof. Medical and religious exemptions can be implemented. The US Equal Employment Opportunity Commission (EEOC; May 28, 2021) also ruled that employers have the right to require vaccination as a COE; this right extends to vaccines under EUA and those that have been fully approved by FDA.
- As of July 29, 2021, 88 US professional societies and organizations signed a joint statement in support of COVID-19 vaccine mandates for all employees in health and LTC settings.
- Health facilities in the US (Mayo Clinic Health System, Indiana University Health, North Carolina Duke University Health System and UNC Health, University of Pennsylvania Health System, Texas Houston Methodist, and a number of LTC operators across the country) have implemented mandatory COVID-19 vaccine policies as a result of increasing cases of COVID-19 nationally, poor vaccination rates in many communities, and the threat of variants.
- Types of HCWs: All employees working at all of the identified health facilities.
- Exemptions: Exemptions are allowed for religious or qualifying medical reasons at Indiana University Health and the University of Pennsylvania Health System.
- Non-Compliance Consequences: At Mayo Clinic Health System, staff who decline to be vaccinated must complete education modules, wear masks, and physically distance. At Houston Methodist, employees who do not comply first have a discussion with their supervisor, then could face suspension, and subsequently later face termination. As of June 7, 2021, Methodist suspended 178 workers who failed to get vaccinated, giving them an additional two weeks to prove they had been immunized; 25 of those employees did. No other information was identified for the other health facilities.
- Oversight: No information identified
- Vaccination Rates: Mandatory COVID-19 vaccination policies have increased vaccination rates in some of the identified health facilities:
- North Carolina Duke University Health System and UNC Health: At Duke University Health System, more than 75% of 22,300 staff were vaccinated before the mandate was announced on July 22, 2021. Between July 26 and August 1, the vaccination rate was nearing 80% as 470 employees received their first vaccination and 73 employees received their second one. Since July 22, 2021, at least 650 of 40,000 (approximately 2%) UNC Health employees were vaccinated, and as of August 3, 2021, more than 72% of employees had been vaccinated.
- Houston Methodist: The mandatory vaccine policy was announced on April 1, 2021. As of March 31, 95% of management and all executives already had at least one dose of a COVID-19 vaccine, and as April 15, 2021, 99.4% of the management team had complied with the mandate. As of April 15, 2021, more than 84% of system employees and 96% of employed physicians had received at least one vaccine dose. As of July 26, 2021, 97% of 26,000 employees compiled, approximately 2% obtained exemptions or deferrals, and approximately 0.6% (153 employees) who refused to get vaccinated were fired or resigned.
- LTC Operators: According to data collected by the Centers for Medicare and Medicaid Services, greater than 38% of LTC staff across the US were not fully vaccinated as of July 11, 2021. After months of declines since February 2021, infections among residents rose nearly four-fold from the weeks ending July 4 to August 1 when 2,092 cases were reported. COVID-19 cases among LTC staff members are also on the rise, with 3,317 new infections and one death reported in the week ending August 1. Some LTC facilities reported that unvaccinated staff were driving the high infection rates. As such, several companies that own LTC facilities across the country mandated COVID-19 vaccination (e.g., IntegraCare, Enlivant, Atria Senior Living, Healthcare Association of Hawaii). The majority of workers, and 100% in some cases, have been vaccinated, and few have quit rather than being vaccinated. For example:
- IntegraCare reached a 100% vaccination rate among staff members at its 13 senior living communities in Maryland, Virginia, and Pennsylvania after introducing a vaccine mandate.
- Enlivant, a senior living operator with 216 sites in 26 states, implemented a mandatory COVID-19 vaccination policy in March 2021. As of March 3, almost 80% of staff and residents were vaccinated, and as of June 14, a 90% vaccination rate was achieved for both staff members and residents, with several sites reporting a 100% staff vaccination rate. Enlivant will continue to mandate employee vaccination with a goal of reaching 100%.
- Unintended Consequences:
- The nursing home industry is hesitant about supporting a vaccine mandate for facility staff due to concerns that such a requirement would worsen existing labour shortages.
- At Houston Methodist, a group of 117 employees sued the hospital over its mandate and to prevent them from terminating unvaccinated workers. A federal judge dismissed the lawsuit, ruling that the hospital was ‘trying to do their business of saving lives without giving [patients] the COVID-19 virus.” The decision is being appealed by a former employee, who has already found a new job at a private nurse-staff company.
- Quebec and Prince Edward Island (PEI) have implemented COVID-19 vaccine mandates:
- Settings and Types of HCWs:
- All Types of HCWs: In PEI, HCWs employed by Health PEI.
- HCWs in Specific Settings: In Quebec, employees who work in health and social services institutions in: emergency units, except psychiatric emergency units; intensive care units, except psychiatric intensive care units; clinics specific to COVID-19, including screening, evaluation, and vaccination clinics; units identified by an institution as reserved for persons with a positive COVID-19 diagnosis; residential and LTC centres; other residential units; pneumology units; and oncology units.
- Exemptions: None identified.
- Non-Compliance Consequences: In Quebec, unvaccinated employees must undergo three COVID-19 tests per week. Employees who refuse/neglect to undergo the screening tests or provide test results or proof of vaccination are reassigned to duties within their job title in another environment. If reassignment is not possible or is refused, employees are not allowed to reintegrate into the work environment and are not paid until they comply. In PEI, unvaccinated employees must always wear a mask while at work and/or may be subject to work restrictions at the employer’s discretion.
- Oversight: Employees must provide employers with a record of their immunization in both Quebec and PEI. Employees must also provide employers with COVID-19 screening test results in Quebec.
- Vaccination Rates: No information identified.
- Unintended Consequences: No information identified.
- Settings and Types of HCWs:
- The Ministry of Health’s Guidance for Prioritizing Health Care Workers for COVID-19 Vaccination (Mar 17, 2021) noted that COVID-19 vaccination is strongly recommended for all HCWs but remains voluntary. An employer may choose to create their own policies regarding mandatory staff immunization as a protective measure for residents and patients.