On 16 June 2021 the Secretary of State for Health and Social Care, Matt Hancock, announced that, subject to parliamentary approval, compulsory vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) for most of the 1.5 million people working in social care in England was to be implemented. The decision to introduce mandatory vaccination for this group of healthcare staff was taken following a government consultation that sought views on the proposal to make it a condition of employment in older adult care homes (Department of Health and Social Care (DHSC), 2021a). The forthcoming decision was discussed in the press even before it was in the public domain. The Guardian (Allegretti, 2021a), for example, reported that the Equality and Human Rights Commission (EHRC), which had contributed to the government review, had endorsed the proposal to prioritise the right to life for care-home residents who are especially vulnerable due to the severe morbidities associated with COVID-19, the disease caused by the SARS-CoV-2 virus.
The human rights watchdog, however, acknowledged that compulsory vaccination is a significant step and that it would be out of line with current health policies. Nonetheless, the EHRC stated that it is not unreasonable to expect care home staff, in particular, to have mandatory vaccination in order to work directly with older and disabled people.
Now that vaccination against the virus has been made mandatory, care home staff will have 16 weeks to get the jab, or risk being redeployed from frontline care, taking redundancy or losing their jobs (Walker et al, 2021). Some employer and staff organisations in the care home sector, are apprehensive and fear that some staff might resign rather than have to be immunised.
Since the announcement that COVID-19 vaccination will be mandatory for care home staff, some senior politicians suggested that vaccination should be made mandatory for all frontline healthcare staff who have direct contact with patients across the NHS in England.
Background
The UK is a liberal democracy, a system of government within which individual rights and freedoms are recognised and protected, and the exercise of political power is limited by the rule of law. However, to put the issue of mandatory vaccination for healthcare workers in context, some patients have developed COVID-19 while being treated in hospital for other conditions, which fails the principle of doing no harm cited by the EHRC, which is now likely to uphold mandatory immunisation for all frontline health workers.
It is important to recognise that staff who work directly in COVID-19 environments are themselves at increased risk of contracting the infection from patients. Some infected care staff may initially be clinically asymptomatic, but they will continue to shed the virus, and thus could transmit the disease to patients and their colleagues.
However, mandatory COVID-19 vaccination for frontline care staff is a conundrum that raises ethical, legal and practical questions. Medscape, the online resource for health practitioners, has endorsed proposals to extend mandatory vaccination to all frontline NHS staff to conduct further consultations during which time staff and representatives will have an opportunity to contribute. Medscape also conducted an online poll (Locke, 2021), with the results showing 58% support for mandatory vaccination.
However, it is concerning that only 65% of care homes for older adults in England are currently meeting the 80% threshold for COVID-19 staff vaccination recommended by the Scientific Advisory Group for Emergencies (SAGE) (Booth and Rawlinson, 2021). This means that vulnerable older adults living in care homes could be at risk from the very staff who care for them. Of particular concern is that in some areas of London one-third of staff in care homes have not received a single vaccine dose to date (Booth and Rawlinson, 2021). Outside London, 27 local authority areas have vaccination rates below 70% (DHSC, 2021b).
Clearly, ministers are apprehensive about introducing new rules that effectively force frontline care staff to have the SARS-CoV-2 vaccination. There remain anxieties among politicians that such a move might make people who are already vaccine hesitant to become even less willing to be vaccinated (Allegretti, 2021b). Of note is that care home workers from some demographic groups, but primarily those from some ethnic minorities, have not taken up vaccination in sufficient numbers. Significantly, this group of care home workers are disproportionately represented in the adult social care sector workforce and especially so in London (Albert, 2021; Allegretti, 2021b).
Do other countries have mandatory vaccination?
Although many countries have initiated a debate about whether to make vaccination against SARS-CoV-2 mandatory for healthcare staff for those working in long-term care, only Italy has so far legally implemented it as a national policy. It became the first country in Europe to make the COVID-19 jab mandatory for healthcare workers after the Italian cabinet passed an emergency decree on 1 April 2021 to introduce the policy (Paterlini, 2021).
Third waves of the disease are becoming apparent in many parts of the world. For example, in the Russian capital Moscow, where the virus appears to be spreading unabated, compulsory immunisation against the virus has been ordered for service sector staff, which includes health and care staff, in an effort to slow the spread of the Delta variant. There are also fears of the virus spreading in St Petersburg, which is hosting some of the UEFA Euro 2020 games. Although the Russian government insists that it is not advocating mandatory vaccination, more than 20 regions, including Moscow, St Petersburg and the Baikal area, have introduced decrees to vaccinate those in the service sector (Khinkulova, 2021; RBK, 2021). The decision is predicated on evidence that suggests that COVID-19 vaccines also help reduce the spread of infection by those already infected.
In the USA, attempts have been made to make the vaccine mandatory for healthcare staff, but in the world's largest liberal democracy the rights of the individual are fiercely protected and previous attempts with regard to flu immunisation have failed.
For example, when Houston Methodist Hospital tried to impose COVID-19 immunisation on its staff, it was challenged by its workers. Employees were told to get vaccinated by 7 June 2021, but a large group filed a lawsuit against the hospital on 28 May 2021, claiming that the vaccines were not safe and demanding that there should be a temporary injunction against the mandatory immunisation policy (Hassan, 2021). However, the judge dismissed the case, stating: ‘This is not coercion … It is a choice made to keep staff, patients, and their families safer’ (Diamond, 2021).
Vaccine hesitancy has been prominent ever since the groundbreaking work of physician Edward Jenner, in the 18th century, who pioneered vaccination against smallpox and is regarded as the father of immunisation. The modern anti-vax movement of COVID-19 deniers has undoubtedly had the benefit of social media. Of concern is that almost three in 10 healthcare employees in some US hospitals have indicated that they do not intend to get vaccinated (Goldstein, 2021).
With regard to other attempts to introduce compulsory vaccination, Field (2009) discussed the failed attempt by hospitals in New York State in 2009 to implement by law mandatory immunisation against influenza on the basis that no one is at greater risk of contracting contagious diseases or of spreading it than healthcare workers. But the effort was short-lived, and the health department subsequently withdrew the proposal (Field, 2009).
Which way forward?
Here in the UK it remains to be seen what will happen as the mandatory vaccination programme is rolled out across the care home sector. Vaccines minister Nadhim Zahawi has stated that no decision has yet been made about extending the policy to the entire NHS in England, but he has highlighted a precedent that surgeons currently have to have mandatory vaccination against hepatitis B before they can perform operations.
Although the decision is yet to be made on whether to introduce the policy across the entire NHS in England, few doubt such an the initiative would save lives. The government view is that the only way to protect the vulnerable sick is to ensure that those caring for them are fully vaccinated against SARS-CoV-2. However, although it could be argued that it is incumbent on healthcare staff to be vaccinated against SARS-CoV-2, and perhaps flu viruses as part of their duty of care, the Royal College of Nursing (2021) is not in favour of compelling staff to have the jab. The college does not support staff being made to or coerced into having the vaccine and does not consider that vaccination should be part of employment contracts.
Deaths due to the COVID-19 pandemic among older adults living in care homes have probably been exacerbated because of the low level of immunisation among care home staff. The new government ruling, which will ensure high levels of vaccination of people working in these settings, should be perceived as an essential public health intervention. Whether the initiative should be extended to the entire NHS in England remains to be determined. It should be stressed that seasonal flu also carries significant levels of mortality, with thousands of deaths each year. Take-up of the flu vaccine is suboptimal and, as with SARS-CoV-2 vaccination, it varies across ethnic groups.
KEY POINTS
- Care home workers from certain demographic groups, primarily from some ethnic minorities, have not taken up vaccination against the SARS-CoV-2 virus
- The government is considering extending mandatory vaccination against the virus to all frontline healthcare workers
- Mandatory vaccination for care home staff means employees will have 16 weeks to get the jab, or risk being redeployed from frontline care or losing their jobs
- Some patients developed COVID-19 while being treated by staff in hospital, which is an argument for promoting mandatory immunisation for all frontline healthcare workers
- The government view is that the only way to protect the vulnerable sick is to ensure those caring for them are fully vaccinated against SARS-CoV-2/COVID-19