Mandatory COVID-19 Vaccination for Healthcare Workers: Need of the Hour

Abstract

The world is in the midst of an ongoing coronavirus disease 2019 (COVID-19) pandemic caused by the emergence of a 2019-novel coronavirus (2019-nCOV) or severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), as it is now known.[1] The global health crisis caused due to the COVID-19 pandemic and the damage to health, wealth, and well-being have been enormous. The consequences of the same have been far reaching, particularly among the healthcare workers (HCW), who got infected and succumbed to COVID-19 globally. The overall global magnitude of COVID-19 among HCWs during the first wave was recently documented in a survey from 37 countries, wherein the authors have documented 2,736 HCW deaths.[2] The World Health Organization (WHO) Director General, Dr. Tedros Adhanom Ghebreyesus, also emphasized during the announcement of the WHO Health Worker Safety Charter September 17, 2020 that “thousands of health workers infected with COVID-19 have lost their lives worldwide.”[3] According to the WHO, 14% of the COVID-19 cases reported worldwide were among HCWs and in some low- and middle-income countries the number has been as high as 35%.[4] HCWs, particularly the doctors and nursing staff, are at highest risk of acquiring COVID-19 infection or spreading it to their patients. The situation turns out to be more challenging in low- and middle-income countries where the healthcare systems are already weak but overwhelmed and the HCWs are working under stressful conditions, sometimes even without proper personal protective equipment (PPE). A recent review published by Mhango et al identified lack of and/or inadequate PPE, exposure to infected patients, work overload, poor infection control practices, and pre-existing medical conditions as important risk factors for COVID-19 infection among HCWs.[5] The capability of SARS-CoV-2 to be transmitted from asymptomatic and presymptomatic individuals may also contribute to the increased risk among HCWs. Estimates based on pooled serological studies performed in different countries suggest that 7 to 8.7% of HCWs were infected by SARS-CoV-2.[6] Data available from various other studies also suggested that frontline HCWs had greater exposure to SARS-CoV-2 infection as compared with nonclinical staff.[7] [8] [9] As per the data available from Indian Medical Association, while 748 doctors died in the first wave of COVID-19 last year, 776 doctors have succumbed to COVID-19 during the second wave across India.[10] Moreover, the shortage of HCWs in India, with only one doctor for every 1,511 people and one nurse for every 670 people, which is well below the WHO's minimum norms, is another crucial challenge for the country.[11] As the highly effective and safe COVID-19 vaccines are now available and with the ongoing worldwide vaccination drive, not only the active cases of COVID-19 have declined but the number of patients seeking hospitalization has also decreased substantially. Mounting evidence suggests that the vaccines are associated with decreased asymptomatic infections and transmission of SARS-CoV-2.[12] Moreover, among those who have been vaccinated but still got infected, the severity of infection has been considerably low and the hope of the return of healthcare system to pre-COVID-19 era has grown stronger. As of now the pandemic is still rapidly increasing in some parts of the world and the protection of HCWs is imperative as they are at the forefront of fighting the pandemic. The formulation of effective and efficient occupational health policies for HCWs especially in the context of COVID-19 pandemic is the need of the hour. Mandatory COVID-19 vaccination for all the HCWs is one such important preventive measure, and if implemented it will not only be helpful to mitigate HCWs exposure risk to COVID-19 infection but will also ensure the safety of their patients, family members, and fellow HCWs. A study from United Kingdom reported a lower risk of COVID-19 infection among household contacts of vaccinated HCWs compared with household members of unvaccinated HCWs.[13] A recent report of COVID-19 outbreak in a skilled nursing facility attributed to an unvaccinated HCW underlines the risk unvaccinated HCWs can pose to their patients and other HCWs.[14] The recognition of HCW vaccination as an essential component of patient and HCW safety programs emerged during in mid-2000s with a focus on influenza vaccination. Mandatory influenza vaccination programs for HCWs have been associated with high vaccination rates and a significant decrease in healthcare associated influenza among hospitalized patients as well as among HCWs.[15] Similar policies can be adopted for formulating mandatory COVID-19 vaccination scheme for HCWs; however, there are several logistic concerns that need to be addressed. First, it is still unclear that any vaccine approved under Emergency Use Authorization by U.S. Food and Drug Administration can actually be mandated or not. Second, separate provisions be made for HCWs who cannot be vaccinated due to some contraindicated medical conditions. For instance, some individuals may develop allergic reactions after first dose of an mRNA vaccine and may not be able to receive second dose to achieve full immunity. Such individuals should be able to opt for other types of COVID-19 vaccines (vector vaccines or inactivated whole virus vaccine), so that the percentage of unvaccinated HCWs remains low. Third, alternative approaches for HCWs who refuse to get vaccinated should be included. Such HCWs should adhere to strict infection control measures like hygiene protocols, use of masks, and PPEs while working in healthcare facility and should undergo periodic testing for any asymptomatic infection while SARS-CoV-2 is still circulating. Moreover, an exemption to vaccination on religious or personal beliefs is another complicated situation, more so in Indian setting, and needs to be reviewed thoughtfully with a non-judgmental approach....