Should the COVID-19 vaccine be mandatory for healthcare workers?

With phase 1a of the COVID-19 vaccine rollout underway this week, questions still stand about the public's appetite to get vaccinated.

Recent data from the Melbourne Institute’s fortnightly Taking the Pulse of the Nation (TTPN) survey found that willingness to take a vaccine has fallen over the last four months, from 74.4 per cent in October 2020 to 66.2 per cent in February 2021.

More worryingly the percentage of people who said they would not take the vaccine rose in the same period from 12 per cent in October 2020 to 19.4 per cent in early February 2021.

Similarly, an ANU study found that six per cent of the population say they definitely won't get vaccinated, with another seven per cent of Australians saying they will probably not get the vaccine. The poll found that 58.5 per cent of respondents said they will definitely get a COVID vaccine once it is available.

There are also questions surrounding uptake amongst healthcare professionals, as seen across the globe.

In the US, a Centre for Disease Control report found that aged care homes had a median vaccination rate of 37.5 per cent for staff during the first month of the federal vaccination effort; by comparison, a median of 77.8 per cent of nursing home residents received the vaccine.

In Los Angeles county, 20 to 40 per cent of the county’s frontline workers who were offered the vaccine declined.

In the UK, Health Minister Matt Hancock says that uptake of the vaccine has been lower among NHS staff than the general population, as reported by The Guardian.

Vaccination rates were more than 90 per cent among the first four age groups to have been offered at least a first injection – which include all those aged 70 and above – but for NHS staff it was about 80 per cent, and for care staff “around two-thirds”, Hancock said.

In mid-December, the national care association in the UK said that up to 40 per cent of care home workers might refuse to take the COVID jab.

Unknown quantity

"It's because I don't know about the side effects. It hasn't been out long," said Cheryl, a care home worker from Enfield in North London.

"I'm not sure. I know I should, and I'm thinking about it," she told the BBC.

"[I'm worried about] the side effects … those things worry me. I hear different stories."

But what about here in Australia? Anecdotally, we've seen and heard some concern surrounding the speed at which the vaccine has been produced, but will healthcare workers be as reticent as their overseas counterparts?

"We should be mindful of talking about trends because here in Australia, we don't necessarily have a huge amount of data to go on, in terms of willingness except for vaccines amongst health and aid care staff. We are working in a little bit of a void. And we go on what we see is happening overseas and the countries that have already launched their vaccine programmes," says Associate Professor Holly Seale, an infectious disease social scientist from UNSW.

Seale says that we have to be careful when talking about hesitancy to get vaccinated for COVID-19 among healthcare workers and she points to the fact that we don't get 100 per cent coverage in the influenza vaccine each year, sometimes being as low as 40 per cent uptake.

"One of the number one reasons there was [for low flu vaccine uptake], was because people didn't feel the need to get the vaccine. And we know we're in a unique situation with COVID, in Australia we don't necessarily have a huge amount of COVID activity right now. We'll need some assistance to help. convince people and talk about the vaccine, so that they can make up their minds about it."

Should the vaccine be mandatory for HCWs?

Last year, the federal government mandated influenza vaccines for anyone entering an aged care facility at the height of the COVID-19 outbreak, however, it has so far resisted doing the same for the COVID-19 vaccine.

Health Department Secretary Brendan Murphy said that while the idea of mandatory vaccinations for healthcare workers is on the table, it won't be put into place until more is known about the vaccine's effect on transmissibility.

"We are waiting until we have data on the transmissibility of the virus in vaccinated people," he said.

"If it is very effective, as we expect, at preventing transmission, once we have an opportunity for all of the workers to be vaccinated, that is something that will be reconsidered."

Former deputy chief medical officer Nick Coatsworth, now a senior administrator at Canberra Hospital, has said that he would not support any moves to make the vaccine mandatory for his staff.

“We need to convince our healthcare workers just as much as the community at large that this is an effective vaccine and a safe vaccine and like the community, we can’t force anyone to take the vaccine,” Coatsworth said in an appearance on ABC TV's Q+A.

In the aged care space, peak body LASA says that it is appropriate to consider mandatory vaccinations in the sector.

"LASA has said throughout the pandemic that it must be a national priority to do all we can to protect older Australians in-care, and the staff that care for them, from the coronavirus," says LASA chief executive Sean Rooney.

"Part of doing all we can to protect older Australians in-care is to consider mandated COVID-19 vaccinations for aged care workers – assuming it is safe to do so and with appropriate exemptions.

"Mandatory vaccinations are not new to aged care as we have had these in place for influenza vaccinations at times.

"It is important that employers carefully consider their position around requiring COVID vaccinations. Clear communication with employees and prospective employees is very important and must be informed by appropriate medical and professional advice."

ANMF federal secretary Annie Butler agrees with the current health advice, and would not be in favour of mandatory vaccinations of nurses and healthcare workers in any setting until that changes.

She is sympathetic to the nurses in her union who have worries about taking the vaccine, especially when there are concerns about the vaccine's effect on women of childbearing age. On average, Australia’s health workforce is predominantly female, and aged 20 to 34 years.

Studies have found that three-quarters of trials for any of the COVID-19 treatments or vaccines have explicitly excluded pregnant women without disclosing why, as reported by The Guardian. 

The article discusses the idea that women from age 30 to 39 were among the most vaccine-hesitant groups in society, and investigates the reasons why.

One reason put forward is that up until 25 years ago, all women of childbearing age were excluded from clinical studies, with scientists assuming that the results of tests done on men could be applied to women. This is all part of a larger pattern of exclusion women have faced from health and science and contributing, in large part, to a distrust of the medical profession.

"Most of our membership will be very keen to participate from what we gather. But, most of our members are female. Many of them are in that childbearing age. We need to be very careful about making sure we get the right advice to give to them," Butler says.

"And then how the workplace will protect them. Let's say they say it shouldn't be given in pregnancy and we've got a pregnant nurse working in ICU. There'll need to be arrangements made for her potentially.

"The average age of your care worker is a little bit older, but they're still predominantly female and they still would have younger women in that workforce. And so we are just being very cautious around that until we get some clear, firm advice from the Australian Technical Advisory Group on Immunisation. The World Health Organization has just issued some cautions around it, but we need to understand it exactly and then Australia will make its own decisions about what we do with pregnant and breastfeeding women."

The legal argument

Butler does worry about what might happen if a workplace takes it upon themselves to mandate vaccines for workers. 

"So if the governments are saying, 'We can't make this mandatory. We'll do everything we can to encourage people, but we can't mandate it,' will employers have a right to themselves turn around and mandate the vaccine? And so we're trying to have discussions with the government about that, working with other unions through the ACTU, about how we manage that, what's the legal rights and responsibilities of everyone," she says.

"In Victoria, in the second wave of COVID here, in its entirety, there were only 15 COVID infections in the publicly state government-run residential aged care. There were only three in residents, the rest were in workers, there was zero deaths. There were 685 deaths in private aged care.

"So there's a bigger risk that employers say, 'I'm going to force you to have the vaccine or I'm going to sack you," rather than go, 'Oh, but there's still fundamental problems, lack of a proper infection prevention and control. There's not good staffing.'"

So what, then, would happen if a nurse, or aged care worker refuses to get vaccinated. Can a workplace sack the worker? And if so, does the worker have legal recourse?

Recently, the Fair Work Commission ruled that a care worker who lost her job after she refused a flu jab will be allowed to argue she was unfairly dismissed.

Maria Corazon Glover refused a vaccination because of an allergic reaction she had 57 years ago, when she was a child living in the Philippines.

"Well, there's workplaces and then there's workplaces," says Dr Giuseppe Carabetta, a senior lecturer in employment law at Sydney University.

"But if we're talking aged care. The general starting position is that all employers in any workplace have a general common law right, so it's an implied right, to issue lawful and reasonable orders.

"Now with something like vaccines, it will come down to not whether the order to vaccinate is lawful. Because it is so unusual it will come down to the second element, which is, is it reasonable?"

Whether it will be deemed reasonable for an employer to place such a caveat on employment will come down to a number of factors, but three major considerations would be used to judge such a case.

Firstly, the nature of the job. Can the employer reasonably redeploy the worker to accommodate them while they still do their job. Secondly, the effectiveness of the vaccine. And thirdly, the personal circumstances of the employee – whether that person has a preexisting condition that might preclude them from taking a vaccine.

But even in that instance, the employer would only have to consider, again, if they can reasonably redeploy the worker and whether they could still complete their tasks.

Carabetta believes that it would be nearly impossible to mount an argument that an order to be vaccinated is unlawful in aged care or for frontline healthcare workers due to the nature of the job.

He says that he understands politically why the government has not as yet mandated the COVID-19 vaccine for healthcare workers, but says that a firm stance by the government would avoid any potential legal headaches for workers and employers in the future.

"From my point of view I wish the government would get in and solve the potential headache," he says.

"My dear mum, she is in aged care. Having my mum there and she is very frail, I think society would expect or wouldn't be too shocked if you said that – as a general rule at least – aged care workers needed to have the vaccine against COVID."

Best way forward

Associate Professor Seale believes that the best way to ensure uptake among the health workforce is as high as possible is made up of a few strands, including educating the workforce and allaying any fears they may have with the right tools and communication strategies.

This includes working with middle managers, as they are influential, trusted and can act as vaccine advocates and agents of change. They may also play a role addressing questions or concerns where they arise.

Making the vaccine as convenient to take as possible, making it available outside normal work hours is another key element to increase uptake.

"In these settings within aged care, within hospital settings, within primary care settings, there are going to be those staff members who are trusted, who can act as diffusers of information, and have the potential to influence uptake and acceptance in a way that a TV ad, or a radio ad, or a poster on the wall won't be able to do. And here's maybe where some peer to peer education may be needed," she says.

"And we've got to think about our hospital environment in the same way, and about the health settings in the same way as we think about our community settings. That, there will be misunderstandings, there will be misinformation passed around, and there will be those that will come out in the end and feel that they don't want to get a vaccine. And what we don't want to happen is for misinformation to be spread and for that to influence people's decisions."

Do you have an idea for a story?
Email [email protected]