The end of the COVID-19 national Public Health Emergency (PHE) on May 11 brought a highly controversial issue to a relatively quiet hiatus: Healthcare workers are no longer federally mandated to receive the SARS-CoV-2 vaccine. The Centers for Medicare & Medicaid Services has ended the requirement, which in any case did not apply to boosters or the bivalent vaccines.
This issue likely will be revisited in the fall when another iteration of a COVID-19 vaccine is expected to be approved by the FDA and greenlit by the CDC. It then will fall to the purview of individual health systems and hospitals to create policies much as they have with seasonal influenza: optional with encouragement or mandated immunization (with appropriate exceptions). Of course, healthcare employment requires many other vaccinations, but mandating SARS-CoV-2 shots led some to walk off the job.
It bears repeating the first mRNA shots and other COVID-19 vaccines were based on years of research since SARS-1 appeared in 2002 to 2003, although the Operation Warp Speed project title suggested hasty concoctions in research labs. This misinformation coincided early on with the idea by some in government and medicine that herd immunity could be achieved by essentially letting the disease run its course through the younger population. Jonathan Howard, MD, a neurologist and psychiatrist in New York City, has written a scathing book on this misguided notion: We Want Them Infected. “In [this] imaginary world, COVID only threatened the old and infirm,” Howard wrote. “In the real world, tens of thousands of children and young adults were seriously harmed or killed by COVID.”1
Thus, the original vaccines were clouded by misinformation, which compounded into widespread refusal to take the 2022 bivalent vaccine. Again, healthcare workers were not federally mandated to take this new vaccine, although some hospitals required it.
“Our position is that COVID-19 vaccines, along with other recommended vaccines, should be considered a condition of employment for healthcare personnel, but I think it will vary from healthcare facility to facility,” notes Deborah Yokoe, MD, MPH, president of the Society for Healthcare Epidemiology of America. “There may be some states and local public health departments that will have requirements for healthcare personnel.”
Flu vs. SARS-CoV-2
Many hospitals mandate seasonal flu vaccination in the name of patient safety, since healthcare workers may spread influenza approximately one day before they become symptomatic.
“Flu viruses can be detected in most infected persons beginning one day before symptoms develop and up to five to seven days after becoming sick,” the CDC stated. “It is theoretically possible that before symptoms begin, an infected person can spread flu viruses to their close contacts. Some people can be infected with flu viruses and have no symptoms but may still be able to spread the virus to their close contacts.”2
Despite its unpredictable efficacy every year, it has been argued a flu shot can keep someone out of the hospital or the morgue. A similar rationale has been made for COVID-19: an imperfect vaccine still can prevent hospitalizations and deaths.
The problem with COVID-19 is those vaccinated can contract the coronavirus and, somewhat remarkably, spread it to others who also are vaccinated. This revelation was disturbingly realized in 2021 after the CDC said those fully vaccinated could take off their masks indoors. In wanting to convey a message of progress and optimism while rewarding and encouraging vaccination, the CDC ran headlong into the emerging delta variant of COVID-19. A couple of months later, in a July 4th celebration in Provincetown, MA, people who were unmasked and indoors both acquired SARS-CoV-2 and transmitted it to others. In the outbreak of 469 cases, 74% were fully vaccinated.3 These breakthrough infections generally are mild but could be a threat to frail patients — and there remains the specter of long COVID for some who contract the virus.
Thus flawed, should COVID-19 vaccines be mandated for healthcare workers?
“A vaccine that does not prevent acquisition nor transmission should not be a healthcare occupational requirement,” says Gabor Lantos, MD, PEng, MBA, president of Occupational Health Management Services in Toronto. “But needless to say, any healthcare worker who is symptomatic and antigen-positive for COVID should not go to work. Healthcare workers should be provided with home-use antigen test kits.”
The COVID-19 vaccines are not without rare but real risks,4,5 which Lantos claims have been generally downplayed by public health officials as part of the effort to immunize the public.
“I want to make it clear that I am not an antivaxxer,” Lantos emphasizes. “As an occ doc to many healthcare institutions, I make vaccines for transmittable diseases a job requirement, including MMR, hep B, hep A, varicella, pertussis, polio, TB surveillance, [and more].”
COVID-19 Is Deadlier
The case has been made, and the numbers would appear to indicate, SARS-CoV-2 is deadlier than seasonal influenza. In arguing the vaccine should be mandated for healthcare workers, the authors of a 2021 study cited otherwise unexplained excess deaths in estimating “the mortality rate for influenza is estimated to be 1 in 1,000, whereas that for SARS-CoV-2 is closer to 1 in 100 to 250. Patients with COVID-19 are more likely to require hospital admission, have respiratory failure, and require prolonged intensive care than those with influenza.”6
While it has been consistent throughout the pandemic that those who are unvaccinated fare worse than the immunized, there is an underlying variable that is receiving more scrutiny and research regarding the true mortality rate of SARS-CoV-2: How many of these patients are dying “with” COVID-19 and not directly because of it? (For more information, see the related story in this issue.)
For her part, Yokoe weighed the risk and benefits and says vaccinating healthcare workers is necessary. “COVID continues to be a risk for our patients and for our healthcare personnel,” she says. “Whatever we can do to prevent infection and to prevent transmission in the healthcare setting I think is worth doing.”
End of PHE Could Expose Vulnerable
Barring some dramatic mutation, COVID-19 is expected to remain an endemic respiratory pathogen, possibly reverting to a seasonal pattern like others of its ilk. With the World Health Organization acting in concert, the timing was appropriate to end the PHE, says William Schaffner, MD, professor of preventive medicine at Vanderbilt University.
“That said, I think most of us in public health and infectious diseases are concerned that the general public may indeed receive this information as though it were ‘mission accomplished,’” Schaffner warns.
To the contrary, COVID-19 is circulating. If it picks up any momentum, vaccine apathy, pandemic fatigue, and public complacency could provide a narrow opening for re-emergence in surges.
“It’s concerning,” Schaffner says. “We’re going to have to keep our guard up with this virus and continue to put in preventive measures in order to deal with it in an ongoing way. Because obviously, the virus has not and will not disappear.”
The end of the PHE could increase risk to vulnerable populations as federal funding is withdrawn and once-helpful programs wither on the vine.
“I’m concerned with dissolution of the PHE, we will go back to our ‘bad’ normal [in healthcare],” Schaffner says. “We have a medical care system in this country, whether for preventive health services or diagnostic and therapeutic services, that still leaves many people uncovered, without easy access to medical care. The disparities that we largely eliminated because of the availability of treatment and vaccines for prevention during the public health emergency will become more apparent again.”
For example, the bivalent shots remain free while supplies last, but if COVID-19 becomes an annual vaccine, it may require health insurance or of out-of-pocket payment.
“If we have a completely new vaccine that comes out, some people will be uncovered,” Schaffner notes. “I am very concerned about that. We don’t want to get too far ahead of our skis here, but we anticipate that this fall, there will be a new updated vaccine available, and it will be recommended to parts of the population. We’ll have to see what that is, but healthcare workers are surely going to be part of it.”
Schaffner concurs the vaccination question and other COVID-19 issues for healthcare workers will revert to local policies and, “unfortunately,” local politics.
The end of PHE also will make it harder to immunize hard-to-reach populations, some of whom received home visits from their local health department as part of emergency funding.
“How much will we be able to get the vaccine out to nursing home residents and senior citizen centers and the like?” Schaffner asks. “All of that takes work. Work takes people. People take salaries. I think much of our capacity to do that will be diminished going forward.”
Still, informed by grueling experience, the healthcare system is much more prepared for COVID-19 than when the pandemic began. “We’re in a much better situation because of vaccines and therapeutics,” Yokoe says. “Early on, a lot of the [pandemic] interventions were being required by public health departments, but now I think there’s been a lot of relaxation of those public health orders. The decision-making is falling more heavily on individual healthcare facilities and experts within those healthcare facilities. We’re all trying to work toward transitioning to more long-term, sustainable strategies.”
Some surveillance efforts will be shut down with the new status, but the CDC still has plenty of ways to track trends and identify potential problems, Yokoe says. The CDC’s remaining metrics include the number of hospitalizations associated with COVID-19 per population.
“They’ve separated that into high-, medium-, and low-risk categories, similar to what they did before with the COVID community levels and transmission levels,” Yokoe explains.
The CDC also uses networks of sentinel systems in laboratories, EDs, and acute care hospitals. Ongoing wastewater surveillance will reveal “hot spots” as well as information about emerging variants, Yokoe says.
REFERENCES
- Howard J. We Want Them Infected: How the failed quest for herd immunity led doctors to embrace the anti-vaccine movement and blinded Americans to the threat of COVID. 2023: Redhawk Publications.
- Centers for Disease Control and Prevention. How flu spreads. Page last reviewed Sept. 20, 2022. https://www.cdc.gov/flu/about/...
- Brown CM, Vostok J, Johnson H, et al. Outbreak of SARS-CoV-2 infections, including COVID-19 vaccine breakthrough infections, associated with large public gatherings — Barnstable County, Massachusetts, July 2021. MMWR Morb Mortal Wkly Rep 2021;70: 1059-1062.
- Naveed Z, Li J, Spencer M, et al. Observed versus expected rates of myocarditis after SARS-CoV-2-vaccination: A population-based cohort study. CMAJ 2022;194:E1529-E1526.
- Finley A. Officials neglect Covid vaccines’ side effects. Wall Street Journal. May 12, 2023. https://www.wsj.com/articles/t...
- Klompas M, Pearson M, Morris C. The case for mandating COVID-19 vaccines for health care workers. Ann Intern Med 2021;174:1305-1307.
The end of the COVID-19 national Public Health Emergency brought a highly controversial issue to a relatively quiet hiatus: Healthcare workers are no longer federally mandated to receive the SARS-CoV-2 vaccine. The Centers for Medicare & Medicaid Services has ended the requirement, which in any case did not apply to boosters or the bivalent vaccines.
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