Time is running out for National Health Service staff in England who have not had a COVID vaccine. Doctors and nurses have until Thursday, February 3, to have their first jab. If they don’t, they will not be fully immunised by the beginning of April and could be dismissed.
But there are reports this week that the UK government is debating whether to postpone the COVID vaccine mandate for healthcare staff. Would that be the right thing to do?
Vaccine requirements are controversial and have led to worldwide protests. Those in favour have argued that it is necessary and proportionate to protect vulnerable patients by making vaccination a condition of employment for healthcare staff. But critics have argued that vaccine mandates amount to a violation of human rights.
The British Medical Association, the trade union for doctors in the UK, has raised concern that mandates will lead to a mass staff exodus.
The introduction of the policy, initially announced late last year, was delayed until April to avoid its impact coinciding with winter pressures on the NHS. Media reports suggest that loss of vital staff is the principal concern prompting the UK government to reconsider its position.
Pointless
We believe that the vaccine mandate for healthcare staff in the UK should be abandoned. However, this is not because mandating vaccination for healthcare workers is unethical. (Vaccine mandates can be ethical.) And it is not because vaccine mandates will threaten NHS staffing – though they might, and that is an important consideration. The reason they should be abandoned is because they are now pointless.
The ethical reason that healthcare and care home workers might be required to have a vaccine is to prevent transmission of the virus to vulnerable patients. To be justified, mandates must be effective in preventing transmission. They will only be necessary if there is no other way of preventing transmission to a similar degree.
Yet there is now evidence to suggest that prior infection (so-called natural immunity) reduces the chance of infection (and hence transmission) to a large degree – similar to immunisation, with a benefit that lasts for at least 13 months. According to the latest infection survey from the Office for National Statistics, two vaccine doses reduced the risk of testing positive by 67% in the delta-dominant period. In comparison, previous natural infection reduced the risk of testing positive by 71%.
Although recent studies suggest that vaccination is still beneficial in those with natural immunity, the absolute reduction in risk that vaccination achieves in those with natural immunity is small. A large study from Sweden, that is yet to be peer-reviewed, found that 767 people with natural immunity needed to be vaccinated to prevent one reinfection during follow-up.
It is not yet clear what effect omicron will have on this sort of data. However, studies suggest that omicron may have substantial ability to evade both vaccine-induced immunity and natural immunity. If that is true, then vaccine mandates will not achieve a large enough benefit to justify their ethical costs.
One simple and ethical way of modifying the vaccine mandate policy would be to exempt healthcare workers who have documented evidence of past COVID infection. Without this, vaccine mandates risk excluding workers unnecessarily.
If applied, it would mean that the COVID vaccine mandate worked in a similar way to the hepatitis vaccine policy in healthcare workers. There is no law relating to hepatitis B vaccine, but hospitals commonly require new employees to either provide proof of immunity or have a vaccine.
But if this policy was adopted in the case of COVID vaccination, then it would in fact undermine the key point of the vaccine mandate. Given high rates of exposure to COVID among healthcare workers, very few will be both unvaccinated and not have had a prior infection. Few would be liable to a mandate that allowed a natural immunity exemption.
Also, given the extremely high rates of asymptomatic infection with omicron (including in those previously immunised), a vaccine mandate will not prevent healthcare workers passing on the virus to patients who are vulnerable to it. Healthcare workers will continue to need to have regular lateral flow tests to pick up asymptomatic infection and then self-isolate.
Rather than impose a vaccine mandate, the most important protective measure that can be put in place in hospitals is the continued testing of staff and vigilance around the use of handwashing and appropriate PPE.
Vaccines are a powerful and effective way of reducing the risk of serious illness from COVID. We should continue to encourage healthcare staff to be vaccinated, both for their own sake and for the sake of others. But, at this point in the pandemic, it is time to rethink the vaccine mandate.
Dominic Wilkinson receives funding from the Wellcome Trust. This work was supported by the UKRI/ AHRC funded UK Ethics Accelerator project, grant number AH/V013947/1.’ The UK Ethics Accelerator project can be found at https://ukpandemicethics.org/
Jonathan Pugh works for The University of Oxford. This work was supported by the UKRI/ AHRC funded UK Ethics Accelerator project, grant number AH/V013947/1.’ The UK Ethics Accelerator project can be found at https://ukpandemicethics.org/
Julian Savulescu receives funding from the Uehiro Foundation on Ethics and Education, NHMRC, Wellcome Trust, Australian Research Council, UK Research and Innovation (Arts and Humanities Research Council) as part of the Ethics Accelerator Award AH/V013947/1, WHO. He is a Partner Investigator on an Australian Research Council Linkage award (LP190100841, Oct 2020-2023) which involves industry partnership from Illumina. He does not personally receive any funds from Illumina. He is a paid member of the Bayer Pharmaceuticals Bioethics Committee
