by Matthew Cote, MD, FACEP

As the first two major vaccinations for COVID-19 have started to be widely distributed in the United States, a disturbing trend is emerging: many healthcare workers who presumably are educated about the vaccine, are declining to receive it.  While not unanticipated, the degree to which it is occurring among healthcare providers is concerning.  The numbers are not trivial, with up to 40% of some healthcare workers declining the opportunity to get vaccinated as reported recently in the LA Times, Forbes, and AP News.  Frontline healthcare workers as a group have the most medical knowledge and firsthand experience in dealing with people who have become infected with COVID-19.  They know how bad infections with COVID can be.  If this group of people remain unconvinced about receiving vaccination for COVID-19, the general public is likely to be at least as reluctant.  

Dr. Fauci has indicated that 75% – 85% of the population will need to be vaccinated to establish enough herd immunity to end the pandemic.  Only in stopping this pandemic can the world begin to recover socially and economically.  The recent emergence of more contagious variant viral strains underscores the need to proceed quickly.  A plan on how society handles people who choose not to be vaccinated needs to be developed.  The most straightforward and practical approach is to make vaccination mandatory if a person wants to continue to enjoy full participation in society.

Mandatory vaccination does not mean holding people down to give them the shot.  It means that those who do not get vaccinated may face restrictions in their ability to fully engage in society.  This is not a new approach.  The United States has had mandatory small pox and polio vaccination policies in years past.  These policies led to the successful eradication of those diseases in the United States.  Today, most public K-12 schools and many universities already require certain immunizations in order for people to attend school, as do certain employers. Immunization against COVID-19 would simply become one more mandatory vaccine.  Those who choose not to receive the COVID-19 vaccination would not be able to attend school nor potentially be able to work at some jobs.  This is no different than the policies already in place for other vaccinations.  

However, in the case of COVID-19, I would anticipate the need to consider additional restrictions for those declining vaccination.  The point of widespread vaccination is to decrease the transmission rate such that every person who has the infection passes it on to less than one other person on average.  If a large percentage of the population remains un-immunized and therefore susceptible to infection, the virus will continue to be passed around.  In order for society at large to reach the 75%-85% level needed for herd immunity and be free from our current social distancing restrictions, people who are not immunized will need to remain socially isolated from the rest  of the population for their own health as well as the health of those who have been vaccinated.  Remember that even people who have been vaccinated can still get sick from COVID-19.  Practical ways of implementing this social distancing include a ban from public transportation, being barred from commercial flights, or even possibly limited access to restaurants or mass gatherings for anyone who chooses not to get vaccinated.

These types of restrictions may seem draconian and intrusive, and compared to our pre-pandemic societal freedoms, they are.  The enjoyment of participating in modern society involves accepting rules and restrictions, so long as they are equitably applied to all members of society and not burdensome to some for the benefit of others.  Certainly no such restrictions should be implemented prior to the vaccine being made available to everyone, nor will these restrictions need to be permanent.  McKinsey and Company estimated that with a smooth vaccine roll out and widespread vaccination, the ‘functional pandemic’ could be over by the third or fourth quarter of 2021.  Unfortunately, the vaccine distribution has not gone as smoothly as desired, and coupled with concerns for lower vaccine acceptance, the pandemic could continue until 2022 or even 2023, unless society acts to mandate the vaccine now.

Healthcare workers who elected not to be vaccinated have cited concerns about the vaccine’s safety.  Some may argue that simply educating the population about the safety of the vaccines would alleviate much of the reluctance people have about being vaccinated.  There may be some people for whom a better understanding of why the vaccine is safe might make them more comfortable getting it.  However, the fact that doctors and nurses who are already medically knowledgeable are refusing the vaccine suggests it is not simply ignorance that is causing them to wait.  This perception of risk and lack of trust absolutely needs to be addressed more vigorously by the CDC and FDA, as well as by the news media at large. However, it’s not a question of either providing more education or instituting a mandate.  We need to do both.  Some people may want more time to learn about the vaccine or perhaps gain confidence in its safety after watching what happens to those of us who have already received it.  They can take all the time they want, but not at the expense of prolonging the pandemic for the rest of society.

Establishing plans to make vaccination mandatory will also provide added incentive for people to do their homework and get vaccinated, not simply drag their feet all the while allowing the pandemic to continue.  A date will need to be announced after which the restrictions will take effect for those not immunized while the social distancing restrictions for those who are vaccinated will be lifted.  Some will choose not to be vaccinated.  I respect their right to do so, but choices do have consequences.  If you don’t want to wear a seat belt or have car insurance, then you can’t drive.  If you want your kids to attend public school, then they need to be vaccinated.  If you want to ride on a bus, plane, or cruise ship, go out to eat, attend a concert or sporting event, you need to be vaccinated against COVID-19, both for your safety and the safety of those around you.  The longer it takes for society to get vaccinated, the longer the pandemic lasts, causing further social and economic damages.  The time to act is now.  Vaccination against COVID-19 needs to be made mandatory.