By Carol A. Kemper, MD, FACP

Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases, Santa Clara Valley Medical Center

California Mandating Healthcare Worker COVID-19 Vaccination

In an unprecedented public health action, the California State Public Health Officer ordered on Aug. 5, 2021, all healthcare workers (HCWs) in the state to receive full COVID-19 vaccination before Sept. 30 or essentially relinquish their positions.1 For the purposes of this order, this includes any paid or unpaid worker in an indoor facility who provides patient care or has access to patients for any reason. This order trumps the California State Governor’s mandate on July 26, requiring all state workers and workers in healthcare and high-risk congregate settings either to show proof of vaccination or submit to weekly testing. Those who are unable to receive vaccination are required to wear an N95 (or similar) mask at all times while working and submit to twice-weekly SARS-CoV-2 testing.

Justification for the California Department of Public Health (CDPH) mandate was based on the continued increase in cases throughout the state, with documentation of 9,300 outbreaks and 113,000 outbreak-related cases since January 2021, with evidence of increasing numbers of cases in HCWs. Despite the availability of a vaccine since early 2021, the current vaccination rate in California is ~63%, with an additional 10% with partial vaccination — certainly better than most states — but leaving one-third of California’s population 12 years of age and older vulnerable to infection. Further, HCWs provide care to the most elderly and the most vulnerable in our society, who remain at the highest risk of severe disease and death.

The CDPH order allows for exemptions for qualified medical reasons and on religious grounds. Religious exemption and “personal belief against vaccination” are hot-button topics, but essentially U.S. citizens do not have a legal right to object to vaccination based on religious grounds or personal beliefs. In 1944, the U.S. Supreme Court in Prince v. Massachusetts ruled that the “right to practice religion freely does not include liberty to expose the community or the child to communicable disease or the latter to ill health or death.” This was the principle driving measles vaccination in the Hasidic community in Brooklyn, NY, in 2018-2019 after two years of ongoing measles infections. However, politically, it has been difficult to eradicate religious exemption as an excuse to decline vaccination. Currently in the United States, all 50 states allow for medical exemption for vaccination for school-age children, and 44 states allow for religious exemption (Connecticut, California, Maine, Mississippi, New York, and West Virginia do not), although generally these exemptions apply to school-age children.

In fact, few religions have an absolute objection to vaccines, mainly the First Church of Christ, Scientist, as well as several smaller churches that rely on faith healing and prayer. These include small Christian churches, such as the Church of the First Born, End Time Ministries, Faith Tabernacle, and First Century Gospel Church, most of which are located in the southern United States. Numbers of Christian Scientists have been dwindling steadily, and as of 2009, only about 50,000 members existed across the United States (0.015% of the population).

Other religious groups opposed to vaccines but that do not prohibit their members from getting them include some Orthodox Jewish communities, some Dutch Reformed Churches, and some Amish communities, as well as some Muslim fundamentalists. Interestingly, some of the more conservative churches actually believe that vaccines are “a gift from God.” Although they had a past objection to vaccines, Jehovah’s Witnesses decided in 1952 that vaccines were not contrary to God’s commandment or in violation of the everlasting covenant with Noah. Following an outbreak of polio in an Amish community in 2005 and the measles outbreak in 2018-2019 in the largely Orthodox Jewish community in Brooklyn, NY, some of these communities embraced vaccination, at least temporarily. But larger outbreaks of measles still continue in the Netherlands in Dutch Reformist groups.

In the United States, Muslims generally are not opposed to vaccines under the principle of necessity, meaning they are necessary for healing and cannot be prohibited by religious law. In 2017, Islamic world leaders signed the Dakar Declaration of Vaccination outlining the importance of vaccination for the protection of children, allowing parents to make their own decisions for their children. For those religions that might object based on the use of cow, pig, or fetal tissue in the manufacture of vaccines, both Islamic organizations and Jewish scholars agree that injectable porcine gelatin is permissible, and Hindus have no theological objection to possible trace bovine material in vaccines. Catholics are decidedly pro-vaccination, even when aborted fetal tissue may have been used in vaccine manufacturing, since the vaccine recipient is not complicit in any previous act, and if there is no other alternative, it is “lawful to use these vaccines if danger to the health of children exists or to the health of the population as a whole.”

This recent surge in COVID-19 cases demonstrates that the “health of the population” is at risk — and we believe this is largely preventable. HCWs might object based on ostensible religious grounds, but they have a moral obligation to their patients and their communities to get vaccinated, and a responsibility to set an example for others. In California, HCWs who decline the vaccine on the basis of religious belief are required to submit a signed declination form attesting to the religious belief (not just check a box). But the new CDPH order does not impose a “sincerely held belief” standard, nor does it require employees to provide supporting information beyond a signed affidavit (in contrast, a signed physician’s letter is required for medical exemption). However, if an employer is aware of facts that provide an objective basis for questioning the sincerity of the religion/belief, the employer is justified in requesting additional supporting information.2 Based on population statistics, healthcare facilities could reasonably anticipate one or two individuals with true religious objections out of an employee base of ~3,000 individuals.

Based on the Civil Rights Act of 1964, employers are required to accommodate religious practices. Legal precedent has allowed for religion to be defined broadly and to encompass not just organized religions but also “sincerely held beliefs.” Religion under the law may encompass non-theistic and moral beliefs — such as veganism in certain circumstances — but a “sincerely held belief” has been shown legally to not include concerns about the health effects of vaccination. As of 2019, 15 states (the last available count) still allowed for personal belief/philosophical exemption.

As the result of measles outbreaks in Disneyland in 2014 and repeated outbreaks of pertussis in schools, health officials lobbied the California state legislature to remove the personal belief clause as an exemption for existing vaccine requirements (e.g., for entry to private or public elementary and secondary schools and daycare centers), resulting in Senate bill 277 in 2015.3 This had an immediate successful effect on vaccination rates in school kids throughout California (parents can choose to home school their children if not vaccinated). However, the senate bill did “allow exemption from future immunization requirements deemed appropriate by the State Department of Public Health for either medical reasons or personal beliefs.” Legal experts say the bill does include a clause allowing CDPH to mandate new vaccines for “any other disease deemed appropriate by the department ... in order to achieve total immunization for appropriate age groups against disease.” Sounds like there might be a legal battle ahead.

It is hoped that this public health order will not lead to a critical shortage of HCWs in the state. Following dismissal of an employee lawsuit in June 2021, when Houston Methodist Hospital mandated COVID-19 vaccination, 178 employees were suspended for two weeks and 150 employees lost their jobs.


  1. Aragon T. California Department of Public Health. Health care worker vaccine requirement. Aug. 5, 2021.
  2. California mandates COVID-19 vaccines for health care workers. The National Law Review. Aug. 6, 2021.
  3. SB-277 Public health: Vaccinations.

Seasonal Coronavirus in Stem Cell Transplant

SOURCE: Pinana JL, Xhaard A, Tridello G, et al. Seasonal human coronavirus respiratory tract infection in recipients of allogeneic hematopoietic stem cell transplantation. J Infect Dis 2021;233:1564-1575.

From 2012-2018 (pre-COVID-19), these authors examined the clinical characteristics, risk factors, and morbidity for seasonal human coronavirus (HCoV) infections in a cohort of allo-hematopoietic stem cell transplant recipients (HSCT) obtained from the Spanish and European bone marrow transplant registries. A total of 402 allo-HSCT recipients developed 449 episodes of upper and lower respiratory tract infection from seasonal HCoV, as demonstrated by a positive polymerase chain reaction (PCR). These included NL63, 229E, OC43, and HKU1. Upper respiratory tract infection (URTI) was defined as one or more upper respiratory symptoms (pharyngitis, rhinorrhea, sinusitis, otitis) without chest radiographic or computed tomographic evidence of pneumonia. Seasonal HCoV infection occurred a median of 222 days after transplantation. URTI occurred in 73%, and the remainder had probable/confirmed lower respiratory tract infection (LRTI). Hospitalization was required in 18% and admission to the intensive care unit (ICU) was required in 3%. Supplemental oxygen was required in 13%.

All-cause mortality for the entire cohort was 7% at three months and 16% for those with LRTI. Three conditions at the time of seasonal HCoV infection were associated with increased mortality, including neutropenia, corticosteroid use, and ICU admission.

Although seasonal HCoV infections were observed throughout the year, most (83%) occurred during the cold months of late December to March, and OC43 was the most frequent subtype observed (38%). The Alphacoronavirus genus (NL63 and 229E) predominated in 2012-2013 and Betacoronavirus (OC43 and HKU1) predominated in 2014-2018. There was a trend toward higher mortality in those infected with Betacoronavirus group than the Alphacoronavirus group. Two or more seasonal HCoV subtypes were detected simultaneously in 15 cases (3%).

Although corticosteroids have become a mainstay of treatment of COVID-19, their use in this group of patients was associated with higher mortality, although this may simply be a marker of disease severity. The amount of corticosteroids employed was not specified. As observed many times with COVID-19 infection, chest computed tomography scans are more sensitive for LRTI, and chest radiographics alone may miss evidence of pneumonia.