CMS Ends COVID Shot Mandate for HCWs
Local hospitals and healthcare systems will make the call
“As conditions and circumstances of the COVID-19 Public Health Emergency (PHE) have evolved, so too has CMS’ response,” the agency stated. “At this point in time, we believe that the risks targeted by the staff vaccination [requirement] have been largely addressed, so we are now aligning our approach with those for other infectious diseases, specifically influenza. Accordingly, CMS intends to encourage ongoing COVID-19 vaccination through its quality reporting and value-based incentive programs in the near future.”
This issue likely will be rejoined in the fall of this year when another iteration of a COVID-19 vaccine is expected to be approved by the Food and Drug Administration and greenlit by the Centers for Disease Control and Prevention (CDC). It then will fall to the purview of individual health systems and hospitals to establish policies much as they have with seasonal influenza: optional with encouragement, or — with appropriate exceptions — mandated immunization.
The Association for Professionals in Infection Control and Epidemiology (APIC) has a standing position supporting mandatory flu vaccination but still is considering whether such a stance is appropriate for SARS-CoV-2.
“APIC supports vaccination to prevent the spread of infectious diseases,” says Pat Jackson, RN, president of APIC. “COVID vaccination has been and continues to be effective in reducing severe illness, hospitalization, and death from COVID-19. And it has been a critical component in helping the United States reach a high level of population immunity, where an estimated 96% of Americans have either been naturally infected, vaccinated, or both.2 But at this point, with a high level of population immunity from the disease, APIC is still weighing the evidence on whether mandating additional COVID-19 vaccines in healthcare workers continues to make sense.” (See “APIC Supports Ending CMS Vaccine Mandate.”)
The original vaccines were clouded by misinformation, which metastasized into widespread public refusal to take the 2022 bivalent vaccine. Healthcare workers were not federally mandated to take this new vaccine, although some hospitals required it.
Deborah Yokoe, MD, president of the Society for Healthcare Epidemiology of America (SHEA), says, “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. And 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 states.3 “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.”
Despite its unpredictable efficacy every year, the argument has successfully been made that a flu shot can keep you out of the hospital or the morgue. A similar rationale has been made for COVID-19; i.e., an imperfect vaccine still can prevent hospitalizations and deaths.
The problem with COVID-19 is that those vaccinated still can contract the coronavirus and 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. Breakthrough infections followed. These breakthrough infections generally are mild but could be a threat to frail patients. There also 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, which Lantos claims have been generally played down by public health officials as part of the effort to get the population immunized.4,5
“I want to make it clear that I am not an anti-vaxxer,” he emphasizes. “As an occ doc to many healthcare institutions, I make vaccines for transmittable diseases a job requirement, including MMR (measles, mumps, and rubella), hep B (hepatitis B), hep A (hepatitis A), varicella, pertussis, polio, TB (tuberculosis) surveillance, etc.”
The case has been made — and the numbers would appear to indicate — that SARS-CoV-2 is more deadly than seasonal influenza. In arguing that healthcare workers should be mandated the vaccine, a 2021 study cited otherwise unexplained excess deaths in estimating that “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
Yokoe says, “COVID continues to be a risk for our patients and for our healthcare personnel. Whatever we can do to prevent infection, and particularly severe infection, to prevent transmission in the healthcare setting, I think is worth doing.”
End of PHE Could Expose the 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 public health emergency on May 11, 2023, 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,’” he says.
To the contrary, COVID-19 still is circulating, and if it picks up any momentum, vaccine apathy, pandemic fatigue, and public complacency could provide a narrow opening for reemergence 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 to deal with it in an ongoing way. Because, obviously, the virus has not and will not disappear.”
The end of the public health emergency also has the potential to increase risk to vulnerable populations, as federal funding is withdrawn and programs that once were helpful wither on the vine.
“I’m concerned [that] with dissolution of the public health emergency we will go back to our ‘bad’ normal [in healthcare],” Schaffner says. “Because 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 — which 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 still are free while supplies last, but at some point, if COVID-19 becomes an annual vaccine, it may require health insurance or out-of-pocket payment to get immunized.
“If we have a completely new vaccine that comes out, some people will be uncovered,” he says “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 that the vaccination question, and other COVID-19 issues for healthcare workers, will revert to local policies and, “unfortunately,” local politics.
The end of the public health emergency also makes it more difficult 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 says. “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 of the surveillance of pandemic virus will be shut down with the new status, but the CDC still has plenty of ways to track trends and identify potential problems, she says. Metrics that still will be available on the CDC website include of the number of hospitalizations associated with COVID-19 per population. The CDC also has networks of sentinel systems in laboratories, emergency rooms, and acute care hospitals. Ongoing wastewater surveillance will reveal “hot spots” as well as information about emerging variants, Yokoe says.
REFERENCES
- 88 Fed Reg 36485 (June 5, 2023).
- Jones JM, Manrique IM, Stone MS, et al. Estimates of SARS-CoV-2 seroprevalence and incidence of primary SARS-CoV-2 infections among blood donors, by COVID-19 vaccination status — United States, April 2021-September 2022. MMWR Morb Mortal Wkly Rep 2023;72:601-605.
- Centers for Disease Control and Prevention. How flu spreads. Last reviewed Sept. 20, 2022. https://www.cdc.gov/flu/about/disease/spread.htm#:~:text=When%20Are%20People%20with%20Flu,days%20after%20their%20illness%20begin
- 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. The Wall Street Journal. Published May 12, 2023. https://www.wsj.com/articles/the-covid-vaccines-neglected-side-effects-neuropathy-nih-fda-cdc-transparency-react19-8afa87b1?mod=opinion_lead_pos5
- Klompas M, Pearson M, Morris C. The case for mandating COVID-19 vaccines for health care workers. Ann Intern Med 2021;174:1305-1307.
On Nov. 4, 2021, the Centers for Medicare & Medicaid Services began requiring healthcare workers to receive at least the initial series of COVID-19 vaccine. After considerable hue and cry — marked by lawsuits and resignations — the requirement was officially rescinded on June 5, 2023.
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