When an unexpected outbreak of COVID-19 in a nursing home in the Landes region of France led to two deaths last month, the media and the government seized upon a surprising fact: Only 60 percent of care home staff were vaccinated, even though they had had access to coronavirus jabs for months.
French Health Minister Olivier Véran immediately blamed the infections on a non-vaccinated caregiver despite the fact that the cluster’s origin couldn’t be confirmed. But he also unleashed a broader debate: What to do with health and social care workers who reject the jab — and whether mandatory vaccination is the answer.
The question has taken on urgency in recent weeks as cases linked to the Delta variant jump and vaccination rates slow across Europe.
For now, momentum is on the side of the mandate camp. Italy was the first to try this route, ordering in March that all health care workers get vaccinated or be suspended without pay. England following in June, announcing mandatory vaccinations for care home workers from October on.
Then, Greece and France announced Monday that vaccines would be compulsory for health care workers, starting in mid-August and September, respectively. And Belgium is soon considering such a move when the government’s pandemic response committee next meets.
The strong-arm approach has provoked fierce pushback and raised questions about whether governments are justified in seeking to protect communities even if they override the rights of individuals.
Rolande Mariel, a nurse at the Cochin hospital in Paris who backs the mandate, said the new measure is “making everyone aggressive and on edge.”
“Some of the staff say … they don’t want rubbish injected into [their] body,” she explained. “But the truth is they don’t trust our leaders and our politicians.”
A matter of trust
Just like with the broader public, health care workers’ confidence in vaccines in general varies widely across Europe. Eastern Europeans tend to be less confident and more skeptical than those in the West, with France as something of an outlier.
The Vaccine Confidence Project, which researched vaccine confidence in all vaccines among health care workers last year, found that confidence among GPs is lowest in Bulgaria, Croatia and Romania. Some of the more specific present-day concerns relate to the nature of mRNA vaccines and side effects on pregnant women. In Bulgaria, only 18 percent of GPs said they would recommend the flu vaccine to pregnant women. Thirty percent in the Czech Republic, Slovakia and Bulgaria said they wouldn’t recommend the HPV vaccine, which prevents cervical cancer.
In a 2015 study, also coordinated by the project, researchers found the main reasons driving hesitancy among health workers were fears of side effects, concerns over new vaccines and low vaccine effectiveness. In some countries, including France and Greece, the study found that hesitancy was linked to mistrust toward state institutions and Big Pharma.
“Some GPs are more wary of vaccines if they feel pharmaceutical companies are pushing them onto populations,” explained its lead Europe researcher, Emilie Karafillakis.
In addition, vaccine confidence “tends to be lower” among nurses, midwives and carers than among doctors, she noted, although each country is different. “In Sweden, where nurses are the key providers of vaccinations, they have stronger confidence in vaccines.”
Sweden’s immunization policy could be instructive, she added. When fellow health care workers administer vaccinations to peers and colleagues, it raises confidence in that group more broadly.
The challenge is that immunization policies vary greatly across Europe, from which vaccines are used to the timing of administration to who gives it. For example, depending on where you live in Europe, you could get your HPV jab from GPs, nurses, gynecologists, obstetricians or schools.
Staff training is also an issue. If health care staff don’t get consistent training about vaccines and how to communicate clearly the benefits and risks, broader confidence in this group is hampered, Karafillakis said.
Pushback
Mariel, the Paris nurse, points to another problem: An underlying resentment among health care workers that they were overworked and disregarded during the pandemic.
“We lived through the COVID-19 crisis from the inside,” she said, adding that the government’s perceived mismanagement on issues like masks and systematic testing eroded trust.
There’s also the problem of institutional distrust, which plays out more specifically through issues like concern over mRNA technology.
Pasquale Sacco, a coroner in Naples and secretary of health workers union FISI, is one of those skeptics. He claims that mRNA vaccines can provoke “serious long term effects, including auto-immune diseases, depression and cancer.” This technology was at first an experiment as a possible vaccine for HIV, but shelved when it was linked to a two-fold increase in the incidence of tumors within three years, he told POLITICO.
“Italy is acting like a dictatorship,” he said. “Everyone in hospitals from cleaners to accountants has to be vaccinated by law. We are being treated as useful idiots by the government.”
“So many colleagues have been suspended, including nurses and care-workers who are paid less,” he added. “I am prepared to be suspended for this — but I am sure history will prove us right.”
In France, however, most unions representing health workers favor mandatory vaccinations.
“We don’t have a choice,” said Luc Duquesnel, a GP who heads the doctors’ union Les Généralistes CSMF. “If patients turn up at hospitals with a heart problem and then catch COVID-19, the consequences can be very serious.”
In one instance, he noted, authorities were forced to close down a heart unit at a hospital in western France because staff couldn’t drive coronavirus infections down to zero.
In Bulgaria, meanwhile — where just 65 percent of doctors and 30 percent of nurses are fully vaccinated against COVID-19, according to Ivan Madzharov, chair of Bulgarian Medical Association — there are no plans to introduce mandatory vaccinations.
“Personally, I have been tirelessly advocating for thorough vaccination,” he said.
The penalties
The consequences of non-compliance have so far been strict. In the U.K., for example, non-vaccinated social care workers will be dismissed from employment and prevented from rejoining the sector. In Italy, health care workers in breach face a job transfer to a less risky venue or suspension without pay.
To some critics, such penalties are deeply unethical, especially for low-paid professions like care home workers, who can’t afford to leave their job. That’s a chief concern of Jeremy Richardson, CEO of Four Seasons Health Care Group, the U.K.’s largest care home provider, which doesn’t back the U.K.’s measures.
“If you are going to mandate it, you are fundamentally taking away people’s individual human rights,” he said. “If you are going to do that you have to be absolutely clear that a threshold is passed whereby a greater good to society supersedes the rights of an individual.”
In Richardson’s view, that threshold hasn’t been reached because the U.K.’s vaccination campaign has been so successful, along with increasingly effective treatments. Deaths in his care home have been lower than average over the past 18 months, he said.
“So by mandating the vaccine for my team [and] taking away their individual rights, what health outcomes am I going to drive for my residents that we don’t already have?” he asked.
In Italy, meanwhile, a legal battle has already begun. On Wednesday, more than 3,000 health care workers brought a case against local health authorities in Brescia, Milan and Parma. The mandate goes against the Italian constitution and European Convention on Human Rights, which guarantee the right to refuse medical treatment, according to the writ.
“This is not an anti-vax battle,” their lawyer, Daniele Granara, told POLITICO. “My clients are not against vaccines in general. But this is a jump in the dark because the safety and efficiency of the vaccines can not be guaranteed.” He cited the unusual speed of the clinical trials as one cause for concern — a chief talking point among vaccine skeptics.
“We haven’t seen the medium or long-term effects,” he said. “In a free country, there must be freedom of choice.”
But his camp may be on shaky precedent. Courts at both Italian and European levels have upheld Rome’s 2017 legislation imposing mandatory vaccines for kids, while an Italian regional court threw out a complaint by parents of a non-vaccinated five-year-old who was denied access to school. And in 2018, the Constitutional Court in Rome ruled that imposing mandatory vaccines is constitutional so long as it does not damage health.
An April ruling this year by the European Court of Human Rights in Strasbourg also gave backing to the pro-mandate camp, provided that such laws address “an urgent social need.”
Legal rationale aside, though, experts remain divided over how effective such mandates are.
Peter English, a retired consultant in communicable disease control, calls such measures “entirely reasonable” and notes that the U.K. already has requirements for some health care workers to be immune — usually through vaccination — to hepatitis B, chickenpox, measles and rubella. So far, these mandates are usually accepted without question.
Most organizations let individuals opt for redeployment or a salary change if merited, he added.
But the National Care Forum, a U.K. organization for not-for-profits in the care sector, is less confident this latest effort will work. In a recent survey, 70 percent of respondents said a compulsory vaccination policy would be difficult to implement, and one-fifth said it would be extremely difficult.
“Keeping track of status is very challenging” was one reason, while others noted that “a clear mechanism for evidencing vaccinations needs to be created.” And some said carrots, in the end, remain preferable to sticks: “[Health care] staff, through gentle persuasion and educated discussion, can be encouraged to take up the vaccine.”
Clea Caulcutt and Carlo Martuscelli contributed reporting
This article is part of POLITICO’s premium policy service: Pro Health Care. From drug pricing, EMA, vaccines, pharma and more, our specialized journalists keep you on top of the topics driving the health care policy agenda. Email [email protected] for a complimentary trial.