COVID-19 vaccine uptake among staff at a large Philadelphia teaching hospital rose from 86% to 99% after implementation of a mandate, finds a study published late last week in Vaccine.
A University of Pennsylvania-led team evaluated COVID-19 vaccine coverage before and after they were required to receive two doses of the Pfizer/BioNTech or Moderna vaccine or one dose of the Johnson & Johnson (J&J) vaccine by September 1, 2021.
Staff who didn't comply faced termination
The hospital rolled out COVID-19 vaccines to staff on December 16, 2020, and announced on May 19, 2021, that all employees were required to complete a vaccine series by September 1 of that year.
To reduce vaccine hesitancy, the hospital held town halls, occupational medicine staff and managers met one-on-one with unvaccinated staff to answer questions and address concerns, and the vaccination clinic expanded its hours to include days, evenings, and weekends. Staff could get vaccinated at any hospital location, but had to provide documentation if vaccinated outside the health system.
Because vaccination rates were lowest among Black and Hispanic healthcare professionals (HCPs), efforts were focused on engaging these groups. Staff could apply for a religious or medical exemption; if granted, employees could work but would have to take two COVID-19 antigen tests each week.
Employees who didn't comply with the mandate were placed on unpaid administrative leave without pay after September 1 and terminated 2 weeks later unless they confirmed that they were planning or starting the vaccination process. Vaccine uptake was evaluated in three phases: phase I (December 16, 2020, to May 18, 2021); Phase 2 (May 19 to September 1, 2021); and phase 3 (September 2 to October 31, 2021).
The median age among 10,889 HCPs was 39 years, 64.4% were women, 51.1% were physicians or nurses, 60.9% were White, 20.3% were Black, 12.6% were Asian, 3.7% were Hispanic, and 2.4% were multiracial.
Uptake jumped as deadline approached
When the mandate was announced, 86.0% of workers had completed a COVID-19 vaccine series, and 1.9% had received one of a two-dose series. During phase 2, vaccine coverage rose slowly among the remaining 1,520 unvaccinated workers but then spiked 2 to 3 weeks before the vaccine deadline.
Among the remaining 1,333 employees, 90.2% completed the vaccine series by the deadline, and with 9.3% had received the one-dose J&J vaccine. Less than 1% of physicians waited until the deadline to be vaccinated. Receipt of the J&J vaccine picked up in the 1 or 2 months before the deadline.
By the deadline, vaccine coverage was 98.7%, and another 0.7% had received one dose of a two-dose series. On September 2, the remaining 131 staff who were unvaccinated or partly vaccinated were suspended for failure to comply and placed on unpaid leave for 2 weeks. By September 15, another 30.5% of these workers completed the vaccine series, and another 33.6% of them completed the series soon after. As of October 31, vaccine uptake among still-employed workers was 99.9%.
Vaccination rates before the mandate announcement by race were 96.2% among Asians, 94.0% among Whites, 89.2% among Hispanics, 77.6% among other or mixed-race, and 64.4% among Blacks. Those vaccinated before the mandate announcement tended to be men, older, and those with more patient contact.
Series completion before the mandate announcement was higher among physicians and nurses with direct patient contact than among those with some or no contact (99.0%, 93.3%, 75.5%, and 81.7%, respectively). The greatest increase in vaccine completion after the announcement was among Black, other or mixed-race, and Hispanic workers (35.6%, 22.4%, and 10.8%, respectively).
There were differences by race in all patient-contact groups except physicians. The lowest series completion rate in each of the three patient-contact groups was among Black HCPs (76.7% for nurses, 54.9% for those with some patient contact, and 63.2% for those with no patient contact).
After adjustment for age and sex, racial differences in vaccine uptake before the mandate persisted for nurses and workers with some or no direct patient contact but not for physicians. Race was strongly tied to series completion for nurses and staff with some or no direct contact, with the highest odds of vaccination among White, Asian/Pacific Islander, and Hispanic employees, compared with Black workers (odds ratio [ORs] ranges, 2.2 to 12.2, depending on group).
High vaccination rates were especially important in the early months of the COVID-19 pandemic in helping to reduce staff shortages due to illness, thus maintaining quality patient care.
Sex had little effect on the four groups based on extent of patient contact, while being 65 years or older was strongly linked to series completion for employees with some or no patient contact (ORs, 7.7 and 4.8, respectively).
Of the 140 medical exemptions requested in Phase 2, 17% were approved, most often for pregnancy or breastfeeding, reaction to the first dose, and allergic reactions to vaccine components or other vaccines or medications. Forty religious exemptions were also approved; the number of applications wasn't available.
Thirty-eight (less than 0.4%) of workers—none of them physicians—said they left their positions, 8 of them voluntarily and 30 involuntarily, because of the vaccine mandate. Twenty-two of the 38 were younger than 40 years, 21 were women, 16 were White, 16 were Black, and 6 were other or multiracial.
Outreach, flu vaccine mandate may have helped
"It is well recognized that HCPs are at increased risk of both contracting infectious diseases and transmitting them to their patients and colleagues," the study authors wrote. "High vaccination rates were especially important in the early months of the COVID-19 pandemic in helping to reduce staff shortages due to illness, thus maintaining quality patient care."
The hospital in this study notified workers early of the times and locations of COVID-19 vaccine clinics and conducted targeted outreach to vaccine-hesitant groups.
"The hospital made tremendous effort to have medical and HR [human resources] personnel reach out to hesitant employees to address their questions and carefully review the available vaccine information," the researchers wrote. "The fact that this hospital also mandates influenza vaccination, with a 95.5% vaccine coverage rate as of December 2021, may have been helpful."
The authors said the results underscore the value of HCP vaccine mandates. "While mandates are not always popular, this study showed that mandates can rapidly increase COVID-19 vaccine acceptance among HCP who are critical to public health and our country’s infrastructure during a pandemic," they concluded.
