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Paul Sax, MD: “It’s almost inevitable that even though we’re at very low infection rates right now that that's going to increase when the season changes, again, in the fall and winter. Coronaviruses are seasonal.”
There is a little bit of wiggle room in his belief that anybody in health care must get the COVID-19 vaccine, but not much, Paul Sax, MD, admits. He tells Infection Control Today® (ICT®) that he can understand medical exemptions. But non-medical exemptions? Not so much. Sax is the clinical director of the infectious disease clinic at Brigham and Women’s Hospital and a professor of medicine at Harvard Medical School. When Houston Methodist Hospital made headlines last week by suspending for two weeks 178 employees who refused to get the COVID-19 vaccine, Sax immediately tweeted his backing of the move, adding that the policy should be seriously considered by all health care facilities. “You know, if you don’t want to do this, and you don’t have a medical reason not to do it—because there are people who have a medical reason not to do it—then I suggest really that you find another job,” Sax tells ICT®. Sax swats away the argument that COVID-19 vaccination should not be mandated because it was granted under the Food and Drug Administration’s (FDA’s) emergency use authorization (EUA). “I think that the fact that they’re not fully FDA approved right now is really more about paperwork and semantics than it is about what we can actually do,” says Sax.
Infection Control Today®: The reason I reached out to you originally is a tweet you sent recently calling mandated COVID-19 vaccinations for health care professionals a win-win. You said it’s good for health care providers and for patients. You also had a blog post on the New England Journal of Medicine’s website recently that more or less makes the same argument. This beat reporter is surprised by how fast this issue came to a head. I’ve put that question to experts even before there were any vaccines: Would hospitals make vaccination mandatory for employees? Almost every expert said “no,” although some said that it might come up at some point far down the road. Yet here we are. Were you surprised?
Paul Sax, MD: I was pleasantly surprised that some of the hospitals have taken the plunge. Houston Methodist Hospital, as you mentioned, but also now following suit: Johns Hopkins Hospital, Penn Medicine: University of Pennsylvania Health System, and New York-Presbyterian Columbia University Medical Center in New York. These are major high-profile institutions. The fact that they would make this mandate stand right now even before full FDA approval shows that they’re comfortable with the benefits of immunization and not concerned about the EUA status of the vaccines.
ICT®: Given your position and your stature, you have your ears to the ground about infectious disease. You say that you were pleasantly surprised. How surprised were you, really? Did you hear rumblings that this was going to happen?
Sax: Well, we all kind of expected that we would cross this bridge if and when it was shown that the vaccines were, A, effective and, B, prevented or reduced the risk of transmitting the virus from one person to another. Once you had both of those things in place, we kind of knew that eventually health care systems would have to make a decision about their health care employees. Remember, one of the key things we learn when we become a health care provider is to do no harm. And one of the most horrible scenarios you could have is to be a person with, say,
asymptomatic or mild COVID-19 and end up transmitting the virus to a vulnerable person who perhaps was vaccinated but has got a weakened immune system and doesn’t respond to the vaccine. There are all kinds of scenarios where people with infection can transmit the virus to vulnerable people in the health care setting and reducing that risk as much as possible is really key. That’s one of the one of the reasons why we have a COVID-19 pandemic is because transmission of the virus does not in any way mandate that you, yourself, are symptomatic. You have people who are pre-symptomatic, and people who are asymptomatic who can transmit it especially to healthy young adults. We always knew that if we had something that works so well to prevent infection and reduce the risk of transmission to others that this would be kind of a no-brainer. And you know, I wrote in that tweet that you quoted that it’s a win-win. It’s even more than that. It’s four wins. It’s a win for the employees themselves because their health is protected. It’s a win for their patients. It’s a win for their coworkers. Because some of the transmissions happen to coworkers. And it’s a win for public health. There are so many reasons why it makes sense. And I want to really give credit to the to the head [Marc L. Boom, MD] of Houston Methodist Hospital for sticking to sticking to his guns and facing this lawsuit. And now also to the federal judge [U.S. District Judge Lynn Hughes] who dismissed it.
ICT®: Is your own facility, Brigham and Women’s Hospital, taking steps to make it mandatory?
Sax: We are part of a much larger organization called Mass General Brigham, and it’s our two large teaching hospitals and then a series of affiliated community hospitals, as well as primary care practices. And at the Mass General Brigham level, it is being looked at very carefully. And I am not in that group to make that assessment. But I can assure you that all of our infection preventionists who have leadership positions are advising them and speaking on the infection preventionists’ behalf. I can tell you that they are strongly for it. It would not surprise me if it comes soon.
ICT®: In your own career, have you run up against vaccine hesitancy among health care professionals? How have you handled that?
Sax: Among health care providers, vaccine hesitancy is less common than among the general population, but there are some [providers who are hesitant]. I feel like it’s our responsibility to keep our patients as safe as possible. I mean, it’s a real privilege to be involved in taking care of patients in their time of need, especially people who are so vulnerable. And to think that you would make a personal decision that puts them at risk is really unconscionable to me. And there is a history as you as you alluded to of mandatory flu vaccination and the argument for COVID-19 vaccination is even stronger than it is for flu vaccine. You know, if you don’t want to do this, and you don’t have a medical reason not to do it—because there are people who have a medical reason not to do it—then I suggest really that you find another job. I am also going to say that people who’ve had COVID-19 previously, that [for them] opting out of vaccination makes some sense because as we know, reinfection is very rare. But I still do advise people in clinical practice who have had COVID-19 to get vaccinated since the protection from the vaccine seems to be stronger than protection from actual previous disease.
ICT®: Would you say that the fact that we are desperately in need health care employees might make this approach somewhat problematic?
Sax: Well, it cuts both ways. On the one hand, you’re right. You’d hate to eliminate from the pool of potential employees, people solely based on their view of vaccines. But another way of looking at it is that you’re much more likely to keep them healthy and in the workforce. It’s almost inevitable that even though we’re at very low infection rates right now that that’s going to increase when the season changes, again, in the fall and winter. Coronaviruses are seasonal. I don’t think anyone—even the most optimistic person—feels like it’s kind of going to be gone. When cases start increasing again, having that vaccinated status among your staff is really going to protect your workforce. I can see both sides of it.
ICT®: Does the Delta variant come into play here at all?
Sax: Absolutely. The Delta variant by all estimates is 50% to 75% more transmissible than the original isolate from China. And that follows on a variant, the Alpha variant, originally identified in Britain, which was 50% more transmissible. The observation in populations that have large proportions of these variants is that you don’t need as much contact with an infected person to catch the virus. And there has also been observations that people with these variants may be contagious for longer. The good news, however, is that people who’ve received two doses of the vaccines—the mRNA vaccines or, at least internationally, the AstraZeneca vaccine—appear to be protected. This ups the importance of vaccination for control of the of the virus in general, and also control of the virus in health care settings in particular. Without a doubt the fact that there are more transmissible variants makes vaccination more important.
ICT®: Do you see an influx of interest leading to an influx of personnel into infection prevention coming out of all this?
Sax: Well, I’m going to speak on the physician side, which is that you know, infectious disease has always attracted people interested in the science of infectious disease, the epidemiology of infectious disease, the treatment of infectious disease, as well as the prevention. That sticks. And then we also have now this extra layer of people who are interested because it’s one of the biggest news stories of the year, if not the biggest of the last year. So we had increase in the number of people interested in infectious disease applying for our fellowship programs, which is very encouraging because you know, this is not something you go into in order to buy your next Maserati or Ferrari. We’re paid fine, but we’re paid on the lower end [in terms of doctor pay scale].
ICT®: What about the argument some of the vaccine hesitant have used that EAU approval makes the COVID-19 vaccines experimental and so therefore there shouldn’t be mandated vaccinations?
Sax: When the emergency use authorizations occurred, people immediately started thinking: “Does this mean that we cannot have any vaccine requirements for employment?” And the U.S. Equal Employment Opportunity Commission (EEOC) weighed in on this and sort of said, “Look, if you need to do this to protect your worker safety, you can do it.” And that has given license to some organizations making vaccination mandatory. And as you probably have heard, there are some big companies—I think Delta Airlines and United Airlines—all their new hires have to be vaccinated. I was most concerned about patient safety when I wrote my [NEJM] piece. But I think we need to also consider that people who come to work in a workplace: You’re spending all this time with other individuals. You’re eating in the lunchroom, etc. I know a physician personally who caught COVID-19 not from a patient with infection, but from one of their office staff with infection. This is a real concern. I think that the fact that they’re not fully FDA approved right now is really more about paperwork and semantics than it is about what we can actually do. I also want to raise a bit of an ironic situation. We have an incredible amount of data—safety and efficacy data—on these vaccines. And they’re very effective, and they’re very safe. And then if you think about a recent big news story about an FDA approval. It was for a drug [aducanumab] to treat Alzheimer’s. The efficacy data for that drug is marginal at best. And so, FDA approval is part of the process. But it really is not the end-all and be-all that I think some people think it is. Anyway, I’m looking forward to when it’s taken care of so that we can stop talking about these, as I said, largely semantic issues.
ICT®: Aside from, as you mentioned, the EEOC, what other federal agencies back full COVID-19 vaccination? The CDC, obviously.
Sax: The CDC strongly recommends immunization for all adults who are eligible, The CDC is just unequivocal about that. I know their position on it. I cannot tell you what the OSHA [Occupational Safety and Health Administration] position is. But I would imagine that since their charge is workplace safety, that they would be in favor as well.
ICT®: You said you favor medical exemptions in some instances?
Sax: I have a colleague who is just very, very severely allergic to multiple things. And that person has talked with their allergist. And they’ve made the decision that they’re not going to go ahead with the vaccine. I think there are individual medical situations where people really don’t feel comfortable getting the vaccines and I understand that you cannot actually apply a mandate to 100% of the population without considering the individual circumstances. I’m much less sympathetic about what are called non-medical exemptions, just as I’m less sympathetic in the school setting. You know, one of the things I love to cite is that one reason why the United States has such low rates of vaccine preventable illness in school children—we really do much better with measles and diseases like that than other countries—is because we have such good school mandates for childhood immunization. And research has shown that having mandates for immunization is the most effective way of getting people to be immunized. And so, a mandate can be overridden by a medical exemption. And I’m totally sympathetic to that. Non-medical exemptions: I’m not so sympathetic.
ICT®: Do you see any middle ground here? Can a health care worker who is vaccine hesitant still work somewhere in a hospital?
Sax: You’re talking about removing people from patient-facing jobs. It depends, of course, on what they’re trained to do. I just want people to remember this is a highly contagious virus getting more so all the time. And even if you’re not in a patient facing role, you’re maybe in a role where you’re sharing an office with someone else. And I just feel like if you’re going to be working in a congregate setting with other people—you know, hospitals can be crowded places—that getting vaccinated is the safest approach for multiple reasons that I have already cited.
ICT®: Doctor Sax is there something that I neglected to ask you that you think is pertinent and that you would like your fellow health care professionals to know about?
Sax: Well, I think it’s OK to use incentives to encourage vaccination. There’s nothing wrong with that as long as it’s not coercive, and I feel like those strategies definitely should be part of it. Employers should also say, “Look, if you need a day off to recover from the vaccine for side effects, that’s fine. You need time off during the day.” You have to make it as easy as possible. Some people haven’t been vaccinated … because they found it too inconvenient. If you can make it as readily available at the site of work; walk-ins, last minute appointments, etc. That’s the kind of approach we need to take to get as many people vaccinated as possible.
ICT®: You mentioned the hospitals that have already mandated COVID-19 vaccination for employees. Will there be many more? Possibly all hospitals? How far reaching do you think this is going to be?
Sax: I would predict that it’s going to have very broad applicability eventually. And it might take the full FDA approval even though I’ve said in my mind that that’s not as important…. It’s going to be something that every hospital is going to have to consider. Because we went through what it was like without having the vaccines. Outbreaks do happen. I’ve mentioned in the piece I wrote about a nursing home that had an employee who came to work with the infection, spread it to multiple residents and staff. Three of the residents of this nursing home ended up dying. This is a real issue. One we need to keep the front and center while this pandemic is still going on.
This interview has been edited for clarity and length.