Mandatory vaccination - Open letter to Ontario’s Premier Hon. Doug Ford

Hon. Doug Ford, Premier
The office of the Premier 
Legislative Bldg Rm 281
Queen’s Park
Toronto, ON M7A 1A1

Dear Premier Ford,

I want to follow up on my messages to you last week regarding the importance of mandatory vaccination for all health-care workers; and take this opportunity to expand on why this is so critical.

RNAO has led the advocacy for mandatory COVID-19 vaccination for health-care workers in Ontario. We are drawing on the research of experts to identify the issues and challenges, and to pave the way forward.

As argued in an article in the Canadian Medical Association Journal (CMAJ), provincial and territorial governments across Canada should institute mandatory COVID-19 vaccination for health-care workers across all public and private settings. On the frontlines, health-care workers are at increased risk of contracting the virus and transmitting it. The authors of this CMAJ article argue that an effective vaccine would protect both the workforce and patients, reducing the overall burden of COVID-19 on services and ensuring adequate, qualified personnel to meet people’s health needs. They also point to other advantages, including the need to alleviate the expense and difficulty of procuring PPE and conducting ongoing COVID-19 testing.

The authors say that clear rules for vaccination should not be left to individual employers. The legality of this is addressed, noting labour laws will determine the “reasonableness” of the directive. In 2019, nurses in B.C. won a case against mandatory influenza vaccination policies at their workplaces. It became a matter of individual choice. However, COVID-19 is not influenza. Given the severity of the global pandemic, the authors suggest it is unlikely that challenges to a government mandate would be successful. The authors believe a challenge under the Canadian Charter of Rights and Freedoms would likely not succeed if provisions were made for those who could not receive the vaccination due to underlying health issues or religious or conscientious objection.

CMAJ published this article in February 2021. Since then, RNAO argues the following five developments have strengthened the conclusions of the study:

1. Growing evidence about the outstanding effectiveness of the COVID-19 vaccines in preventing serious illness and hospitalization (much higher than the effectiveness of the typical influenza vaccine).
2. Mounting evidence that vaccines reduce transmission of the virus (although they do not eliminate it).
3. Deployment of the vaccines and the minuscule rate of serious side effects across millions of individuals. This has reinforced their safety profile.
4. The arrival of new variants, such as delta and lambda, that are more transmissible and dangerous and that target those who are unvaccinated.
5. The major health human resources crisis – especially in nursing – that makes COVID- 19-related absences from work more challenging.

From a legal perspective, the health rewards from mandating the vaccine, and the risks from remaining unvaccinated have both increased. In short, the “reasonableness” test for mandating vaccines has strengthened.

Further, a consensus statement by The Society for Healthcare Epidemiology of America (SHEA) and six other leading U.S. organizations representing medical professionals working in infectious diseases, infection prevention, pharmacy, pediatrics and long-term care, supports the need for mandatory vaccination. The group specifies exemption for those with medical contraindications and some other circumstances in compliance with federal and state laws. The guidelines issued by the coalition — which include recommendations for engaging wary employees, navigating regulations, and how to enforce a mandatory vaccination policy — were crafted by a team of nearly 30 experts during the past two months. The recommendations are supported by American infectious-disease expert Anthony S. Fauci, who suggests “there should be more mandates” at the local level to curb virus spread.

A paper published by the prestigious JAMA Network calls for COVID-19 vaccination of health-care professionals as a condition of employment and argues it is a logical addition to institutional safety programs. It says alternative approaches for health-care workers who are unable or refuse to be vaccinated should be included, such as masking and periodic testing.

Premier, we at RNAO know that mandatory vaccination will encourage the vast majority of health-care workers to take the vaccine, but it will also raise resistance from a small number of opposers. Know that we will support you in addressing opposers. There are important examples that highlight leadership on this point. Houston Methodist, a large U.S. hospital system, announced to staff on April 1, 2021 that they would need to be vaccinated to keep their jobs. While 24,974 workers are now vaccinated, about 150 resigned or were fired for refusing to do so. Last month, a federal district court judge dismissed a lawsuit brought by Jennifer Bridges, a former nurse, who alleged the policy was unlawful and forced staffers to be “guinea pigs” for vaccines that had not gone through the full Food and Drug Administration approval process. Again, know that RNAO will stand with you on this.

Lastly, we want to highlight two papers (here and here) in the U.K.-based BMJ journal. They assess the international experience implementing mandatory vaccination for health-care workers. Most countries are yet to tackle the difficult question. Among those that have, policies differ in terms of the types of workers, situations and strictness:

• In March 2021, the Italian government introduced a requirement for health workers, including pharmacists, to be vaccinated before treating patients. Those who refuse face suspension without pay for the rest of the year. The government moved after clusters of hospital infections were linked
• to unvaccinated staff. The policy is designed to combat an endemic anti-vaccination movement in the country.
• Serbia is considering a similar policy as above.
• Saudi Arabia has taken the hardest line. In May, its government said employees in the public, private and non-profit sectors must be vaccinated before they can return to work.
• In Moscow, two million people in public facing jobs, including frontline health workers, have been
• told they must be vaccinated by the city’s mayor after a spike in cases. Businesses will be monitored to make sure they comply – at least 60 per cent of employees must have their first dose by July 15 or risk being fined.
• Ireland hasn’t ruled out mandatory vaccination for health workers, but the country’s health
• regulator called it the “most intrusive step” that should only be considered if the risk to patients from unvaccinated health staff was high because of increased community transmission. Some hospital trusts in Ireland have already sent home those who refuse vaccination, on full pay.
• France announced on July 12 that vaccinations will be mandatory for health-care workers. Mandatory vaccination applies to anyone who comes into contact with vulnerable people, including doctors, nurses, office staff and volunteers. They must be fully vaccinated by Sept. 15 or will risk not being paid.
• Greece recently announced that nursing home staff need to get vaccinated immediately, adding that from September, vaccinations will be compulsory for all health-care workers in both public and private sectors.
• The UK government will make vaccination mandatory for home care staff starting in October 2021, and is considering whether to extend the policy to other frontline workers. Advocates argue it is similar to Hepatitis B vaccination, which is required by some hospital trusts. But such policies have never been tested legally. Staff are asked to take the vaccine but, in practice, those who decline are simply taken off duties that could expose them to the disease.

Experts agree that simply imposing a mandate to vaccinate is not enough. There must be accompanying policies to promote, facilitate and encourage vaccination. An article in The Conversation focuses on the Australian mandate for COVID-19 vaccination for residential aged-care workers (known in Canada as long-term care workers), with the aim to ensure all have had a first dose by mid-September. The author identifies several actions and policies to support implementation:

• More on-site vaccination at workplaces. This will address difficulties with variations in staff working hours and subsequent access issues. In addition, seeing co-workers getting vaccinated may help build confidence in those who are unsure.
• Support conversations to ensure staff understand why the shift in policy has occurred, to address any misinformation, and to support vaccine uptake.
• Efforts to ensure information and booking systems are available in different languages.
• Adoption of best practices to support engagement with vaccine services for people from culturally and linguistically diverse communities.
• Support in booking appointments for workers who may have limited computer skills.
• Paid time off to take the vaccine and to recover from any adverse reactions.

Premier, this growing body of evidence speaks to the critical need for mandatory vaccination of health- care workers in Ontario.

A grave concern is that it appears there is no data publicly available on the current vaccination rate among health-care workers in Ontario. An urgent responsibility for government is to make sure this data is made public.

We will continue our advocacy calling you to mandate vaccination for all health-care workers. We will also continue to call on all nurses to get two doses and become role models for other health-care workers.

Just imagine being a patient in primary care, a hospital, a nursing home or receiving home care. Should you have to worry whether the caregiver is fully vaccinated or not? Ontarians requiring health services already have a health concern – we must not burden them with the fear of contracting COVID-19.

Yours warmly,

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Doris Grinspun RN, MSN, PhD, LLD(hon), Dr(hc), FAAN, FCAN, O.ONT.                                                                     
Chief Executive Officer 
Registered Nurses’ Association of Ontario    

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Morgan Hoffarth RN, MScN
President
Registered Nurses’ Association of Ontario   

Cc:
Hon. Christine Elliott, Deputy Premier and Minister of Health Hon. Rod Phillips, Minister of Long-term Care
Ontario Cabinet Ministers
Andrea Horwath, Official Opposition Leader, Ontario New Democratic Party France Gélinas, Health Critic, Ontario New Democratic Party
Steven Del Duca, Leader of the Ontario Liberal Party John Fraser, MPP, Ontario Liberal Party
Mike Schreiner, Leader of the Green Party of Ontario
Dr. Kieran Moore, Ontario Chief Medical Officer of Health Ontario Science Table

The Registered Nurses’ Association of Ontario (RNAO) is the professional association representing registered nurses, nurse practitioners, and nursing students in Ontario. Since 1925, RNAO has advocated for healthy public policy, promoted excellence in nursing practice, increased nurses’ contribution to shaping the health system, and influenced decisions that affect nurses and the public they serve. For more information about RNAO, visit RNAO.ca or follow us on Twitter, Facebook and Instagram.

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