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Head To Head Covid-19

Patient commentary: Protect patients like me—make covid vaccines mandatory for all eligible staff in care settings

BMJ 2021; 374 doi: (Published 05 August 2021) Cite this as: BMJ 2021;374:n1921

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Should covid vaccination be mandatory for health and care staff?

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  1. Michael Mittelman, patient
  1. Philadelphia, Pennsylvania, USA
  1. mikemitt{at}

Contact with unvaccinated care staff and volunteers makes Michael Mittelman worry about risks from covid-19. He agrees with over 50 US medical organisations that are calling for compulsory vaccination—with exemptions only for medical reasons

The US president, Joe Biden, has now said that all civilian federal workers must have covid-19 vaccination or face once or twice weekly testing and other restrictions.1 A number of US healthcare settings already have a mandatory covid vaccination policy, but too many allow exemptions for religious, philosophical, or other reasons.

I have a rare kidney disease, three transplants, and other chronic conditions. People like me, at high risk from covid-19, must be protected by and from the staff caring for us. All patients and staff could have their exposure to SARS-CoV-2 reduced if countries, municipalities, and businesses worldwide required all healthcare employees to get a covid vaccination, with exemptions only for medical reasons.

This should include all staff members who have direct contact with patients, such as people who deliver meals, staff helping older care residents, emergency technicians, and janitorial staff, as well as doctors and nurses. Not being able to trust the healthcare worker treating me, or the person bringing me a meal, breeds anxiety as covid variants spread.

Covid vaccination presents particular risks to immunosuppressed people like me, but I still decided to have the vaccine.2 I didn’t know whether it would work for me because of the anti-rejection drugs I take, but I was relieved when I recently tested positive for antibodies: I now have some protection against covid-19. Many immunosuppressed patients are testing negative for antibodies after vaccination, however.2

Ken Sutha, a Stanford University paediatric nephrologist and also a transplant recipient, told me, “I worry about my patients’ exposure to covid-19 by unvaccinated healthcare workers. Young children may be ineligible for vaccination or might not mount a full response due to their anti-rejection medications.

“As a transplant recipient myself who did not form detectable antibodies after full vaccination, I also worry about my own risk of exposure and the possibility not only that I might spread the virus but also that I might serve as an incubator for developing new variants due to my own immunosuppression if I were to be infected.”

Covid-19 vaccination is mandatory at Stanford, but staff can opt out for a plethora of reasons.

Paid time off

Employers should make vaccination as easy as possible for staff by offering paid leave for vaccination, paid time off if they have reactions, and transportation and childcare costs. Staff who are medically ineligible for vaccination should be required to work away from patient facing roles and certainly not with patients at high risk from covid-19.

Over 50 US medical organisations—including the American Medical Association, the American College of Physicians, the American Nurses Association, and the American Public Health Association—are calling for compulsory vaccination of healthcare staff.3 Some countries, US states, and organisations have already made covid vaccination mandatory for healthcare staff,4 including the US Department of Veterans Affairs,5 university hospitals such as University of Pennsylvania, and others such as Atrium Health in North Carolina.6

California recently announced mandates for its public employees.7 Houston Methodist in Texas was one of the first health systems to make the vaccine mandatory. Under this hard mandate, employees were told to get the vaccine or find a new job: 97% of employees complied, while about 150 employees sued and lost their case.8

Weekly testing is not good enough

Rules should make employment in healthcare settings conditional on having the vaccine, rather than softer mandates offering options of weekly testing. The Mayo Clinic will require its employees to be vaccinated or instead to have additional training and agree to social distancing and wearing facemasks. Employees who don’t do so will be placed on unpaid leave.9

New York City has said that all healthcare workers must be vaccinated or undergo weekly testing instead.10 But only 60% of the city’s public hospital workers are vaccinated, and weekly testing is not good enough, as I could get sick from a person who tested negative yesterday but would test positive today.11 As a patient who needs care in multiple settings, I hope that mandatory vaccination rules become universal, with only medical exemptions permitted. It would alleviate some of my anxiety in receiving care.

Despite what some people may say, the pandemic is not over. We supposedly live in the era of collaborative care, shared decision making, and patient centred care. For us to truly live a “patients first” ethos, our leaders must be bold and require vaccination of all staff in all health and care settings.


  • doi: 10.1136/bmj.n1903
  • Patients’ consent obtained.

  • Competing interests: MM is a three time transplant recipient and rare disease patient advocate. He works in cybersecurity and is a former patient editor at The BMJ, a global PCORI (Patient-Centered Outcomes Research Institute) ambassador, and board president of the American Living Organ Donor Fund. He is also a board member of the Light Collective and a special adviser to the United Network for Organ Sharing, a patient adviser to Pfizer (paid) and the Agency for Healthcare Research and Quality (paid).

  • Provenance and peer review: Commissioned; not externally peer reviewed.

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