Canadian Medical Association, nurses association call for mandatory COVID-19 vaccines for health-care workers

Christy Somos

CTVNews.ca Writer

 Tuesday, August 3, 2021 

TORONTO -- The Canadian Medical Association (CMA) and the Canadian Nurses Association (CNA) are calling for COVID-19 vaccines to be mandatory for health-care workers.

In a news release, the CMA and CNA stated jointly that in the face of the highly contagious COVID-19 variants and the plateauing of Canada’s vaccination rate, the mandatory vaccination of health-care workers is “an additional measure to protect patients, the health workforce and health-care system capacity.”

“What we're seeing is that these variants of the COVID virus are much more contagious and that makes the cry for vaccination even stronger,” said CMA president Dr. Ann Collins in a telephone interview with CTVNews.ca Tuesday. “And at the same time, we're seeing a plateauing in vaccine uptake and we know that vaccines are what are going to get us through and out of this pandemic. So we felt it was important, along with our nursing partners, to bring this forward.”

Collins said that so far, reaction to the announcement has been positive because the public recognizes that the organizations are “putting patients at the centre of their call-to-action.”

The organizations are also calling on all levels of government and employers to implement strategies to lower barriers to vaccine access, the statement says.

“While vaccines are readily available across Canada, we recognize that the history of inequity within the health-care system impacts trust,” the statement continues. “Therefore, governments and employers must continue to support and address vaccine hesitancy and system barriers to achieving the highest rate of vaccination among the public and health workforce.”

Health-care workers were among the first to receive COVID-19 vaccines to protect them and their patients from infection and to prevent outbreaks, but specific data on how many chose to get inoculated is not readily available.

As of Tuesday, 67 per cent of Canada’s eligible population has been fully vaccinated against COVID-19.

Requiring vaccinations as a condition of employment in health-care settings like hospitals and long-term care homes is not a new phenomenon, as many workplaces require doctors, nurses and support staff to be fully immunized against diseases like tetanus and hepatitis B.

In Europe, France has ordered all health-care workers to get vaccinated by mid- September, with Greece and Italy following suit with their own mandates in the face of the Delta variant driving COVID-19 cases up.

Ontario Premier Doug Ford told reporters in July that health-care workers have a “constitutional right” to opt out of vaccination, saying he doesn’t “believe in forcing anyone to get a vaccination that doesn’t want it.”

Alberta Premier Jason Kenney also flatly dismissed the idea of mandatory vaccines, going so far as to amend Alberta’s Public Health Act and removing a century-old order that allows the government to force people to be vaccinated.

“We have an incredibly powerful tool at our disposal to combat this virus and its variants,” Collins said. “We should be using everything that we can to get people vaccinated.”

A woman wears a face mask as she walks by a COVID-19 vaccination sign in Montreal, Sunday, August 1, 2021, as the COVID-19 pandemic continues in Canada and around the world. (THE CANADIAN PRESS/Graham Hughes)

Research Letter 

Infectious Diseases

July 28, 2021

Effect of Targeted Behavioral Science Messages on COVID-19 Vaccination Registration Among Employees of a Large Health SystemA Randomized Trial

Henri C. Santos, PhD¹; Amir Goren, PhD¹; Christopher F. Chabris, PhD^1,2; et alMichelle N. Meyer, JD, PhD^1,3

Author Affiliations Article Information

JAMA Netw Open. 2021;4(7):e2118702. doi:10.1001/jamanetworkopen.2021.18702

Introduction

The first opportunities to field test interventions to increase COVID-19 vaccination were among health care workers (HCWs), who were among the first to be offered COVID-19 vaccines. After 1 large Pennsylvania health system sent 36 vaccine-related mass emails to employees over 5 weeks (eAppendix in Supplement 1), 9723 of 23 700 HCWs (41%) had still not scheduled their vaccination. We sought to determine whether individually addressed emails designed with behaviorally informed features^1-5 could increase vaccination registration compared with a delayed control group.

Methods

This project followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline. The Geisinger institutional review board determined that this health care operations project did not constitute human participants research and that a follow-up research analysis was exempt from review or the requirement for informed consent under 45 CFR §46.104(d)(4)(iii). The trial protocol is available in Supplement 2.

In this randomized trial, we assigned 9723 employees (eFigure in Supplement 1) who had not scheduled a COVID-19 vaccination to a delayed control condition (3241 [33%] randomized; 3179 [33%] received intervention) or to receive 1 of 2 individually addressed emails with 3 components. Both emails explained that Pennsylvania would soon expand vaccine eligibility beyond HCWs, reducing employees’ access to appointments, and encouraged them to schedule an appointment. The 6482 employees in these intervention groups were assigned to receive an email that framed the decision to be vaccinated either by noting that many US residents and fellow employees had chosen to be vaccinated, ie, social norms² (3241 [33%] assigned; 3198 [33%] received intervention) or by favorably juxtaposing the vaccine’s risks with those of COVID-19, ie, reframing risks³ (3241 [33%] assigned; 3190 [33%] received intervention). Both emails asked employees to make an active choice⁴ to receive a vaccine (hyperlinked to a scheduling portal) or not (hyperlinked to a survey soliciting their primary reason for declining). Employees in the delayed condition were randomly assigned to receive 1 of these emails (social norms: 1589 [50%]; reframing risks: 1589 [50%]) 3 days later. The primary outcome was registration on the vaccination scheduling portal during the 3 days after the first emails were sent.

Random assignment (with the randomizr package) and logistic regression analyses were conducted using R version 4.0.2 (R Project for Statistical Computing). For all analyses, odds ratios (ORs) from logistic regressions were calculated, along with asymptotic 95% CIs; 2-tailed P < .05 was used to determine statistical significance. Detailed methods appear in the eAppendix in Supplement 1.

Results

The overall employee population of 23 700 HCWs comprised 17 362 (73%) women and 21 168 (89%) White employees, with a mean age of 43 years. Of the 9723 targeted employees, 9457 (97%) had valid email addresses. Both emails (ie, social norms and reframing risks) led to more registrations in the first 3 days than the delayed condition (delayed control group: percentage of participants registering: 3.17%; 95% CI, 2.62%-3.85%; social norms: percentage of participants registering, 6.47%; 95% CI, 5.67%-7.38%; OR, 2.11; 95% CI, 1.65-2.69; P < .001; reframing risks: percentage of participants registering, 6.90%; 95% CI, 6.07%-7.83%; OR, 2.26; 95% CI, 1.77-2.87; P < .001) (Figure 1). There was no significant difference in registrations between the 2 email conditions (OR, 1.07; 95% CI, 0.88-1.30; P = .50). Among the 1229 HCWs who declined to register and then completed the survey, the most common reasons were unknown vaccine risks (430 [35%]) and pregnancy-related concerns (165 [13%]) (Figure 2).

Discussion

During the 3-day study period, an individual email nudge caused more than twice as many HCWs to register for a COVID-19 vaccination compared with HCWs in the control condition, with no significant difference between the 2 emails. A limitation of this trial is that due to the imminent closure of employee-only vaccination clinics, we could only delay the intervention in the control group by 3 days. Moreover, by choosing to compare 2 behaviorally informed emails, we are unable to exclude the possibility that a plain reminder might have had the same effect. Furthermore, we could not measure actual vaccination, as appointment slots were unexpectedly unavailable for many who registered for one.

Given the large volume of previous COVID-19 vaccine promotion to HCWs, it may seem counterintuitive that a single additional reminder could increase vaccination by late adopters. However, competing demands on attention, behavioral inertia, and unwieldy processes that make it hard to follow through on intentions likely conspire to make a single, timely, targeted reminder helpful.^2-5 The emails’ behavioral features—active choice, appeal to authority, and emphases on scarcity, social norms, and risk recalibration (eAppendix in Supplement 1)—may have contributed to their effect. The 3.17% absolute increase in vaccination appointments we observed is larger than many real-world nudges⁶ and may be greater among recipients who are less hesitant about receiving the vaccine. Sending targeted emails, patient portal messages, or text messages designed with behavioral science is inexpensive, scalable, and easily implemented and could be an effective way to encourage vaccination by HCWs and the general public.

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Article Information

Accepted for Publication: May 24, 2021.

Published: July 28, 2021. doi:10.1001/jamanetworkopen.2021.18702

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Santos HC et al. JAMA Network Open.

Corresponding Author: Michelle N. Meyer, JD, PhD, Center for Translational Bioethics and Health Care Policy, Geisinger Health System, 100 N Academy Ave, Danville, PA 17822 (michellenmeyer@gmail.com).

Author Contributions: Dr Santos had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Chabris and Meyer contributed equally.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Santos, Chabris, Meyer.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Santos, Goren.

Obtained funding: Meyer.

Administrative, technical, or material support: Chabris.

Supervision: Goren, Chabris, Meyer.

Conflict of Interest Disclosures: None reported.

Trial Registration: ClinicalTrials.gov Identifier: NCT04728594

Data Sharing Statement: See Supplement 3.

Additional Contributions: We thank Marguerite Macpherson, BS, Elizabeth S. Humphrey, BA, and Peter Rowe, BA, for administering the emails; Greg Strevig, AAS, for help in obtaining data for analysis; and Daniel Rosica, BA, Tamara Gjorgjieva, BS, and Maheen Shermohammed, PhD, for research assistance. All contributors are affiliated with Geisinger Health System, and none received compensation for this work other than their usual employment salary.

Additional Information: The data, materials, and reproducible code used in this study will be deposited to OSF: https://osf.io/qg5m6/.

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