National discussions on mandatory vaccination for long-term care staff in 24 countries. LTCcovid international overviews of long-term care policies and practices in relation to Covid-19 (No. 1, May 2021)

Contributors:

Jorge Browne Salas, Adelina Comas-Herrera, Gemma Drou Roget, Stefanie Ettelt, Cleusa P. Ferri, Paulo José Fortes Villas Boas, Nina Hemmings, Manuela Hödl, Roxanne Jacobs, Yorelle Kalika, Ngaire Kerse, Florien Kruse, Shoshana Lauter, Kai Leichsenring, Klara Lorenz-Dant, Lee-Fay Low, Terry Lum, Joanna Marczak, Christine Musyimi, Elisabetta Notarnicola, Déborah Oliveira, Eleonora Perobelli, Camille Oung, Maria Pierce, Tan Maw Pin, Tara Puspitarini Sani, Andrea Schmidt, Marguerite Schneider, Cheng Shi, Heidemarie Staflinger, Marta Szebehely, Lisa van Tol, Patrick Alexander Wachholz, Petr Wija, Gloria Wong, Kayla Wong, Yida Ying, Jessica Yu 

(please see below for author affiliations, acknowledgements and suggested citation).

About this series:

This is the first of a new LTCcovid series of international overviews that aims to provide concise and timely information on current long-term care policies and practices in relation to Covid-19. These overviews are generated by sending a question to a list of experts in long-term care who have volunteered through the LTCcovid initiative. If you would like to be part of the list of experts or would like to suggest a question for the next overviews, please email a.comas@lse.ac.uk.

Introduction

Following the enormous impacts of Covid-19 among people who use long-term care, most countries have prioritized people who live and work in care homes for vaccinations. However, there are concerns that vaccine supply, vaccine hesitancy and other barriers to vaccination are affecting the vaccination uptake among people who work in long-term care. In some countries this has led to a debate on whether it should be compulsory for people working in this sector (or particularly in care homes) to be vaccinated, or whether there are other measures that may be more acceptable and effective at increasing vaccination take-up and may not deter people from working in the sector. This post provides an overview of the situation in May 2021 in 24 countries.

The question:

Is there a discussion on making vaccination for Covid-19 compulsory in your country for long-term care staff in your country? Is this happening already for vaccinations for other conditions (such as flu)?

Overview:

  • Most countries have stated that staff working in long-term care would be among the first groups to be prioritized for Covid-19 vaccinations but in many countries there have been practical difficulties in facilitating access to vaccination for this group which, added to some vaccine hesitancy, has resulted in lower vaccination rates for staff than ideal. 
  • Vaccines are mandatory for healthcare personnel in Italy.
  • While many countries have debated whether to make Covid-19 vaccinations mandatory for certain groups, including people working in long-term care, none of the 24 countries for which we have information have adopted this as a national policy, although there are some local/regional examples where this has become the practice or where providers require that their employees are vaccinated.
  • There are a few examples of other vaccinations (such as flu) being made mandatory for staff working in long-term care and/or health care.
  • Most countries do not have data systems that support monitoring of vaccination rates among staff working in the long-term care sector.
Australia

COVID-19 vaccination is not compulsory for long-term care staff. There was discussion of this, but it has not been made mandatory. Aged care staff are in the highest priority group (1a) for vaccinations, however rather than being vaccinated at work with residents, they have been asked to obtain their vaccinations through their GP or at a vaccination clinic. This means that rollout has been slow, and data is difficult to obtain on how many long-term care staff have been vaccinated, we have regularly updated data on residents. Here is the information for workers on vaccinations https://www.health.gov.au/initiatives-and-programs/covid-19-vaccines/information-for-aged-care-providers-workers-and-residents-about-covid-19-vaccines/covid-19-vaccine-aged-care-readiness-toolkit/information-for-residential-aged-care-providers-to-support-covid-19-vaccination-of.   

In contrast, during 2020, flu vaccinations were mandatory for staff by a certain date, and there were staff made redundant because they did not want to be vaccinated (as opposed to showing that there were medical reasons why they couldn’t be vaccinated).

In 2020 the government introduced public health orders requiring flu vaccinations for all people entering residential care homes. From 1 June to 30 September, this includes staff, visitors, health practitioners, volunteers, and other people entering the facility (e.g. cleaners, tradespeople, gardeners and maintenance staff). These groups are required to provide evidence that they received a dose of the 2021 influenza vaccine or Covid-19 vaccine. Special exemptions include for medical reasons; where a person has had a Covid-19 vaccine in the last 2 weeks; or is booked in to have a Covid-19 vaccine. Those who have not had a flu vaccine but can demonstrate Covid-19 vaccination in the last 2 weeks are allowed entry. https://www.health.nsw.gov.au/Infectious/covid-19/Pages/racf-latest-advice.aspx  https://www.health.gov.au/sites/default/files/documents/2020/06/coronavirus-covid-19-restrictions-on-entry-into-and-visitors-to-aged-care-facilities.pdf    

The federal government National Cabinet are deliberating on whether to mandate Covid-19 vaccination for staff in the aged care sector. There are live discussions among employers on whether care providers will be able to require their staff to receive a Covid-19 vaccination, following a recent verdict by the Fair Work Commission which upheld the sacking of a childcare worker who refused a flu jab. https://www.theguardian.com/australia-news/2021/apr/21/australian-employers-could-require-some-workers-to-be-vaccinated-after-commission-ruling

Austria

Currently there is only a recommendation to get vaccinated in place for care staff, but no obligation. An obligatory regulation is also not foreseen in the near future. However, there is a law (Epidemiegesetz 1950) that could make this possible. 

It is possible, however, when hiring new staff, that employers ask for tighter tests in the hospital or care sector (e.g. for measles, hepatitis, not influenza). Only in one region (Styria) there are some legal possibilities to oblige staff to have specific vaccinations done. In general, across Austria care personnel that are still undergoing training might not be accepted if no tighter tests are provided. Care homes deviate in their views on how to handle the situation (whether or not to make vaccinations obligatory).

Information in German on COVID-19 vaccinations for care personnel: https://www.sozialministerium.at/Themen/Gesundheit/Impfen/Impfempfehlungen-Allgemein/Empfehlung-f%C3%BCr-Gesundheitspersonal.html    

Brazil

Although recommended at the federal level, the definition of priority groups in Brazil currently follows state and local protocols. The Brazilian vaccination strategy has been primarily focused on age, rather than risk or levels of exposure (except for healthcare professionals who were the first group to be vaccinated). More recently those with comorbidities aged 44 to 60 years have been included as a priority group. While in some regions of Brazil long-term care (formal\paid) workforce were included in the first priority groups to receive vaccines against COVID-19, along with residents, in other regions they remain unvaccinated or partially vaccinated. Scientific Societies like the Brazilian Geriatric and Gerontology Society reinforced the importance of vaccination for the long-term care workforce (paid and unpaid). Managers and workers engaged with the ‘Frente Nacional de Fortalecimento à ILPI’ claim that most workers at LTC facilities have now had access to vaccines, but there is a lack of formal evidence on this specific group. There are also no figures on family\informal carers, or domiciliary formal carers, vaccination rates.

Canada

COVID-19 vaccination policies are created by each of the thirteen provinces or territories. As a result, significant variation exists across the country. As of June 23, 2021, no jurisdiction in Canada has completely mandated COVID-19 vaccinations for long-term care (LTC) workers. Instead, five provinces (Ontario, Quebec, New Brunswick, Prince Edward island, and Manitoba) have incentivized vaccination through the introduction of policies for unvaccinated or partially vaccinated LTC workers including educational requirements, testing requirements, and employment restrictions.

The rest of the Canadian provinces and territories, including British Columbia, Alberta, Saskatchewan, Nova Scotia, Newfoundland and Labrador, Yukon, Northwest Territories, and Nunavut, have no policies mandating or incentivizing COVID-19 vaccination for their LTC home workers, although some are considering it. As of June 23, 2021, each provincial or territorial government has encouraged and recommended that their citizens get a COVID-19 vaccine but have not made it compulsory.

The Ministry Health is taking an educational approach, informing staff working in Long-Term Care instead of making vaccines compulsory (https://vancouversun.com/news/covid-19-high-rate-of-vaccinations-among-care-home-staff-dispels-anti-vax-fears).

As of April 30, 2021, 142,000 healthcare, assisted-living and long-term care staff in British Columbia (B.C.) had received vaccinations but the percentage of vaccinated staff in the province is unknown because not all provincial health authorities report total number of registered staff. 82.9 per cent of Vancouver Coastal Health’s eligible staff had received a first dose of COVID-19 vaccine, leaving more than 4,200 workers unvaccinated (https://www.cbc.ca/news/canada/british-columbia/bc-health-care-worker-vaccination-1.6008486).

Until December 2019, flu shots were mandatory for nurses working in BC. Nurses had to “vaccinate or mask”, with the latter requiring nurses to wear masks for the duration of their shift (https://www.cbc.ca/news/canada/british-columbia/b-c-nurses-no-longer-required-to-get-flu-vaccine-or-wear-mask-1.5384902).

Educational Requirements:

As of July 1, 2021, the Ontario government requires that LTC workers either show proof of vaccination, provide proof of a medical exemption from vaccination, or participate in a mandatory COVID vaccine education program to understand the benefits and risks of vaccination (https://news.ontario.ca/en/release/1000230/ontario-mandates-immunization-policies-for-long-term-care-homes).

Testing Requirements:

As of April 10, 2021, healthcare workers, including workers in LTC homes in Quebec, are required to show their employer proof of at least one dose of COVID-19 vaccination. If they are unable to provide this, they are required to undergo COVID-19 screening tests at a minimum of three times per week. If the worker refuses the screening tests, they can be redeployed to other work where possible (https://cdn-contenu.quebec.ca/cdn-contenu/adm/min/sante-services-sociaux/publications-adm/lois-reglements/AM_2021-024.pdf?1618075211).

Similarly, in New Brunswick, unvaccinated LTC workers in homes where the vaccination rate is less than 50% are required to take a COVID-19 test every other day (https://www.princeedwardisland.ca/sites/default/files/publications/ltc_nursinghomes_staffmovement20210430.pdf).

Single-Site Requirements:

In Prince Edward Island and Manitoba, vaccines are not mandatory. However, they are highly encouraged as unvaccinated LTC workers cannot work in multiple care homes, which is a common practice in the Canadian long-term care sector. (https://www.princeedwardisland.ca/sites/default/files/publications/ltc_nursinghomes_staffmovement20210430.pdf; https://news.gov.mb.ca/news/index.html?item=51142&posted=2021-04-19).

Chile

Currently all Covid-19 vaccines available have “Emergency approval in Chile” so there is no legal ground to make it compulsory. This might change in the future. 

China

In Mainland China, long-term care staff have been identified as the priority group to receive COVID-19 vaccination in national level. For now, there is no sign that Covid-19 vaccination will be mandated in law for long term care staff, however, in practice, local government and care providers have made vaccination compulsory already without passing any regulation. Care staff and care institutions have very high willingness be vaccinated. 

Other vaccinations such as flu are not compulsory.

Czech Republic

Covid-19 vaccination is not compulsory for anyone. However, care home workers were among the first groups, together with health care workers, who were offered vaccination. The Czech Association of Social Services Providers published several surveys on progress in vaccination in social services – we published the findings in this article (in Czech only): https://socialnipolitika.eu/2021/01/socialni-sluzby-se-potykaji-s-nedostatkem-vakcin-i-informaci

There has been no specific vaccination campaign at national level targeting long-term care staff, nevertheless they are prioritized group, and were among the first groups who got vaccinated. There has been a more general campaign to promote vaccination among vulnerable groups and prioritized group of workers.

Denmark

In November 2020 new legislation was proposed which would give the Danish Health Authority the power to “define groups of people who must be vaccinated in order to contain and eliminate a dangerous disease”. (https://www.thelocal.dk/20201113/explained-what-is-denmarks-proposed-epidemic-law-and-why-is-it-being-criticised/

In January 2021 the proposed legislation was not passed due to concerns about the application of force, and physical detainment, to control the disease. Any proposed future interventions will require a parliamentary vote. The Health Minister noted: “We are simply writing all forms of forced vaccination out of the epidemic law because we believe that information and openness are better for the vaccination case than threats and force” (https://www.thelocal.dk/20201221/denmark-scraps-provision-for-enforced-vaccination-in-new-epidemic-bill/).

England

The Department of Health and Social Care are consulting on a proposed legislative change to make Covid-19 vaccinations mandatory for staff deployed in a care home with at least one older adult (aged 65 or older) resident. They are also considering including wider groups within the scope of this policy, such as visiting healthcare professionals; those providing close care (eg. hairdressers); essential caregivers; and any professionals who enter a care home regardless of their role (eg. electricians).  (https://www.gov.uk/government/consultations/making-vaccination-a-condition-of-deployment-in-older-adult-care-homes

France

Covid-19 vaccinations are not compulsory for now, but mandatory vaccination has been considered given low rates (in line with French flu vaccination rates). Mandatory vaccination of health and social care staff has been endorsed by the national academy of medicine, stating it to be “ethically unacceptable” for health and social care staff (including personal assistants for older people) to not do so.  This would however require new legislation, rather than an amendment to existing legislation.  Mandatory vaccination for both flu and Covid-19 were discussed in Autumn 2020 in the context of Covid Winter planning. https://www.academie-medecine.fr/communique-de-lacademie-vacciner-tous-les-soignants-contre-la-grippe-une-evidente-obligation/#:~:text=En%20cons%C3%A9quence%2C%20l’Acad%C3%A9mie%20nationale,auxiliaires%20de%20vie%20pour%20personnes

Most recent visiting guidance places the ethical responsibility for vaccination on care staff and highlights that full ‘return to normal’ is not possible without high vaccination rates among staff. In absence of vaccination for staff, these must be ‘very frequently’ tested

There are mandatory vaccinations for Tuberculosis, DTP (diphtheria, pertussis, tetanus), hepatitis B, and typhoid on the legal basis of personal (rather than societal) risk.  DTP is mandatory for all citizens. Mandatory flu vaccination was implemented for 10 months in 2006 but it was removed from the list as it did not present ‘risk to professionals’. An amendment to the Public Health code of 2016 introduced a condition that health and social care professionals should be vaccinated if it presents a risk to those they care for.  The mandatory flu vaccine was implemented for 10 months but eventually removed from the mandated list as it was not deemed to present a personal ‘risk to healthcare/social care professionals’, and there was limited evidence as to the impact of infection from personnel in residential care for the over 60s on flu rates, and very low impact on hospital admissions. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005187.pub5/full#CD005187-abs-0001

Germany

There is no mandatory Covid-19 vaccination in Germany for any group so far. There has been some debate about introducing mandatory vaccination for health and LTC workers earlier this year, but the Government has decided against it (see https://www1.wdr.de/nachrichten/themen/coronavirus/corona-impfung-faq-impfpflicht-100.html)

However, it is possible that vaccination will be a condition for participation in certain services such as air travel and tourism. There is substantial debate about vaccinated people having more “freedoms” than the non-vaccinated, especially once the vaccination passport is introduced in the EU. 

Some researchers strongly recommend making vaccination mandatory, given that vaccination rates among care home staff are reported to be low in some areas, e.g. Nuremberg: https://www.br.de/nachrichten/bayern/studie-aus-nuernberg-corona-impfpflicht-fuer-personal-in-heimen,SW3wZxz

To provide some context there is no mandatory vaccination in Germany for children or adults in general: https://www.bundesgesundheitsministerium.de/themen/praevention/impfungen/schutzimpfungen.html

However, mandatory vaccination against measles was made compulsory from March 2020 for children and adults born after 1970 in communal settings such as child day care and schools. This also applies to employees in ambulatory and stationary health and social care settings. The change in law has been preceded by substantial debate and much opposition (see https://www.kbv.de/html/1150_43061.php and https://www.bundesgesundheitsministerium.de/impfpflicht.html)

Hong Kong SAR

On 1st May, following discussions with the governments of Phillipines and Indonesia, and in light of concerns raised by  labour groups, the government abandoned their proposal to make Covid-19 vaccination mandatory for foreign-born domestic care workers (many of whom provide domestic services to older people in their own homes)  (https://www.todayonline.com/world/hong-kong-scraps-mandatory-vaccines-foreign-domestic-workers_). The proposal required foreign-born domestic workers to demonstrate they had received two doses as condition of approval or renewal of work visas. Covid-19 vaccination therefore remains voluntary in Hong Kong.

The Hospital Authority usually check all their new nurses for vaccination records and will “highly recommend” them to get vaccinated before starting employment. We are unsure about the current practice in Nursing Homes. The Hong Kong government has not published any data about the adoption of vaccination among healthcare workers.

Under the Residential Care Home Vaccination Programme administered by the Department of Health, it provides free Seasonal Influenza Vaccination and Covid-19 Vaccination for all residents and staff at residential care homes. Residents and staff who wish to receive vaccination would need to provide consent. Enrolled doctors, i.e. Visiting Medical Officers (VMOs), would administer vaccinations at residential care homeshttps://www.chp.gov.hk/en/features/21702.html. Besides, residents and staff can also arrange their own appointments to receive Covid-19 Vaccination in Community Vaccination Centres, private hospitals or clinics. Staff who have completed two doses of vaccination are exempted from the regular compulsory testing of Covid-19https://www.covidvaccine.gov.hk/pdf/RVP_DoctorsGuide.pdf.

Indonesia

Although the Covid-19 vaccine has not been made compulsory for Long-Term Care staff nationwide, staff in LTC facilities managed by the central government through the Ministry of Social Affairs are being prioritised and have started to receive it. Vaccination of residents in nursing homes has also taken place. For regional government-operated or privately-owned LTC facilities, the vaccination of staff depends on regional regulations.

Ireland

In Ireland, an international review of policies relating to this issue was undertaken by the Health Information and Quality Authority (HIQA) in April 2021.  https://www.hiqa.ie/sites/default/files/2021-04/International_review-HCPs_who_do_not_avail_of_vaccination.pdf

A report outlining advice to the National Public Health Emergency Team (NPHET)  by HIQA relating to this issue was also produced in April 2021. In this report, the evidence from the literature and input from the COVID-19 Expert Advisory Group was considered. 

A summary of the evidence synthesis, the points raised by the EAG and the advice given by HIQA to NPHET can be found in the report at this link: https://www.hiqa.ie/sites/default/files/2021-04/Advice-to-NPHET_HCPs-who-do-not-avail-of-vaccination.pdf

The report states that, among the Covid-19 Expert Advisory Group, ‘there was a general consensus that mandating Covid-19 vaccination may not be appropriate at this time as this may act as a deterrent. Additionally, such a measure may be perceived as being overly harsh on a workforce that have had a particularly traumatic year. If all lesser restrictive measures have been exhausted and there is still low uptake, consideration may be given to mandatory vaccination in the future. However, caution was expressed with regards to how far one should go to ensure high levels of vaccination, and the potential creation of a negative work environment.’ (HIQA, 2021 p. 14). 

The advice given to NPHET by HIQA is to maintain a ‘support and encourage’ model, whereby staff are facilitated to make the decision to become vaccinated in a supportive environment’ (HIQA, 2021, p.15). According to the report, anecdotally, uptake and demand for COVID-19 vaccine among healthcare workers are currently high.  

According to HIQA (2021, p.12), ‘in Ireland, mandatory vaccination is in place for healthcare workers if proof of immunity cannot be provided against certain pathogens but not for SARS-CoV-2.’   The specific example given in the report is how refusal to get vaccinated for Hepatitis B could prevent surgeons from conducting certain high-risk operations (p. 14). 

Israel

The Green Passport gives vaccinated people access to most places in society and is seen as an incentive towards vaccination. There was some discussion of mandatory vaccination but this was not taken forward (https://www.timesofisrael.com/energy-minister-proposes-enacting-mandatory-vaccinations-report/). 

Italy

There has been discussion on making vaccination compulsory for long-term care staff, but the vast majority of political parties are against such an approach (since no vaccination is compulsory for LTC staff at present). Some nursing homes adopted some temporary measures (e.g. forcing staff on vacation) to keep non-vaccinated people away from residents but this cannot be a permanent measure. 

However, Covid-19 vaccination is compulsory for Healthcare workers (as of March 2021). Emergency legislation was introduced to make coronavirus vaccines mandatory for all health care workers, including pharmacy staff. Those who refuse can be transferred to another job without risk of spreading infections, or suspended without pay for up to a year.

Kenya

The Ministry of Health in Kenya prioritized the use of COVID-19 vaccine based on the World Health Organization (WHO) Strategic Advisory Group of Experts (SAGE) Roadmap and targeted high priority groups (at higher risk of exposure)  (Africa Medical and Research Foundation (AMREF) https://amref.org/coronavirus/vaccine/) such as health care workers, other front-line workers, individuals above 50 years as well as adults with underlying conditions. Although the Ministry of Health urged eligible populations to receive the vaccines due to the high transmission rates (10-11%), it is not yet mandatory and an individual may decide not to be vaccinated. Whilst receiving the vaccine is very important for all Kenyans, the government is only able to use a phased approach to provide vaccines to different populations in order to reduce the risk of social injustice in case there is inadequate supply of vaccines. 

As has been the case before emergence of COVID-19, staff working in nursing homes and long-term care facilities are urged to receive hepatitis B, typhoid and seasonal influenza vaccination due to daily interaction with the special risk groups (Ministry of Health National Policy Guidelines on Immunization, 1–74). Staff in these settings are considered as front-line health care workers and therefore are eligible to receive the COVID-19 vaccine.

Other vaccines such as polio, Diptheria, Pertussis, Tetanus, pneumonia, rotavirus, measles, hepatitis B and Haemophilus Influenza – Type B are mandatory for children below nine months. However, the flu vaccine is not included in the Kenya Expanded Programme on Immunization (KEPI) Schedule because there is no clear level of national burden of flu and for this reason; neither children nor adults receive it as part of the regular immunization programme. Though unaffordable to many Kenyans, the flu vaccine can still be provided in private hospitals at a fee.

Malaysia

Covid-19 vaccination is voluntary. The government required care homes to submit name lists by end of February but they have not yet delivered vaccines to care homes. So far 400 out of an estimated 1500 homes in Malaysia have submitted name lists, constituting 300 of the estimated 350 legally-registered home and only 100 out of the 1000 or so unregistered homes. So far, the Ministry of Health and Department of Welfare have not guaranteed protection against prosecution for homes that are unregistered and this may be reducing the willingness of unregistered homes to submit name lists for vaccination. Most healthcare workers have been vaccinated and the country is now well into the second vaccination phase, which targets vulnerable groups.

The Netherlands

Vaccinations are voluntary, according to guidelines of the ministry of Health Welfare and Sports. This statement is supported by all professional associations in the long-term care sector. In accordance with the General Data Protection Regulation (GDPR) by the European Union (EU), it is not mandatory for employees to inform their employer of their vaccination status. Among politicians and within the media, debate about making vaccinations for long-term care staff compulsory has been limited. There has been some discussion about the legal grounds on which an employer could change the terms of employment for employees who work with vulnerable people and refuse to be vaccinated: https://www.skipr.nl/nieuws/weigeren-ongevaccineerde-zorgmedewerker-mag-in-uiterste-geval/. Vaccinations for other conditions such as the flu are also voluntary for long-term care personnel.


In December 2020, before the vaccination program was rolled out, some polls found that vaccine hesitancy among healthcare personnel (in long-term care and other healthcare sub-sectors) was about 30% (https://www.volkskrant.nl/privacy-wall/accept?redirectUri=%2Fnieuws-achtergrond%2Fvaccinatiebereidheid-onder-zorgpersoneel-laag-blijkt-uit-peiling-slechts-een-derde-wil-coronavaccin%7Eb3875965%2F&authId=b64a1a22-28ba-4848-b512-68eeb08b1dde). Currently this hesitacy is lower, (see news articles: https://www.ad.nl/gouda/waarom-steeds-meer-zorgmedewerkers-een-coronaprik-halen-het-besef-dringt-nu-door~a603518d/?referrer=https%3A%2F%2Fwww.google.com%2F and https://www.rtvoost.nl/nieuws/1493157/Ziekenhuispersoneel-in-Twente-laat-zich-massaal-vaccineren-Ongelooflijk-blij-mee.) However, overall and exact numbers are missing.  

The National Institute for Public Health and the Environment [RIVM] shows that among the total Dutch population approximately 90% are willing to get a vaccine, 5% are still in doubt, and 5% refuse (https://www.rivm.nl/gedragsonderzoek/maatregelen-welbevinden/vaccinatiebereidheid).

Strategies of long-term care organizations to stimulate vaccination among personnel are currently being studied: https://www.lumc.nl/org/unc-zh/onderzoek/Kwaliteit-van-leven/Corona-onderzoekVerpleeghuizen/

New Zealand

In NZ vaccinations are offered to LTC staff but not mandatory. Uptake has been high for staff. Currently vaccinations are being rolled out to Aged Residential Care facilities, and the process has been variable regionally.  

Singapore

Covid Vaccinations have been voluntary for the whole healthcare sector (and country), but Care Providers proactively educate their staff and regularly report vaccination rates.  As of Mid-February, already 73% of healthcare workers had been vaccinated with at least 1 dose (the vaccination campaign started around Mid-Jan, so the coverage is likely much higher now) https://www.moh.gov.sg/news-highlights/details/progress-of-covid-19-vaccination-programme/

South Africa

Covid-19 vaccinations are completely voluntary in South Africa.  The Constitution protects individuals’ rights to decide for themselves, without due influence.  Care homes strongly encourage vaccination of staff (flu and covid) but cannot make it compulsory or preclude staff from coming to work (this would become a labour law issue).  The phase 2 of vaccination (general population – beyond health care workers) started during May and, at least the in Western Cape (if not the whole country) people in Long-Term Care Facilities and people aged 60 or over are being prioritized. 

Spain

In Spain, like with any other vaccine, vaccination for COVID-19 is voluntary for all the citizens, including workers from the health sector and the long-term care sector. Workers from the health and the long-term care sector have been prioritized groups in the COVID-19 vaccination strategy, but vaccination is not compulsory (https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/covid19/docs/COVID-19_Actualizacion6_EstrategiaVacunacion.pdf). Vaccination for some other infectious diseases, such as flu, is also recommended for workers from the health sector in the specific vaccination programmes for such diseases, but has never been compulsory (https://www.mscbs.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/docs/Recomendaciones_vacunacion_gripe.pdf).  

Sweden

No vaccination is compulsory in Sweden and, comparatively, there is very high acceptance of all kinds of vaccines.  A survey from March showed that 91% of the population intended to take the COVID-19 vaccine when offered. There was some discussion (at the local level) that staff who refused vaccination would not be allowed to work directly with residents in care homes, but more recently that does not seem to be on the agenda (probably due to the clear evidence of the rapidly declining number of cases among residents once they have been vaccinated). From the beginning, care home staff were in the first priority group together with care home residents, but when there were problems with the amount of doses arriving, the vaccination of care home staff stopped and instead the recommendation is to prioritise only according to age (once care home residents and home care users have got their first dose). 

There are regular statistics on the vaccination in different groups: https://www.folkhalsomyndigheten.se/folkhalsorapportering-statistik/statistikdatabaser-och-visualisering/vaccinationsstatistik/statistik-for-vaccination-mot-covid-19/uppfoljning-av-vaccination/vaccinationstackning-i-prioriterade-grupper/. For instance, almost 90% of care home residents are fully vaccinated and close to 70% of the population aged 70 or more got their first dose as of the 5th of May 2021. In care homes, 73% of registered nurses and 62% of assistant nurses/care aides have got their first dose; in home care the proportions are 76 and 51%, respectively and in hospitals 74 and 70%.

Contributors and affiliations:

Jorge Browne Salas (Facultad de Medicina, Pontificia Universidad Católica de Chile)

Adelina Comas-Herrera (Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, UK)

Gemma Drou Roget (Department of Epidemiology and Methodology of Social and Health Sciences, UManresa, Universitat de Vic-Universiat Central de Catalunya, Spain)

Stefanie Ettelt (Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, UK)

Cleusa P. Ferri (Universidade Federal de São Paulo, Department of Psychiatry, Escola Paulista de Medicina – Unifesp, Brazil)

Paulo José Fortes Villas Boas (Botucatu Medical School, São Paulo State University – Unesp, Brazil)

Nina Hemmings (Nuffield Trust, UK)

Manuela Hödl (Institut für Pflegewissenschaft, Medical University of Graz, Austria)

Roxanne Jacobs (Alan J. Flisher Centre for Public Mental Health, University of Cape Town, South Africa)

Yorelle Kalika (Active Global Home & Community Care, Singapore)

Ngaire Kerse (Department of General Practice and Primary Health Care, New Zealand)

Florien Kruse (Radboud University Medical Centre, IQ healthcare, the Netherlands)

Shoshana Lauter (Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, UK)

Kai Leichsenring (European Centre for Social Welfare Policy and Research, Austria)

Klara Lorenz-Dant (Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, UK)

Lee-Fay Low (University of Sydney, Australia)

Terry Lum (University of Hong Kong)

Joanna Marczak (Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, UK)

Christine Musyimi (Africa Mental Health Research and Training Foundation, Kenya)

Elisabetta Notarnicola (CERGAS – SDA Bocconi School of Management, Italy)

Eleonora Perobelli (CERGAS – SDA Bocconi School of Management, Italy)

Déborah Oliveira (Universidade Federal de São Paulo, Department of Psychiatry, Escola Paulista de Medicina – Unifesp, Brazil and Inter-American Development Bank)

Camille Oung (Nuffield Trust, UK)

Maria Pierce (Independent consultant, Ireland)

Tan Maw Pin (University of Malaya, Malaysia)

Tara Puspitarini Sani (Atma Jaya University, Indonesia)

Andrea Schmidt (Austrian National Institute of Public Health, Austria)

Marguerite Schneider (Alan J. Flisher Centre for Public Mental Health, University of Cape Town, South Africa)

Cheng Shi (University of Hong Kong)

Heidemarie Staflinger (Chamber of Labour for Upper Austria)

Marta Szebehely (Department of Social Work, Stockholm University, Sweden)

Lisa van Tol (Leiden University Medical Center, Department of Public Health and Primary Care, the Netherlands)

Patrick Alexander Wachholz (Botucatu Medical School, São Paulo State University – Unesp, Brazil)

Petr Wija (Institute for Social Policy and Research, Czech Republic)

Gloria Wong (University of Hong Kong)

Kayla Wong (University of Hong Kong)

Yida Ying (Active Global Home & Community Care, China)

Jessica Yu (Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science, UK)

Acknowledgements: 

This overview has been edited by Adelina Comas-Herrera and Nina Hemmings, who are supported by the Social Care COVID Recovery and Resilience Project (funded by the National Institute for Health Research (NIHR) Policy Research Programme (NIHR202333)). The views expressed in this article are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care).

Suggested citation:

National discussions on mandatory vaccination among long-term care staff in 23 countries. LTCcovid international overviews of long-term care policies and practices in relation to Covid-19 (No. 1, May 2021)

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