The number of major cancer centers across the United States that are mandating COVID-19 vaccination for employees is on the rise. But nationwide, there is no consistent policy despite growing calls from leading medical organizations saying that such requirements are necessary to protect patients and stem the surging infection rate.

As the number of COVID-19 cases has surged in recent weeks, so has the number of U.S. cancer centers mandating COVID-19 vaccination for employees. But nationwide, no consistent policy exists, which worries many oncology professionals.

“It doesn't have to be this way,” says Joseph McGuirk, DO, medical director of the blood and marrow transplant program at the University of Kansas Cancer Center in Kansas City, where immunization is not required for hospital personnel. “All cancer health care professionals—from the person who greets you at the front door to the nurses and the doctors and the health care techs to the pharmacy staff—everyone needs to be vaccinated to help protect our patients.”

Although McGuirk's opinions do not reflect the official position of his cancer center, many leading health authorities agree with him. On July 26, more than 50 medical organizations and societies issued a joint statement calling upon all health care and long-term care employers to require their workers to receive the COVID-19 vaccine to help reduce the virus's spread, especially in light of the highly contagious Delta variant.

“This is the logical fulfillment of the ethical commitment of all health care workers to put patients as well as residents of long-term care facilities first and take all steps necessary to ensure their health and well-being,” the statement reads in part.

The American Society for Radiation Oncology; the American Society of Hematology; the Association for Clinical Oncology, an affiliate of the American Society of Clinical Oncology; and the Society of Gynecologic Oncology (SGO) were among the signatories to the joint statement.

“From a cancer standpoint, we believe this is vital because of the increased risk to cancer patients with compromised immune systems,” says SGO President Diane Yamada, MD, head of gynecologic oncology at the University of Chicago Medicine in Illinois.

Whether the joint statement will affect policies at the country's major cancer centers remains to be seen.

Several European countries already insist upon COVID-19 vaccination as a condition of employment for health care workers. And on July 29, U.S. President Joe Biden issued new requirements for all federal workers and onsite contractors to be vaccinated or submit to regular COVID-19 testing, masking, and other measures. But among cancer centers in the United States, requirements can vary widely from one clinic to the next—even when those oncology practices are part of the same cluster of hospitals and medical facilities.

Consider the Texas Medical Center area in Houston, home to both Houston Methodist Hospital and The University of Texas MD Anderson Cancer Center. Houston Methodist was one of the first health systems to require COVID-19 shots. In June, 153 people (about 0.6% of the hospital's workforce) resigned or were fired for noncompliance; the number who worked in the hospital's cancer center has not been released.

Meanwhile, nearby MD Anderson's stance is that immunization remains optional, with ongoing workforce vaccination clinics and safety precautions, including masking and social distancing, in place in clinical areas. According to hospital data, 81% of the staff had been vaccinated as of late July; an unknown remaining fraction of the workforce may have received the shots elsewhere.

As in Houston, vaccination policies at cancer centers across the nation range from mandatory to optional with other protective measures in place, such as masking and social distancing, regardless of immunization directives. At the Medical University of South Carolina Hollings Cancer Center in Charleston, for example, clinicians and patient-facing staff must provide proof of COVID-19 vaccination or obtain a waiver for medical or religious reasons. In contrast, neither Vanderbilt-Ingram Cancer Center in Nashville, TN, nor Moffitt Cancer Center in Tampa, FL, currently oblige employees to be vaccinated, although inoculation is strongly recommended.

More immunization mandates are on the horizon. Come September 1, medical staff at several academic cancer centers—including those affiliated with Indiana University in Indianapolis and the University of Pennsylvania in Philadelphia—must have received their shots. St. Jude Children's Research Hospital in Memphis, TN, and others have set later dates for compliance, whereas Dana-Farber Cancer Institute in Boston, MA, currently plans to implement immunization requirements after federal regulators convert the vaccines' current emergency-use authorizations to full approvals. Such a regulatory change could come in the next month or two.

Rather than impose full mandates, some cancer centers are adopting hybrid approaches. At the University of Virginia Cancer Center in Charlottesville, for instance, only employees hired after June 25 who started on or after July 11 must be inoculated. Beginning in August, all unvaccinated staffers must undergo weekly COVID-19 testing—unless they always work remotely or tested positive for the virus in the previous 150 days.

In national surveys, health care workers often cite the vaccines' lack of FDA approval and unease over the speed of vaccine development, a lack of trust in the regulatory process, and insufficient data on long-term safety or efficacy as reasons to avoid getting the shots.

Mindful of those concerns, some hospital administrators might avoid mandates so as not to infringe on workers' autonomy or inflame feelings of mistrust in the system, says Olivia Kates, MD, a bioethicist and infectious disease specialist at Johns Hopkins Transplant and Oncology Infectious Diseases Center in Baltimore, MD, who has studied the issue (Open Forum Infect Dis 2021;8:ofab155).

Vaccine hesitancy is also more common among people of color and those in lower-paying support staff jobs. As such, Kates notes, compulsory immunization policies are likely to disproportionately affect those racial communities and socioeconomic groups—the same ones that were disproportionately burdened by the economic and health consequences of the pandemic—thus pitting public health priorities against ethical principles of equity and justice. “In order to resolve that,” she says, “the best we can probably do is to include diverse members of the workforce in policy development.”

Politics and legal factors have also played into the patchwork of policies. Oregon, thanks to a 32-year-old law, prohibits hospitals from requiring their workers to receive any immunizations. It is the only state that currently does so. Many other states have passed laws in recent weeks to ban COVID-19 vaccine mandates at most businesses, but such measures typically exempt the health care sector.

Although full FDA approval of the vaccines may boost acceptance of mandates, there is currently no legal barrier to cancer clinics imposing requirements for vaccines authorized on an emergency-use basis during a public health crisis.

Hospital administrators on the fence about mandates might look to the experiences of other cancer clinics to inform their decision-making. At Sherbrooke University Hospital Centre in Quebec, Canada, for example, at least four patients receiving inpatient cancer care died following a COVID-19 outbreak in May, likely due to seven SARS-CoV-2–positive staffers, most of whom weren't vaccinated.

Under pressure from Michel Pavic, MD, director of hematology and oncology at Sherbrooke, who led the effort, and 14 of his hospital colleagues, the province now requires all workers in cancer wards to be vaccinated or undergo coronavirus testing three times a week. Since the rule change, the rate of vaccination on Pavic's unit has risen from 85% to 95%, he says, with no further cases of hospital-acquired COVID-19. –Elie Dolgin