Vaccination Mandates for Caregivers in Pediatric Health Care?

A recent JAMA article discussed the role of caregiver vaccination status in pediatric hospitals and ethics of exclusion.

Spring is here and COVID is gone? Not exactly. In fact, the numbers are climbing in Europe and China at alarming rates, which means that those rapid relaxation of public health efforts, like masking, testing, and vaccination requirements, may just be biting us. Now more than ever we are working to continue protection against SARS-CoV-2 while seeking to find a middle ground in public health mandates.

One area often left out of this conversation though is health care. Beyond employee vaccination requirements, what about visitors? During the first waves of COVID-19, many hospitals implemented visitor restrictions, in which patients were not allowed to have visitors. Restrictions like this are common in health care during respiratory virus season (flu season), and definitely in pediatric hospitals. For example, many pediatric health care facilities will opt to restrict visitors younger than 12 years of age to help reduce the risk of spreading seasonal respiratory viruses during flu season. In the United States, there have been more than 2.17 million cases of COVID-19 in children aged 0 to 4 years and 4.5 million cases in those aged 5 to 11. Knowing this, it’s not surprising that there would be consideration for limiting visitors but also adopting policies of restricting visitors who are not vaccinated.

In the case of pediatric patients though, how do we handle parents or guardians who are not vaccinated? Knowing that for a considerable period of this pandemic, children couldn’t be vaccinated and were vulnerable, how would we approach this without doing harm? A recent article in JAMA Pediatrics discussed the role of caregiver vaccination status in pediatric hospitals and ethics of exclusion. Caregivers provide an essential piece of support and advocacy for children during the care process. The authors note that “ Apart from mandatory COVID-19 vaccination for patients awaiting organ transplant in some centers, there is no precedent for denying health care to patients who are unvaccinated. However, to deny caregiver presence to a child, who has no say in their caregiver’s vaccination status and whose care is dependent on that caregiver’s presence, is to effectively restrict that child’s access to health care on the basis of caregiver vaccination status.’

The authors asked if less restrictive measures can help achieve those benefits intended by excluding unvaccinated caregivers. Visitor restrictions continue to be an important piece of infection prevention and public health measures for those patients and healthcare workers within in the facilities. Consideration should be made though, for non-pharmaceutical interventions like masking and distancing and how this may work if vaccine efficacy allows for removing these barriers or their role for unvaccinated caregivers instead of exclusions. As the authors emphasize, “a more immediate challenge for hospitals providing adult and pediatric care is the tension between equity and equality; imposing adult exclusionary guidelines equally on unvaccinated pediatric caregivers is inequitable. Furthermore, many adult patients’ unvaccinated caregivers might play a similarly essential role in patient care (eg, for patients who lack decision-making capacity or those with a language barrier or intellectual disability) and merit exemptions from exclusionary policies in which alternative safeguards are in place.”

Ultimately, unvaccinated caregivers can be accommodated with masking, testing, and screening, but these must be stringent efforts that often require resources and planning. The authors emphasize that excluding a child’s caregiver due to vaccination status is not ethically permissible except for extreme situations and it’s important that we address this complex situation.