Quality Quarterly

Examining COVID-19 Vaccine Hesitancy Among Health Care Workers

Since states began establishing their vaccine plans late last year, health care workers were seen as a critical population for receiving the first doses of the COVID-19 vaccine. In parallel, the national vaccine rollout plan established by the Centers for Disease Control and Prevention (CDC), made it a priority to provide the initial limited doses to health care workers. The aim was to protect not only frontline workers, but also to ensure the safety of their families, the patients they closely interact with, and the community at large

In January 2021, Contagion Live, an online infectious disease resource, published the results of a survey showing that a high number of health care workers were hesitant to vaccinate against COVID-19.  The survey, conducted by Surgo Ventures, “a privately funded action tank” (Surgo Ventures) comprised of scientists and technologists, is said to be the first U.S. research to measure COVID-19 vaccine hesitancy.

Over 2,500 health care workers participated in the survey, which was conducted Dec. 12-30, 2020, during the early phase of the vaccine rollout. The survey respondents included three distinct groups: 

  • Group 1: Physicians, nurses, dentists 
  • Group 2: Emergency Medical Services (EMS) providers, health technicians, home health workers 
  • Group 3: Administrative, support, and operations staff 

At the time of the survey, not all participants were offered the vaccine. Of the 53% of respondents who were offered the vaccine, 20% confirmed they received their first dose, while the remaining 18% were not yet vaccinated, and 15% chose to remain unvaccinated.

The literature documents three predictors for vaccine hesitancy among health care workers. The first determinant is a health care worker’s specific role. Using influenza vaccine coverage data may provide valuable insight into the expected COVID-19 vaccination rate.

For the 2019-2020 season, the CDC reported that flu vaccine rates were “highest among physicians (98%), nurses (92%), pharmacists (91%) and physician assistants (89%).” Conversely, flu vaccine rates for other clinical care workers, aides and assistants and other non-clinical care workers were lower at 82%, 72% and 77%, respectively. By comparison, the COVID-19 survey reported the largest unvaccinated group (22%) were EMS personnel, health technicians, and home health workers. Many are aides or assistants with 14% being African American workers. In general, this group consists of people of color and a large proportion of immigrants.

The second determinant that affects vaccination rates is the setting where a health care worker is employed. Those working in long-term care settings had flu vaccine coverage at 69%, compared to 93% in acute care settings. Likewise, the survey confirmed that employees who worked in long-term care facilities were more reluctant to receive the COVID-19 vaccine compared to those who worked in the same role in acute care.

The third determinant is the employer. In this instance, there is direct correlation between the setting size of the employer and vaccine coverage. Many larger settings such as hospitals that mandate vaccinations or offer free onsite vaccinations and/or practice other vaccine promotion interventions have shown to have the highest flu vaccination rates at 94%. Similarly, survey respondents who worked in larger settings were more likely to receive the COVID-19 vaccine onsite, hence a higher vaccination rate. Respondents from smaller settings, by contrast, were shown to have a lower rate as the vaccine was not as readily available during the initial rollout. However, there is now an overabundance of three different vaccines available, but best practices and supportive policies to promote vaccination remain absent among some of these smaller settings. “In organizations with 50 or fewer employees, an average of only 29% of healthcare workers had been offered the vaccine (in Dec 2020).” (Contagion Live, 2021).

Reasons for vaccine hesitancy among health care workers include: 

  • Questionable effectiveness and safety of the vaccine (31%) 
  • Fear of serious adverse events (24%)  
  • Concerns that the vaccine approval process was fast-tracked too quickly (16%)   

While the survey did not address general mistrust and skepticism of the medical system by people of color, it has been documented and received extensive media coverage as an impediment to COVID-19 vaccination. The concern takes special personal precedence when that mistrust is viewed in the context of one’s pre-existing condition, comorbidities, a bias toward natural immunity after contracting the coronavirus, a need for autonomy, and fear of an unknown substance/new technology that was, until recently, approved for emergency use only.

The September 2020 Weekly Morbidity and Mortality Report published by the CDC describes the following demographic profile of health care workers who die after contracting COVID-19:  

They “tended to be older, male, Asian, Black, and have an underlying medical condition when compared with HCP (healthcare personnel) who did not die.” Furthermore, nursing was the most common job role with nursing/residential long-term care facilities as the typical congregate setting with a high prevalence of COVID-19 infection.

In response to the alarming rise in cases from the Delta variant with more than 150,000 daily new cases reported as a seven-day average nationwide, on Aug. 5, the California Department of Public Health (CDPH) announced a new policy to mandate that health care workers get fully vaccinated by Sept. 30 or undergo weekly testing. Subsequently, the Food and Drug Administration moved to endorse the Pfizer COVID-19 vaccine to full approval for people 16 years and older. The ensuing impact of these two events has had a rapid domino effect across public and private institutions as other states began to execute similar policies.

As of Sept. 3, the CDC’s Data Tracker indicates more than 545,000 health care workers have contracted COVID-19 and 1,737 have died. Moreover, about 30% of health care workers employed in the 50 largest U.S. hospitals remain unvaccinated, according to data from the Department of Health & Human Services (HHS). In collating these statistics, it’s important to remember that reporting health care worker vaccination numbers is voluntary. Only 50% of hospitals have shared their data with HHS, while other states, like Texas, have elected to block the publication of this information.

Last May, CHPSO and HQI hosted a vaccine hesitancy webinar presented by Tyler Seto, MD, from the City of Hope. In addition to his role as VP of enterprise quality and patient safety, Dr. Seto also serves as the COVID-19 incident commander where he oversees the vaccine rollout program for health care personnel, patients, and the community. He shared some lessons learned and other operational strategies for reducing the barriers of vaccine hesitancy. They included the following:

  • Invitations were sent out for patients to self-schedule through a patient portal system, which allowed flexibility and left the decision-making to the individual 
  • Staff appointments were booked with the assistance of their managers 
  • Vaccine type was guaranteed 
  • Hospital staff were on standby for any questions  and opportunities for education 

While vaccine hesitancy is not a new phenomenon in the U.S., the World Health Organization considers its impact a leading global threat to public safety. The Delta variant, which now constitutes over 98% of the circulating COVID-19 today, is highly transmissible with reports of viral loads 1,000 times higher and two times as infectious as the Alpha variant. Even with state mandates for health care personnel to be vaccinated, unless exempted, there will be others who may instead choose weekly COVID-19 testing or even decide to quit. This is the reality and one that is upending an already existing labor shortage within our nation’s workforce. Despite this conundrum, it’s vital to continue outreach efforts by not overselling the benefits of COVID-19 vaccines, listening compassionately to concerns about vaccines, being transparent with what vaccines can and can’t do, and lastly, acknowledging that we don’t know everything. It’s also important to combat deliberate disinformation and overcome mistrust. All these interventions can be blueprints for improving COVID-19 vaccine rates for our health care workers who put their lives at risk daily and are critical resources to the welfare of our community. We are only safe when everyone is safe, and that includes the lives of our scarce health care workforce.

References and Resources 

Killian Meara, January 18, 2021, Contagion Live   

Survey Finds 15% of US Healthcare Workers Refuse to Take COVID-19 Vaccine 


Influenza Vaccination Information for Health Care Workers 

Surgo Ventures 


Amna Nawaz, February 2021, PBS Newhour 

Despite Being First in Line, Many Health Care Workers are Delaying Vaccinations


Update: Characteristics of Health Care Personnel with COVID-19 — United States, February 12–July 16, 2020