Page 232 - GHES-3-3

Global Health Economics and
Sustainability
COVID-19 vaccination decisions and mandate impact

were effective because they had increased vaccination COVID-19 vaccination is an article of faith, such that
uptake among them (Okpani et al., 2024). However, the there appears to be no empirical evidence or legitimate
authors noted that under-resourced regions may have been moral principle that could lead any reasonable person
especially impacted by staff losses – at least 2,400 HCWs to decline it, making the claims in this literature
terminated for non-compliance in studies reporting unfalsifiable. Policy recommendations tend to logically
numbers, and as high as 50% of staff losses in studies follow: to deploy behavioral/educational interventions
reporting percentages (Okpani et al., 2024). However, they – if not mandates – to persuade recalcitrant, assumed to
did not elaborate on the impact of these losses on patient be ill-informed recipients to accept COVID-19 vaccines
care. They also failed to identify methodological biases, (Achat et al., 2022; Choi et al., 2022; Dubov et al., 2021).
such as their inclusion criteria, in which they only measured The present study has limitations. First, despite our
vaccination rates within the active labor force; thus, efforts to promote the study to HCWs of all vaccination
this approach, by design, excluded inactive HCWs (i.e., statuses, a greater number of unvaccinated than vaccinated
terminated HCWs), leading to studies that unsurprisingly HCWs responded to the call. As a result, our findings do
confirmed that the mandates had “worked.” Despite not represent most HCWs in the province who were and
the authors’ declaration of the mandates’ effectiveness, continue to be vaccinated, although as per one national
they still noted that no included study had reported that survey, as of November 2023, only slightly under half of
mandates had impacted SARS-CoV-2 infection rates HCWs in the country had been boosted twice (PHAC,
among HCWs, except for two studies that included the 2023a). However, our research addresses a gap, since
reports of infection rates among HCWs, but those were most studies on the impact of vaccination mandates have
“not linked to the rate changes associated with the timing been conducted with predominantly vaccinated HCWs.
of the mandates” (Okpani et al., 2024, p. 1,029, emphasis For example, in a systematic review of the attitudes
added). This finding, which clearly calls into question the of HCWs toward mandatory vaccination policies, the
scientific rationale for mandated vaccination, still failed to authors reported a “very important finding,” indicating
undermine the authors’ enthusiasm for vaccination. that their review was potentially biased because all the

Finally, the frequently repeated claim that COVID-19 studies included respondents who reported high rates of
vaccines “saved millions of lives” and that HCWs who do COVID-19 vaccination (Politis et al., 2023), a predictable
not embrace them are not fit for the job has often relied finding given widespread vaccination or termination
on mathematical modeling – as reported in studies such as policies in the industry. Second, the use of convenience and
Mathieu et al. (2024), Meslé et al. (2024), and Watson et al. snowball sampling also challenges the generalizability of
(2022) – which contradict actual data. On examination, the our findings, although, as mentioned earlier, this was also
data indicated that rather than saving lives, “the mortality the approach adopted by the largest survey of HCWs in
of the vaccinated part of the population in 2021 was 14.5% Canada, as well as by many studies of primarily vaccinated
higher than the mortality of the unvaccinated part of the HCWs (Asut et al., 2024; Digregorio et al., 2024; Galanis et
population” (Sorli, 2025, p. 1). al., 2022; Taruvinga et al., 2023).

These examples illustrate a trend in the literature Other limitations include that our study is cross-
exploring the impact of COVID-19 vaccination mandates sectional, and since we only conducted descriptive statistical
in healthcare and beyond, such as the neglect or dismissal analyses, we were unable to track changes in patterns over
of evidence that challenges their justification. This includes time or examine correlations between variables. However,
evidence of the vaccines’ inability to stop transmission these types of surveys are not unusual in health services
or infection (Shitrit et al., 2021b), the age-stratified research (Wang & Cheng, 2020). In addition, our study was
nature of COVID-19 infection (COVID-19 Forecasting not adequately powered to apply a meaningful multivariate
Team, 2022; Pezzullo et al., 2023), the potential harms approach to fully assess the impact of vaccination mandates
of the vaccine (Mevorach et al., 2021), irregularities in on specific population groups or regions, a feature that is
major vaccine trials that question the positive results the norm in exploratory research (Stebbins, 2001). While
communicated to the public (Coombes, 2025), and the such analyses may disprove our conclusions, they could
alternatives that can prevent serious COVID-19 effects also reinforce them. For example, the observation that
(Argano et al., 2023; Borsche et al., 2021; McCullough most respondents were not only unvaccinated but also
et al., 2021; Santin et al., 2021). This neglect or dismissal middle-class, Canadian-born women could be interpreted
of counter-evidence is especially notable in the literature as suggesting a disproportionately negative impact of
focused on the perceived problem of “vaccine hesitancy” mandates on women, exacerbating other gender inequities
(Chaufan et al., 2022). In this literature, embracing identified in the sector (Hennein et al., 2023; Llop-Gironés

Volume 3 Issue 3 (2025) 224 https://doi.org/10.36922/GHES025080014