The Victorian Government has mandated that all ‘authorised employees’ (list here) must have had their first dose of a COVID-19 vaccine by last Friday, 15 October 2021. If they failed to do so, they will not be permitted to return to work until they have received their first dose. Similarly, these employees will need to have their second shot by 26 November 2021 or face the same restriction. As such, over one million employees will either need to be vaccinated, or risk being turned away by their employers.
As a result, there has been an increase in requests for medical exemptions from general practitioners. Indeed, there have been a significant number of people who are vaccine hesitant attending general practitioner clinics demanding an exemption; for which few actually qualify. These requests can be difficult to deal with and we discuss below the actions and considerations general practitioners should take in these circumstances to ensure they comply with their professional obligations.
Patients with a medical contraindication
On 8 October 2021, ATAGI updated its clinical guidance on the use of the COVID-19 Vaccine in Australia. We recommend that all general practitioners review the ATAGI guidelines to ensure they are fully informed of the acceptable reasons for granting an exemption. The guidance includes an analysis of contraindications to receiving the Vaxzevria (AstraZeneca) and Comirnarty / Spikevax (Pfizer / Moderna) vaccines. In circumstances where the patient has contraindications against both types of vaccines or is suffering an ‘acute major medical condition’, then ATAGI has noted this may warrant a temporary medical exemption. Further, the Medical Board of Australia has made it clear that a medical exemption is strictly limited to those who have a medical contraindication to all the vaccines. If a patient does present with a condition that may be considered a contraindication, then a course of action may be to refer them to the Victorian Specialist Immunisation Services (VicSIS) to perform a comprehensive analysis. This should help ensure your patient receives the best care and you have fulfilled your own professional obligations to make appropriate specialist referrals under clause 6.3 of the Medical Board of Australia’s Code of Conduct (Code).
Notably, there are no recognised mental health conditions that contraindicate the provision of a COVID-19 vaccine, provided it does not satisfy the ‘serious adverse event’ criteria as outlined in the ATAGI guidelines. Similarly, there are no recognised religious, political, or social views which have been considered valid objections to receiving the vaccine.
If a general practitioner is satisfied that a patient meets the criteria outlined in the ATAGI guidelines, then a temporary medical exemption can be provided. In this regard, ATAGI has also released guidelines on providing a temporary medical exemption, to be reviewed when completing the Australian Immunisation Register immunisation medical exemption form (IM011). Both sets of guidelines indicate that:
- there are no identified contraindicators that warrant a permanent exemption, with the exception of a serious adverse reaction following immunisation, for example an allergic reaction to an ingredient in all available COVID-19 vaccines;
- there are very few contraindicators or acute medical conditions that warrant a temporary exemption of no more than 6 months; and
- any exemption should be reviewed by a doctor and or specialist before being re-issued for another period of up to 6 months.
Patients without a medical contraindication
Where a general practitioner is satisfied that a patient does not have a medical contraindication included in the ATAGI guidelines covered above, it may be appropriate to decline the patient’s request for an exemption. In this instance, and particularly where a patient is pressuring the general practitioner, the general practitioner may wish to seek support and or advice from a senior colleague, their medical defence organisation and or professional indemnity insurer. A refusal to provide an exemption is fertile ground for a patient to make a complaint. If a general practitioner is not of the view their patient qualifies for an exemption, they may assist the patient to explore other options, such as a letter of support from the general practitioner simply reiterating the patient’s views, suggesting the patient seek advice on their position from a union, lawyer or other service or consider a referral to a specialist immunisation service. In any event, the paramount consideration is that an exemption is not granted where there is no recognised contraindication.
Obligations and safeguards
In light of the above, general practitioners should assess their patients’ eligibility against the ATAGI guidelines and make their decision on that assessment only. Failure to do so, or providing an exemption where it is not warranted, can lead to general practitioners running afoul of their professional obligations as outlined in the Code. Some obligations that may be breached by failing to adhere to the ATAGI guidelines include professionalism, providing good care, and working within the healthcare system. Further, the vaccine rollout is part of a broader strategy to achieve herd immunity in the population. General practitioners have an obligation, per clause 7.4 of the Code, to ensure they participate in efforts to promote the health of the community and prevent disease. Providing an exemption where there is no justifiable cause weakens the ability of the public to reach the intended vaccination targets and may be a breach of the Code.
Ultimately, general practitioners must not provide a medical exemption from the COVID-19 vaccine to patients simply because they are asked. Rather, general practitioners’ professional obligations require them to discuss the vaccines in detail with their patients, provide up-to-date and factual advice, and base their assessment on the most current clinical guidance. Providing an exemption in any other circumstances has the potential to lead to disciplinary and other adverse action.