Ms R worked in a large hospital as a nurse. She had been employed by the hospital since 2008, and her reviews had been consistently positive. In 2011, the hospital changed its policy and began requiring new employees to get the tetanus, diphtheria, and pertussis vaccine (Tdap). In April 2015, the hospital sent a memo to all its employees, including Ms R, notifying them that it was instituting a new policy requiring all clinical employees to obtain the Tdap vaccine.

The hospital’s memo explained that pertussis is a highly contagious infectious disease and noted that the Advisory Committee on Immunization Practices (ACIP) recommends that all adults aged 19 years and older should receive a dose of the immunization. The memo stated “this recommendation is especially important for all healthcare workers who have not been previously vaccinated.” Employees were advised to either get vaccinated at the hospital’s employee health services department or to schedule an appointment with their own provider. Employees were given until May 15 to be vaccinated.

Ms R had not had the Tdap immunization, and she did not want to get it. After the May-15 deadline had passed, the hospital’s employee health services coordinator contacted Ms R, notifying her that her vaccination was overdue. Ms R responded that she had an appointment with her personal physician on June 2 to discuss the vaccine.

Ms R’s physician was Dr S, whom she had been seeing for several years. At the appointment, Ms R expressed to her physician that she had great anxiety about potential adverse effects of the vaccine and that she had not been able to sleep the past week due to her concern about it. She reminded the physician that she suffered from various allergies, as well as eosinophilic esophagitis. In response, the physician wrote a note to the hospital asking that Ms R be “medically exempt from receiving the Tdap immunization for medical concerns.”

Upon receiving the physician’s note, the employee health services coordinator wrote back to the physician and explained that the Tdap vaccine was mandatory for Ms R’s employment, and she specified the scientific evidence for why it was necessary. The coordinator then listed the manufacturer’s contraindications for vaccination, which included hypersensitivity (anaphylaxis), encephalopathy, latex sensitivity, Guillain-Barré syndrome and brachial neuritis, syncope, progressive or unstable neurologic disorders, Arthus-type hypersensitivity, and altered immunocompetence. The coordinator then asked the physician to identify the medical contraindication prohibiting Ms R from getting the mandatory vaccination and to provide documentation reflecting the reason.