Several hundred hospital workers in Virginia have been suspended or lost their jobs because they refused to get vaccinated against the coronavirus, as required by most major health-care systems.

The earliest vaccine mandates went into effect Sept. 1, with two other waves set for Oct. 18 and Nov. 1, according to a survey of hospital policies.

Across the country, health-care systems that have instituted mandates have seen some workers leave or be terminated over their refusal to get the shot, exacerbating a shortage in skilled nursing and bedside care.

Health-care systems in rural areas of Virginia, where there is generally more vaccine resistance, are being hit harder by an employee exodus over mandates than urban and suburban hospitals, which generally have larger staffs and are better able to withstand some unvaccinated employees leaving.

Inova in Northern Virginia lost 89 workers for noncompliance with the system’s requirement, which is less than half of 1 percent of its workforce, while Valley Health, based in the northern Shenandoah Valley, fired a little over 1 percent of its workers for not getting a vaccine.

Hospital officials say the reasons that workers refuse to get vaccinated mirror hesitancy in the larger community, especially in rural counties, including historical distrust of medical institutions and worries about the development of the vaccine technology.

Some area health systems have opted not to require vaccination against the coronavirus, for fear too many workers would leave over it. Alan Levine, the CEO of Ballad Health, estimated a mandate would cost Ballad 5 to 10 percent of its staff; about 63 percent of its staff are already vaccinated, which is higher than the southwest Virginia and northeast Tennessee communities the system serves.

“In a rural hospital it doesn’t take a whole lot of people to walk away for it to have a serious effect on your hospital,” Levine said. “It’s a lot easier to recruit nurses to Northern Virginia than it is to Southwest Virginia.”

As a result, many officials are considering a policy where unvaccinated workers contribute more to their health insurance. “Perhaps it’s a choice but it comes with a financial consequence,” he said.

Ballad, which recently reinstated a policy of postponing elective surgeries, hit its peak of 413 in-house covid patients last month, including 120 in the ICU, most of whom were on ventilators, he said. By Friday, the number was down to about 300, Levine said.

In contrast, J. Stephen Jones, the president and CEO of Inova, which operates the state’s largest hospital, Inova Fairfax, said the Northern Virginia system’s Sept. 1 vaccine mandate helped with recruitment. Jones said that nurses in the urban and suburban hospitals want to know they are working with vaccinated colleagues out of concern for their own safety.

Still, of 20,000 Inova employees, 89 left as of last week because they would not get vaccinated.

“First and foremost, vaccination mandates work,” Jones said in an interview. “Recognizing that people are dying by the thousands, mandates are going to have to be the solution to get us beyond this.”

Before vaccines were available, several hundred workers at a time could be isolating due to being ill with covid-19 or having had a coronavirus exposure, but Jones said as of Friday, only 20 workers were out with covid-19 and none were hospitalized.

“The mandate is based on very strong, extremely clear guidance on the safety and efficacy of the vaccine,” he said.

Officials at Valley Health, a health-care system that operates Winchester Medical Center and serves the northern Shenandoah Valley, said 72 employees were terminated on Sept. 21, for noncompliance with the Sept. 7 vaccine mandate.

The system granted about 300 employees — or 5 percent of its 6,000 workers — a religious or medical exemption from the mandate, officials said.

Jeff Feit, vice president for community and population health at Valley Health, declined to detail why people requested exemptions, but said the confidential process was “rigorous and consistent.”

In mid-August, about 20 people, many of them nurses, stood outside Winchester Medical Center to protest the requirement. A judge last week dismissed a lawsuit filed by three unvaccinated employees of the hospital who wanted to keep their jobs despite the mandate, the Northern Virginia Daily reported.

“I’m very respectful that this was a hard decision for a lot of people, but it was their decision,” Feit said of the mandate in general. “It’s wonderful to live in a country where we have free choice.”

The D.C. Hospital Association, which expressed support in June for mandatory vaccination as a condition of employment, said in a statement that hospitals in the city had seen “tremendous” upticks in vaccinations among licensed and unlicensed hospital staff in recent weeks, particularly among those who have been hesitant. The city mandated vaccination for all health-care workers in D.C. by Sept. 30, unless they had a religious or medical exemption.

“While hospital policies vary, some of our members will begin taking employment actions in accordance with their policies on October 1,” the statement said. “DC hospitals do not take these actions lightly. The singular objective of our member hospitals is to ensure a safe environment to work and care for patients, and vaccination is key to that goal.”

Here’s where major area health systems stand with vaccine mandates:

● Virginia Hospital Center in Arlington does not have a vaccine mandate, but about 92 percent of employees are already fully vaccinated, spokeswoman Maryanne Boster said.

● VCU Health System required employees to get their first dose by Sept. 15.

● Four systems serving Virginia's Hampton Roads region — Sentara Healthcare, Chesapeake Regional Healthcare, Children’s Hospital of The King’s Daughters Health System and Riverside Health System — require employees to be vaccinated by Oct. 18. Of 28,000 Sentara employees, 13 people have resigned due to the vaccine requirement, spokeswoman Kelly Kennedy said.

● UVA Health requires all employees to be fully vaccinated by Nov. 1. As of Friday morning, the system had 66 employees on paid administrative leave for a coronavirus infection or exposure, spokesman Eric Swensen said.

● Johns Hopkins Medicine required clinical and nonclinical personnel to be fully vaccinated by Sept. 1.

● Luminis Health, which operates Doctors Community Hospital in Lanham and Anne Arundel Medical Center, had an Oct. 1 deadline and said it will have more information about compliance among its 6,700 employees next week. But as of Friday, spokesman Justin McLeod said 2 percent, or about 134 workers, were not vaccinated.

● University of Maryland Medical System also set an Oct. 1 vaccine requirement deadline, and officials said Friday that 98 percent of full-time and part-time clinical staff and 96 percent of nonclinical staff were vaccinated. The system has nearly 30,000 workers.

● Children’s National Hospital in June was one of the first children’s hospitals in the nation to announce a vaccine mandate, which went into effect Sept. 30. All 8,500 employees are vaccinated and no one lost their job over the requirement, spokeswoman Diane Troese said.

● United Medical Center spokeswoman Toya S. Carmichael said every health-care worker in D.C. was required to receive at least the first dose of a vaccine by Sept. 30, and she said 86 percent of staff are fully vaccinated. Unvaccinated staff have until Oct. 30 to obtain a waiver from D.C. Health, she said.

● MedStar Health says all employees must be fully vaccinated by Nov. 1.

Michael Brice-Saddler contributed to this report.