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U.S. cases of COVID-19 rising despite success of vaccines

By Jeff Levin-Scherz, MD, MBA | July 20, 2021

From issues relating to a mental health crisis to vaccine mandates, employers are faced with new concerns in the wake of COVID-19.
Health and Benefits|Benessere integrato
Risque de pandémie

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About our “The COVID-19 Crisis” series

“The COVID-19 Crisis” series is a weekly update by Dr. Jeff Levin-Scherz covering the latest developments related to the COVID-19 pandemic in the U.S. Explore the entire blog series.

Cases of COVID-19 in the U.S. continue on the upswing. The counties with the highest rates of new infections are almost all those with very low vaccination rates, but all 50 states saw increases in rate of infection last week. This demonstrates the impact of the Delta variant, which is now responsible for over half of all new infections.

Over the last two weeks, hospitalizations in the U.S. are up by 26% and deaths are up by 9%. High vaccination rates among the elderly in the U.S. will mean we are unlikely to face the high death tolls we saw this winter, but the upswing in cases is worrisome, and the problems surrounding the pandemic are clearly still affecting employers.

The past two weeks have seen an uptick of new cases with the seven-day moving average number at 26,011 on July 18, 2021.
Daily trends in number of COVID-19 cases in the U.S. reported to the CDC

The seven-day moving average was 26,011 on July 18, 2021. Source: CDC

COVID-19 is well on its way to becoming endemic, and we’ll need to continue planning to keep our workplaces as safe as possible, knowing that we will be living with the threat of COVID-19 for the coming months and years.

Public health advocates argue for mandates

We have seen few employer mandates outside of healthcare and higher education so far. In a survey we completed in late May, only 9% of employers stated they already mandated vaccination, and 19% said they were planning or considering mandating vaccination.

Employers cite many reasons to be cautious in mandating vaccinations. They are available under an emergency use authorization from the Food and Drug Administration (FDA), and the consent form asks those getting vaccinated to confirm that this is voluntary. Vaccination has unfortunately become politicized, and some states are seeking to prohibit mandates and have already made it difficult to require reporting vaccination status.

The Equal Employment Opportunity Commission has clearly stated that employers can ask about vaccination status, and the Occupational Health and Safety Administration has clearly stated that employers can mandate COVID-19 vaccination.

Dr. Anthony Fauci said, “I do believe at the local level…there should be more mandates,” when asked whether he supported vaccine mandates in businesses and schools earlier this month. Dr. Ashish Jha, Dean of Brown University School of Public Health wrote that the Hippocratic oath “do no harm” requires healthcare providers to mandate worker vaccinations. Ezekiel Emanuel and colleagues from the University of Pennsylvania wrote that healthcare workers should be “vaxxed or axed.”

Mandates and the implications for employers: Increased rates of infections due to the Delta variant point to the importance of clear policies to prevent workplace transmission. This includes indoor mask mandates for the unvaccinated and continued decreased capacity. Employers should continue to monitor vaccine uptake among their employees and in their communities.

Employees who have compromised immune systems, from chemotherapy or various drugs, are less likely to be fully protected, and the Americans with Disabilities Act requires that employers offer them a safe workplace.

I believe more employers will consider vaccine mandates if vaccination rates remain below 80% to 90% in the fall after the FDA has fully approved one or more of the vaccines. Employers will need policies to allow exemptions for those with medical or religious reasons to avoid vaccination if they implement mandates.

Johnson & Johnson vaccine associated with another rare complication

The FDA added a new warning to the Johnson & Johnson (J&J) vaccine, which has been associated with about 100 cases of Guillain Barre Syndrome in the U.S., usually around six weeks after vaccination. This rare autoimmune phenomenon has been associated with vaccines in the past — most notably the 1975 swine flu vaccination. There are also reported cases with the similar adenovirus-based AstraZeneca/Oxford vaccine.

Some important perspective here:

  • The J&J vaccine has been administered to over 12 million people. It’s likely that a few more cases will be found — but this is a single case per 120,000 people who get the vaccine. There are still parts of the country with 25 to 90 new cases of COVID-19 per 100,000 people per day.
  • There are 3,000 to 6,000 cases of Guillain Barre Syndrome each year in the U.S. The FDA has found a “signal” that individual risk is heightened by getting this vaccine, but it's possible some of these cases would have happened without the vaccine.

J&J risks and the implication for employers: The J&J vaccine looked like it would be an especially good fit for onsite vaccination clinics, given it needs only refrigeration and requires only a single shot. However, employers are less likely to use this given the very small risk of blood clots in young adults, and the very small risk of Guillain Barre in older adults.

Opioid deaths increased 30% in 2020

We know that mental health took a beating during the pandemic — and it’s not a surprise that deaths from drug overdoses continue to increase. The CDC reported this month that 92,183 people died of drug overdoses in 2020 and expects this number to climb to over 93,000 when reporting is more complete. This means that there were more deaths from drug overdose than from diabetes, and almost twice as many deaths from drug overdoses as suicide.

Drug overdose deaths have risen from around 50,000 per year in 2015 to over 90,000 per year in 2020, with a significant increase from 2019 to 2020.
12-month-ending provisional number of drug overdose deaths

Source: CDC based on data available on July 4, 2021.

The recent rise in drug overdoses and the implications for employers: Substance use disorder is a major problem in the employed population and among adult dependents of employees. Medication Assisted Treatment (MAT) has been shown to be effective in decreasing deaths from overdoses, yet many have difficulty obtaining these services. One advance during the pandemic was a decrease in the requirement for daily or very frequent in-person visits for MAT. Employers can ask their carriers for reporting on MAT access and use and should expect costs for treatment of substance use disorder to increase to meet this urgent need.

COVID-19 is well on its way to becoming endemic. Armed with the knowledge that we will be living with the threat of COVID-19 for the coming months and years, employers will need to continue planning to keep workplaces as safe as possible.


Population Health Leader, Health and Benefits, North America

Jeff is an internal medicine physician and has led WTW’s clinical response to COVID-19 and other health-related topics. He has served in leadership roles in provider organizations and a health plan and is an Assistant Professor at Harvard Chan School of Public Health.

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