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Government and employers take action as dangers of Delta variant come into focus

By Jeff Levin-Scherz, MD, MBA | August 3, 2021

As new information about the Delta variant comes to light, authorities announce initiatives, incentives and mandates.
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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.

New information about the danger of the Delta variant gives us good reason to increase our level of caution. We also have the first reported evidence of transmission of COVID-19 from those who were already vaccinated, and reassuring news that the vaccines remain highly effective in preventing severe illness, hospitalization and death. With this in mind, government agencies and employers have begun requiring vaccination or routine testing for in-person employees in efforts to reduce further spread.

COVID-19 cases continue to rise

There were over 86,000 new reported cases on July 28, and we are at a seven-day rolling average of over 67,000 cases a day. This is similar to the rate of new infections in mid-April and almost four times as high as at the beginning of this month. New hospitalizations are up to about 5,500 per day, about three times as high as the beginning of this month. In general, the rise in hospitalizations has been much lower (proportionately) to the increase in cases due to the Delta variant.

The seven-day moving average continues to increase and was at 67,556 for July 29, 2021.
Daily trends in number of COVID-19 cases in the U.S. reported to CDC

The seven-day moving average was 67,556 for July 29, 2021.
Source: CDC

Vaccination rates continue at a bit over 600,000 new shots per day in the U.S. At this rate it would take seven months for us to get to 75% of the population. Vaccinations given today will help mitigate future COVID-19 waves but are unlikely to meaningfully decrease the current increase in cases, as it takes between four to six weeks after the first inoculation to develop robust immunity.

CDC documents point to increased contagiousness of the Delta variant

The Washington Post published an internal CDC presentation on Thursday that documented the contagiousness of the Delta variant. Current studies suggest that its “R0 value,” the measure of how many people would be infected by each new case, is close to five. The initial novel coronavirus strain had an R0 of between two and three people. This means that exponential spread happens much more quickly — and is why increasing our vaccination rate is critical. It also explains the terrible tragedy in India in April and May, when as many as four million may have died of COVID-19.

The CDC reported that before Delta, those who were vaccinated and had “breakthrough” infections had 40% lower viral loads. But the Delta variant has meant that patients in general have 10 times higher respiratory viral loads — and those with breakthrough infections have viral loads that are similar to the viral loads of those who are unvaccinated. An outbreak in Provincetown, Massachusetts, demonstrated the first fully investigated cases of transmission of virus from one fully vaccinated person to another — a worrisome sign indeed. This means we can no longer say with confidence that those who are vaccinated are unlikely to transmit the virus if they get infected.

Worse, the CDC cites three studies that suggest that the Delta variant is more dangerous:

  • In Canada, higher likelihood of hospitalization (2x), intensive care unit (ICU) admission (3.7x) and death (2.4x)
  • In Singapore, higher odds of pneumonia (1.9x) and need for oxygen, ICU admission or death (4.9x)
  • In Scotland, higher odds of hospitalization (1.9x)

The information about the contagiousness of the Delta variant explains the CDC’s new recommendation that the vaccinated should mask and distance in areas of substantial or high transmission. With a more contagious virus in widespread circulation, even the vaccinated are better protected when they add the additional layer of protection a mask provides. But masks are a good addition to vaccination, not a substitute. Those at higher risk should consider using the most effective masks, such as those labeled N95 or KN95, while indoors with others.

COVID-19 vaccines prevent severe illness and death

Even though there are more breakthrough infections given the increased viral loads, the vaccines remain incredibly effective at preventing severe illness, hospitalization and death. Information from the CDC shows that those who are vaccinated are eight times less likely to be infected and 25 times less likely to be hospitalized or die compared to the unvaccinated.

This week, the four billionth dose of vaccine was administered globally (344 million in the U.S.), so those who are worried the vaccine is “new” should be reassured and roll up their sleeves.

Government and employers take action on the new information

President Biden announced a series of government initiatives to address the Delta variant on Thursday. These include:

  • Requiring all federal employees to attest to their vaccination or be tested at least once a week. He said he would seek to expand this to the military and to federal contractors.
  • Calling on employers to give time off. (Our survey showed that 55% were already doing this in May, and that percentage has likely increased.)
  • Calling for states to pay $100 to those who get vaccinations going forward.
  • Calling on employers to implement their own mandates.

Employers have increasingly been doing just that. Vaccination mandates are already common in health care, and 55 health organizations including the American Medical Association, the American Hospital Association and the American Nurses Association have recommended mandatory vaccination. Vaccination mandates are also common in higher education, which is good since colleges have been a major source of community outbreaks. We’ve also seen increasing adoption of vaccine mandates in financial services (Morgan Stanley, Blackrock) and technology (Google, Facebook, Netflix).

Even employers with a vaccine mandate will not have a 100% vaccination rate, since they will need to offer exemptions for religious and medical reasons. Therefore, employers who implement mandates will need an approach for those who remain unvaccinated. I believe frequent testing, as the federal government will implement, is the best approach. This testing should be once to twice a week depending on rate of community transmission.

There are two ways to frame a vaccination mandate:

  1. Vaccine mandate, with testing for those who have not been vaccinated
  2. Testing mandate, with exemption for those who are vaccinated

These might appear equivalent, but they are likely to lead to different vaccine uptake rates. The first option is likely to get more people vaccinated because it creates an expectation of vaccination. But this will also create more protest. Some unions have already announced that they believe vaccine mandates must be subject to negotiation. The second option will lead to less blowback, but likely won’t be as effective at boosting vaccination, since it doesn’t create an expectation of vaccination. The “framing” matters substantially here.

Be cautious on premium surcharges for the unvaccinated

A few clients have asked us about using premium surcharges (or reductions) as an incentive for getting vaccinated. Here is why I think this is not a good idea:

  • Premium surcharges and reductions are relatively ineffective at promoting the desired behavior.
    • The incentive is given long after the desired activity, and humans are subject to “present bias” where we over-discount benefits in the future.
    • The incentive is embedded in a larger sum (paycheck), so it's easy for our brains to frame this as smaller than it really is.
  • Clients would likely need to give credit for a "reasonable alternative standard" for those with exemptions.
  • Total wellbeing incentives are capped by the Affordable Care Act to 30% of total premium, so employers would need to coordinate this with other existing incentives. The Equal Employment Opportunity Commission’s regulations around this were thrown out in court and have not been resubmitted, so there is uncertainty around this.
  • This would likely redistribute employer premium subsidy away from low wage workers, who have a lower vaccination uptake rate.
  • To qualify, employees would have to start the vaccination process between two weeks before open enrollment (for the J&J vaccine) and six to seven weeks before open enrollment (for Pfizer, Moderna vaccines), which complicates communication.
  • Additional complexity increases execution risk at open enrollment.
  • Positive incentives are hard to remove, and so it might be difficult to sunset this in the future.

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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