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Vaccination mandates gain steam as eligibility for third dose is approved

By Jeff Levin-Scherz, MD, MBA | August 24, 2021

As employers consider adopting a vaccine mandate, they must also address whether to include a requirement to get a third booster.
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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.

We continue to see increases in infection rates in both adults and children throughout the U.S., and these continue to be worse in geographies with low vaccination rates. Texas, Florida, Mississippi, Arkansas, Missouri and others have reported a shortage of intensive care beds. We are up to an average rate of over 130,000 new cases per day, a rate we haven’t seen since early February. The number of reported cases continues to be an undercount, as we are clearly not doing enough testing. Forty-two states report positive test rates of over 5%.

The seven-day moving average on August 20, 2021, was 137,188.
Daily trends in number of COVID-19 cases in the U.S. reported to CDC

The seven-day moving average on August 20, 2021, was 137,188.
Source: CDC

Implication for employers: More employers are further delaying the return of remote workers. Employers are also planning for the pandemic to continue in some form or another for many months to come. Their employees might again have childcare challenges, as high community transmission rates could lead to intermittent school closures.

The Biden administration announces vaccine boosters

Vaccination rates have been rising a bit and are now an average of over 880,000 new shots per day. This is a big improvement compared to over a month ago, although at this rate, it would still take four more months to get to 75% of the population fully vaccinated.

Research shows that the COVID-19 vaccines continue to provide robust protection against severe illness, hospitalization and death. But it’s clear from published reports and from most of our personal experience that many who are fully vaccinated are getting symptomatic cases of COVID-19. Those who are vaccinated clearly have viral loads that decrease more quickly than in the unvaccinated, but it appears that they can infect others.

In light of reports of waning immunity, the Biden administration announced that those who got mRNA vaccines (Pfizer and Moderna) would be eligible for a third dose eight months after their second doses. There is no recommendation about a booster shot for the Johnson & Johnson vaccine yet, but it was introduced over two months later, so there is more time to review real-world data to decide about boosters. The Biden administration said that this approach was dependent on approval by the Food and Drug Administration and the CDC’s Advisory Committee on Immunization Practices – but this seems likely to come quickly. Those with immune suppression should already be seeking a third injection.

Implications for employers: Employers will need to create policies and procedures to make it easy for employees to get that third jab. They will need to decide whether to include the booster in any vaccination mandate, too.

Vaccination mandates gain steam

In the three weeks since the federal government announced that federal workers would be required to get vaccinated, we’ve seen substantial movement toward vaccine mandates in both the public and private sectors. Many states have announced requirements for vaccination of healthcare workers; a number of states will require vaccination of all state employees, including California, New York, Massachusetts, the District of Columbia, Hawaii, Minnesota, Oregon, Pennsylvania, Puerto Rico and Virginia. All will have religious or medical exemptions, and many will require testing for those who are not vaccinated.

The Biden administration announced this week that nursing homes would need to have a vaccine mandate in place to be eligible for Medicare and Medicaid reimbursement. That’s especially important, since there have been deaths among vaccinated nursing home residents who were infected by unvaccinated employees.

We’ve also seen widespread vaccine mandates for employees of healthcare facilities and of colleges and universities. Campus outbreaks have been associated with nursing home outbreaks, so campus vaccine mandates protect the broader community.

Companies across multiple industries have also started announcing and implementing mandates. These include, among others:

  • Technology: Apple, Cisco, Facebook, Google,* Lyft,* Microsoft, Uber*
  • Financial Services: Blackrock, Citigroup, Goldman Sachs, Morgan Stanley
  • Retail: Saks, Walmart,* McDonalds,* Walgreens*
  • Media: CNN, NBC Universal, Netflix, The New York Times, The Washington Post
  • Manufacturing: Tyson
  • Transportation: Amtrak, United Airlines

*Note: Some companies require vaccination of their corporate employees but not their service workers.

Companies that implement mandates need to communicate them far in advance, since it takes five to six weeks from a first mRNA vaccine to be considered fully vaccinated. They should also clearly define what counts as being vaccinated. For instance, does vaccination with a non-U.S. approved vaccine count, and are recommended boosters part of the requirement? Employers are required by the Equal Opportunity Employment Commission to have a process to allow for religious and medical exemptions, and many are requiring frequent testing of those with exemptions.

Some employers will wonder whether employees will support or oppose vaccine mandates. A recent Gallup Poll last month shows that a majority of employees (52%) favors or strongly favors employer vaccine mandates. Increasing percentages of employees “strongly favor” mandates versus “strongly oppose” them (29%, according to Gallup), as mandates continue to be a polarizing issue.

Implication for employers: While no strategy is likely to lead most companies to a 100% vaccination rate, a vaccine mandate – implemented thoughtfully – is likely to lead to a higher level of vaccination than many other approaches and is worth consideration.

Premium surcharges for those who are not vaccinated

We’ve heard that a number of employers are considering premium surcharges, but these have significant disadvantages. My colleague Julie Stone and I coauthored an article, Employers should think twice about using premium surcharges to boost vaccination, in


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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