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Debate over vaccine mandates continue as employers await OSHA rule

By Jeff Levin-Scherz, MD, MBA | September 22, 2021

As U.S. vaccination rates lag those of other developed countries, about one in five employers already have a vaccine mandate in place.
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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.

President Biden directed the Department of Labor’s Occupational Safety and Health Administration (OSHA) to issue emergency temporary standards requiring employers with more than 100 employees to mandate vaccines and require weekly testing for employees who are not fully vaccinated. These regulations have not yet been published, and a number of governors and attorneys general have already expressed their intention to sue to block enforcement.

According to our most recent survey of almost 1,000 employers in late August, about one in five employers had vaccination mandates in place, and 52% reported they would have a mandate in place, were planning a mandate or were considering a mandate before the end of this year. Many employees feel reassured to know that most or all of their colleagues will be vaccinated. Although some employees say they will quit if faced with a mandate – real world experience is that a very small number will leave (this was well under 1% at Houston Methodist). An appropriate exemption policy that includes testing at the appropriate frequency can help prevent attrition among employees who are opposed to vaccinations while maintaining workplace safety.

Employers that achieve high vaccination rates among their employees significantly decrease their business risks, as unvaccinated employees could get sick, could bring COVID-19 to the workplace and would have to quarantine for 14 days if they have an exposure inside or outside the workplace. Vaccine mandates might not be right in all instances, but are clearly an effective way to protect companies, their employees and families and the community.

Implication for employers: Vaccine mandates can decrease risks from unvaccinated workers. Employers need not wait until the emergency temporary standard is in place and has been fully litigated to implement a vaccine mandate.

CDC shows continued effectiveness of vaccination

The CDC published research in their Morbidity and Mortality Weekly Review showing that the vaccinations remain highly effective in preventing hospitalization and death, and very effective at preventing COVID-19.

The graphic below illustrates that those who are vaccinated are more than five times less likely to get infected (that’s an 80% vaccine effectiveness rate) and more than 10 times less likely to get hospitalized or die (that’s a 95% vaccine effectiveness rate).

Those who are vaccinated are more than five times less likely to get infected and more than 10 times less likely to get hospitalized or die – a 95% vaccine effectiveness rate.
Weekly trends in age-standardized incidence of COVID-19 from 13 U.S. jurisdictions

Rates are standardized by age, according to the 2000 U.S. Census age distribution. Vertical lines indicate when the Delta variant reached a threshold of >50%, using weighted estimates for 13 jurisdictions combined. Source: CDC September 10, 2021.

Notice that the purple line (vaccinated) is always at much lower risk than the yellow line (unvaccinated). There is a modest uptick of cases among those who are fully vaccinated (left), but only a very small uptick for hospitalizations (middle) and deaths (right) among the vaccinated. The CDC also showed that protection from the vaccines remains strong across all age groups but was strongest in those who were younger (age 18 to 49) and weakest among those over age 65.

We see news reports regularly showing someone who dies of COVID-19 despite being fully vaccinated. But someone staying healthy is not news. We don’t see many news reports heralding the estimated 279,000 whose lives were saved (as of July 2021) by the U.S. vaccine rollout.

Unvaccinated employees continue to represent a business risk to employers, and they should continue to do everything they can to increase employee vaccination rates.

Vaccines continue to be effective against the Delta variant, but at least some will need boosters

The Food and Drug Administration’s (FDA) advisory committee voted last week to recommend booster shots of the Pfizer COVID-19 vaccine (Comirnaty) for those over age 65 and at high risk from COVID-19. This is consistent with recommendations in many other countries, although the Biden administration had announced wider booster availability, and the World Health Organization has urged countries to delay booster shots to send vaccines to countries where few have had their first shots. The FDA is not obligated to follow this recommendation, and the CDC’s Advisory Committee on Immunization Practices will formulate its recommendations after the FDA decision. At this point, there are no recommendations for booster shots for those who received the Moderna or Johnson and Johnson (Janssen) vaccines.

New England Journal of Medicine (NEJM) published research on Thursday that showed the Pfizer vaccine remained 91.3% effective at preventing all disease six months after vaccination. The NEJM also published an article showing that COVID-19 rates were reduced substantially in about a million people age 60 and over who received a booster shot compared to those who did not get a booster shot. The study done by the Israeli Ministry of Health is huge (1.1 million over age 60 got booster shots), but it is limited to 25 days. An observational study like this can miss some confounding issues (like age), and we don’t know if a temporary boost in antibodies provides sustained benefits.

Implications for employers:

  • Employers shouldn’t place restrictions to prevent payment for administrative costs for a third dose, as this is already recommended for some employees.
  • It’s premature to include boosters in any vaccine mandate program at this point, although employers can “future proof” their vaccine mandate program by designing it to capture the information necessary to add these if indicated in the future.

U.S. COVID-19 surge continues

The number of average daily cases is back up to over 146,000 after declining over the past few weeks. We’re at just under 2,000 deaths per day – nowhere near as bad as winter 2021 – but still a terrible toll. Hospitals have reported being overwhelmed in a number of states, including Alabama, Idaho, Alaska, Iowa and Oregon. The U.S. vaccination rate continues to lag other developed countries; our seven-day average is around 600,000 per day, although this rate has  fallen over the past few days.

After a slight dip a week ago, both new COVID-19 cases and deaths are climbing.
Daily trends in number of cases and seven-day cumulative incidence rate of COVID-19 deaths in the U.S. reported to the CDC, per 100,000 population

Source: CDC, September 17, 2021.

According to the New York Times, one in four hospitals in the South have reported that over 95% of intensive care unit beds are occupied. This may mean that elective surgeries will be deferred in some regions and non-COVID-19 care will be adversely impacted.

Implications for employers: The continued high rate of new cases and hospital overload are compelling reasons to continue to press for more vaccination, and people should wear masks indoors in public spaces in communities with high rates of transmission. Employers will likely continue to pause or slow plans to return employees to the workplace until this wave has subsided.

Data on long COVID-19

Long COVID-19 has been reported since the spring of 2020. Jackie Reinberg, Mike Xarras and I published an article on disability implications for employers in Human Resources Executive in May.

The CDC surveyed over 3,000 U.S. adults, and about 22% of reported a positive COVID-19 test result. Many of the symptoms of long COVID-19 reflect complaints often expressed by those who are otherwise healthy, so the researchers compared complaints in the post-COVID-19 group with those reported by respondents who never had COVID-19.

The researchers found that those who had previous COVID-19 infections were substantially more likely to suffer from loss of taste or smell, shortness of breath, chest pain, cough, post-exertional malaise and fatigue. They did not report more cognitive dysfunction than respondents with no history of COVID-19, and surprisingly had significantly less mood change, muscle pain and insomnia. Other studies have shown more cognitive dysfunction.

65.9% of respondents whose COVID-19 test results were positive reported symptoms lasting over four weeks compared with 42.9% of those whose test results were negative.
Long-term symptoms among adults tested for COVID-19

Source: CDC, Wanga V., Chevinsky J.R., Dimitrov L.V,, et al, January 2020 – April 2021.
*Indicates a statistically significant increased risk for those who had COVID-19.

An earlier Swedish study of healthcare workers who had mild COVID-19 found that 8% had symptoms that interfered with their work eight months after infection, compared to 4% in the control group of healthcare workers who did not have COVID-19.

Implications for employers: COVID-19 has already been reported to be a leading cause of short-term disability; vaccination reduces the risk of long COVID-19 and the likelihood of employees’ requiring leave time while managing debilitating symptoms.


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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