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Should employers require masks and vaccination?

By Jeff Levin-Scherz, MD, MBA | September 7, 2021

As Delta cases continue to rise, our survey shows twice as many employers’ report vaccine mandates compared to May 2021.
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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.

The U.S. continues to see a high number of cases of COVID-19. We remain at over 150,000 new cases a day — and that’s likely an underestimate because many with mild cases have not been tested and more people are using home antigen tests. Hospitals continue to report shortages of ICU beds in states, including Alabama, Florida and Texas, although the national average of new hospitalizations is down about 2% from the previous week.

The seven-day moving average was 150,316 on September 3, 2021.
Daily trends in number of COVID-19 cases in the U.S. reported to CDC.

The seven-day moving average was 150,316 on September 3, 2021. Source: CDC

A randomized, controlled trial of mask use

Researchers in Bangladesh enrolled almost 350,000 people from 600 rural villages in Bangladesh and randomly assigned village interventions that promoted the use of surgical masks while the Alpha variant predominated. The most effective interventions were providing free masks, communicating the importance of covering the mouth and nose, reminding people who were unmasked to mask in public and role modeling by community leaders. Mask use more than tripled (from 13% to 42%) in the communities that used these interventions. Cloth masks reduced infections too, but this protection did not reach statistical significance. The rate of respiratory symptoms decreased by 12% in the villages with higher surgical mask use, and blood tests confirmed COVID-19 decreased by 11%. Many commentators have pointed out that this 12% protection rate is likely a “floor,” and protection would be greater if mask use were higher.

Implications for employers: This evidence supports guidelines to encourage or mandate masks indoors. Almost every county (96.7%) has high or substantial transmission right now, although hopefully that will decrease later this fall. Wearing high quality masks properly is most effective.

Willis Towers Watson’s recent vaccination survey highlights

Nine hundred and sixty-one employers with a total of 9.7 million employees completed our most recent survey on COVID-19 and the workplace.

Our recent survey found twice as many employers (21%) report vaccine mandates already in place compared to May 2021 (9%). Another 8% of employers are planning mandates in Q3, and 23% are considering mandates in Q4.
Companies with vaccination requirements in the workplace

Twice as many employers (21%) report vaccine mandates already in place compared to May 2021 (9%). Another 8% of employers are planning mandates in Q3, and 23% are considering mandates in Q4. Source: Summer 2021 COVID-19 Vaccination and Reopening the Workplace Survey

Among other important findings:

  • One in six employers reported that they offer financial incentives (17%), and an additional 15% were planning or considering.
  • Only 1% currently offered premium reductions or surcharges, although 13% to 16% were planning or considering.
  • Almost two-thirds were tracking (59%) or planning to track (8%) vaccination status.
  • Most required proof of vaccination, such as a completed CDC card (62%). Only 2% expected to include electronic validation with a state database, and 36% reported they relied on self-reporting.
  • Only one in 11 (9%) reported they were requiring vaccine as a condition of employment now; 5% were planning to do so, and 17% were considering.
  • 80% said they were requiring employees to wear masks indoors; five times as many (76%) said this requirement was for all employees as opposed to unvaccinated employees only (15%).
  • Four times as many respondents (39%) said they would not reach their “post-COVID-19 normal” until Q2 2022, compared to 10% of respondents in late May.

Employer vaccination mandates: Key considerations

Many of our clients are considering vaccine mandates. Here’s a list of key questions to ask:

  1. Who is subject to the mandate?

    Most companies will make their mandates universal, although some will implement these for segments of employees. Some companies in the U.S. have mandated vaccination for corporate employees but not frontline workers, even though they are at higher risk of COVID-19. Employers can strongly encourage but cannot mandate vaccination of spouses and dependents.

  2. What vaccines are acceptable?

    Most companies will accept any vaccine that is authorized for use in the U.S., (i.e., those manufactured by Pfizer, Moderna and Johnson & Johnson). An alternative is to accept any vaccination approved by the World Health Organization. Booster shots are just becoming available; most companies will not initially require booster shots as part of an initial mandate, although this can be added later.

  3. What proof of vaccine is required?

    In our survey, most companies (62%) reported that they would require employees to provide proof such as their CDC vaccination card. Thirty-six percent said they would ask employees to attest to vaccination, while only 2% said they would search state databases for vaccination. Companies that collect employee vaccination status must store this data securely to protect employee privacy.

  4. What are criteria for exemption?

    Most employers will accept a provider note for medical exemption and a personal statement for a religious exemption. They will rarely require a note from the clergy, as an employee can have a sincerely held religious belief that is not reflected in the formal doctrine of their religious organization.

  5. What are accommodation standards for those who are exempted?

    Employers mandating vaccination can require that those who receive exemptions be tested regularly or tested more frequently than vaccinated employees. Those with positive tests should not come to work and should get a PCR test for confirmation.

My colleague Mike Orszag and I provide further insights on this topic in our recent article, Should your company implement a vaccination mandate? in Harvard Business Review.


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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