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Coercion and incentives: Two approaches to increase COVID-19 vaccination rates

Health and Benefits|Wellbeing
COVID 19 Coronavirus

By Jeff Levin-Scherz, MD | June 15, 2021

Daily COVID-19 vaccinations have recently risen to back over one million a day as organizations and government work to increase rates in areas that lag behind.

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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.

COVID-19 immunizations have ticked up a bit over the last week to 1.13 million doses a day. Currently, 142 million in the U.S. are fully vaccinated. States have been bringing vaccines to the unvaccinated, and many states are doing lotteries or other approaches to increase public attention to the widespread availability of safe vaccines, which can help us all return to normal.

Philadelphia vaccine lottery

The city of Philadelphia unveiled an interesting new lottery designed by behavioral economists at University of Pennsylvania. Every resident of Philadelphia is automatically entered into the lottery, and there will be three drawings over six weeks with prizes ranging from $1,000 to $50,000. Residents will have to show that they had at least one vaccination before the drawing to be eligible to collect the prize. There is a secondary drawing two weeks before each lottery to designate one of twenty ZIP codes with low vaccination rates; half of the winners in each drawing will come from the chosen ZIP code.

There is a lot to like about this approach:

  • It prioritizes motivating under-vaccinated communities.
  • This is a “regret lottery” where those who are chosen, who didn’t get vaccinated, will know that they lost thousands.
  • The lottery is repeated – leading to more publicity.
  • There are many prizes – not just one giant prize, and the amounts are significant.

I’ll be watching to see how the lottery affects the vaccination rate in Philadelphia as this rolls out. The city now has vaccinated only 48.3% of its adults age 18 and older, compared to 64% for the entire country.

Hospital system suspends employees who are not vaccinated

Houston Methodist was the first hospital system to publicly announce a vaccine mandate for employees. The hospital system earlier this week suspended 178 employees who were not fully vaccinated. Of those, 27 had a single dose and could be reinstated when they finished the course of vaccination. There was a very high rate of compliance with vaccination in that hospital system and the hospital offered some exemptions. Many health care facilities are likely to mandate vaccines because of the risk posed by unvaccinated people to patients, some of whom have compromised immune systems and could be susceptible to COVID-19 even if they were vaccinated.

Big drop-off in childhood vaccinations

The CDC reported today that childhood vaccinations, which dropped precipitously in Spring 2020, didn’t recover very much in the summer and early fall. This could mean a high risk of outbreaks of measles, chickenpox and other childhood diseases as children return to school and the world reopens. Although employers generally focus on the care of adults, increased childhood illness could have a devastating effect on employees and the workplace. Decreased HPV vaccination could also lead to preventable cervical, and head and neck cancers for decades to come. Childhood vaccinations prevent illness, save lives and decrease net medical costs. Employers should emphasize the importance of childhood vaccinations when they are communicating about preventive care.

Data from Spring of 2020 document a marked decline in typical pediatric vaccine administration.
Data from 10 U.S. jurisdictions, March 2020 to September 2020

Early reports during the pandemic documented a marked decline in pediatric vaccine administration.
Source: CDC

COVID-19 numbers in the U.S. continue to improve, and we are at less than 15,000 new cases a day. New hospitalizations are down to 2,238 a day (down almost eight-fold from January), and the seven-day average of deaths per day is under 350. The COVID-19 pandemic still represents a terrible tragedy for many who are sick and for their loved ones and friends, but all signs suggest that we will continue to see a decline in cases, hospitalizations and deaths in the coming months.

The moving seven-day average for June 12, 2021, was 13,005.
Daily trends in number of COVID-19 cases in the U.S. reported to CDC

The moving seven-day average for June 12, 2021, was 13,005.
Source: CDC.

Effective immunity from past COVID-19 infection

The Cleveland Clinic reported that there were no cases of COVID-19 for five months after employees had a natural infection. There were also no COVID-19 cases in employees who were vaccinated. This is a large study, over 50,000 employees, but people who have already had COVID-19 should still get vaccinated. The antibody levels from vaccination are higher than those from natural infection and will likely persist for longer. The Gamma variant (P.1, Brazil) appears better able to evade immunity from natural infection and was likely uncommon in the Cleveland Clinic population during this study.

Update on variants

While we’re talking about variants, here is the latest CDC data on variants of concern in the U.S. Alpha variant (B.1.1.7, U.K.) remains dominant, and there is not much Delta variant (B.1.617, India), although that is likely to increase. The Delta variant now represents 91% of cases in the U.K., and the U.K. has reported a dozen deaths among those fully vaccinated.

The U.K. (B.1.1.7) variant is by far the most common in the U.S.
COVID-19 variant proportions in the U.S. reported to CDC

The U.K. (B.1.1.7) variant remains the most common in the U.S.
Source: CDC.

As the effort to vaccinate all those age 12 and older continue and as variants persist, states and employers should continue efforts to increase public attention to the widespread availability of safe vaccines, which can help us all return to normal.


Population Health Leader, Health and Benefits, North America

Jeff is a practicing physician and has led Willis Towers Watson’s clinical response to COVID-19. 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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