Employer interest in mandates rises as Pfizer vaccine receives FDA approval

Although vaccine rates are up, COVID-19 cases continue to climb in the U.S., reaching almost 150,000 new cases per day. Only four states have seen a decline in cases over the last week — they are the states that had the highest rates of infections over the last month (Missouri, Arkansas, Louisiana and Mississippi). Most of the country continues to have high or sustained rates of community transmission (more than 100 cases per 100,000 per week for high transmission, and 50 to 99 cases per 100,000 per week for sustained). We are moving into school reopening season with relatively high rates of COVID-19 infection in most states, and we’ve already seen outbreaks around the country at schools that reopened in August.

The FDA’s full approval of the Pfizer COVID-19 vaccine, now named Comirnaty, has increased employer interest in vaccine mandates. The U.S. military announced a vaccine mandate, as did Walt Disney Co., CVS Health Corp. and Chevron Corp. Vaccine mandates had earlier been announced by a wide variety of companies. Vaccine rates are also up — we are now giving an average of 892,000 doses per day — which means it would take four months to get 75% of the population fully vaccinated.

Daily trends in number of COVID-19 cases in the U.S. reported to CDC

The seven-day moving average on August 27, 2021, was 149,334.
Source: CDC

Implications for employers: Many employers have already delayed or scaled back returning remote workers to the workplace, and that trend will likely continue. We should be prepared for schools to intermittently close or require quarantines for exposure, which will require continued flexibility for employees with children.

New vaccine effectiveness and safety data

Increased risk from COVID-19 infection per 100,000

Those who had COVID-19 suffered substantially more kidney disease, heart disease and blood clotting. Source: New England Journal of Medicine, August 25, 2021.

A large study from Israel published in the New England Journal of Medicine shows the impressive safety and effectiveness of the Pfizer vaccine. Researchers matched over 800,000 members of one health maintenance organization who were vaccinated with those who were unvaccinated and found the vaccine to be incredibly safe. Then they compared those who were vaccinated with 234,000 people who had documented COVID-19 infections, which illustrated that those who had COVID-19 suffered substantially more kidney disease, heart disease and blood clotting.

Meanwhile, the CDC published data from 4,000 healthcare workers showing that effectiveness of vaccines against the Delta variant remains robust, but diminished compared to effectiveness against previous strains. Overall, efficacy of vaccines was 85% for the first four months after vaccination, 81% for the next month, and 73% for six or more months after full vaccination. This is part of the reason why there is a move to recommend booster shots even for those with no immune system impairment. Overall, vaccine efficacy dropped from 91% pre-Delta to 66% since the Delta variant has become the predominant strain.

Implications for employers: COVID-19 vaccines are still the best way to prevent workplace exposure and decrease COVID-19 infections in the community. Since the vaccine’s protection is less complete with the Delta variant, indoor mask mandates that include those who are vaccinated can further prevent exposure.

COVID-19 in children

Pediatric cases are increasing. The latest report from the American Academy of Pediatrics shows that 180,175 cases were added in the week prior, which is essentially at the high-water mark for pediatric cases last winter. California and Florida have the highest cumulative cases (probably because of their larger populations), but Mississippi and Hawaii have the largest growth in cases.

Fortunately, hospitalizations and deaths remain much rarer among children compared to adults, but with the increasing numbers of infections, these outcomes are rising as well.

Why is this happening?

• Delta is different. Delta is much more infectious than its predecessors and the rise in pediatric cases in the U.S. tracks with the rise of the Delta variant.
• Mask/Social distancing measures were eased or removed. In late spring and early summer almost all mandatory restrictions around movement and closeness had been removed, which contributed to the ease of virus transmission.
• School restarted. For many school districts, particularly those in the southern part of the U.S., school starts in August. The comingling of children likely contributed to higher infections. Additionally, some kids may have been tested prior to starting sports or other activities, and thus they were identified when perhaps they wouldn’t have been without the start of school and activities.
• Variable vaccination rates. The largest increase in cases (for adults and children) are in the states with the lowest vaccination rates. If the adults are infected, children at home are more likely to be infected.
• No vaccinations for children under 12 years of age. The lack of available vaccines for this age group makes them more vulnerable. One would expect them to become a higher proportion of the total cases as a result, but the proportion at this time (22% of all cases are pediatric) is quite high — likely driven by the factors noted above.
• Respiratory syncytial virus (RSV) season. Lastly, some children may become sicker with COVID-19 if they have underlying RSV, which commonly gives children respiratory illness in winter. For reasons not completely understood, the U.S. is having a peak in cases during summer, which may be driving some of the pediatric hospitalizations.

As for whether this is a harbinger of things to come, employers should anticipate that pediatric cases will increase over the next month as more schools open across the country, then we’ll likely see a decrease. Hopefully, the Pfizer vaccine will be approved for age five to 11 by September/October, which would cover most school-age children. If that happens, along with whatever mandates might occur, this may drive down the infection rate among children by the end of the calendar year.

Authors

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Jeff Levin-Scherz, MD

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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Patricia Toro, MD

MPH WTW Senior Director, Health Management Practice, Health and Benefits

Patricia is a physician and infectious disease specialist who consults with employers to improve the quality and cost-effectiveness of health care delivery. She has guest lectured at Harvard Medical School and currently develops pandemic responses and programs to address chronic conditions.

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