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Though controversial, vaccine mandates are effective

Health and Benefits|Wellbeing
COVID 19 Coronavirus

By Jeff Levin-Scherz, MD | October 20, 2021

Amid declining cases nationwide, employers should continue to create plans to comply with the upcoming federal vaccine mandates and determine the logistics of testing, if applicable.

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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.

Vaccine mandates are being used globally, from Italy (where rules require all workers to be vaccinated) to much of Europe (where rules require vaccination to enter many public spaces), to Indonesia (where all adults must be vaccinated).

In the U.S., the deadline for federal contractors to be vaccinated is December 8, which means that those getting the Moderna vaccine would be required to have their first shots by October 20. Employees have generally complied with employer mandates, and fears of shortages of healthcare workers in New York and police in various locations have not been borne out.

Nonetheless, some states are forbidding mandates. Texas Governor Greg Abbott imposed a ban on COVID-19 vaccine mandates last week, although major employers including those based in Texas have signaled that they intend to abide by the conflicting, soon-to-be-released federal rules on vaccine mandates. The Occupational Safety and Health Administration Emergency sent temporary standards to the Office of Management and Budget this week.

Implications for employers: Employers should continue to build their plans to comply with the upcoming vaccine mandates and work out the logistics of testing, if applicable. Many employers should consider starting to communicate details of their mandates to employees soon.

FDA panel unanimously recommends booster shots of Moderna and J&J vaccines

With Pfizer booster shots already underway, the Food and Drug Administration (FDA) Advisory Committee unanimously recommended booster shots for those over age 65 and those at increased occupational or residential risk who received the Moderna vaccine six or more months earlier. The booster shot, with half the active ingredient of the initial inoculations, was shown to substantially increase antibodies, and there is good reason to believe it will decrease the rate of infections. This recommendation still needs to be approved by the FDA and guidelines for use must be approved by the CDC – but both are likely to act quickly, and Moderna boosters will likely be available in the next few weeks.

The FDA also recommended boosters for those who received the single-dose Johnson & Johnson (Janssen) vaccine last week, and reviewed evidence from a number of trials that suggests “mixing and matching” vaccines can produce more effective protection. Many countries are already using mRNA vaccines as boosters for those initially given adenovirus vaccines (like J&J and AstraZeneca) or inactivated-virus vaccines (Sinovac and Sinopharm). We’ll learn later this week what final recommendation the CDC will make on boosters for both Moderna and Johnson & Johnson vaccines.

We clearly need to increase vaccine production to get vaccination rates up in lower income countries, but people in wealthier countries like the U.S. are getting boosters from supplies that cannot easily be transferred elsewhere, so should not feel guilty about getting boosters. Boosters are most important for the elderly and those whose immune systems are compromised. The boosters are likely to decrease risk much less than the primary series, so getting the unvaccinated their initial inoculations remains most important.

Much of the evidence supporting booster shots has come from Israel. Below is a graphic showing a decline in new cases about two weeks after the country started giving booster shots to those over age 60. Data from 3.7 million third doses showed fewer adverse effects than from the second dose.

In Israel, new cases began to decline for those over the age of 60+ about two weeks after the country started giving booster shots to this age group. They continued to increase for those over age 60 who hadn’t received a booster.
COVID-19 cases in Israel for age 60+ versus those under age 60 – post-administration of 60+ COVID-19 booster

Source: Israel Ministry of Health via the FDA, October 14, 2021.

Implications for employers: The evidence for booster shots is improving, and companies that are collecting data on employee vaccination should consider tracking boosters too, although at this point, they shouldn’t include the requirement for boosters in any mandates.

Cases still on the decline in the U.S., although hospitals are still short of capacity in a few states

Case counts are down about 12% from last week, and both hospitalization and death rates are also declining.

On Oct 15, 2021, the seven-day moving average for new cases was 80,313 and there were 169 deaths per 100,000.
Daily trends in number of COVID-19 cases and deaths in U.S. reported to CDC

On Oct 15, 2021, the seven-day moving average for new cases was 80,313. Source: CDC

Nonetheless, 88.5% of U.S. counties continue to report high levels of community transmission (>100 cases per 100,000 residents per week), and 7% of counties report substantial rates of community transmission (>50 cases per 100,000 residents per week). It’s heartening to see that cases are not increasing with schools open across the country, although hospitals in a few states, including Minnesota and Michigan, are facing hospital and ICU bed shortages.

Implications for employers: School disruptions have not been widespread and are stabilizing. The high rate of community transmission in most of the country means that indoor masks are still recommended, and efforts to increase vaccination are still critical to decrease community transmission.

The majority of the U.S. still has a high rate of community transmission.
Level of community transmission

Source: CDC, October 15, 2021

The majority of counties in the U.S. have high or substantial levels of COVID-19 transmission with the following data: High Total 2730, Percent 84.73%, Change -4.44% Substantial Total 320, Percent 9.93%, Change 3.2%
Data on infections among the vaccinated from the U.K.

The U.K. has been assiduously tracking infection rates among those who are vaccinated, and the data show a complicated but ultimately reassuring picture. In contrast, the U.S. decided to track only severe disease and death among those who are vaccinated, and reporting varies substantially by state, so it’s much harder to draw conclusions from U.S. data.

Data from the last four weeks show that vaccinated people in the U.K. in their forties are twice as likely to have a COVID-19 infection compared to those who are unvaccinated. There are some potential explanations, including that those who are vaccinated are more likely to be tested if they have mild symptoms; therefore, they are more likely to be diagnosed.

Vaccinated adults in the U.K. in their forties are twice as likely to have a COVID-19 infection compared to those who are unvaccinated, but less likely to be hospitalized or die from the infection.
COVID-19 relative risk for vaccinated adults in the U.K.

Source: U.K. Health Security Agency, COVID-19 vaccine surveillance report.

The most commonly used vaccine in the U.K., the AstraZeneca vaccine, appears to be less effective than the mRNA vaccines (e.g., Pfizer, Moderna) mostly used in the U.S. But look at the yellow and blue bars in the graph above to see the good news here. In every adult age group, those who are vaccinated are about four to five times less likely to be hospitalized, and about five to eight times less likely to die compared to those who are unvaccinated.

It’s disheartening to see how many so-called “breakthrough” infections are reported, although those who are vaccinated are highly likely to have milder symptoms and less likely to get long COVID-19. The data further support booster shots, although it will be months before we know just how much additional protection these offer. There is no question that the data illustrate the enormous value of vaccines to prevent hospitalization and death.

U.K. summary of continued effectiveness of vaccinations
Source: U.K. Health Security Agency, COVID-19 vaccine surveillance report
Outcome Pfizer (Comirnaty) Moderna (Spikevax) AstraZeneca (Vaxzevria)
Infection 75% – 85% Not enough data 60% – 70%
Symptomatic disease 80% – 90% 90% – 99% 65% – 75%
Hospitalization 95% – 99% 95% – 99% 90% – 99%
Mortality 90% – 99% Not enough data 90% – 95%

Implications for employers: Focus should remain on getting employees their primary vaccination series. Unvaccinated employees continue to be far more likely to spread disease.


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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