Since the United States Food and Drug Administration approved the first vaccine for COVID-19 in December 2020 under an Emergency Use Authorization (EUA), many Americans have eagerly awaited their turn for inoculation amid nationwide shortages, while others have indicated that they are unlikely to get vaccinated at all.^1-3 These issues have prompted concern among public health officials that the voluntary uptake of the vaccine will ultimately be inadequate to reduce transmission of the virus.

In a study published in JAMA Network Open, Largent et al conducted a Gallup survey with a demographically representative national sample of 2730 adults in the United States to explore their likelihood of getting a COVID-19 vaccine and their views toward mandatory vaccination.³ The results indicated that 61.4% of the total sample was likely to get vaccinated, with variations by race and political party.

Black respondents indicated a lower likelihood of getting vaccinated (43.6%; 95% CI, 39.2%-48.2%) compared to non-Black respondents (63.7%; 95% CI, 62.3%-65.2%).

Such disparities have led to discussion about the potential role of vaccine mandates to promote sufficient uptake in the general population and within specific groups. In the Gallup survey, respondents were widely divergent on this topic. Regarding the question of whether vaccination should be required for children attending school, 48.6% of respondents (95% CI, 44.8%-53.0%) indicated that this would be acceptable, while 38.4% of respondents (95% CI, 34.6%-42.0%) viewed it as unacceptable.³

Regarding the issue of state-level vaccination mandates for adults, 40.9% of participants (95% CI, 37.2%-45.0%) viewed them as acceptable, while 44.9% of participants (95% CI, 41.0%-49.0%) viewed them as unacceptable. Regarding employer-enforced vaccination mandates for employees, 47.7% of participants (95% CI, 43.8%-52.0%) found these acceptable, while 38.1% of participants (95% CI, 34.4%-42.0%) found them unacceptable.³

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The greater acceptance observed for employer-enforced employee mandates points to a “potential role for employers to increase COVID-19 vaccine uptake, particularly among key groups such as frontline workers,” wrote Largent et al.³ In December 2020, the US Equal Employment Opportunity Commission issued guidance regarding employers’ rights to require employee vaccination and how to provide needed accommodations.⁴

The variation in acceptance of COVID-19 vaccine mandates by race and partisanship suggest that enacting mandates could prove ineffective and may even lead to backlash in certain geographic areas, according to the authors. In general, vaccine mandates “should be used only if COVID-19 continues to be inadequately contained and voluntary vaccine uptake is insufficient,” they concluded.³

We checked in with the following experts for additional perspectives regarding this controversial topic: Dorit Rubinstein Reiss, professor of law at the University of California Hastings College of the Law in San Francisco, California, and member of the Vaccine Working Group on Ethics and Policy and Lawrence O. Gostin, JD, professor of medicine and faculty director of the O’Neill Institute for National and Global Health Law at Georgetown University in Washington, DC, director of the World Health Organization Collaborating Center on National and Global Health Law at Georgetown, and professor of public health at Johns Hopkins University in Baltimore, Maryland. Dr Reiss and Dr Gostin each co-authored recent papers on the topic.^5,6

What are your expectations about public perceptions of COVID-19 vaccination mandates? 

Professor Reiss:I expect that opinions will diverge. Some people would feel that a mandate is important to protect them from harm and would prefer, for example, a business that mandates COVID-19 vaccines. Others would see a mandate as an unjustified intrusion on their personal autonomy.

Dr Gostin: I don’t believe that the public would trust government mandates, especially as the vaccine is so new. I do think that there would be a more accepting reaction to employer mandates and I expect that many employers, including universities, will require employee vaccination.

What are some of the top anticipated challenges associated with such a mandate? 

Professor Reiss: First, we can expect legal challenges to any mandate. I would anticipate legal challenges alleging that a vaccine cannot be mandated under an EUA. There could be legal challenges demanding a religious exemption, and just direct challenges to the mandate based on personal autonomy. Second, there would be various implementation challenges.

Dr Gostin:I believe that religious communities will want ample exemptions, as will those who have a conscientious belief against vaccinations.

What are some key ways in which these challenges may be addressed?

Professor Reiss: On the EUA front, responses to the legal challenges in court would draw on the fact that the language of the law is not directed at employers or states, and that it expressly suggests that there may be consequences to refusal. On religion, it will be more dependent on the circumstances, and employers may have to provide accommodations.

Dr Gostin:We need to build community trust in the COVID-19 vaccine before we mandate it.

What are recommendations for clinicians regarding how to address this issue in practice?

Dr Gostin:In practice, physicians should carefully listen to patient concerns about the vaccine and seek to reassure them of its safety and efficacy.

What are recommendations for health care facilities considering vaccine mandates for employees?

Professor Reiss:Clinics should consider how to set up mandates if they impose them. At least 5 areas need to be addressed:

What are the consequences of non-compliance? Firing? Working remotely? Extra PPEs?
If all or some of the workforce is unionized, does the clinic need to negotiate with the union? Where does the union stand?
How would the clinic handle medical exemptions? Would it accommodate those who need them, and if so, how? Options include reassignment away from patients, remote work, and again, extra PPEs.
How would the clinic handle requests for accommodation of sincere religious beliefs? Would it provide accommodation, and if so, which process will it use to assess sincerity? A reasonable approach is to require a letter setting out the religious objection, potentially followed by an interview on any questions that arise.
What will the clinic use as documentation of vaccine receipt, and how would it preserve privacy?

Disclosures: Dorit Rubinstein Reiss declared financial affiliations with GlaxoSmithKline.

References

1 Spalding R. Explainer: U.S. has authorized the first COVID-19 vaccine – when will I get it? Reuters. December 11, 2020. Accessed February 5, 2021.

2. Szekely P.Scattered U.S. vaccine shortages halt some COVID-19 inoculations. Reuters. January 15, 2021. Accessed February 5, 2021.

3. Largent EA, Persad G, Sangenito S, Glickman A, Boyle C, Emanuel EJ. US public attitudes toward COVID-19 vaccine mandates. JAMA Netw Open. 2020;3(12):e2033324. doi:10.1001/jamanetworkopen.2020.33324

4. US Equal Employment Opportunity Commission. What you should know about COVID-19 and the ADA, the Rehabilitation Act, and other EEO laws. Updated December 16, 2020. Accessed February 5, 2021.

5. Reiss DR, Caplan AL. Considerations in mandating a new Covid-19 vaccine in the USA for children and adults. J Law Biosci. 2020;7(1):lsaa025. doi:10.1093/jlb/lsaa025

6. Gostin LO, Salmon DA, Larson HJ. Mandating COVID-19 vaccines. JAMA. Published online December 29, 2020. doi:10.1001/jama.2020.26553

COVID-19 Vaccine Mandates: Public and Expert Viewpoints

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