State COVID-19 vaccine mandates increased vaccine uptake by healthcare workers in 2021

In a recent study published in JAMA Network Openresearchers investigated the relationship between state mandates for 2019 coronavirus disease (COVID-19) vaccination for health care workers (HCW) and vaccination rates among them.

Background

Vaccines are vital in combating devastating epidemics such as smallpox, cholera and bubonic plague. However, personal experience, religious views, and cultural attitudes all influence vaccination decisions. Policy initiatives, such as vaccination mandates, are critical to promoting widespread vaccination, particularly in hospitals.

Before COVID-19, more than 20 US states mandated flu shots for health care workers, and more than a dozen added comparable requirements for hepatitis B and measles, mumps, and rubella vaccination. As of mid-2021, 17 states have mandated COVID-19 vaccines for healthcare professionals, sparking heated debate over ethics, personal autonomy, and considerations of public benefit. Divergent views were discovered among HCWs, with acceptance rates varying between generations. More empirical information is needed to determine the impact of these laws on health care personnel.

About the study

In the present cross-sectional study, researchers examined the impact of the COVID-19 vaccination regulations on healthcare professionals in the United States. They investigated whether the association changed based on the stringency of the mandate, the availability of the test option, and the age of the HCW.

The researchers included 16 states, namely Connecticut, Colorado, California, Illinois, Delaware, Maryland, Maine, New Jersey, Massachusetts, New York, New Mexico, Pennsylvania, Oregon, Washington, Rhode Island and Washington, District of Columbia, excluding Mississippi. They analyzed individual-level, twice-weekly data from Household Pulse Survey (HPS) participants between May 26 and October 11, 2021. HPS respondents were aged 25 to 64 and had volunteered or worked in health care settings since January 2021 .

The researchers conducted analyzes from November 2022 to October 2023. The report of the study was the statement of state-level vaccination requirements for healthcare professionals for COVID-19. Primary outcome measures were rates of vaccination against COVID-19 and completion status of the primary vaccine series. The researchers used the difference-in-differences (DID) laddered-type approach to assess vaccination uptake among health care professionals in mandated and non-mandated states before and after the mandate.

The researchers stratified the sample by availability of COVID-19 testing instead of vaccinations (ie, testing options) and by HCW age (25- to 49-year or 50- to 64-year-old groups) to assess heterogeneous associations. Study covariates included age, sex, race, ethnicity, education, marital status, household income, and severity of COVID-19. The researchers measured the intensity of the pandemic based on state-level deaths two weeks before each survey week in 2021. They incorporated survey weights that indicate the inverse probabilities of sampling people in the HPS study. Additionally, since the scope of the mandate may vary from state to state, they performed a robustness check by excluding states with long-term and state-level mandates for hospitals and health care facilities.

Results

Among 31,142 health care personnel (median age, 46 years, 72% female, 72% white, and 87% non-Hispanic) from 45 US states, including 16 that announced vaccination mandates for COVID-19, 43% were from mandate states and 57% came from unauthorized states. Compared with HCWs from control states, those from mandate states tended to be Hispanic (16%), college graduates (51%), and earned at least $100,000 per year (35%). They were least likely to be married (58%), black (14%) or white (67%).

Most HCWs were vaccinated before the mandate (84%), of which 88% were from mandate states and 82% from control states. The analysis showed a 3.5% increase related to the mandate in the percentage of health care workers who had ever received vaccines for COVID-19 and a 3.7% increase in the percentage of HCWs who had completed or wanted to complete two-week primary vaccinations after the mandate statement from the base rates of 88% and 86%, respectively.

Stratified analyzes showed positive associations only for mandate states with no testing options and among health care workers between the ages of 25 and 49, indicating vaccination rate improvements of 3.2% to 7.1% compared with the basic rates. Estimations using Sant’Anna and Callaway covariates and two-way fixed effect (TWFE) estimators yielded similar results. Excluding states with mandates only for hospitals, long-term care facilities, and government health care facilities provided consistent results.

conclusions

The study reveals that state-level COVID-19 vaccination mandates for health care workers in mid-2021 significantly increased vaccination uptake and completion rates. The team mainly noticed an increase in the first four weeks after the order was announced. They found positive associations only in states without testing options and among younger health care workers. The study demonstrates that vaccination mandates can increase vaccine uptake in a widely vaccinated population, especially with stringent requirements.

The rapid impact of the requirements may come from employer mandates pushed by health care groups and the federal government ahead of the Center for Medicare and Medicaid Innovation (CMS) nationwide order announced on November 4, 2021. improvements in vaccine uptake waned in weeks four and five of the post-mandate period, which corresponds to the CMS plan to require COVID-19 vaccination in all Medicare- and Medicaid-funded health care facilities in September 2021.