Intended for healthcare professionals


Covid-19: US imposes mandatory vaccination on two thirds of workforce

BMJ 2021; 374 doi: (Published 13 September 2021) Cite this as: BMJ 2021;374:n2238

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  1. Owen Dyer
  1. Montreal

All US companies employing more than 100 people must require their staff to be fully vaccinated or have weekly covid tests, said President Joe Biden in a televised speech that was marked by a new, harsher tone towards unvaccinated people.

“My message to unvaccinated Americans is this,” said Biden. “What more is there to wait for? What more do you need to see? We’ve made vaccinations free, safe, and convenient. We’ve been patient, but our patience is wearing thin, and your refusal has cost all of us. So please, do the right thing.”

With just 53.7% of Americans fully vaccinated, the number of new infections has climbed steadily to above 150 000 cases a day and deaths to about 1500 a day, mostly among unvaccinated people.

The vaccine requirement for large employers will cover about 80 million workers. Biden’s executive order also requires the vaccination of all workers in healthcare settings that bill Medicaid or Medicare. That measure covers roughly 50 000 providers and 17 million healthcare workers.

“Today, in total, the vaccine requirements in my plan will affect about 100 million Americans, two thirds of all workers,” said Biden.

The government will also strengthen the mandate on its own employees. Until now, these have had the options of vaccination or weekly testing. The weekly testing option will now be removed, a measure the Biden administration is urging state governments to follow.

Biden will also order the Transportation Security Administration to increase fines on travellers who do not wear masks in airports or on buses and trains. The minimum penalty for a first offence will double, to $500 (£360; €425).

A bill introduced in Congress on 10 September by the Virginia Democratic representative Don Beyer would also require proof of vaccination or a negative test from all domestic travellers at US airports.

Governors of several Republican led states immediately vowed to fight Biden’s executive orders in court. The governor of Texas, Greg Abbott, called the regulations “an assault on private businesses” and said his state was “already working to halt this power grab.”

Republican voters are far less likely than Democrats to be vaccinated. An NBC poll last month found that 88% of Democrats but only 46% of Trump supporting Republicans said they had been vaccinated.1 Several Republican led states with low vaccination rates have been hard hit by the delta variant, such as Texas, North Dakota, and Georgia. The president pointed to their governors in his remarks.

“What makes it incredibly more frustrating is we have the tools to combat covid-19, and a distinct minority of Americans, supported by a distinct minority of elected officials, are preventing us from turning the corner,” said Biden.

“These pandemic politics . . . are making people sick, causing unvaccinated people to die. If these governors won’t help us beat the pandemic, I’ll use my power as president to get them out of the way.”

Reaction to the new rules from the business world was muted. The Business Roundtable, a group of chief executives of some of the country’s largest companies, said it “welcomes the Biden administration’s continued vigilance in the fight against covid.” The US Chamber of Commerce said it would “carefully review the details of the executive orders and associated regulations.”

Some large companies, such as McDonald’s, Delta Air Lines, and Tyson Foods, already require either vaccination or regular testing among their US workforces.

Polling shows the public evenly divided on mandatory vaccination for staff, with 50% of working Americans supporting such measures in a recent Associated Press and University of Chicago poll and 52% of all Americans in a Washington Post and ABC poll.23 In both polls Republicans were largely opposed and Democrats largely in favour.

In both polls, majorities of non-workers and remote workers favoured mandatory vaccination among employees, but only 47% of those who go to work did. While many employers will secretly welcome the push from outside, many workers and managers will be dreading office showdowns. In the Washington Post and ABC poll, 72% of workers who were not vaccinated claimed that they would quit before accepting a mandatory shot.