Vaccine Mandates Are Becoming More & More Common. Will They Work?

In light of the contagious Delta variant, an uptick in COVID-19 cases, and dwindling vaccination rates across the U.S., there's been more and more discussion and debate about the ethics — and efficacy — of vaccine mandates. Companies, including some airlines, are requiring that employees get vaccinated before entering the workplace, and many schools and colleges are also mandating students get jabbed. But 18 months after the first confirmed case of COVID in the U.S., is it time for something more drastic?

While some critics are frustrated that President Joe Biden hasn't done more in favor of vaccine mandates (on July 6, White House Press Secretary Jen Psaki said that the administration has no plans to encourage schools and companies to require vaccination), Dr. Anthony Fauci has pushed for more local mandates, but not a federal one. As The New York Times points out, it's mostly up to states, local governments, and private companies to make these kinds of decisions. What, then, would it take to get more local vaccine mandates in place? And more importantly, would they help us flatten the rate of infection in the U.S.?

Although COVID-19 is an unprecedented crisis, a vaccine mandate is would hardly be a novel concept, especially for American public school students. When it comes to schools, states — rather than the federal government — set vaccination requirements, all with different regulations and reasons for exemption. In 15 states, for example, students can sidestep a vaccination if they have "moral and ethical" concerns, while all 50 states allow exemptions for medical reasons, like weak immunity or allergies. 

According to Dr. William Schaffner, MD, a professor of preventive medicine and infectious diseases at Vanderbilt University Medical Center, "We obliged essentially all of our children to be vaccinated against a whole series of diseases, most of them viral diseases." When this is done, he tells Refinery29, "you can essentially eliminate diseases from whole populations."

Dr. Schaffner cites measles, mumps, and German measles, also known as rubella, as examples of mandated vaccine efficacy. And while COVID, much like the flu, has mutations that may be endemic, he still believes that vaccine requirements might be the next frontier. "We don't expect that to happen with COVID — these are spectacular vaccines, but they're not able to eliminate a disease completely," he says. "But they are able, through widespread use, to really profoundly reduce transmission."

Historically, vaccine mandates — when they are in effect — have proven to work. In fact, one way you can tell they're effective is that, when these systems are breached, viruses may quickly take hold of even the smallest populations.

The MMR vaccine, for instance, which protects children from measles, mumps, and rubella, is extremely commonplace — it's required for students in every state. "In California, we had a season in which doctors were creating fraudulent medical exemptions for a number of students," Jessica Malaty Rivera, MS, an infectious disease epidemiologist and the science communication lead at The COVID Tracking Project, tells Refinery29. "And when that happened, what did we expect to see? Measles outbreak. And that's exactly what happened."

Measles, like COVID, is extremely contagious: According to the U.S. Department of Health & Human Services, an unvaccinated person can catch measles if they enter a room that an infected person was in two hours ago. In 1978, as the CDC upped its efforts to eliminate measles, some states started requiring vaccination (although there isn't much data on how this requirement was enforced). According to the CDC, measles reached "elimination status" in 2000 (meaning there's been an "absence of endemic measles virus transmission in a defined geographical area (e.g. region or country) for at least 12 months"), but even by 1981, cases had dropped by 80% compared to the year prior. To echo Malaty Rivera, the occasional measles outbreak that occurs in the U.S. today can be directly traced back to communities that sidestepped the vaccine.

The COVID vaccine, however, comes with its own unique set of complications. People typically get the MMR vaccine in their infancy, but none of the three authorized COVID vaccines have been made available for children yet. And all three vaccines were administered through an expedited Emergency Use Authorization (EUA) — which creates a major roadblock. Some lawsuits, including one filed against the Houston Methodist Hospital and another against Indiana University, claim that employers and schools can't legally require the vaccine because it isn't authorized by the Food and Drug Administration.

It's also difficult to say whether a widespread vaccine mandate would be effective, and even more difficult to say how it might be enforced. But many experts agree that the FDA needs to fully authorize at least one vaccine in order to raise the now-stagnant vaccination rate: It could assuage some skeptics, and also protect companies and venues that do want to impose mandates from lawsuits.

Malaty Rivera says we can expect "more enforceability" of vaccine mandates after a full authorization, but she points out that an EUA is still very legitimate. "The burden of proof is the same. It's the same safety and efficacy standards, it's just more volume of data," Malaty Rivera says. "The vaccine doesn't change, the data doesn't change, it's just a piece of paper. But if it takes that piece of paper for folks to feel more comfortable or for it to be enforced, then great."

Widespread vaccine requirements, too, could spread a powerful message to the public. "Vaccine mandates have been very successful in the United States and globally, even in politically difficult situations, because they make becoming vaccinated the default," Lawrence O. Gostin, a professor of global health law at Georgetown University, told The New York Times. "We have to make being unvaccinated the hard choice, not the easy one."

As of July 1, over 100 million eligible Americans weren't vaccinated — and that group isn't a monolith. A mandate would undoubtedly make more people to get vaccinated; as Andy Slavitt, a healthcare advisor who recently stepped down from the Biden Administration's COVID-19 response team, told NBC News, "a number of people in surveys" repeat the phrase, "I'm not going to take it unless it's required." Those requirements could also help youth vaccination rates — as David Engber wrote for The Atlantic, many younger people aren't necessarily opposed to the vaccine, but might not go out of their way to get the shot because they're less likely to get seriously ill or die.

Of course, some people will still resist a mandated COVID vaccine, just like they resist MMR and other vaccines, and might respond better to information and encouragement from trusted friends, family members, and community leaders. "We're now past the mass vaccination efforts," says Dr. Schaffner. "We have to do it person by person by person. So it's slower. It's more difficult. And we have to get into the psychology of the person and find out what their concerns and objections are, and try to help them feel comfortable with getting vaccinated."