• William Miller, MD

On Mandating COVID Vaccinations

This week, Governor Gavin Newsom announced that all California state employees will be required to either be vaccinated or be tested twice weekly for COVID. The California Department of Public Health (CDPH) announced that it will extend this mandate to all health care employees in the state. While Governor Newsom, who is facing a recall election, may have been politically forced to allow people to opt out of vaccination by getting twice weekly testing, that is not the best strategy for putting this pandemic behind us. Here is an argument for why mandating full COVID vaccination makes sense.


First, some relevant facts. According to the CDPH website, in the past six months 99% of all new COVID cases in California have been in unvaccinated persons. The number of daily new cases in the state has jumped from about 1,000 per day at the start of July to now over 10,000, with hospitalizations on the rise as a result. Currently, 62% of the approximately 36 million Californians ages 12 and above are fully vaccinated, with an additional 9% being partially vaccinated and 29% being unvaccinated.


Against the previous variants, the Pfizer and Moderna vaccines were 95% effective in fully vaccinated people, meaning that 1 out of 20 who are vaccinated still will become symptomatic if exposed to COVID versus 1 out of 3 in unvaccinated persons. Partial vaccination only conferred about 60% effectiveness.


The new variant, delta, is roughly twice as contagious meaning that the doubling rate for cases is about twice as fast. An unvaccinated person who now has a greater than 50% chance of contracting COVID if exposed. It also appears to be more virulent, meaning causing worse illness. Previous variants cause hospitalization rates of about 12% while twice as many, or about 24%, of people who get delta require hospitalization. Currently, it is the dominant variant in California, the US and around the world, comprising about 83% of new cases in our state.


Fully vaccinated persons with Pfizer and Moderna appear to still be 88% protected from developing symptoms if they get infected with the delta variant, while the Johnson & Johnson and AstraZeneca vaccines may be less effective in preventing symptoms. However, while the rate of preventing symptoms is lower against the delta variant, all of the vaccines remain effective at preventing progression to more serious illness and death. Vaccinated persons who become symptomatic may be contagious, suggesting that the vaccines may become less useful over time in curbing the pandemic if new variants are allowed to develop. Currently, from a strategy of protecting oneself as well as the population at large, vaccination remains a very powerful strategy.


The explanation for the change between the previous variants and delta is natural selection. With every surge of new cases, there are tens of thousands of people reproducing hundreds of millions of new copies of the virus. At that rate, there will be a lot of errors in the replication of the viral genetics, called mutations. Most mutations are basically duds. However, when we are talking about large numbers of people getting infected during a surge, then there will be gradual changes in the virus that will lead to its ability to evade the vaccines. Unless nearly everyone is vaccinated, there will, over time, be a selection for those viruses that are resistant to the vaccine. When that happens, the effectiveness of the vaccines may drop to significantly to the point where we are back to having an unprotected population.


These vaccines are safe and effective. They are not experimental, do not cause infertility, do not implant you with a tracking device or any of the other myriad arguments against the vaccines that end up amounting to nothing more than unfounded opinions, rumors, and fears.


When it comes to people who are still undecided or flatly against vaccination, we have probably gone as far as we can with strategies of educating, cajoling, and offering financial incentives. It seems that the next step in getting us to the level of vaccination that will put this pandemic firmly behind us may be to mandate that everyone gets vaccinated before a surge in unvaccinated people leads to some new strain that renders the vaccines ineffective. It is at least worth further discussion.

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