The Department of Veterans Affairs, which runs one of the nation’s largest health systems, announced Monday it would mandate coronavirus vaccines for its front-line workers, becoming the first federal agency to do so and signaling what some experts said could be a national pivot to such requirements.

Faced with the explosive growth of a new virus variant, the state of California and the city of New York gave workers a choice: Get vaccinated or provide proof of a negative test every week. And an array of hospitals from coast to coast, including the prestigious Mayo Clinic, declared they would require staff to get vaccinated, following a joint plea from the nation’s major medical groups.

Health care leaders say the moves represent an escalation of the nation’s fight against the coronavirus – the first concerted effort to mandate that tens of millions of Americans get vaccinated, more than seven months after regulators authorized the shots and as new cases rip through the nation. VA’s mandate applies to more than 100,000 front-line workers, New York City’s applies to about 45,000 city employees and contractors, and California’s applies to more than 2.2 million state employees and health workers.

“You can call it a tipping point,” said Mark Ghaly, California’s health secretary, noting that millions of people have declined the shots despite public health experts’ appeals and a range of incentives. “For so many Californians and Americans, this might be the time to get vaccinated.”

Ghaly noted that in California, about 900 coronavirus cases in mid-June were severe enough to require hospitalization versus nearly 3,000 now, driven by the hyper-transmissible delta variant. “As we stare down schools opening up in just a matter of a couple of weeks, as we look at the projections with delta, we felt now is the right time,” he said.

Confirmed coronavirus infections nationwide have quadrupled in July, from about 13,000 cases per day at the start of the month to more than 54,000 now, according to Washington Post tracking. Hospital leaders in states such as Alabama, Florida and Missouri have implored holdouts to get vaccinated, citing data that the shots prevent the most severe forms of the disease that lead to hospitalization and even death.

“We have reached a confluence where health care workers want vaccine mandates, and government is responding,” said Ezekiel Emanuel, a bioethicist at the University of Pennsylvania who organized the joint statement from nearly 60 medical groups, including the American Medical Association and the American Nurses Association, urging every health facility to require workers to get vaccinated.

“I fully expect more health care employers – health systems, long-term care companies, pharmacies and others – will mandate their employees get vaccinated,” Emanuel added. “The nation will be better off for it.”

About 60% of all U.S. adults are fully vaccinated, with the rate of new immunizations slowing since mid-April, according to The Washington Post’s tracking. The White House has said it will not impose national mandates but supports private employers that create new requirements for their workers.

Many health care workers also remain unvaccinated, despite having priority access to coronavirus vaccines, which first became available in December. More than 38% of nursing home staff were not fully vaccinated as of July 11, despite caring for patients at elevated risk of the coronavirus, according to data collected by the Centers for Medicare and Medicaid Services and analyzed by LeadingAge, which represents nonprofit nursing homes and other providers of elder care.

An analysis by WebMD and Medscape Medical News estimated that 25% of hospital workers who had contact with patients had not been vaccinated by the end of May.

One factor behind the slow uptake: Health care organizations had largely avoided imposing vaccination mandates, fearing the risk of lawsuits or staff defections. Fewer than 9% of hospitals had required their workers to get vaccinated as of last Thursday, according to tracking by the American Hospital Association.

Some health care union officials who had raised previous concerns about vaccination mandates remained largely silent after the wave of announcements Monday. Representatives for National Nurses United and the SEIU did not return requests for comment.

But other labor organizers spoke out against the push.

“In order for everyone to feel safe and welcome in their workplaces, vaccinations must be negotiated between employers and workers, not coerced,” Randi Weingarten, the president of the American Federation of Teachers, said in a statement.

“If the Mayor wants to mandate Vax or weekly testing for City employees, he must first [bargain] over its impact #cityworkerslivesmatter,” tweeted Henry Garrido, the executive director of District Council 37, New York City’s largest municipal employees union.

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The flurry of activity kicked off on Monday morning, when medical groups representing millions of doctors, nurses, pharmacists and other health workers issued a statement urging mandatory vaccinations for all U.S. health personnel, framing the move as a moral imperative as new infections mount.

“The health and safety of U.S. workers, families, communities, and the nation depends on it,” the American Pharmacists Association, the American Public Health Association and 55 other groups wrote in the statement.

The move represented an increasingly tough stance by the medical and public health establishment amid the sluggish pace of national vaccinations.

Health leaders said the slowed pace of vaccinations, coupled with the threat of the delta variant, compelled them to act.

“We feel that it’s important to sign our name onto this,” said Rachel Villanueva, an OB/GYN and the president of the National Medical Association, which represents more than 50,000 Black physicians and is calling for a vaccination mandate for the first time.

Villanueva added that new coronavirus cases could disproportionately affect front-line workers – many of whom are African American – and communities of color that continue to lag behind Whites on vaccination rates. “We want to continue to dispel myths, educate, increase confidence and increase vaccination rates in our communities,” she said.

Emanuel, who spent two weeks organizing the effort, said he believed that requiring vaccinations in health care would ripple beyond the industry.

“Despite everything – cajoling, making access readily available at any pharmacy, making it free, having the president plead – all of this hasn’t really moved the needle very much in the nation,” he said, praising the wide buy-in from medical groups.

“One of the things that resonated with people is, ‘Look, we’re the medical community. This is a health problem. We need to lead – and we need to have the courage of our convictions,'” Emanuel added.

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By Monday afternoon, an array of organizations had announced their own vaccination mandates, led by VA – the nation’s largest integrated health system, which serves more than 9 million veterans – and the Mayo Clinic.

VA’s mandate – which applies to front-line workers, including physicians, dentists, podiatrists and registered nurses – gives workers eight weeks to comply. Agency officials said the decision was driven by the determination to protect both workers and patients, noting that four unvaccinated employees recently died of covid-19 and that there was an outbreak among staff and unvaccinated trainees at a VA training center.

“Since the pandemic began, we have tragically lost tens of thousands of Veterans to this deadly disease,” said VA spokesperson Randal Noller. “This action is aimed at ensuring that we are doing everything we can to protect our veterans and the system that serves them.”

Mayo Clinic leaders, meanwhile, grew concerned about an uptick of cases linked to the delta variant. The health system is headquartered in Minnesota but also operates in hard-hit states like Florida and Arizona, allowing officials to gauge how different parts of the country are experiencing the pandemic and adjust systemwide policies, said Amy Williams, Mayo Clinic’s executive dean of practice.

“The seriousness of the delta variant, as we’re watching this, we thought, ‘OK, we have to do more,'” Williams added.

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For months, health care facilities had hesitated to mandate coronavirus vaccines for employees, noting that the vaccines have not yet received full approval from the Food and Drug Administration and citing the threat of lawsuits.

Houston Methodist, which has said it was the nation’s first health system to impose a coronavirus vaccination mandate when the policy was announced in March, faced protests from some staffers – including more than 150 who refused to get vaccinated and left the organization. But 97% of Houston Methodist workers complied, with about 2% obtaining exemptions or deferrals. A federal judge also dismissed a lawsuit filed by former staff members, ruling that Houston Methodist was “trying to do their business of saving lives without giving [patients] the covid-19 virus.”

Emanuel said the University of Pennsylvania Health System, which imposed its own coronavirus vaccination mandate two months ago, also has seen a similar uptake in shots.

“The sky didn’t fall,” Emanuel said. “When we do it, and we have a good justification, people respond.”

Hundreds of colleges and universities also have imposed vaccination mandates, which are expected to move forward after a federal judge last week upheld Indiana University’s mandate.

Americans’ opinions on requiring coronavirus vaccines vary by industry. A Politico-Harvard poll released this month found that 66% of adults supported health care organizations requiring employees to get the shots, but Americans were about evenly divided over whether other workers or schoolchildren should be required to do so.

“Our take is that there is a substantial opposition to workers and schoolchildren being required to be vaccinated. It may be getting slightly better over time, but that is a lot of employed people who do not want a requirement,” said Robert Blendon, a professor of health policy and political analysis at Harvard University who studies public attitudes. “If I were a legislator looking at our findings, I would be very cautious of forcing a mandate for employed people and parents of kids over 12, particularly in Republican-oriented states.”

Health care leaders frame vaccinations in their industry as a shared responsibility. Ernest Grant, president of the American Nurses Association (ANA), said his members are reeling from the prospect of another surge of coronavirus cases, many of which might be prevented.

“I get phone calls and emails and conversations on a daily basis from nurses across the country that are saying, ‘I just reached my limit, I’m exhausted,'” Grant said. “It is very frustrating when you know there are vaccines out there that are effective and can drive down the spread.”

About 83% of nurses were vaccinated as of early May, according to an ANA survey – a figure Grant said was heartening, citing data that about two-thirds of nurses in March 2020 said they had no immediate desire to get vaccinated or else were opposed.

“Nurses are people, too,” he said, conceding that some were still questioning the vaccines’ effectiveness.

Other health leaders acknowledged that some medical workers may oppose the new mandates, adding that it may require several more months to address their questions and give them time to get vaccinated.

“As our members consider a vaccine mandate, they’ll do it thoughtfully. They’ll do it with lots of education. And the ones that have [already] done it, they’ve done it with kind of an on-ramp,” said Katie Smith Sloan, president and chief executive of LeadingAge, which called for vaccine mandates in nursing homes on Monday. “It’s not something that happens overnight.”

Said Villanueva of the National Medical Association: “As an organization, we really have to act in the best interest of public health. While we respect everybody’s opinion, and there may be pushback, knowing what has happened to our patients – and even to our own physician community – during the pandemic, I don’t think we can do anything else but to support mandatory vaccination for health care workers.”


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