Cases of COVID-19 have surged once again due to the more transmissible Delta variant, straining healthcare systems and making the goal of herd immunity even more difficult to achieve. Widespread vaccination can slow the spread of disease and extend protection to vulnerable groups, including children and immunocompromised individuals.1 High rates of vaccination are needed to better protect both groups.

Mandates can significantly improve vaccination rates and protect against vaccine-preventable diseases. In the 2017-18 influenza season, rates of vaccination among healthcare personnel were much higher (94.8%) in settings where employers required vaccination and much lower (47.6%) when employers did not require or provide vaccines. Coverage was still suboptimal (70-76%) in locations where employers provided or encouraged but did not require vaccination.2

All states require children to receive certain vaccines before entering school and many universities require proof of vaccination from their students. Non-medical exemptions from these mandates, while protective of individual autonomy and choice, can compromise community immunity and are offered by many states.3 Almost all states allow religious exemptions, and the additional availability of personal belief exemptions in some states and the liberal granting of exemptions have both been associated with increased incidence of disease.4

Legal actions concerning COVID-19 vaccine mandates and exemptions have had mixed results. In August, the Supreme Court upheld Indiana University’s plan to require vaccines. In September, a federal judge temporarily suspended New York State from enforcing its vaccine mandate for healthcare workers who claim religious exemptions. In October, Governor Greg Abbott of Texas banned vaccine mandates for employees and consumers across the state by executive order. FDA approval of at least one COVID-19 vaccine to date lowers some of the legal and ethical barriers to vaccine mandates and could reduce distrust for mandates that might have existed under emergency use authorization.5

There is still considerable variation in mandate status and vaccine hesitancy among states, contributing to different rates of COVID-19 vaccination and SARS-CoV-2 virus transmission. Numbers of COVID-19 cases and hospital admissions are higher in states with lower vaccination coverage.6 From late June to July 2021, rates of hospitalization and death were 10 times higher in unvaccinated adults ≥18 compared with those who were fully vaccinated.7

Tens of millions of adults 18 years of age and older remain unvaccinated. COVID-19 vaccination rates must improve to safeguard community immunity; yet, several states have banned vaccine mandates by law or executive order. As vaccine effectiveness and safety data continue to accumulate, mandates should be considered as an option for protecting individuals in the workplace and the broader community. Until vaccination is more widespread, individual healthcare providers and community members will continue to be tasked with protecting the community by promoting confidence in COVID-19 vaccines.


  1. Anderson EJ, Daugherty MA, Pickering L K, et al. Protecting the community through child vaccination. Clin Infect Dis. 2018 Jul 18;67(3):464-471. doi: 10.1093/cid/ciy142.
  2. Black CL, Yue X, Ball SW, et al. Influenza vaccination coverage among health care personnel—United States, 2017–18 Influenza Season. MMWR. 67(38):1050–1054.
  3. Exemptions Permitted to School and Child Care Immunization Requirements. Immunization Action Coalition. Updated May 2021. Accessed October 12, 2021.
  4. Omer SB, Pan WKY, Halsey NA, et al. Nonmedical exemptions to school immunization requirements: Secular trends and association of state policies with pertussis incidence. JAMA. 296(14), 1757–1763.
  5. Gostin LO, Salmon DA, Larson HJ. Mandating COVID-19 vaccines. JAMA. 325(6), 532–533.
  6. Siegel DA, Reses HE, Cool AJ, et al. Trends in COVID-19 cases, emergency department visits, and hospital admissions among children and adolescents aged 0–17 years—United States, August 2020–August 2021. MMWR. 70(36):1249–1254.
  7. Scobie HM, Johnson AG, Suthar AB, et al. Monitoring incidence of COVID-19 cases, hospitalizations, and deaths, by vaccination status—13 U.S. jurisdictions, April 4–July 17, 2021. MMWR. 70(37):1284–1290.



ACLGIM, COVID-19, Health Policy & Advocacy, Medical Education, Medical Ethics, Social Determinants of Health

Author Descriptions

Ms. Castleman ( is a clinical research assistant in General Pediatrics at Cohen Children’s Medical Center/Northwell Health. Ms. McNally ( is the assistant dean for experiential education at Michigan State University College of Law and president of the Franny Strong Foundation. Dr. Bernstein ( is professor
of pediatrics at Zucker School of Medicine at Hofstra/Northwell and Cohen Children’s Medical Center.