August 14, 2024 • 11 mins
Interview with Charles Stoecker, PhD, and Yin Wang, MA, authors of State COVID-19 Vaccine Mandates and Uptake Among Health Care Workers in the US. Hosted by JAMA Network Open Associate Editor Angel N. Desai, MD, MPH.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Desai (00:01):
Hello, and welcome to JAMA Network Open Conversations.
I'm Angel Desai, associateeditor for JAMA Network Open.
Today, we are speakingwith Yin Wang and Dr.
Charles Stoecker about state COVID-19vaccinate mandates, an uptick
among healthcare workers in the US.
Welcome to the both of you.
To begin, can you pleaseintroduce yourselves?
Wang (00:19):
Yeah, sure.
My name is Yin Wang.
I'm a PhD student at TulaneUniversity School of Public
Health and Tropical Medicine.
Thank you for having me here.
Dr.
Charles Stoecker is my mentor.
Stoecker (00:31):
I'm a health economist at Tulane.
I do a lot of work on vaccines, andvaccination policy, and vaccine uptick.
Excited to talk to you today.
Desai (00:39):
That's great.
I really enjoyed reading this study.
It's of course very timely, as we considerour future viral respiratory seasons.
Can you just start by telling us a littlebit about the background of the paper?
Wang (00:50):
Of course.
Vaccines have played a pivotal rolein shielding us from lethal epidemics.
But the decision to vaccinate can beaffected by multiple factors, such
as individual experience, religiousbelief, and societal attitudes.
These ultimately drive theneed for policy intervention to
support widespread immunization.
(01:12):
Among these policy interventions,vaccine mandates have remained an
important public health strategy,especially in the healthcare settings.
Prior to the research, there havebeen studies that investigated the
impact of state COVID-19 vaccinemandates for nursing home employees.
They provide pretty enlightening findings.
(01:33):
We attained them, seeking to explore theimpact of state COVID-19 mandates for
the entire healthcare worker population.
Desai (01:41):
That's a great background.
Thank you.
Can you tell us a bit about what you didin the study to get at that question?
Wang (01:47):
We collected the COVID-19 vaccine mandated policies for
healthcare workers from the ThompsonReuters Practical Law Database for
Vaccine Mandates and Prohibitions.
Then we checked them throughstate news releases and
memorandum, and related website.
We excluded six states from the study,due to different reasons that may
(02:09):
affect our matter of the policy impact.
Then, regarding thedata used for analysis.
We obtained biweekly individuallevel data from the Household Pulse
Survey, which was initiated by theCensus Bureau at the beginning of
the pandemic, to collect informationon how individuals and households
(02:30):
have been affected by the pandemic.
To me, it's really like a goldmine toexplore because the data had a rapid
turnaround time, that is biweekly.
You can neatly define the policyintervention, and the pre-period, that
is pre-intervention period, somethingthat monthly or yearly data cannot do.
Desai (02:50):
I think the repeated cross-sectional nature of the
data is really interesting,particularly for this question.
Dr.
Stoecker, can you talk us through someof the big takeaways from your results?
Stoecker (03:01):
When we think about vaccine mandates, there's three levels
that we have policy action at.
The city, the state, and the federal.
There's three main scenarios or venueswhere these mandates are applied.
Schools is probably one thata lot of people are familiar.
Healthcare settings, obviously.
And then, bars and restaurants,particularly during the COVID pandemic.
I think this study is interesting becauseit's about a federal mandate, which we
(03:24):
really don't have for other healthcareworker vaccines, such as influenza.
Those are left to the states to regulate.
Here, the Fed stepped in and passedthis rule about this setting.
Now, there's trade-offs toall of these vaccine mandates.
What we have to balance, is we have tobalance the benefits, more protection
for people, against the drawbacks.
(03:45):
These could be somethinglike inconvenience.
It could be something like underminingsupport for vaccines in general.
I think we saw a lot ofpoliticization of the COVID vaccine.
We actually have some more work inthis area that, if you'll permit
me to plug, we have a study that'sin process looking at the impact of
these bar and restaurant mandates.
What kind of impacts didthose have on vaccine uptake?
(04:06):
Because the first thing that youwant to know about each of these
vaccine mandates is did they work?
Did people take more vaccines?
And does that imply that there was moreprotection running around the community?
Then on the other side of the coin,you want to know about the costs.
The costs are particularlyinteresting in the healthcare worker
setting because of staffing issues.
A lot of people were talking aboutquitting and people were fired.
(04:27):
We had a lot of news reports,especially during this era.
We'll also have a study ongoingthat looks at those staffing issues.
You put both the benefit sidetogether and the harm side together.
The Feds have actuallyreversed themselves.
Last year, they did repealthe Federal mandate.
Now, it devolves to the states,and then possible, also to the
hospital organizations themselves,to decide how strict these mandates
(04:50):
are going to be, and whether they'regoing to have a mandate at all.
Desai (04:53):
That's great.
Can you tell us a little bit aboutthe main results of the study?
Wang (04:58):
With regard to the mean analysis, we find that the state vaccine mandate
for healthcare workers were associatedwith a balanced rate of 4 percentage point
increase in both of our outcome areas.
That is a proportion of healthcare worksever vaccinated against COVID-19, and
the proportion of healthcare workersthat have completed or intended to
(05:19):
complete a primary vaccination series.
Any dates in association were manifestedtwo weeks after mandate announcement.
More importantly, these vaccinationincreases were achieved from a baseline
vaccination rate of around 86%, whichis a proportion of vaccinated healthcare
workers in the sample week immediatelyprior to the mandate announcement.
(05:43):
To our knowledge, 86% is a comparativelyhigh vaccination rate, if we
consider that was still in May 2021.
Which means we still saw mandateassociated vaccine increase, although
the healthcare worker populationhad already been broadly vaccinated.
Then moving to the stratified analysis.
(06:03):
When we stratified the sample bythe availability of a test out
option, we only find a statisticallysignificant vaccination increases
in states with no test out option.
Moreover, in the stratified analysisaccording to the ages of healthcare
workers, we only find a statisticallysignificant results among younger
(06:24):
healthcare workers aged 25 to 49 years.
All these increases wereconcentrated within the first four
weeks after mandate announcement.
The finding of the stratified analysissuggests at there's statistically
significant results in the meananalysis could be mainly driven by
the vaccination uptick increase instates with no test out option, and
(06:47):
among younger healthcare workers.
And in these findings were anchored byprior research on vaccine on nursing
home employees, and the municipalemployees, and the vaccine passport
mandated for the general population.
Stoecker (07:02):
One thing that we do hear that is a particularly helpful
contribution is we bring this relativelynew technique called staggered
differences-in-differences to bear.
Standard differences-in-differencesuses states that didn't pass vaccine
mandates as counter-factuals forstates that did pass those mandates.
With the staggereddifferences-in-differences model, we
can account for the fact that statespassed their mandates at different times.
(07:24):
We can line up all of thosemandates, and then compare them
to trends in control states.
We can actually pin down exactly whenthe increases of the mandate happened.
I think it should give readers ofthe study some assurance that what
we're finding is a real effect.
That the effects manifest twoweeks after the implementation.
If you think, you're a healthcare worker,the state has mandated that you need to be
(07:46):
vaccinated or you'll be fired, two weeksis about a reasonable time for you to go
out and find a vaccination site, and getvaccinated, and then get back to work.
What's also assuring about thistechnique is we can look at the
time periods before the statespassed the vaccine mandate laws.
We find no effects in the statesthat passed these laws one week
before, two weeks before, four weeksbefore, six weeks before, et cetera.
(08:09):
That, again, gives us some assurance thatthese are not states that are, say doing
poorly on vaccination outcomes, and thenpassing these laws to make up for it.
They're also not states that are doingparticularly well on vaccinations,
and this is a part of the packageof interventions that they use
to promote the COVID vaccine.
Desai (08:26):
That makes a lot of sense.
In many ways, I think the findingstoo, are fairly intuitive.
But I wonder, you've discussedthis in the manuscript, this
idea that mandates are of coursechallenging for a myriad of reasons.
I wonder if you could talk a littlebit about how you think, without going
too far out of the scope of the study,how do you think this kind of data or
approach could potentially public healthor public health policy in the future?
Stoecker (08:50):
One really cool thing about the data that we're using
here is it's high frequency.
That allows us to identify the timing.
A lot of your surveys, some aregoing to be only annual surveys,
and then even some are monthly.
But this is a biweekly survey.
The other cool thing is that thesurvey was collected before the
policies were put into place sowe can get some baseline here.
(09:11):
I think this study really speaks to thevalue of good public health surveillance.
If we were not looking for the outcomebefore we passed the policies that changed
that outcome, we would be unable to makesuch a convincing case that actually,
these policies did affect this outcome.
I think that's one part of it.
As for broader complications,the Feds have repealed this law.
(09:31):
If this law was a useful law in boostingvaccination rates, if we decide as a
society that this small percentage pointincrease in healthcare worker vaccinations
is worthwhile, then we need to consider atwhat level the appropriate law would be.
We really don't have Federalvaccine mandate laws.
Each state now has to consider, ontheir own recognizance, whether it's
(09:53):
important for them to have a mandate.
And then, of course, healthcareorganizations themselves need to decide
if their states aren't going to mandateit, if they want to mandate it themselves.
But now, this evidence is out there.
It says what kind of effects you canachieve, even when your workforce is
already relatively highly vaccinated.
Desai (10:11):
That's great.
Before we wrap up, any final thoughtsregarding this paper or this topic?
Stoecker (10:16):
Good policymaking is always about trade-offs.
We need to compare the benefits ofincreased vaccinations with the cost of
requiring people to do those vaccinations.
I think any time that there's a pandemic,a spike in infections, any time that we
want better outcomes, we need to weightthe benefits, which this study identifies,
with the costs from one of our forthcomingstudies of things like increased
(10:39):
vaccine hesitancy or making harder toget healthcare workers, to employ them
at a place that requires vaccines.
Desai (10:46):
I think that's a great thought to end on.
Thank you so much, to Yin Wang and Dr.
Charles Stoecker, for speaking with metoday, about this very prescient topic.
This episode was produced byDaniel Morrow, at the JAMA Network.
To follow this and other JAMANetwork podcasts, please visit us
online at jamanetworkaudio.com.
Thanks for listening.
Hello, and welcome to JAMA Network Open Conversations.
I'm Angel Desai, associateeditor for JAMA Network Open.
Today, we are speakingwith Yin Wang and Dr.
Charles Stoecker about state COVID-19vaccinate mandates, an uptick
among healthcare workers in the US.
Welcome to the both of you.
To begin, can you pleaseintroduce yourselves?
Wang (00:19):
Yeah, sure.
My name is Yin Wang.
I'm a PhD student at TulaneUniversity School of Public
Health and Tropical Medicine.
Thank you for having me here.
Dr.
Charles Stoecker is my mentor.
Stoecker (00:31):
I'm a health economist at Tulane.
I do a lot of work on vaccines, andvaccination policy, and vaccine uptick.
Excited to talk to you today.
Desai (00:39):
That's great.
I really enjoyed reading this study.
It's of course very timely, as we considerour future viral respiratory seasons.
Can you just start by telling us a littlebit about the background of the paper?
Wang (00:50):
Of course.
Vaccines have played a pivotal rolein shielding us from lethal epidemics.
But the decision to vaccinate can beaffected by multiple factors, such
as individual experience, religiousbelief, and societal attitudes.
These ultimately drive theneed for policy intervention to
support widespread immunization.
(01:12):
Among these policy interventions,vaccine mandates have remained an
important public health strategy,especially in the healthcare settings.
Prior to the research, there havebeen studies that investigated the
impact of state COVID-19 vaccinemandates for nursing home employees.
They provide pretty enlightening findings.
(01:33):
We attained them, seeking to explore theimpact of state COVID-19 mandates for
the entire healthcare worker population.
Desai (01:41):
That's a great background.
Thank you.
Can you tell us a bit about what you didin the study to get at that question?
Wang (01:47):
We collected the COVID-19 vaccine mandated policies for
healthcare workers from the ThompsonReuters Practical Law Database for
Vaccine Mandates and Prohibitions.
Then we checked them throughstate news releases and
memorandum, and related website.
We excluded six states from the study,due to different reasons that may
(02:09):
affect our matter of the policy impact.
Then, regarding thedata used for analysis.
We obtained biweekly individuallevel data from the Household Pulse
Survey, which was initiated by theCensus Bureau at the beginning of
the pandemic, to collect informationon how individuals and households
(02:30):
have been affected by the pandemic.
To me, it's really like a goldmine toexplore because the data had a rapid
turnaround time, that is biweekly.
You can neatly define the policyintervention, and the pre-period, that
is pre-intervention period, somethingthat monthly or yearly data cannot do.
Desai (02:50):
I think the repeated cross-sectional nature of the
data is really interesting,particularly for this question.
Dr.
Stoecker, can you talk us through someof the big takeaways from your results?
Stoecker (03:01):
When we think about vaccine mandates, there's three levels
that we have policy action at.
The city, the state, and the federal.
There's three main scenarios or venueswhere these mandates are applied.
Schools is probably one thata lot of people are familiar.
Healthcare settings, obviously.
And then, bars and restaurants,particularly during the COVID pandemic.
I think this study is interesting becauseit's about a federal mandate, which we
(03:24):
really don't have for other healthcareworker vaccines, such as influenza.
Those are left to the states to regulate.
Here, the Fed stepped in and passedthis rule about this setting.
Now, there's trade-offs toall of these vaccine mandates.
What we have to balance, is we have tobalance the benefits, more protection
for people, against the drawbacks.
(03:45):
These could be somethinglike inconvenience.
It could be something like underminingsupport for vaccines in general.
I think we saw a lot ofpoliticization of the COVID vaccine.
We actually have some more work inthis area that, if you'll permit
me to plug, we have a study that'sin process looking at the impact of
these bar and restaurant mandates.
What kind of impacts didthose have on vaccine uptake?
(04:06):
Because the first thing that youwant to know about each of these
vaccine mandates is did they work?
Did people take more vaccines?
And does that imply that there was moreprotection running around the community?
Then on the other side of the coin,you want to know about the costs.
The costs are particularlyinteresting in the healthcare worker
setting because of staffing issues.
A lot of people were talking aboutquitting and people were fired.
(04:27):
We had a lot of news reports,especially during this era.
We'll also have a study ongoingthat looks at those staffing issues.
You put both the benefit sidetogether and the harm side together.
The Feds have actuallyreversed themselves.
Last year, they did repealthe Federal mandate.
Now, it devolves to the states,and then possible, also to the
hospital organizations themselves,to decide how strict these mandates
(04:50):
are going to be, and whether they'regoing to have a mandate at all.
Desai (04:53):
That's great.
Can you tell us a little bit aboutthe main results of the study?
Wang (04:58):
With regard to the mean analysis, we find that the state vaccine mandate
for healthcare workers were associatedwith a balanced rate of 4 percentage point
increase in both of our outcome areas.
That is a proportion of healthcare worksever vaccinated against COVID-19, and
the proportion of healthcare workersthat have completed or intended to
(05:19):
complete a primary vaccination series.
Any dates in association were manifestedtwo weeks after mandate announcement.
More importantly, these vaccinationincreases were achieved from a baseline
vaccination rate of around 86%, whichis a proportion of vaccinated healthcare
workers in the sample week immediatelyprior to the mandate announcement.
(05:43):
To our knowledge, 86% is a comparativelyhigh vaccination rate, if we
consider that was still in May 2021.
Which means we still saw mandateassociated vaccine increase, although
the healthcare worker populationhad already been broadly vaccinated.
Then moving to the stratified analysis.
(06:03):
When we stratified the sample bythe availability of a test out
option, we only find a statisticallysignificant vaccination increases
in states with no test out option.
Moreover, in the stratified analysisaccording to the ages of healthcare
workers, we only find a statisticallysignificant results among younger
(06:24):
healthcare workers aged 25 to 49 years.
All these increases wereconcentrated within the first four
weeks after mandate announcement.
The finding of the stratified analysissuggests at there's statistically
significant results in the meananalysis could be mainly driven by
the vaccination uptick increase instates with no test out option, and
(06:47):
among younger healthcare workers.
And in these findings were anchored byprior research on vaccine on nursing
home employees, and the municipalemployees, and the vaccine passport
mandated for the general population.
Stoecker (07:02):
One thing that we do hear that is a particularly helpful
contribution is we bring this relativelynew technique called staggered
differences-in-differences to bear.
Standard differences-in-differencesuses states that didn't pass vaccine
mandates as counter-factuals forstates that did pass those mandates.
With the staggereddifferences-in-differences model, we
can account for the fact that statespassed their mandates at different times.
(07:24):
We can line up all of thosemandates, and then compare them
to trends in control states.
We can actually pin down exactly whenthe increases of the mandate happened.
I think it should give readers ofthe study some assurance that what
we're finding is a real effect.
That the effects manifest twoweeks after the implementation.
If you think, you're a healthcare worker,the state has mandated that you need to be
(07:46):
vaccinated or you'll be fired, two weeksis about a reasonable time for you to go
out and find a vaccination site, and getvaccinated, and then get back to work.
What's also assuring about thistechnique is we can look at the
time periods before the statespassed the vaccine mandate laws.
We find no effects in the statesthat passed these laws one week
before, two weeks before, four weeksbefore, six weeks before, et cetera.
(08:09):
That, again, gives us some assurance thatthese are not states that are, say doing
poorly on vaccination outcomes, and thenpassing these laws to make up for it.
They're also not states that are doingparticularly well on vaccinations,
and this is a part of the packageof interventions that they use
to promote the COVID vaccine.
Desai (08:26):
That makes a lot of sense.
In many ways, I think the findingstoo, are fairly intuitive.
But I wonder, you've discussedthis in the manuscript, this
idea that mandates are of coursechallenging for a myriad of reasons.
I wonder if you could talk a littlebit about how you think, without going
too far out of the scope of the study,how do you think this kind of data or
approach could potentially public healthor public health policy in the future?
Stoecker (08:50):
One really cool thing about the data that we're using
here is it's high frequency.
That allows us to identify the timing.
A lot of your surveys, some aregoing to be only annual surveys,
and then even some are monthly.
But this is a biweekly survey.
The other cool thing is that thesurvey was collected before the
policies were put into place sowe can get some baseline here.
(09:11):
I think this study really speaks to thevalue of good public health surveillance.
If we were not looking for the outcomebefore we passed the policies that changed
that outcome, we would be unable to makesuch a convincing case that actually,
these policies did affect this outcome.
I think that's one part of it.
As for broader complications,the Feds have repealed this law.
(09:31):
If this law was a useful law in boostingvaccination rates, if we decide as a
society that this small percentage pointincrease in healthcare worker vaccinations
is worthwhile, then we need to consider atwhat level the appropriate law would be.
We really don't have Federalvaccine mandate laws.
Each state now has to consider, ontheir own recognizance, whether it's
(09:53):
important for them to have a mandate.
And then, of course, healthcareorganizations themselves need to decide
if their states aren't going to mandateit, if they want to mandate it themselves.
But now, this evidence is out there.
It says what kind of effects you canachieve, even when your workforce is
already relatively highly vaccinated.
Desai (10:11):
That's great.
Before we wrap up, any final thoughtsregarding this paper or this topic?
Stoecker (10:16):
Good policymaking is always about trade-offs.
We need to compare the benefits ofincreased vaccinations with the cost of
requiring people to do those vaccinations.
I think any time that there's a pandemic,a spike in infections, any time that we
want better outcomes, we need to weightthe benefits, which this study identifies,
with the costs from one of our forthcomingstudies of things like increased
(10:39):
vaccine hesitancy or making harder toget healthcare workers, to employ them
at a place that requires vaccines.
Desai (10:46):
I think that's a great thought to end on.
Thank you so much, to Yin Wang and Dr.
Charles Stoecker, for speaking with metoday, about this very prescient topic.
This episode was produced byDaniel Morrow, at the JAMA Network.
To follow this and other JAMANetwork podcasts, please visit us
online at jamanetworkaudio.com.
Thanks for listening.
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