One junior at New Jersey’s Rutgers University, the first to mandate COVID-19 vaccination, said, “I’m not antivax, I’m anti-mandate. My education should not be restricted based on my personal decision to receive the COVID-19 vaccination.”
First came COVID-19; then, blessedly, the vaccines. But then…vaccine resistance.
About 47.7% of Americans 12 years and older are fully vaccinated as of this writing but—doing the math—that leaves about 52.3% who are not.1 The holdouts offer a variety of reasons for delaying or refusing vaccinations, so states and communities are dangling a variety of carrots, according to their means and what their reluctant residents are likely to respond to.
Most incentives are relatively low-key: free beer in New Jersey, a complimentary beverage in Connecticut, and free weed in Washington state. In New York, New York, the vaccinated can opt for free tickets to Lincoln Center and the Bronx Zoo, among other offers. Maine residents can choose from a free park pass, a hunting or fishing license, or an L.L.Bean gift card. In Alabama, vaccinated residents can drive 2 laps on the Talladega Superspeedway.
At UCLA, investigators have interviewed more than 75,000 people over the past 10 months, testing the effectiveness of different messages about getting vaccinated. For example, framing the benefits as “It will protect you” or “It will protect you and those around you” produced similar results: About two-thirds of each group said they intended to get the shots.2
For some, like the vaccine hesitant, money talks loudest. In the UCLA study, roughly one-third of 7249 respondents said a cash payment would make them more inclined to get a shot. Interestingly, the percentages were close, whether the amount was $25, $50, or $100, although willingness did increase in the $100 group by 6 points over the $25 group.3
Early on, payments seemed to have a negative effect on some people. With the hesitant group, however, payment has an edge, and some states are getting creative—maybe desperately creative—to take advantage of that. In parts of Alaska, getting vaccinated might get someone $500 for groceries or food. In Ohio, it could earn a person a million bucks.
In a press conference in May, Gov Mike DeWine (R) of Ohio said, “Now, I know that some of you are shaking your head and saying, ‘That Mike DeWine, he’s crazy!’ Why? ‘Because he had just announced 5 Ohio Vax-a-Million drawings—a lottery for vaccinated residents.’ ”3
Asked at a mid-May press conference whether the $5 million might have been better spent in some other way—public service announcements, for instance—Ohio Health Director Stephanie McCloud said that, in fact, the previous Friday the state had seen its highest vaccination numbers since April 23. Specifically, she pointed to a 6% increase in vaccination rates among people aged 30 to 74—and this was after 3 weeks of steady decline.4 “I don’t know for $5 million…that this would be something we could have spent in other ways to get this much attention, interest, uptake.”
It seems to be working just fine. In the week following the lottery launch, vaccinations in Ohio increased 94% among those 16 and 17 years old, 46% among those aged 18 and 19, and 55% among those between 20 and 49 (the first lucky winners were announced May 26), according to a statement from DeWine’s office.4
In the spirit of one-upmanship, Gov Larry Hogan (R) of Maryland launched a $2 million lottery on May 20, with dozens of $40,000 cash prizes for vaccinated state residents, as well as 1 grand prize of $400,000.
On the Fence
The push to vaccinate is now targeting teens and young adults. A College Finance survey of more than 1000 college students found that although 88% said they are planning to get vaccinated, 8% said they’re unsure and 4% said they won’t.5 A little more than 7 in 10 believe it should be compulsory for college admission. Those who don’t often mirror an opinion found in the general US public: One junior at Rutgers, The State University of New Jersey and the first university to mandate COVID-19 vaccination, said, “I’m not antivax, I’m antimandate. My education should not be restricted based on my personal decision to receive the COVID-19 vaccination.”6
What happens on college campuses may seem somewhat far afield of what infection preventionists (IPs) do in hospitals except that—as Infection Control Today® reported in our March 2021 issue—there may be a growing demand for IPs outside traditional health care settings such as hospitals. Businesses, public health departments, and schools, including colleges and universities, all need infection prevention guidance. 7
Unfortunately, although young adults have been the source of some of the worst spikes in COVID-19 cases, until recently, they have been last on the priority list for vaccination. In April, Rochelle Walensky, MD, MPH, the director of the Centers for Disease Control and Prevention (CDC), said that more younger adults are being admitted with COVID-19 as more contagious variants spread.8 In New York State, the COVID-19 positivity rate among people aged 18 to 24 years is on the rise, as of this writing. In Michigan, case rates are at an all-time high for those aged 19 years and younger.9
Not incidentally, given the young age of many vaccine-unsure people, Ohio is also giving away 5 full college scholarships to vaccinated students. And in West Virginia, everyone aged 16 to 35 will get a $100 savings bond for getting vaccinated.
In a press briefing in late April, Gov Jim Justice announced that the median age of West Virginians testing positive for COVID-19 had dropped to 34. “When it recently came down to 44 years of age, we thought, ‘Uh-oh. We’ve got a problem,’” he said. “But now we’re down to 34, and that means we’ve got a ton of young people that are testing positive. We’ve absolutely got to get our young people vaccinated.”
As part of the “Call to Arms” vaccine initiative, state COVID-19 pandemic response leaders set a goal of administering at least 1 dose to 65% of all eligible residents by West Virginia’s 158th birthday on June 20, 2021. “We are at 57% right now, so we’ve only got 8% to go,” Justice said 2 weeks ahead of the deadline.10 (As of this writing on July 12, 2021, the number stood at 58%, according to the CDC.)
To help move the needle on the number of young, vaccinated people, schools, like states, are offering rewards, bribes, and outright cash, no strings attached—other than getting vaccinated. The intent is to not only encourage vaccination but also make it easier for schools to get back to normal, with in-person classes and some form of regular school activities.
Rowan University in Glassboro, New Jersey, is planning an in-person commencement for the Class of 2021, with 20 ceremonies. To help make that possible, the university is offering a $500 credit to full-time students who show proof of vaccination; residential students will receive an additional $500 credit to their housing bill. The school is also developing incentives for employees (in compliance with union regulations). “Our message today is simple,” Ali Houshmand, PhD, the university’s president, said in a letter to the college community. “We believe the path to normalcy is through widespread vaccination, and we want our entire community to commit to reaching the goal of widespread vaccination. If we work together, we can reach this goal and offer the Rowan University experience that we all deserve.”11
A senior admissions information coordinator at Bucknell University, a well-respected liberal arts college in rural Pennsylvania, says her school is mandating vaccination for the students. Staff and faculty will have to wear masks and get tested every 2 weeks. When asked how Bucknell will manage having half the school community (the students) inoculated and the other half (staff and faculty) not, she laughs. The incentive for staff: “If you get vaccinated, you won’t have to get tested every 2 weeks.”
Risks and Benefits
All 50 states have at least some vaccine mandates for elementary and high schools, and colleges often require vaccinations for certain diseases, such as measles and meningitis. Those mandates all have medical exemptions and sometimes religious or even philosophical exemptions. The American College Health Association has recommended that colleges require all students on campus to receive a COVID-19 vaccine, calling it “the most effective way for institutions of higher education to return to a safe, robust on-campus experience.”12 So far, hundreds of colleges and universities have said vaccinations will be mandatory for the fall 2021 semester.13
Schools are walking a tightrope, though, and it’s wrapped in thorns. There’s a downside to virtually every choice. If they demand vaccination, they’re bound to lose some prospective students, and the past year has made the coming year critical for enrollment. According to the National Student Clearinghouse Research Center, spring undergraduate enrollment is down 5.9%—the steepest decline since the beginning of the pandemic. Overall postsecondary enrollment is down 4.2% from a year ago.14
If schools don’t mandate vaccination—well, consider the fact that rising infections among young adults create a “reservoir of disease” that eventually “spills over into the rest of society,” Judith Malmgren, PhD, an epidemiologist at the University of Washington, said in an NPR interview.15
Implementing vaccine coverage comes with a multitude of practical headaches. “At this point, I would like the reassurance that anyone I come in contact with at the college has been vaccinated,” said Patricia Johannsen, PhD, professor and coordinator of graphic design in the Media Arts and Technologies Department at Montgomery College, a community college in Rockville, Maryland, that enrolls more than 50,000 students each year. “But how do you enforce that every day and night? Guards to check everyone as they drive or walk on to campus or get off the buses? Our campus boundaries are too porous. Guards at every entrance to every building—on all 3 of our main campuses and our numerous auxiliary sites.”
College administrators have yet another balancing act to perform: keeping students and staff safe while offering the activities that make campus life enjoyable. Older teens and young adults are more likely to be involved in high-risk behaviors, such as going out to bars.
Johannsen added this point: “What about the college’s on-campus activities for the community? It’s more than students coming for classes and employees coming to work.”
Then there’s the issue of whether the college or university should provide the place to get vaccinated. Nearly all the college-attending respondents to the College Finance survey believe colleges are responsible for the well-being of their students, but only those at the larger schools are likely to get the shot where they attend classes. Smaller colleges were least likely to offer vaccines and vaccination sites, and only about 35% and 46%, respectively, of larger universities were likely to offer those services, according to the survey.4
Cue the Lawsuits
Not surprisingly, the pushback through lawsuits and legislation began almost preemptively and largely on political divides. Whereas blue states like California and Maryland are encouraging state schools to require vaccination and some New York lawmakers are considering legislation requiring vaccinations for private and public colleges, several typically red states are actively moving in the opposite direction. For instance, in Utah, Gov Spencer Cox (R) signed legislation prohibiting colleges or universities from requiring proof of vaccination to enroll. Gov Ron DeSantis (R) of Florida signed legislation preventing businesses from requiring vaccines, which is having a knock-on effect among higher education institutions. In Texas, Gov Greg Abbott (R) issued an executive order prohibiting state-funded organizations—including colleges receiving state aid—from requiring vaccinations. Their decisions meant schools such as St Edward’s University in Texas and Nova Southeastern University in Florida, which had announced a mandatory vaccine policy, were forced
However, other colleges and universities with mandates are holding their ground. For one thing, mandatory immunizations during a public health crisis were approved 100 years ago by the US Supreme Court (Jacobsen v Massachusetts). And the ground has been tested with influenza vaccines for health care workers—21 states have a law in place. Similarly, employers in general have the right to require influenza shots unless an established exemption is present.18 Mandates have been effective: For the 2013-2014 influenza season, the highest coverage of health care workers was nearly 98%—where vaccination was required. Elsewhere, coverage among health care workers in general was 75%.
Requiring vaccination for staff raises both legal and ethical concerns. On one hand, sharing vaccination status with an employer is legal. On the other, employers cannot always ask about vaccination status. “I’m sure [our] college is concerned about the bottom line, if we lose students who won’t or can’t get vaccinated,” Johannsen said. “And then there are all the employees. Do you fire the ones who won’t or can’t get vaccinated? Sounds like lawsuits in the making.”
When it’s necessary for the job, it’s legal for employers to require vaccination, but according to health care labor and employment attorney Kevin Troutman, interviewed for the Washington Post, “They’ve got to be able to establish and prove why it’s a job-related requirement.” Employers can not only ask whether a job candidate is vaccinated; they can require proof. But if a potential job candidate is qualified but unvaccinated, the employer might not know that it’s because of a disability or religious beliefs and cannot pry to find out.19
Lawyers have OK’d the legality of mandating vaccines, but the largest schools with the safest bank balances (like Harvard and Yale) are the ones that can probably defend the decision most easily. Other smaller, less well-endowed schools have to weigh the risk of lawsuits and effects on enrollment with the benefits of requiring vaccinations.
Some schools have already been sued for vaccine mandates. The University of California was sued after mandating the influenza vaccine for the 2020-2021 influenza season. It won the case, but universities should note a key distinction, wrote Michael Vernick, Brennan Meier, Molly Whitman, and Jessica Mannon in University Business: “Historically, only vaccines with full FDA approval have been mandated. There is little precedent indicating whether mandatory COVID-19 vaccines will receive the same treatment in court; the available vaccines currently have only FDA emergency use authorization.” (In early May, Pfizer and its vaccine partner BioNTech started an application to request full FDA approval.)
The authors said that some states are considering or have enacted legislation providing universities with limited legal immunity for claims related to COVID-19, and some legislation includes protection related to claims for tuition and fees.
However it pans out and whatever new rules they have to satisfy this year, students are eager to get back to the nonvirtual college experience—that heady mix of study and social whirl—that they missed so much this past year. The respondents to the College Finance survey were cautiously optimistic: About 70% were at least somewhat hopeful that things would get back to normal this semester, but about half really thought it would take until spring 2022.
An admissions officer at a liberal arts college in central Pennsylvania, who did not wish to be identified, has 3 children, 2 of whom are college age. One is starting at Hawaii Pacific University this fall, and another is going back to Stetson University in Florida. Neither school is requiring vaccinations at this point. But it doesn’t matter—the kids would be fine with it, they say. “I’m OK if it gets mandated. They make us take other vaccines before we can attend, so this is just another one,” the college freshman said. “But I know some people think this is different since it’s so new.”
As for the high-school senior heading to Hawaii—well, he’s a high school senior heading to Hawaii. But that actually isn’t the best part, he says: “I’m excited about going since it will be my first year at college and I’ll have 2 roommates in my dorm.”
Roommates in a dorm. Just like the old days.
JAN DYER is a writer and editor specializing in clinical topics. She lives in Suffern, New York.