As states reopen, incentivizing Americans to vaccinate against covid-19 is an urgent priority

Nakisa B. Sadeghi and Leana S. Wen

The authorization of safe and effective covid-19 vaccines and subsequent efforts by the US government to increase supply and distribution are pivotal steps to end the coronavirus pandemic. An even greater barrier lies ahead: overcoming vaccine hesitancy.  

Experts estimate that approximately 70 to 85 percent of the US population would need to be immune to covid-19 through vaccination or recovery from covid to reach herd immunity. Given that children aged 12 and under will likely not be eligible for vaccination until 2022, reaching this threshold will require a substantial majority of the adult population to be vaccinated in the next several months. 

Yet, according to a Pew Research Center survey conducted in February 2021, nearly one in three respondents said that they would not receive the covid-19 vaccine if it were available to them. A study by Kaiser Family Foundation found that the majority who said no to vaccination identified specific and nuanced concerns rather than expressed absolute opposition to vaccination in general. This suggests that a critical segment of the population may be receptive to efforts to encourage vaccination. 

The US faces a unique, time-sensitive opportunity to incentivise vaccination by tying reopening policies to vaccination status. Already, many states are lifting restrictions that were implemented earlier in the pandemic. At least six states have rescinded or announced the planned repeal of indoor capacity restrictions, with states like Arizona and West Virginia allowing restaurants and bars to fully reopen. Texas businesses can operate at full capacity as of 10 March, and mask mandates are not in place in at least 16 states. Even states that had previously exercised significant caution, with early and aggressive closures, are removing restrictions: Connecticut is eliminating capacity limits for fitness centers, places of worship, and restaurants on 19 March, and Maryland is allowing all but large venues to operate at 100 percent capacity on 12 March.

There is a narrow window of opportunity for the federal government to urge states to implement policies based on vaccination. However, national public health guidance is falling short. The US Centers for Disease Control and Prevention (CDC) last week issued interim guidance on what fully vaccinated people can do. The guidance states that they can visit other fully vaccinated people without masks or maintaining six feet of distance, and that they may forego quarantine or testing following exposure to the virus if they remain asymptomatic. Furthermore, it states that vaccinated individuals can visit a household that has unvaccinated people, so long as those unvaccinated are not at high risk for severe illness from covid-19, themselves.

This is a good start, but it does not go nearly far enough to illustrate the freedoms that can and should come with vaccination, based on current data. Travel, for example, is a glaring omission. Many people have families that reside outside of their local areas, and travel itself has been found to have a low risk of disease transmission with the use of appropriate protective measures. If vaccinated individuals pose such a low level of risk to themselves and others following a covid-19 exposure that they do not even require quarantine, then vaccinated people should be able to travel to see extended family with precautions such as wearing masks and maintaining physical distance. 

There are two alternate approaches that could be taken instead to integrate vaccination into evidence-based reopening policy. One method is to offer specific guidelines that would apply to unvaccinated people, from which vaccinated individuals would be exempt, in order to incentivize more people to be vaccinated. For example, perhaps the unvaccinated must undergo pre-departure testing and post-arrival quarantine while those who are vaccinated do not have restrictions around travel. Businesses could be required to operate at a limited capacity, with the exception of certain hours or days when they can open at 100 percent occupancy for vaccinated people. Another approach is to use the level of vaccination in a community as a metric for reopening. Instead of instituting a blanket removal of restrictions, a city or county could be required to reach a certain percentage of people vaccinated in order to ease restrictions.

The US should look to other countries that are intentionally incentivizing vaccination on the individual and community level. Israel has instituted a “green badge” that allows individuals with proof of vaccination or acquired immunity to enter indoor public facilities, including sport venues, places of worship, and gyms. “Whoever does not get vaccinated will get left behind,” the health minister has said. China has launched a certificate for cross-border travel, and the European Union is exploring a “Digital Green Pass” to allow vaccinated travelers to bypass entry restrictions posed by member states. 

Some may counter this proposal with arguments about equity: wouldn’t such a system be unfair to those who want to be vaccinated, but aren’t able to yet? They are right, but the lack of access to vaccines will be a problem for just a matter of months as the distribution speeds up. Continued lack of herd immunity, however, could extend the current crisis for years to come with significant impacts on all communities. Others might point to the possible risk of vaccinated people infecting others. There is growing evidence that this risk is very low, making it a risk worth taking given the very real possibility of not reaching the threshold for herd immunity. Moreover, the reality is that states are lifting restrictions anyway, permitting the unbridled spread of disease including by the large majority of the US population that remains unvaccinated. Widespread vaccination offers the best chance to minimize that risk.

The covid-19 vaccine presents a critical opportunity to halt the course of the pandemic once and for all. In the coming days and weeks, US policymakers and public health leaders can capitalize on this pivotal moment to ensure that vaccine hesitancy does not stand in the way of this hard-earned and long-awaited goal.

Nakisa B. Sadeghi is a fourth-year medical student at the University of North Carolina School of Medicine. 

Leana S. Wen is a visiting professor of Health Policy and Management at the George Washington University’s School of Public Health, where she is also a distinguished fellow at the Fitzhugh Mullan Institute for Health Workforce Equity. 

Competing interests: NBS none declared. LSW is a contributing columnist for the Washington Post and CNN medical analyst.