Grading Each State’s COVID Response

Sometime next month, the United States will surpass one million reported deaths from COVID-19. So, how did your state compare in combating the pandemic? I graded each state by four measures: (1) total cases per 100,000 population, (2) total deaths per 100,000 population, (3) seroprevalence, and (4) percent of the population fully vaccinated. I then created a composite score using all four metrics to give an overall grade for every state plus Washington DC and Puerto Rico. Grades for each metric from A+ through F were assigned with 4 states getting any given grade.

  1. Total cases per 100,000 population. These are the cases reported by state health departments to the CDC as of April 28, 2022. The higher the number, the more documented cases occurred since January 2020 per capita. This number does not reflect the true number of cases since many people test positive with home test kits that are not reported to their health departments and many patients with mild or no symptoms do not get tested.
    • Grade A+ states: Puerto Rico, Oregon, Maryland, Hawaii,
    • Grade F states: Alaska, Rhode Island, North Dakota, Tennessee
  2. Total deaths per 100,000 population. These are the deaths reported by state health departments to the CDC as of April 28, 2022. The higher the number, the more deaths occurred since January 2020 per capita. Because the deaths from COVID are only counted if COVID is listed as a cause of death on the death certificate, these numbers are undoubtedly also an underestimate since COVID may not be listed on a death certificate if a person did not have a COVID test before dying or if a person died at home and no information about symptoms was available to the physician signing the death certificate.
    • Grade A+ states:Vermont, Hawaii, Puerto Rico, Utah
    • Grade F states: Mississippi, Arizona, Alabama, Tennessee
  3. Seroprevalence. This is from the February Nationwide Antibody Seroprevalence Survey. In this study, left-over blood samples from blood drawn from clinical labs are tested for antibodies against the COVID-19 virus. Notably, the specific antibodies tested for are those generated from actual infection and do not result from vaccination. The higher the number, the greater the percentage of the state’s population has actually had a true COVID-19 infection (of note, there is no recent data for North Dakota; because there was no data for Montana and New Hampshire from the February study, data from the January study was used for these two states). Overall, this study estimates that 57.5% of Americans have had a COVID infection. However, because antibody levels decline over time, many people who have had an infection many months previously will no longer have antibodies. Therefore, these numbers likely underestimate the actual percentage of the population that has had an infection.
    • Grade A+ states: Vermont, New Hampshire, Hawaii, Puerto Rico,
    • Grade F states: Iowa, Texas, Mississippi
  4. Percent of the population fully vaccinated. This is the percentage of people in each state that have received at least 2 doses of the Pfizer vaccine, 2 doses of the Moderna vaccine, or 1 dose of the Johnson & Johnson vaccine as reported by the CDC. This percentage reflects the entire population of the state, including young children who are not yet eligible to receive vaccinations and therefore the percentage of adults fully vaccinated will be higher.
    • Grade A+ states: Puerto Rico, Rhode Island, Vermont, Maine
    • Grade F states: Alabama, Wyoming, Mississippi, Louisiana
  5. Overall score. For each of the above four metrics, states (plus Washington D.C. and Puerto Rico) were ranked 1 through 52. The overall score was calculated by adding the ranks for each of the four metric and determining the average of those 4 numbers. For North Dakota, there is no data available for the seroprevalence study so the overall score was calculated by the average of the other 3 metrics.
    • Grade A+ states: Puerto Rico, Vermont, Hawaii, Maine
    • Grade F states: Tennessee, Mississippi, Arkansas, Alabama

Here are the scores for each state


  • Case Rate per 100,000 = 26,524; grade: C-
  • Death Rate per 100,000 = 398; grade: F
  • Seroprevalence = 66.0%; grade: D
  • Percent Fully Vaccinated = 51.1%; grade: F
  • Overall Rank = 49; grade: F


  • Case Rate per 100,000 = 33,479; grade: F
  • Death Rate per 100,000 = 166; grade: A
  • Seroprevalence = 61.0%; grade: C
  • Percent Fully Vaccinated = 62.3%; grade: C+
  • Overall Rank = 26; grade: C+


  • Case Rate per 100,000 = 27,773; grade: D
  • Death Rate per 100,000 = 411; grade: F
  • Seroprevalence = 63.0%; grade: C-
  • Percent Fully Vaccinated = 61.5%; grade: C
  • Overall Rank = 48; grade: D-


  • Case Rate per 100,000 = 27,683; grade: D
  • Death Rate per 100,000 = 377; grade: D-
  • Seroprevalence = 64.0%; grade: D+
  • Percent Fully Vaccinated = 54.4%; grade: D-
  • Overall Rank = 50; grade: F


  • Case Rate per 100,000 = 23,281; grade: B+
  • Death Rate per 100,000 = 226; grade: B+
  • Seroprevalence = 55.5%; grade: B
  • Percent Fully Vaccinated = 72.0%; grade: B+
  • Overall Rank = 12; grade: A-


  • Case Rate per 100,000 = 23,979; grade: B
  • Death Rate per 100,000 = 210; grade: A-
  • Seroprevalence = 47.9%; grade: A-
  • Percent Fully Vaccinated = 70.2%; grade: B
  • Overall Rank = 10; grade: A-


  • Case Rate per 100,000 = 21,204; grade: A-
  • Death Rate per 100,000 = 303; grade: C+
  • Seroprevalence = 44.4%; grade: A
  • Percent Fully Vaccinated = 79.2%; grade: A
  • Overall Rank = 11; grade: A-


  • Case Rate per 100,000 = 26,902; grade: D+
  • Death Rate per 100,000 = 298; grade: C+
  • Seroprevalence = 54.0%; grade: B+
  • Percent Fully Vaccinated = 69.1%; grade: B
  • Overall Rank = 23; grade: B-

Washington D.C.

  • Case Rate per 100,000 = 20,112; grade: A-
  • Death Rate per 100,000 = 189; grade: A-
  • Seroprevalence = 63.6%; grade: D+
  • Percent Fully Vaccinated = 74.1%; grade: A-
  • Overall Rank = 13; grade: B+


  • Case Rate per 100,000 = 27,568; grade: D
  • Death Rate per 100,000 = 344; grade: C-
  • Seroprevalence = 58.4%; grade: B-
  • Percent Fully Vaccinated = 66.9%; grade: B-
  • Overall Rank = 35; grade: C-


  • Case Rate per 100,000 = 23,689; grade: B
  • Death Rate per 100,000 = 356; grade: D
  • Seroprevalence = 63.8%; grade: D+
  • Percent Fully Vaccinated = 54.7%; grade: D-
  • Overall Rank = 37; grade: D+


  • Case Rate per 100,000 = 17,089; grade: A+
  • Death Rate per 100,000 = 99; grade: A+
  • Seroprevalence = 34.2%; grade: A+
  • Percent Fully Vaccinated = 78.2%; grade: A
  • Overall Rank = 3; grade: A+


  • Case Rate per 100,000 = 24,947; grade: C+
  • Death Rate per 100,000 = 275; grade: B
  • Seroprevalence = 67.8%; grade: D-
  • Percent Fully Vaccinated = 54.0%; grade: D-
  • Overall Rank = 31; grade: C


  • Case Rate per 100,000 = 24,686; grade: B-
  • Death Rate per 100,000 = 298; grade: B-
  • Seroprevalence = 60.8%; grade: C+
  • Percent Fully Vaccinated = 68.7%; grade: B-
  • Overall Rank = 20; grade: B


  • Case Rate per 100,000 = 25,263; grade: C+
  • Death Rate per 100,000 = 350; grade: D+
  • Seroprevalence = 61.2%; grade: C
  • Percent Fully Vaccinated = 54.8%; grade: D
  • Overall Rank = 39; grade: D+


  • Case Rate per 100,000 = 24,189; grade: B
  • Death Rate per 100,000 = 302; grade: C+
  • Seroprevalence = 70.7%; grade: F
  • Percent Fully Vaccinated = 61.9%; grade: C+
  • Overall Rank = 32; grade: C


  • Case Rate per 100,000 = 26,561; grade: C-
  • Death Rate per 100,000 = 295; grade: B-
  • Seroprevalence = 62.2%; grade: C-
  • Percent Fully Vaccinated = 61.4%; grade: C
  • Overall Rank = 29; grade: C


  • Case Rate per 100,000 = 29706; grade: D-
  • Death Rate per 100,000 = 346; grade: C-
  • Seroprevalence = 56.6%; grade: B-
  • Percent Fully Vaccinated = 57.4%; grade: D+
  • Overall Rank = 42; grade: D


  • Case Rate per 100,000 = 25,226; grade: C+
  • Death Rate per 100,000 = 370; grade: D-
  • Seroprevalence = 68.9%; grade: D-
  • Percent Fully Vaccinated = 53.5%; grade: F
  • Overall Rank = 45; grade: D-


  • Case Rate per 100,000 = 18,124; grade: A
  • Death Rate per 100,000 = 169; grade: A
  • Seroprevalence = 35.3%; grade: A
  • Percent Fully Vaccinated = 79.5%; grade: A+
  • Overall Rank = 4; grade: A+


  • Case Rate per 100,000 = 17,039; grade: A+
  • Death Rate per 100,000 = 239; grade: B
  • Seroprevalence = 49.9%; grade: A-
  • Percent Fully Vaccinated = 75.6%; grade: A-
  • Overall Rank = 9; grade: A-


  • Case Rate per 100,000 = 25,387; grade: C
  • Death Rate per 100,000 = 293; grade: B
  • Seroprevalence = 52.6%; grade: B+
  • Percent Fully Vaccinated = 78.9%; grade: A
  • Overall Rank = 15; grade: B+


  • Case Rate per 100,000 = 24,291; grade: B-
  • Death Rate per 100,000 = 360; grade: D
  • Seroprevalence = 56.9%; grade: B-
  • Percent Fully Vaccinated = 60.1%; grade: C-
  • Overall Rank = 27; grade: C+


  • Case Rate per 100,000 = 25,692; grade: C
  • Death Rate per 100,000 = 226; grade: B+
  • Seroprevalence = 60.8%; grade: C+
  • Percent Fully Vaccinated = 69.1%; grade: B
  • Overall Rank = 18; grade: B


  • Case Rate per 100,000 = 26,788; grade: D+
  • Death Rate per 100,000 = 417; grade: F
  • Seroprevalence = 69.4%; grade: F
  • Percent Fully Vaccinated = 51.8%; grade: F
  • Overall Rank = 51; grade: F


  • Case Rate per 100,000 = 23,156; grade: B+
  • Death Rate per 100,000 = 330; grade: C
  • Seroprevalence = 55.7%; grade: B-
  • Percent Fully Vaccinated = 56.0%; grade: D
  • Overall Rank = 17; grade: B


  • Case Rate per 100,000 = 25,617; grade: C
  • Death Rate per 100,000 = 313; grade: C+
  • Seroprevalence = 47.5%; grade: A-
  • Percent Fully Vaccinated = 56.7%; grade: D+
  • Overall Rank = 19; grade: B


  • Case Rate per 100,000 = 24,798; grade: B-
  • Death Rate per 100,000 = 216; grade: A-
  • Seroprevalence = 65.4%; grade: D
  • Percent Fully Vaccinated = 63.6%; grade: C+
  • Overall Rank = 22; grade: B-


  • Case Rate per 100,000 = 23,332; grade: B
  • Death Rate per 100,000 = 349; grade: D+
  • Seroprevalence = 60.1%; grade: C+
  • Percent Fully Vaccinated = 60.8%; grade: C-
  • Overall Rank = 25; grade: C+

New Hampshire

  • Case Rate per 100,000 = 22,740; grade: A-
  • Death Rate per 100,000 = 182; grade: A-
  • Seroprevalence = 33.1%; grade: A+
  • Percent Fully Vaccinated = 70.2%; grade: B+
  • Overall Rank = 6; grade: A

New Jersey

  • Case Rate per 100,000 = 25,355; grade: C+
  • Death Rate per 100,000 = 376; grade: D-
  • Seroprevalence = 60.9%; grade: C+
  • Percent Fully Vaccinated = 75.6%; grade: A-
  • Overall Rank = 33; grade: C-

New Mexico

  • Case Rate per 100,000 = 24,886; grade: B-
  • Death Rate per 100,000 = 356; grade: D
  • Seroprevalence = 49.1%; grade: A-
  • Percent Fully Vaccinated = 71.0%; grade: B+
  • Overall Rank = 21; grade: B-

New York

  • Case Rate per 100,000 = 26,376; grade: C-
  • Death Rate per 100,000 = 347; grade: D+
  • Seroprevalence = 61.5%; grade: C
  • Percent Fully Vaccinated = 76.9%; grade: A
  • Overall Rank = 36; grade: C-

North Carolina

  • Case Rate per 100,000 = 25,355; grade: C
  • Death Rate per 100,000 = 223; grade: B+
  • Seroprevalence = 52.0%; grade: B+
  • Percent Fully Vaccinated = 61.0%; grade: C-
  • Overall Rank = 14; grade: B+

North Dakota

  • Case Rate per 100,000 = 31,620; grade: F
  • Death Rate per 100,000 = 297; grade: B-
  • Seroprevalence data not available
  • Percent Fully Vaccinated = 54.9%; grade: D
  • Overall Rank = 41; grade: D


  • Case Rate per 100,000 = 22,999; grade: B+
  • Death Rate per 100,000 = 328; grade: C
  • Seroprevalence = 63.2%; grade: C-
  • Percent Fully Vaccinated = 58.4%; grade: C-
  • Overall Rank = 24; grade: B-


  • Case Rate per 100,000 = 26,293; grade: C-
  • Death Rate per 100,000 = 360; grade: D
  • Seroprevalence = 69.1%; grade: D-
  • Percent Fully Vaccinated = 57.2%; grade: D+
  • Overall Rank = 47; grade: D-


  • Case Rate per 100,000 = 17,038; grade: A+
  • Death Rate per 100,000 = 177; grade: A
  • Seroprevalence = 46.9%; grade: A
  • Percent Fully Vaccinated = 69.9%; grade: B
  • Overall Rank = 5; grade: A


  • Case Rate per 100,000 = 21,973; grade: A-
  • Death Rate per 100,000 = 348; grade: D+
  • Seroprevalence = 54.6%; grade: B
  • Percent Fully Vaccinated = 68.4%; grade: B-
  • Overall Rank = 16; grade: B+

Puerto Rico

  • Case Rate per 100,000 = 16,358; grade: A+
  • Death Rate per 100,000 = 131; grade: A+
  • Seroprevalence = 34.3%; grade: A+
  • Percent Fully Vaccinated = 83.0%; grade: A+
  • Overall Rank = 1; grade: A+

Rhode Island

  • Case Rate per 100,000 = 33,226; grade: F
  • Death Rate per 100,000 = 333; grade: C-
  • Seroprevalence = 53.4%; grade: B+
  • Percent Fully Vaccinated = 82.5%; grade: A+
  • Overall Rank = 30; grade: C

South Carolina

  • Case Rate per 100,000 = 28,592; grade: D-
  • Death Rate per 100,000 = 344; grade: C-
  • Seroprevalence = 64.5%; grade: D+
  • Percent Fully Vaccinated = 56.6%; grade: D
  • Overall Rank = 46; grade: D-

South Dakota

  • Case Rate per 100,000 = 26,882; grade: D+
  • Death Rate per 100,000 = 329; grade: C
  • Seroprevalence = 61.3%; grade: C
  • Percent Fully Vaccinated = 61.4%; grade: C
  • Overall Rank = 38; grade: D+


  • Case Rate per 100,000 = 29,715; grade: F
  • Death Rate per 100,000 = 382; grade: F
  • Seroprevalence = 67.4%; grade: D
  • Percent Fully Vaccinated = 54.5%; grade: D-
  • Overall Rank = 52; grade: F


  • Case Rate per 100,000 = 23,215; grade: B+
  • Death Rate per 100,000 = 298; grade: B-
  • Seroprevalence = 69.7%; grade: F
  • Percent Fully Vaccinated = 61.4%; grade: C
  • Overall Rank = 28; grade: C+


  • Case Rate per 100,000 = 29,026; grade: D-
  • Death Rate per 100,000 = 147; grade: A+
  • Seroprevalence = 69.2%; grade: D-
  • Percent Fully Vaccinated = 64.3%; grade: C+
  • Overall Rank = 34; grade: C-


  • Case Rate per 100,000 = 18,336; grade: A
  • Death Rate per 100,000 = 96; grade: A+
  • Seroprevalence = 28.9%; grade: A+
  • Percent Fully Vaccinated = 81.1%; grade: A+
  • Overall Rank = 2; grade: A+


  • Case Rate per 100,000 = 19,912; grade: A
  • Death Rate per 100,000 = 236; grade: B+
  • Seroprevalence = 45.1%; grade: A
  • Percent Fully Vaccinated = 73.1%; grade: A-
  • Overall Rank = 8; grade: A

Washington State

  • Case Rate per 100,000 = 19,609; grade: A
  • Death Rate per 100,000 = 166; grade: A
  • Seroprevalence = 54.3%; grade: B
  • Percent Fully Vaccinated = 72.5%; grade: B+
  • Overall Rank = 7; grade: A

West Virginia

  • Case Rate per 100,000 = 27,938; grade: D-
  • Death Rate per 100,000 = 382; grade: D-
  • Seroprevalence = 54.6%; grade: B
  • Percent Fully Vaccinated = 57.6%; grade: D+
  • Overall Rank = 44; grade: D


  • Case Rate per 100,000 = 27,604; grade: D
  • Death Rate per 100,000 = 247; grade: B
  • Seroprevalence = 66.7%; grade: D
  • Percent Fully Vaccinated = 65.5%; grade: B-
  • Overall Rank = 40; grade: D+


  • Case Rate per 100,000 = 27,049; grade: D+
  • Death Rate per 100,000 = 313; grade: C
  • Seroprevalence = 62.5%; grade: C-
  • Percent Fully Vaccinated = 51.6%; grade: F
  • Overall Rank = 43; grade: D

The data indicates that during the pandemic, you were best off living on an island (Puerto Rico or Hawaii). If you couldn’t live on an island, then you were best off living in either Vermont or Maine. The states that were the worst to live in during the pandemic were Tennessee, Mississippi, Arkansas, and Alabama.

But the pandemic is not yet over. Today’s epidemiologic data from the CDC shows that we are likely entering a new COVID -19 surge. Since the beginning of the pandemic, we have seen that the percent test positivity starts going up about 2 weeks before the case numbers rise followed a few days later by a rise in hospitalization rates and then about 2 weeks later by a rise in death rates. The graph below shows that the test percent positivity (yellow curve) began to increase on March 19, 2022 and the case numbers then began to increase on April 5, 2022.

The number of COVID-19 hospitalizations (yellow curve in the graph below) then began to rise on April 7, 2022:

The daily death rate began rising on April 27, 2022 (not shown). With a recent societal move toward elimination of masking and social distancing, the number of cases, hospitalizations, and deaths will likely continue to rise in the coming weeks. So, there is still a chance for states to pull up their grades. But given the geographic variation in cultural attitudes toward infection control, I don’t expect this to happen.

April 29, 2022


How Do We Overcome Vaccination Hesitancy?

Today, I got my second COVID-19 booster. On December 15, 2020, I was one of the first healthcare workers in the United States to get the newly approved Pfizer vaccine. In the nearly 16 months since then, I’ve had a total of 4 COVID vaccinations, 2 shingles vaccinations, and an influenza vaccination. I’m alive, I’m healthy, and I want to stay that way.

But in my home of Franklin County, Ohio, only 74% of adults are fully vaccinated with the initial doses of COVID vaccines and only 41% of adults are both fully vaccinated and received a booster. Franklin County’s vaccination numbers are only slightly worse than the United States as a whole. We are now approaching 1 million American deaths from COVID-19. More than a third of those have occurred since vaccines were available to all adults making most of these deaths preventable. So, why aren’t Americans getting vaccinated?

Vaccine hesitancy is the intersection of ignorance, cowardice, obstinance, and selfishness. Most people who unvaccinated fall into one or more of these categories. Improving vaccination rates requires different tactics for each of these groups of people.

The four causes of vaccine hesitancy

Ignorance. Ignorance about disease and about vaccines is hard to break. Nevertheless, it is probably the easiest of the four barriers to vaccination to overcome. The ally of ignorance is misinformation. A famous adage (incorrectly attributed to Mark Twain) states: “A lie can travel halfway around the world before the truth is putting on its shoes“. I the era of the internet, cable news, and social media, a better adage is: “A lie can travel around the world ten times before truth gets out of bed in the morning“. A subset of the ignorant is the skeptics who can be educated but will only accept education from members of their own kind. An OSU Buckeye fan will won’t be convinced by a Michigan Wolverine fan but might be convinced by a fellow Buckeye. Science is hard to understand and misinformation is a lot easier to understand. Education about vaccines needs to start in middle school science classes, continue in high school health classes, and continue further in physician offices.

Cowardice. Fear is amplified by ignorance. Like ignorance, misinformation is the ally of fear. Some people fear the metal needle, others fear the stuff that is in the syringe, and others just fear science in general. The great facilitator of fear is gossip. When one person tells another that he got a COVID vaccination and his arm was sore for a day, that story gets told to another person who tells another person, and on and on. By the time the tenth person tells the story, the report is that the vaccination caused the guy so much pain that he passed out, had a heart attack, and became impotent. Although education can help overcome cowardice, reassurance is more powerful, particularly when it comes from people you trust like pastors, sports figures, and movie stars. Once again, tribalism plays a role in reassurance. A Republican who won’t accept any reassurance from a Democrat might listen to a fellow Republican.

Obstinance. Some people are impossibly stubborn and no amount of education or reassurance will change their mind. Obstinance is the realm of the hard-core anti-vaxxers. At one extreme are those people who crave the attention they get by being anti-vaxxers or make money by being anti-vaxxers. This kind of secondary gain is nothing new and was the main motivation of snake oil salesmen, purveyors of patent medicines, and ponzi schemers. Robert F. Kennedy, Jr. and Dr. Sheri Tenpenny are examples of people who make a living by being anti-vaxxers. At the other extreme are those people who just can’t admit that they are wrong about anything and will dig their heels in deeper to try to convince themselves that they were right all along. Some obstinate people look for reasons to justify their decisions. For centuries, obstinate people have used their personal interpretation of 2,000 year old passages from the Torah, the Bible, and the Quran to justify a whole variety of hatreds, unhealthy behaviors, social deviance, and crimes. During the COVID pandemic, obstinate people used similar interpretations to claim religious exemptions from vaccination. Obstinance is hard to overcome and sometimes the only tactic that works is public shame.

Selfishness. People who do not get vaccinated because of selfishness often know that vaccines work. They just figure that if everyone else gets vaccinated then the disease will go away and they won’t need a vaccine. The best friend of selfishness is cowardice and the two often go hand-in-hand. Overcoming selfishness often requires a combination of reassurance and shame. However, unlike obstinance, selfishness can sometimes be overcome by private shame rather than public shame.

How do we fix it?

As healthcare workers, our main tools are education and reassurance. As such, we can have the biggest impact on those who are hesitant to get vaccinated because of ignorance and cowardice. It is tempting to use shame but shame is no more useful in changing ignorance than education is in changing obstinance. The trick is to know one’s audience – we should focus on people who are hesitant to get vaccinated because of ignorance or fear. Wasting time and emotional energy on those whose vaccine hesitancy is motivated by obstinance or selfishness is unproductive, frustrating, and exhausting.

COVID-19 is not the first deadly pandemic that the human race has faced and it certainly will not be the last. But we can learn from our public health failures in vaccination and use that knowledge to lay the foundation for more effective public health measures when the next pandemic comes around. The adults when the next pandemic occurs are the children of today. Our focus needs to be on education and reassurance of our children so that ignorance, cowardice, obstinance, and selfishness does not kill them when they are adults.

This pandemic appears to be waning and there are signs that life may be getting back towards normal. For all of the unvaccinated people who are happy to now be taking off their masks and going to restaurants, you can thank everyone who got a vaccination and made it possible.

…you’re welcome.

April 2, 2022


What We Can Learn From The COVID Seroprevalence Study

This week, the latest results of the Nationwide COVID-19 Infection-Induced Antibody Seroprevalence (Commercial laboratories) Study was released. These results estimate the percentage of the population of each state that has been infected with COVID-19 as of the end of December 2022. The results are quite remarkable and indicate that there has been enormous variation in the frequency of the infection among the states and among different age groups.

The commercial laboratories seroprevalence study is done monthly and uses left-over samples of blood drawn by commercial laboratories for routine blood tests. Patients getting tested specifically for COVID-19 are excluded. The antibodies detected in this study are directed against the nucleocapsid antigen and these antibodies are only produced from actual infection by the virus. The COVID vaccines produce antibodies against the spike protein antigens and these are not measured by the tests used in the commercial laboratories seroprevalence study.

Limitations of the seroprevalence study

The methodology of the seroprevalence study was published in the April 2021 edition of JAMA Internal Medicine. Because the samples are anonymous, there are several potential limitations of the study that could affect the prevalence results:

  1. Healthy adults and children are less likely to have routine blood tests. Therefore, people with chronic diseases are more heavily represented in the samples. If patients with chronic diseases are also more likely to get infected with COVID-19, then the results may overestimate the percentage of the population previously infected with COVID.
  2. Because the results depend on blood tests drawn in December 2021 from live patients, those people who died of COVID-19 prior to December 2021 are not included. This results in the study underestimating the percentage of the population infected since the beginning of the pandemic. This limitation can be corrected by adding the number of COVID deaths to the seroprevalence data to get total infection data (see the analysis later in this post).
  3. People who do become infected with COVID-19 frequently have lingering symptoms (“long-haulers”) that could prompt their physicians to order various blood tests and this could result in the the seroprevalence study overestimating the percentage of the population previously infected with COVID.
  4. Because antibody levels decline over time, it is likely that some patients who had COVID-19 infection early in the pandemic no longer have detectable antibodies against the virus. This could result in the study underestimating the percentage of the population infected since the beginning of the pandemic.
  5. People with less access to healthcare due to socio-economic disparities and people who choose to avoid healthcare are less likely to have routine blood tests drawn. These groups include the uninsured, those who choose to not get vaccinated, residents of rural areas, and the poor. These groups are known be at higher risk of becoming infected with COVID-19. This could result in the study underestimating the percentage of the population infected since the beginning of the pandemic.
  6. The number of blood tests from North Dakota, South Dakota, and Wyoming was too low for statistical analysis and so the study does not include seroprevalence rates from these three states.

Despite these limitations, compared to other epidemiology studies, the commercial lab seroprevalence study gives us the most accurate estimate of the percentage of the U.S. population that has had a COVID-19 infection. First, it is likely that the limitations above that result in overestimation are balanced out by those limitations that result in underestimation of the number of infections. Second, it is likely that the above limitations apply more-or-less equally among different states, allowing reasonably accurate comparison of the rates of infected between different states.

Differences between states

The CDC regularly reports on the total number of infections (based on nasopharyngeal PCR or rapid antigen tests) per 100,000 population since the pandemic began. These results indicate a low of 12.2% of the population in Maine to a high of 30.2% of the population in Rhode Island. However, these results depend on COVID test results reported to local health department and underestimates the true number of infections because (1) many infected people are asymptomatic and do not get tested, (2) many infected people use retail COVID tests with results that are not reported to the health department, and (3) many symptomatically infected people choose to not get tested. For these reasons, the seroprevalence studies offer a more accurate measure of the true rates of infection. The commercial lab study indicates enormous variations in the rate of COVID among the states and territories from a low of fewer than 1 out of every 10 people to a high of nearly 1 out of every 2 people

States with the lowest rates of infection. 15 states and territories had antibody prevalence rates of less than 30% of their population. The lowest rates were in Puerto Rico (9.7% of the population previously infected) and Hawaii (11.1% of the population previously infected. Living on an island was protective against becoming infected. Rhode Island (which is not really an island) is notable because by nasopharyngeal testing, it has had the highest rate of infection in the U.S. but by seroprevalence testing, it has had one of the lowest rates of infection. Rhode Island has the third highest vaccination rate (78.1% of its population) in the country. It is likely that for Rhode Island, the seroprevalence data is more accurate than the case rates determined by nasopharyngeal testing. The common feature of these 15 states & territories is that they all have high COVID vaccination rates with greater than 65% of their population fully vaccinated. We’ll give these states a grade of “A” for controlling the pandemic.

States with intermediate rates of infection. 19 states had rates of infection between 30-40% of their populations. We’ll give these states a grade of “C” for controlling COVID-19. With a United States overall average of 33.5% of the population previously infected, these states performed about average overall.

States with high rates of infection. 15 states had antibody prevalence rates above 40%. Iowa and Montana tied for the highest rate of infection with 47.7% of their population having been infected during the pandemic. These states also have low COVID vaccination rates with all of these states having fewer than 65% of their population fully vaccinated. This provides additional evidence that vaccination prevents infection. We’ll give these states a grade of “F” for controlling the pandemic. Lamentably, my own state of Ohio is the 4th worst in the country for antibody prevalence. The tone for Ohio’s response to COVID-19 was set early in the pandemic when AR-15 wielding anti-maskers protested in the front yard of our state’s Director of Public Health when she was trying to get her children off to school… she resigned, leaving Ohio with no health department director for months.

Differences between genders

Overall, there was no difference in the antibody prevalence among men (33.2%) and women (33.8%). In most states, the difference in rate of infection between men and women was less than 5 percentage points. However, three states had gender differences of more than 6 percentage points:

  • Pennsylvania: 30.3% of men and 39.6% of women
  • Indiana: 37.4% of men and 45.0% of women
  • Montana: 51.4% of men and 43.9% of women

Differences by age

There was a striking relationship between age and seroprevalence of COVID-19 antibodies with the study indicating that far more younger Americans have been infected than older Americans:

In this table, the second column from the left is the seroprevalence of COVID-19 antibodies indicating past infection for each age group. The third column is the percentage of the population in each age group that has died of COVID since the pandemic began. The fourth column is the sum of the seroprevalence plus the percentage of each age population that died of COVID; this column gives a more accurate number of the total percentages of Americans in each age group that became infected with COVID and then either lived (seropositive group) or died of COVID (% died group). Even correcting for the fact that most of the deaths from COVID occurred in people over age 65, it is still clear that younger Americans were more likely to become infected than older Americans.

The causes for the age differences in infection rates is likely multifactorial. Younger people were more likely to have employment or school exposures whereas retired older people were more likely to be able to isolate at home during the pandemic. Younger people tend to live in larger households with children and adults together whereas older people are more likely to live with only their spouse or to live alone. Older Americans are more likely to be vaccinated than younger Americans. Older people are also more risk-adverse than younger people when it comes to masking and social distancing in public areas.

So what does all of this mean?

There are two ways to get immunity to COVID-19: (1) get vaccinated or (2) get infected. Immunity causes a reduction in the chance of subsequent infection (or re-infection). Immunity causes a greater reduction in the chance of hospitalization from infection (or re-infection). And immunity causes an even greater reduction in the chance of dying from infection (or re-infection).Which type of immunity is better? It appears that vaccination gives better immunity than past infection. But even if the two give equivalent immunity, the risk of dying from a COVID vaccine is negligible whereas the risk of dying from a COVID infection is 1 out of 85 – getting immunity from vaccination is far safer than getting immunity from infection.

Epidemiologists talk of “herd immunity” when enough of the population has immunity from either vaccination or past infection. Most epidemiologists now believe that between 75% and 90% of the population must have immunity in order to bring an end to the pandemic by herd immunity. Because people can get re-infected with COVID, the coronavirus will probably never go away but if we achieve herd immunity, we should be able to keep the number of new infections relatively low. More importantly, herd immunity should keep the number of hospitalizations and deaths extremely low. In other words, the goal of herd immunity is not to prevent all COVID infections but instead to prevent COVID hospitalizations and COVID deaths. Indeed, the current data indicates that most of the people who are hospitalized with COVID are unvaccinated and almost all of the people who are die of COVID are unvaccinated.

Currently, we know that 64% of the U.S. population has immunity by being fully vaccinated. We know that 33.5% of the U.S. population has immunity by having had a past COVID infection. What we do not know is to what extent these two populations overlap; that is, how many people who have had a COVID vaccination also had a COVID infection (either before or after they got their vaccination). Another way of looking at this is that we do not know how many people have immunity from either vaccination or past infection. Certainly more than 64% of the U.S. population has immunity but probably less than 90% has immunity.

To forecast what COVID may look like in future years, consider rhinoviruses. They cause 1/3 to 1/2 of all common colds. Given that the average person gets 2-3 colds per year, most people become infected with a rhinovirus every year and nearly everyone has been infected at least once by adulthood. Because re-infection with COVID can occur, it is likely that COVID will continue to circulate in the community for the indefinite future. Eventually, nearly everyone will have either been infected or been vaccinated. At that point, hospitalization or death from COVID should become uncommon. In other words, COVID won’t go away but it won’t kill you in the future.

The primary goal of medicine is to prevent people from becoming severely ill or dying from infections. A more aspirational (but usually unobtainable) goal is to prevent all infections, even mild ones. As long as there are people with weak immunity against COVID (either because they are not vaccinated or they have not yet been infected), then COVID will continue to cause hospitalization and death.

Therefore, our realistically obtainable goal in public should be to prevent severe COVID infection and prevent death from COVID. In that sense, we are reaching a point where we should not be looking at vaccine mandates but instead be looking at immunity mandates. In other words, instead of requiring all of a business’s employees to be vaccinated, we should be requiring all employees to either be vaccinated or have antibodies indicating past infection.

Immunity mandates should become our new public health doctrines – for our workplaces, our schools, and our military. For me personally, sign me up for a second booster when they become available… but I’ll pass on getting a COVID-19 infection to keep my immunity up.

February 5, 2022


A Postmortem Examination Of The Pandemic

In Monty Python and the Holy Grail, the cart-master chants “Bring out your dead”and a man carries a plague victim and throws him on the cart. The plague victim cries out “But I’m not dead”. The same is true for the COVID-19 pandemic: we want to bury it and go back to normal life but the pandemic is not quite over yet. Nevertheless, it is not too early to determine which states fared best in the epidemiology of the pandemic. So, let’s take a look at the pandemic losers and winners based on CDC data as of today.

Case numbers

The best way to compare case numbers between different states is by using the number of cases per 100,000 population. The lower the number, the better states did in controlling the spread of the disease.

The Winners:

  1. Maine 12,225. The lowest case rate in the United States was our northeastern-most state. Maine took an early, aggressive approach to slowing the spread of COVID-19 with closure of restaurants and bars to dine-in customers on March 18, 2020 and with institution of a mandatory 14-day quarantine period for visitors from any other state on April 3, 2020. When restaurants re-opened, face masks were required for all customers and even now, face masks are still required for unvaccinated customers.
  2. Hawaii 12,737. On the opposite side of the world, Hawaii took even more aggressive infection control measures, initially prohibiting travelers from other states and then later requiring travelers to provide documentation of vaccination and of a negative COVID test. Because of its isolation, Hawaii was able to maintain tight oversight of anyone coming onto its islands. Currently, Hawaii is considering requiring all visitors to the island to have a booster vaccination.
  3. Oregon 13,039. Early institution of state-wide school closures, a stay-at-home order, and an indoor mask mandate helped Oregon keep its case numbers the third-lowest in the U.S.
  4. Puerto Rico 13,388. Like Hawaii, Puerto Rico benefited by being an island during the COVID-19 pandemic. Additionally, COVID public health measures were far less politicized in Puerto Rico than in the rest of the country, perhaps because Puerto Ricans do not vote in presidential elections and do not have elected members of the U.S. congress. It is notable that there are no full service Fox Network TV channels or Spanish versions of Fox News in Puerto Rico.
  5. Vermont 13,631. Early in the pandemic, Vermont issued a quarantine order for all visitors to the state and also issued a stay-at-home order. Vermont was very aggressive in its vaccination efforts and currently is the most vaccinated state in the country with 78.9% of its population fully vaccinated – Puerto Rico comes in next at 78.5%.

The losers: 

  1. Rhode Island 30,265. I was surprised to find that Rhode Island has had the highest case rate in the country. Throughout the pandemic, the Rhode Island case rate looked quite similar to the rest of the country but during the Omicron surge, Rhode Island’s cases peaked at more than 500 per 100,000 on January 11, 2022 which is the highest daily case rate for any state at anytime during the pandemic. This is despite the state having a very high vaccination rate. The good news for residents of Rhode Island is that their COVID death rate has remained relatively low despite the high case numbers.
  2. North Dakota, 26,551. Intuitively, one might think that North Dakota’s largely rural population would be protected from COVID-19 given how spread out people are from each other. But state-wide resistance to the institution of infection control measures and a very low vaccination rate resulted in North Dakota having the second highest case rate in the U.S.
  3. Utah 25,040. A strongly conservative state, Utah has resisted mask mandates and other infection control measures.
  4. Alaska 24,918. A lack of mask mandates and other infection control measures combined with an influx of tourists in the summer of 2021 resulted in a high early fall surge followed by a high Omicron surge.
  5. Tennessee 24,782. When Michelle Ficus, the Tennessee vaccination director, raised alarm about the rising case rate and suggested that children should get vaccinated, Tennessee Republican lawmakers’ response was to fire her. This is a reflection of the state’s reluctance to institute public health measures during the pandemic which resulted in Tennessee having the fifth highest case rate in the country.

Death rate

Although case rates do give important information about how easily COVID-19 was spread in a given state, the case rate can be influenced by testing availability and by the population’s willingness to get tested. Also, if more tests are done for screening purposes in one state, then infected but asymptomatic people will be identified which can drive case numbers higher than in other states. The death rates are not affected by these factors. However, death rates can be affected by how well a given state protects its vulnerable population (nursing home residents, the elderly, etc.) and can be affected by the availability and quality of health care in that state. The following are the winners and losers with respect to the number of deaths per 100,000 population.

The Winners:

  1. Vermont 75. There is no surprise here. Vermont also had the 5th lowest case numbers in the country and the fewer cases of COVID occur in a state, the fewer people will die of COVID in that state. Vermont also has one of the lowest rates of obesity in the country and obesity is a major risk factor for dying if a person does get COVID. Vermont has the 5th lowest percentage of the population that is uninsured. Together, these factors resulted in Vermont having the lowest COVID mortality rate in the U.S.
  2. Hawaii 78. Once again, having a low number of COVID cases results in a low COVID mortality rate. Hawaii’s strict infection control measures including quarantine of incoming visitors kept its COVID deaths much lower than the rest of the country.
  3. Puerto Rico 111. Living on an island provided some of the best protection against getting COVID and consequently from dying of COIVD.
  4. Utah 124. The state of Utah is a paradox with the third highest case rate but the fourth lowest mortality rate. Utah benefited by having a higher proportion of its cases occurring in the later stages of the pandemic, when the more contagious but less fatal Omicron variant replaced the considerably more lethal Delta variant.
  5. Maine 125. The same measures that gave Maine the lowest case rate in the country also gave it the fifth lowest death rate in the country. This is despite Maine having the highest percentage of its population over age 65 compared to all other states. The implications is that community infection control measures are effective, even when you have an inherently high-risk population.

The losers: 

  1. Mississippi 359. The state with the highest rate of obesity has had the highest COVID mortality rate. Mississippi also has the fifth highest percentage of its population being uninsured. In addition, Mississippi has the lowest per capita income in the U.S. which likely contributed to barriers to healthcare access. Relative to its population, more Mississippians died than residents of any other state.
  2. Arizona 349. On the surface, Arizona should not have the second highest death rate in the country. It is closer to average when it comes to the rate of obesity, population over age 65, income, and vaccination rate. Despite this, COVID has become the state’s most common cause of death.  Arizona’s high death rate has been attributed to its lawmaker’s unwillingness to adopt COVID mitigation measures and its governor has been called the “anti-science governor”.
  3. Alabama 342. Factors that contributed to Alabama having the third highest death rate include having the second lowest vaccination rate in the country and the third highest obesity rate in the country. For the first time in history, the annual number of deaths in Alabama exceeded the annual number of births in Alabama.
  4. New Jersey 341. Early in the pandemic, there were no vaccines, there were no monoclonal antibody treatments, and infection control measures were not yet fully instituted. The bulk of New Jersey’s deaths occurred in the first 3 months of the pandemic, coincident with the surge in deaths in adjacent New York City. Since then, New Jersey’s death rate has been lower than average but so many people in New Jersey died early in the pandemic that it results in the state having the fourth highest death rate for the pandemic overall.
  5. Louisiana 327. Like its neighbor Mississippi, Louisiana has a high rate of obesity and a low per capita income. Like New Jersey, Louisiana experienced a much higher surge in COVID in the first 3 months of the pandemic when we understood less about how COVID is transmitted and about how to treat COVID infection. When COVID hit New Orleans in March 2020, the number of cases overwhelmed the city’s healthcare system and many residents died.

Case fatality rate

If a state had a high case rate, it would be expected to also have a high mortality rate, simply because more people were infected with COVID. The case fatality rate overcomes this by telling us how good a state’s health care systems were in protecting its most vulnerable populations and about how good the health care systems were in treating patients who became ill with COVID. The case fatality rate is the percentage of people infected with COVID who then died of COVID. The case fatality rate averaged 1.2% for the United States as a whole.

The Winners:

  1. Utah 0.50%. Having a lower percentage of the population over age 65 than any other state, Utah benefited by being the youngest state in the country. Utah also has a low percentage of the population that is obese. As a consequence, the population of Utah as a whole is considerably less vulnerable to severe COVID and death-by-COVID than other states.
  2. Vermont 0.55%. Vermont is one of the clear winners in the COVID pandemic and its second to the lowest case fatality rate is a result of having the highest vaccination rate in the U.S.
  3. Alaska 0.56%. Alaska has had one of the highest case number rates in the country but Alaskans who got infected were less likely to die. Because a large portion of Alaska’s COVID cases occurred in the latter portion of the pandemic, a larger number of Alaska’s cases occurred in vaccinated individuals with those vaccines conferring protection against death from COVID. Additionally, a large percentage of its infections were due to the Omicron variant which has a lower case fatality rate than other variants. Alaska also has the second lowest percentage of its population over age 65 in the country meaning that its population was less vulnerable to death, even before vaccines were available.
  4. Hawaii 0.61%. With early institution of visitor quarantining and public health measures, Hawaii was able to keep its case numbers very low in the first half of the pandemic and as a consequence, most of Hawaii’s COVID cases occurred in the latter portion of the pandemic, when a large portion of its population was vaccinated and thus protected from COVID death. Hawaiians have good healthcare with only 4.1% of its population uninsured, second only to Massachusetts. Hawaii also has the third lowest rate of obesity and fifth highest rate of vaccination in the country.
  5. Puerto Rico 0.83%. Like Hawaii, Puerto Rico was able to keep its case numbers exceptionally low in the first stages of the pandemic when COVID was more likely to be fatal. It has only been in recent months that the territory has seen its cases surge from the less lethal Omicron variant in the setting of having a larger percentage of its population vaccinated than most states.

The losers: 

  1. Mississippi 1.61%. The combination of being the most obese state and the fifth least vaccinated state proved lethal to Mississippi residents who became infected with COVID who were more likely to die of their infection than residents of any other state. A high percentage of the state’s population is uninsured with the result of disparities in access to healthcare as well.
  2. Pennsylvania 1.54%. Compared with other states, Pennsylvania is fairly average with respect to risk factors such as population over age 65, obesity, vaccination rates, per capita income, and percentage of the population that is uninsured. Pennsylvania was also able to keep its case rate relatively low in the first half of the pandemic. So why were Pennsylvania residents second only to Mississippi residents with respect to likelihood of dying if they became infected with COVID? One possibility is that there was less testing done in Pennsylvania compared to other states with the result that fewer asymptomatic or mildly symptomatic COVID infections were identified, thus driving up the fatality rate among those people who were actually diagnosed. This is suggested by the fact that Pennsylvania’s death rate of 3.2 per 100,000 is closer to average among the states.
  3. Arizona 1.52%. The same reasons that Arizona has had the second highest death rate in the country have contributed to it having the third highest case fatality rate. A relatively high case number rate suggests that there was plenty of testing being down (as opposed to Pennsylvania). Arizona did not have a disproportionate number of cases occurring early in the pandemic (as opposed to New Jersey). Arizona’s high case fatality rate may be more a result of its lawmaker’s public health policy and less a result of an inherently more vulnerable population.
  4. Alabama 1.52%. A very high rate of obesity coupled with a low vaccination rate resulted in Alabama residents being the fourth most likely to die if they contracted COVID.
  5. New Jersey 1.50%. Although New Jersey currently has one of the highest vaccination rates in the country, a large percentage of its cases and deaths occurred in March 2020, before vaccines were available resulting in a high case fatality rate early in the pandemic. In recent months, however, New Jersey’s case fatality rate has been much lower than average and as a result, New Jersey’s experience provides strong evidence that vaccinations prevent deaths.

Vaccination rate

In the preceding analysis, it is pretty clear that states with higher vaccination rates fared better during the COVID pandemic than states with lower vaccination rates. In a previous post, I showed how political party voting patterns are strongly associated with how likely a state’s residents are to be vaccinated. The five states with the highest percentage of the population vaccinated all voted Democrat in the last presidential election and the five states with the lowest vaccination rates all voted Republican in the last presidential election.

The vaccination rate is important not only for keeping a state’s residents alive, but may also be a determining factor for business development in the future. Businesses do want their employees to all be vaccinated in order to control expenses by reducing absenteeism and reducing health care costs. Vaccination also translates into fewer dead employees. But businesses are loath to unilaterally impose mandates for fear of losing some employees and for fear of negative public opinion. Therefore, many businesses may chose to expand their operations in those states where their employees are likely to be vaccinated without having to impose an employee vaccine mandate. In this sense, the vaccine winner states today could become the business winner states in the future.

The Winners:

  1. Vermont 78.9%
  2. Puerto Rico 78.5%
  3. Rhode Island 78.1%
  4. Maine 77.1%
  5. Connecticut 76.0%

The losers: 

  1. Idaho 47.6%
  2. Alabama 48.9%
  3. Wyoming 49.5%
  4. Mississippi 49.7%
  5. Louisiana 51.4%

How you can be a winner

Overall, Americans who get COVID have a 1.2% chance of dying from it. In other words, 1 out of every 83 people who become infected will die. So, when you get infected, you are taking a gamble with life and death. By looking at those states that fared well during the pandemic and those that fared poorly, you can determine how to improve your odds of surviving the pandemic:

  • Live in a state where lawmakers take science seriously
  • Get vaccinated
  • Don’t be obese
  • Live on an island
  • Have health insurance
  • It was more important to be strict with infection control measures early in the pandemic than later in the pandemic

January 22, 2022

Epidemiology Outpatient Practice

COVID And Travel

We are now two years into the COVID-19 pandemic and there is a lot of pent-up demand for travel. Canceled vacations are being rescheduled. Postponed weddings are being booked. Grandparents want to see grandchildren who live in distance cities. People just want to get out. But the pandemic is far from over and travel precautions are as important now as ever. So, how should we advise our patients, families, and co-workers who plan travel?

First… the obvious

There are some travel precautions that can apply to anyone. Travel advice that should be universal includes:

  • Delay traveling until you are vaccinated
  • If you are vaccinated, get a booster before traveling
  • Make sure that your traveling companions are vaccinated
  • If you or your traveling companions have COVID-related symptoms, do not travel

What should you pack?

Since the pandemic began, I’ve made several driving trips to North Carolina, Maryland, and Virginia. I flew to Bar Harbor, Maine for a week of hiking. I flew to northern California for a week at the coast. I flew to San Francisco to visit with a new grandchild for several weeks. Here is my COVID packing list:

  • Rapid COVID tests. You never know whether test kits will be available at your travel destination. You may need one because of symptoms or because it will be prudent to test prior to visiting a relative with risk factors for severe COVID.
  • Extra face masks. Face masks get stuffed into pockets, get left on kitchen counters, and fall off into the mud. The elastic ear loops on surgical masks tend to break. Always carry extras with you.
  • Hand sanitizer. A good idea for travel before COVID and an even better idea during COVID. TSA now allows passengers to carry up to 12 ounces of alcohol hand sanitizers on aircraft. Keep a bottle in your car or in your purse.
  • Clorox wipes. Did a snotty nosed kid grab the door knob to the gas station two minutes before you did? Keeping sanitizing wipes in your car or hotel room can bring piece of mind.
  • Thermometer. Jet lag and sunburn can cause symptoms that can resemble COVID. You keep a thermometer at home in case you get a febrile illness – take it with you on vacation.
  • Oximeter. OK, admittedly I’m biased by being a pulmonologist. But I’ve seen too many “happy hypoxemic” COVID patients in the hospital who had oxygen saturations in the 80’s without any shortness of breath. If you do get COVID, checking your oxygen saturation is just as important as checking your temperature (and maybe more important).
  • Acetaminophen and/or NSAID. If you do get COVID while traveling, you are going to need to isolate yourself. That means not going to the local pharmacy to buy Tylenol so carry some with you.
  • Vaccine card. Here in Ohio, the idea of requiring a vaccine card is about as socially acceptable as laws about gun restriction. However, many communities require documentation of vaccination to go into a restaurant or bar. Even when not required by local ordinances, some restaurants and venues require evidence of documentation because it brings in otherwise wary customers. Take a picture of your card and keep it on your phone.
  • Extra medications. If you take prescription medications, bring enough to get you through a quarantine period in case you or a travel companion have to extend your travel time due to a COVID infection.

Travel within the U.S.

Check the websites first! The CDC’s COVID data website can give you up to date information about the prevalence of COVID at your travel destination and about percent of the county that is vaccinated. In addition, each state’s department of health website can give you even more data. City department of health websites can tell you about local indoor masking and vaccination documentation requirements. Current COVID-related hospital occupancy data can tell you whether or not you will have available healthcare if you fall and break your leg.

Car travel. Keep hand sanitizer, Clorox wipes, and extra masks in your car. Wear masks at all times when indoors at restaurants, rest stops, and gas stations. When driving from Ohio to North Carolina, we no longer stop at restaurants – we pack a lunch and eat it in the safety of our car. If you have to go through toll roads, EZpass allows you to skip the toll both attendants.

Restaurants. Check restaurant websites to find out if they require employees and/or customers to be vaccinated – if nothing else, these restaurants attract customers who take COVID seriously and consequently are less likely to be infected. Eat at off hours – instead of eating dinner at 6:00 PM, consider eating at 4:30 or 9:30 when the building will be less crowded. Consider carry-out – In Bar Harbor, we ate all of our dinners as carry out on the balcony of our hotel room overlooking the ocean – better scenery and no worrying whether the anti-masker at the table next to you is going to cough in your direction while you are eating your sandwich. In cities like New York and San Francisco, you must show your vaccine card to enter.

Minimizing risks during air travel

The airport is often riskier than the plane. Modern aircraft have very advanced air filtration systems. Cabin HEPA filters remove 99.9% of airborne viruses and the volume of air in the cabin is exchanged every 2-3 minutes. Air enters the cabin through the ceiling and exits the cabin through floor vents in the seat rows. In addition, each passenger can adjust their own personal overhead air vent for additional comfort and air flow. So, even though passengers are seated close together, the airflow systems provide a lot more safety than in a building, such as the airport. Furthermore, people tend to be less attentive to masking and social distancing in the terminals than once they get on the plane

In the airport: Avoid traveling on busy travel days – Tuesdays and Wednesdays tend to be the least busy. Use hand sanitizer liberally – as noted above, TSA currently allows you to carry 12 ounces of alcohol hand sanitizer, rather than the 3 ounce limit on other liquids. Maintain social distancing whenever possible – TSA precheck lines are generally less congested than the regular TSA lines; if you have layover, find the least busy gate to sit and wait until your aircraft boarding time. Avoid airport restaurants and bars – eat a meal before you leave home.

In the plane: Turn on your overhead air vent to increase the filtered air that you are breathing. Avoid or minimize eating and drinking during the flight – when the flight attendants pass out beverages and snacks, everyone tends to take their masks off to eat/drink at the same time so wait to eat or drink until after everyone else has finished and re-masked. When eating or drinking on the plane, try not to take your mask off for any longer than you can hold your breath. Wear a mask at all times – the greater the filtration of the mask the better; I am fortunate that I was fit-tested for an N-95 mask (with a beard) and that is the mask I wear.

Travel outside of the U.S.

Check the websites first! COVID travel restrictions are constantly changing and each country is very different. Some countries are not currently permitting non-essential travelers to enter. Check the government websites of any country you plan to visit to find out their specific travel requirements. Next, check the U.S. state department website for travel safety information about the country you will be traveling to. Finally, check the CDC website that stratifies the COVID risk of each country. Don’t go to countries that are classified as level 4 risks and if you can, select from those that are level 1 risks.

You may need COVID travel insurance. Although many commercial health insurance policies will provide at least some coverage for illness-related expenses abroad, most do not cover the cost of medical evacuation or quarantine housing. Many countries now require documentation of a COVID-specific travel insurance policy. These can be purchased on-line and typically run about $500 per person, depending on one’s age and duration of travel.

COVID testing prior to arrival. Most countries currently require travelers to have a negative COVID test prior to entry. Some require a PCR test while others will accept a rapid COVID test. Some require the test to be done within 24 hours prior to arrival, others require it within 48 hours, and others require testing to be done in the immigration area of the airport at the time of arrival. In all cases, some form of documentation of the test is required. For this reason, the self-read home test kits sold at your local pharmacy will not be sufficient. Many pharmacies and U.S. airports will do travel COVID testing with advance scheduling. If the country that you will be traveling to requires testing to be done in their immigration area, they will likely require payment in cash at the time of testing.

Will you need a COVID certificate? Some countries (for example, member of the European Union) require you to have a COVID certificate in order to go just about anywhere in that country. These can be obtained on-line from the each government’s website.

Returning to the U.S.

Check the websites first! The CDC travel website provides up to date information about entry requirements to get into the U.S., including requirement for U.S. citizens returning from travel abroad. These requirements can change so check this website when first planning a trip and again shortly before departing.

You will need a COVID test. The U.S. requires documentation of a negative COVID test (rapid or PCR) within 1 day prior to arrival. This is slightly different than the 24 or 48-hour requirement of most other countries. The test can be done anytime the day before arrival in the U.S. Many hotels and airports in other countries will perform testing and provide documentation for a fee. You can also do an at-home test that has telehealth proctoring. Importantly, most of the commercial test kits sold at pharmacies are self-read and do not have a telehealth component. Because you have to present documentation of a negative COVID test to get into the U.S., these self-read tests will not suffice. Examples of acceptable at-home tests include:

  • Abbott BinaxNOW
  • Ellume-AZOVA
  • Cue
  • Quered

Note that there are two versions of the Abbott BinaxNOW test – one that is sold at retail pharmacies and does not have a telehealth component and a second version that is sold on-line that does have a telehealth component. Only the second version is accepted for entry into the U.S. can can be ordered online at emed or optum. It is a good idea to pack at least one of these tests for each traveler, even if you plan to get your pre-U.S. entry COVID test at a hotel or airport at your travel destination – you just can predict if the hotel will run out of tests or if the airport has staffing issues on the day that you plan to fly back to the U.S.

Weighing the risks of travel

Patients would often ask me “Is it OK for me to travel?” Sometimes, the answer was a flat-out ‘no’ but more often, it was varying degrees of ‘maybe’. There are two considerations: the traveler’s personal risk factors and the risks associated with the travel destination. The good news is that people who have been vaccinated and boosted are at relatively low risk of getting so sick that they require hospitalization or die if they do get COVID while traveling. However, risk factors for severe infection such as advanced age, obesity, diabetes, hypertension, or immunosuppression must be factored in, even for those who are fully vaccinated. The travel destination is at least, if not more important. Locations where there is a culture of masking and vaccination are lower risk than areas dominated by anti-maskers and anti-vaxxers. Destinations where you won’t encounter crowds and where you will mostly be outdoors are lower risk than destinations where there will be crowded indoor areas. A vacation rental home where you will be eating your own meals is less risky than a hotel. Cruises are probably among the highest risk travel options.

Just being a human poses some degree of risk in this COVID pandemic. Traveling incurs some additional risk but the good news is that most people can minimize that risk by careful planning and taking the right precautions.

January 5, 2022


The Relationship Between Political Party And Deaths From COVID

Most Americans have had a sense that the COVID-19 pandemic has been politicized. By analyzing publicly available datasets, it is clear that there are striking differences between Republicans and Democrats with respect to COVID deaths, COVID infections, and COVID vaccination rates.

If you have not seen the graph created on the Infection Prevention, Emergency Management, & Safety blog, please click here to view it. This graph shows that there is a dramatic relationship between U.S. counties voting Republican versus Democrat in the 2020 presidential election and the rate of death from COVID infection in those counties. This graph was the inspiration for the following analysis.

Analysis Methods

Data regarding vaccination rates and death rates was obtained from the COVID-19 data sets available on the Centers for Disease Control’s COVID Data Tracker website. Data regarding COVID seroprevalence rates was obtained from the Nationwide Commercial Laboratory Antibody Surveillance Survey website. Results of the 2020 presidential election are available at many sources, including the Federal Elections Commission website. Data from all 50 states plus Washington D.C. were included (Puerto Ricans cannot vote in presidential elections). Statistical analysis was performed using 2-sample t-tests. For death rate analysis, data was obtained from three dates:

  1. January 23, 2020 to present. This represents death rates for the entire pandemic
  2. December 15, 2020 to present. This represents death rates since the date that COVID vaccines were first made available to limited U.S. populations
  3. April 19, 2021 to present. This represents death rates since the date that COVID vaccines became available to all Americans over age 16

Republicans are dying of COVID at a higher rate than Democrats

Because the population size of each state is different, the total number of COVID deaths per state tells us very little. Of greater importance is the number of deaths per 100,000 people in each state. Since April 19, 2021 (when vaccines were available to everyone over age 16), states that voted Republican in the 2020 presidential election have had a higher death rate from COVID than states that voted Democrat (89 per 100,000 versus 53 per 100,000; p < 0.0001).

Analyzing each state separately, there was a direct correlation between the percentage of voters in each state voting Republican and the death rate from COVID since April 19, 2021, regardless of whether the Republican or Democrat party won that particular state. The higher the percentage of Republican voters, the higher the death rate from COVID in individual states. Washington DC had both the lowest COVID death rate (15 per 100,000) and lowest percent of the population voting Republican (5.4%). Wyoming had both the highest COVID death rate (137 per 100,000) and the highest percent of the population voting Republican (69.9%). 

On December 15, 2020, COVID vaccines first became available to restricted populations. In most states, vaccines were initially limited to healthcare workers and high-risk nursing home residents. Assessing deaths since December 15, 2020, Republican states still have had a higher death rate than Democrat states (160 per 100,000 versus 111 per 100,000; P < 0.001)

Once again, there is a direct correlation between the percentage of voters in each state voting Republican and the death rate from COVID since December 15, 2020:

The first cases of COVID-19 in the United States occurred in January 2020. In the first months of the pandemic, there was slow adoption of social distancing and mask-wearing throughout the nation and as a consequence, the largest outbreak of infection initially occurred in New York City (New York voted Democrat in 2020). Despite this, Republican-voting states have had a significantly higher COVID death rate since the pandemic began than Democrat-voting states (252 per 100,000 versus 211 per 100,000; p = 0.019). However, the death rates are not as divergent as they have been since vaccines have been available.

There has been a direct correlation between COVID death rates and the percent of each state voting Republican in 2020 since the beginning of the pandemic on January 23, 2020. However, the slope of the correlation is not as steep as it is since vaccines became available, as shown in the previous scatter graphs.

More Republicans have had COVID-19 infection than Democrats

There are 3 databases that track the number of Americans who have had COVID infection: (1) nasopharyngeal testing reported to the CDC, (2) blood donor surveillance testing, and (3) the Nationwide Commercial Laboratory Antibody Surveillance Survey. In a previous post, the advantages and disadvantages of each of these was discussed but overall, the infection rates determined by the Commercial Laboratory Survey are probably the most accurate.

By comparing the seropositivity data from each state and then comparing states that voted Republican versus states that voted Democrat in 2020, a higher percentage of the population in Republican-voting states have had COVID infection since the pandemic began than in Democrat-voting states (34% of people in Republican states have been infected versus 24% of people in Democrat states; p = 0.0001).

As with the death rate data, there is a direct correlation between the percent of voters voting Republican in each state and the percentage of people in each state that have had a COVID infection since the pandemic began:

Republicans are less likely to be vaccinated than Democrats

Surveys, such as the Kaiser Family Foundation Vaccine Monitor, have indicated that Republicans are less likely to get vaccinated than Democrats. Although one’s political party is not asked about when getting vaccinated, by comparing state voting records with CDC vaccination data, Republicans do appear to be less vaccinated than Democrats. In states that voted Democrat in the 2020 presidential election, 78% of the population has received at least one dose of a COVID vaccine versus 63% of the population in states voting Republican (p < 0.0001).

Similar to the other analyses, there is a direct correlation between the percentage of voters in each state that voted Republican and the likelihood of being vaccinated:

The implications are clear

COVID infection is expensive. At the least, it results in greater employee absences, resulting in significant cost to employers. For many people, infection requires hospitalization, resulting in expensive healthcare costs that are passed on to taxpayers (through Medicare and Medicaid) and American workers (through commercial insurance premiums). Prolongation of the pandemic results in supply chain disruptions that in turn lead to costly increases in inflation. By being less vaccinated and having more COVID infections, Republicans are costing the nation more than Democrats.

The tragedy of COVID is not the financial costs but the cost of human lives. Thus far, more than 800,000 Americans have died from COVID and the projections are for the United States to surpass 1 million deaths before next summer. The above analysis indicates that Republicans are dying at a much faster rate than Democrats. It is my sincere hope that the party leaders get the message that dead people cannot vote and as the pandemic continues, there will be fewer Republicans alive to vote in the 2024 election. With the 2020 presidential election decided by razor-thin margins of votes in Georgia, Arizona, and Wisconsin, it is clear that neither political party can afford to have a disproportionate number of its voters die. However, by politicizing vaccination, mask-wearing, and social distancing, Republican voters are disproportionately dying and the Republican party is thus giving up votes to the Democrats.

As a full disclaimer, I am politically independent and do not affiliate with either party. In the 2020 general elections, I financially supported 2 Democrats and 2 Republicans running for various state and national offices. In this war of the pandemic, the enemy is not Democrats or Republicans, it is the virus… and you cannot win a war unless you know who the enemy really is. It is time for all of us to put our political party preferences aside and fight the true enemy.

December 17, 2021


One Year Of COVID Vaccines

One year ago today, at 7:00 AM on December 15, 2020, I was one of the first people in the United States to receive a Pfizer COVID-19 vaccination. What a wild and weird year it has been since then.

When the vaccines became available, many physicians thought that vaccination would bring an end to the pandemic by the summer of 2021, myself included. In fact, I was so confident that I timed my retirement to May 2021 to coincide with what was anticipated to be a return to normalcy. I could not have been more wrong.

In the first month of vaccine availability, the demand for vaccines greatly exceeded the supply of vaccines and consequently, a nationwide prioritization plan was developed. In Ohio, our governor directed that the first to be vaccinated were front-line healthcare workers and nursing home residents. It was up to individual hospitals to prioritize their healthcare workers. So, our medical center created a committee to determine which healthcare workers would be first to get vaccinated. We started with doctors, nurses, and respiratory therapists in the emergency departments and the intensive care units. As a critical care physician who was intubating and performing bronchoscopy on COVID patients, I was in the first group. I got the first vaccination appointment on the first day of the roll out at 7 AM on December 15th – not because I was the medical director of the hospital, but because I was the fastest to click on the on-line scheduling app when the emails went out to the ED and ICU staff announcing vaccination eligibility.

In the subsequent weeks, there was much controversy about which groups of healthcare workers would be eligible for vaccination next. Should outpatient primary care physicians be prioritized before radiology technicians? When should pharmacists get their vaccinations? What about housekeeping staff? The medical students lobbied to the Dean that they should get vaccinated and then opinion articles in our local newspaper complained that young medical students who were not caring for COVID inpatients were getting vaccinated before senior citizens with health conditions. Every day, those of us on the prioritization committee got emails from impassioned healthcare workers lobbying to be moved up on the vaccination schedule. January 2020 was a month of endless controversy.

As vaccine production ramped up, the Pfizer and Moderna products became more plentiful. The Governor made the vaccines available to Ohio seniors, followed by grocery workers and then first responders. On March 1, 2021, the Johnson & Johnson vaccine was authorized. On April 19, 2021, COVID-19 vaccines became available for all American adults under FDA emergency authorization and then on August 23, 2021, vaccines were fully approved by the FDA for all American adults. On October 29, the Pfizer vaccine was authorized for anyone over age 5 years old. The COVID pandemic should have been over by December 1st. But it wasn’t and it isn’t.

As of today, the CDC reports that 76.6% of Americans over age 5 have received at least one dose of a COVID vaccine and 64.8% are fully vaccinated. As of today, 29.2% of adults have received a booster dose. But there are still too many who are unvaccinated. Fully 15% of American adults have not received a dose of a COVID vaccine. Some have not been vaccinated because they are among the crazies or have gullibly been misinformed by the crazies; most have not been vaccinated because they are cowards.

So, who is left to get infected?

COVID infection can be prevented by either getting vaccinated or having antibodies from past infection. Neither of these will completely eliminate the risk of future COVID infection but they will reduce it and they will nearly eliminate the risk of dying from it. We have great data on the number of Americans who have been vaccinated but it is more difficult to know how many have already been infected. We have 3 databases that tell us how many Americans have been infected, each with its own advantages and disadvantages:

  1. Nasopharyngeal testing data. When a person gets a nasal swab to test for the SARS-CoV-2 virus, the results of that test are reported to the local health department that in turns reports the information to the CDC. Nasopharyngeal testing data indicates that there have been 50,082,008 cases of COVID or 15.0% of the U.S. population. Death certificate data indicates that there have been 796,010 deaths from COVID. Both of these numbers are underestimates. Many people who are infected do not get tested either because they are asymptomatic or because they choose not to be tested. In addition, many retail self-test kits do not require reporting results to the health department so people who do at-home tests can be positive but the CDC cannot track their numbers. The deaths are tracked by death certificate reports and if a physician does not list COVID on the death certificate, the health department will not know if COVID was responsible. Furthermore, many COVID victims are simply found dead at home without having undergone COVID testing and those patients’ primary care physicians simply make their best guess at the cause of death.
  2. Blood donation antibody data. The CDC has a program that anonymously tests samples from blood donations for antibodies against COVID. However, the antibodies tested can be from either previous vaccination or from previous infection. This data indicates that 91.8% of blood donors have either gotten vaccinated or have been infected. A problem with this data is that blood donors are not representative of the U.S. population at large. Blood donors tend to be more socially responsible and are thus more likely to be vaccinated than the average American. In addition, adults with chronic disease and children under age 16 cannot donate blood. The current data can be found here on the CDC website.
  3. Clinical laboratory antibody data. When a person has blood drawn for a clinical laboratory test, left over blood can be used (anonymously) for testing for COVID antibodies through a second CDC seroprevalence program. These can be blood samples drawn because a person was ill or because a healthy person was getting a routine cholesterol screening test. An important difference with this data versus the blood donation data is that the commercial lab testing only tests for antibodies that result from infection and not antibodies that result from vaccination. According to this data, 29.4% of Americans have been infected in the past. This implies that 87,128,000 Americans have had a COVID infection, nearly double the number determined by the nasopharyngeal testing data. Texas has the highest past infection prevalence at 43% of its population. Vermont has the lowest prevalence at 7.7% of its population A limitation of this data is that older people and chronically ill people are more likely to have blood tests than younger people and otherwise healthy people and so the information may not be representative of the American population as a whole. The up to date data can be found here on the CDC website.

In a previous post, I noted that there are demographic groups of the unvaccinated. They are more likely to be younger, male, Republican, rural residents with lower education levels and lower incomes. This has created a uniquely American political dilemma – this is a group that tends to be very vocal but is a group that does not tend to have a lot of money to spend in the economy. As a consequence, our elected officials can score political points and votes by appeasing them even though they do not have much economic clout. The past year has proven that science and public service announcements will not sway this demographic to get vaccinated. Instead, to convince them to get vaccinated will require harnessing that most powerful of all influencers – American advertising. Our corporate advertising agencies have been enormously successful convincing us to buy stuff that we don’t really need and it is in corporate interest to keep us buying stuff instead of dying from COVID. After all, dead people can’t buy cigarettes, tickets to NASCAR races, or country music records… and dead people can’t vote for the candidates from their favorite political party.

Vaccination is the road to a return to normal

This month, I traveled to San Francisco, California and what a difference it was compared to Columbus, Ohio. In San Francisco, everyone wore masks indoors at stores and public buildings; about half of people even wore masks walking outdoors on the sidewalk. The city has an ordinance that requires showing proof vaccination to enter a restaurant, club, bar, or gym. And the stores and restaurants were full – in short, life is almost back to normal. Shoppers feel safe going into a store and diners feel safe eating in a restaurant. More than 95% of all San Francisco residents over age 12 have received a COVID vaccine. As a consequence, despite the fact that the stores and businesses are bustling, the rate of new COVID infections (30 per 100,000 population) and COVID hospitalizations (only 21 in the past 7 days) are among the lowest in the United States.

Meanwhile, back in Columbus, those few restaurants that elected to require customer vaccination get picketed by anti-vaxxer protesters. Only 73.5% of residents over age 12 have gotten a vaccine. The rate of new COVID infections is currently 300 per 100,000 population and there were 351 COVID hospitalizations in Columbus during the past 7 days. In other words, despite being a much more densely populated community, the rate of COVID infection and hospitalization in San Francisco are only 1/10th of the rates in Columbus.

I felt comfortable shopping in San Francisco. It will be a long time before I am willing to eat in a restaurant or enter a store for anything other than essentials in Columbus.

Internationally, countries with more of their population vaccinated are poised to emerge from the pandemic sooner and return to economic prosperity faster. Those countries with fewer of their citizens vaccinated are doomed to pandemic-induced economic stagnation, supply chain disruption, and prolonged inflation. Countries that are leading in the vaccination race are (percent of population vaccinated):

    • United Arab Emirates (100%)
    • Cuba (90.1%)
    • Cayman Islands (89.9%)
    • Chili (89.8%)
    • Portugal (88.1%)
    • Cambodia (88.1%)

The United States is in 28th place overall with 72% of the total population receiving a vaccine. Among the states, there are some clear winners – New Hampshire (with 92% of its population having received a vaccine) leads the rest of the states followed by West Virginia (89%), Massachusetts (88%), Vermont (87%), and Connecticut (86%),  Ohio (with 59% of its population having received a vaccine) ranks 43rd out of all of the states in vaccination rates. Only Alabama (57%), Tennessee (57%), Louisiana (56%), Indiana (56%), Mississippi (54%), Wyoming (54%), and Idaho (51%) have worse vaccination rates. Ohio is in a race to the bottom – our vaccination rate is currently in-between that of India and Venezuela; more closely resembling a third world country than an industrialized nation. As a rule, businesses and tourists do not elect to go to war zones – the U.S. in general (and Ohio in particular) remains a COVID war zone while our competitors are winning their COVID wars.

If we want to get our Ohio businesses to successfully compete with businesses in other states and if we want to get U.S. tourism to successfully compete with tourism in other countries, then we need to get our populations vaccinated. Countries and states with high vaccination rates are poised to become the economic winners; those that do not will become the losers. After a full year of vaccine availability, we really should have done better.

December 15, 2021


It’s Time To Put The Pandemic Blame On The Unvaccinated

Today is December 7, 2021 and the 80th year since the attack on Pearl Harbor that brought the United States into World War II. Today, we are in a different war – a war against the coronavirus. In every war there are those who sympathize with the enemy. In today’s war, the sympathizers are the unvaccinated.

On April 19, 2021, COVID-19 vaccines became available for all American adults under FDA emergency authorization and on August 23, 2021, vaccines were fully approved by the FDA for all American adults. Since that time, public health authorities have been careful to avoid placing any blame for the pandemic on the unvaccinated in order to avoid further political polarization. I am not a public health authority so I’m going to say it like it is – the unvaccinated are a primary reason that we are still in a pandemic. It is what doctors and nurses all over the country think but have not wanted to come out and say. The SARS-CoV-2 virus essentially declared war against the human race. Anti-vaxxers and anti-maskers do not stand for freedom – they are sympathizers with the virus in this COVID-19 war.

In the week after the attack on Pearl Harbor, a Gallop poll found that 9% of Americans did not want to fight back against Japan – presumably, these people just wanted the U.S. to roll over and become a Japanese territory. In the American Revolution, 15-20% of Americans were Loyalists (“Tories”) who sympathized with the British and were opposed to American independence – after the war, an estimated 200,000 of them left the new United States for Canada, the Caribbean, and England. Presently, 16.5% of American adults have not received at least one dose of a COVID-19 vaccine, roughly the same percentage of American adults who were Loyalists during the Revolution. Wittingly or unwittingly, they have sided with the virus and against the human race.

Who are the unvaccinated?

The unvaccinated are not the old and wise; instead, they are mostly younger. According to the CDC, >95% of American adults over age 65 have received at least one dose of a COVID-19 vaccine as of December 6, 2021. Based on the CDC graph below, 99.9% of Americans between 65-74 years old have received a COVID vaccine; in other words, only 1 out of 1,000 Americans in that age range has not been vaccinated! American seniors got vaccinated not because they were required to by employment mandates – most of them are already retired. They got vaccinated because they have lived long enough to know that in any war, when the enemy attacks you, your family, and your country, the only way you survive is by defending yourself. In this war, the only defenses that work are vaccination, wearing masks, and social distancing.

So, who are the unvaccinated? They are mostly young. According to data from the CDC, only 68.9% of American adults between 18 and 24 years old have received a vaccine. The likelihood of being vaccinated goes up in direct proportion to one’s age.

The unvaccinated are also more likely to be men. When you look at Americans of all age groups (including young children), 72.6% of women and girls have received a vaccine but only 68.0% of men and boys have received a vaccine.

Vaccination rates by race and ethnicity are much more difficult to determine. According to CDC vaccine administration data, Native Americans are the most vaccinated group followed by Asian Americans, Hispanic Americans, White Americans, and Black Americans. However, the CDC does not have race or ethnicity data for fully 1/3 of people who have been vaccinated. Therefore, statistics from the CDC vaccine administration race and ethnicity data are incomplete. 43 states report race/ethnicity statistics from state health department data. According to these state statistics, Asian Americans are the most vaccinated, followed by White, Hispanic, and then Black Americans. A third way of examining race and ethnicity vaccination differences is by telephone surveys. The National Immunization Survey is a telephone survey involving a sample of the adult population in all states. According to the most recent survey, Asian Americans are the most vaccinated followed by Hispanic, then Black, then White. An inherent problem with telephone surveys is that their accuracy depends on (1) who has a telephone, (2) who is willing to take a survey when the phone rings, and (3) how accurately and honestly a person answers the survey questions. Given the rather dramatic differences in the results of the three methods of assessing the data, the only conclusion that seems certain is that Asian Americans are the most heavily vaccinated group and beyond that, we really do not know how race and ethnicity affect vaccination rates.

There is better data on vaccination rates by community size. The larger the city or town a person lives in, the more likely that person is to be vaccinated. People living in rural communities have the lowest rates based on CDC data. The graph below shows urban versus rural fully vaccinated rates for all ages (not just adults).

Not surprisingly, states with large urban populations are doing better than states with larger rural populations. Coastal states have a greater percentage of their populations vaccinated than southern and midwestern states. My state of Ohio is among the worst performers from a vaccination standpoint. Much has been written about vaccination disparities among racial/ethnic groups but those differences pale when compared to the rural versus urban disparities. When vaccines first became available, the thought was that the low vaccination rates in rural areas were due to less access to the vaccines in those areas; now that vaccines are widely available, it is clear that remaining unvaccinated is a conscious choice that rural people are making.

The unvaccinated are costing all of us

When a person becomes hospitalized because of illness, the cost of that hospitalization is paid for by an insurance company or the federal government (by way of Medicare, Medicaid, VA benefits, or the Federal Employees Health Benefits program). Those costs are then transferred to all Americans by higher health insurance premiums and higher taxes. At this point in the pandemic, the overwhelming majority of Americans hospitalized with COVID-19 are unvaccinated. People who are not vaccinated are 12 times more likely to be hospitalized with COVID-19. Most of the vaccinated patients who are hospitalized are immunocompromised – transplant patients, patients taking chemotherapy, and patients with immunodeficiencies. We are all paying the enormous healthcare costs for the minority of Americans who choose to be unvaccinated.

In addition to occupying our hospital beds, the unvaccinated are far more likely to occupy our hospital morgues. Unvaccinated people are 14 times more likely to die of COVID-19 than the vaccinated. Once again, most of the vaccinated who die of COVID-19 are immunocompromised.

More unvaccinated = more variants

Viruses mutate – that is how they survive. Mutations occur predictably based on the number of individual viruses that exist at any given time. The more people who are unvaccinated, the more viruses are in circulation. Mutations that result in a more contagious variant then quickly become the dominant virus – it is simple survival of the fittest.

The Delta variant originated in India in December 2020. The reason? Vaccines were not yet available and India was undergoing a surge in COVID-19 cases that month. With the massive number of viruses circulating in India, the Delta variant was born.

The Omicron variant originated in South Africa in November 2021. The reason? South Africa had a very low vaccination rate with only 23% of the population fully vaccinated. Omicron causes infection that is far more contagious than the original COVID-19 infections. As an example, there were 120 people who attended a corporate Christmas party in Norway on November 26, 2021. One attendee had just arrived from South Africa and was infected with Omicron. By the end of the party, more than half of the attendees had become infected with Omicron. Fortunately, the attendees were all young (it was a corporate event – they were all of working age) and were all vaccinated so the Omicron illnesses were relatively mild and no one died (at least, not yet). Had it been a nursing home Christmas party rather than a company holiday party, the death toll would have been staggering.

Delta and Omicron will not be the last COVID variants. As long as there are groups of unvaccinated people, new and more contagious variants will emerge.

How do we bring an end to the coronavirus war?

In the beginning of the pandemic, we all owned it – every human being on the planet. Now, it is the unvaccinated who own it. To those who cry “Freedom!” in the name of being unmasked and unvaccinated, I say that if you want life to get back to a pre-pandemic normal, then get vaccinated and wear a mask. You are the ones who are holding us back. Our country prevailed in the American Revolution and in World War II because Americans had a common enemy. The SARS-CoV-2 virus is the human race’s common enemy – black and white, urban and rural, Republican and Democrat. The longer we bicker among ourselves by perpetuating a myth that the pandemic is a political issue, the more casualties the virus will inflict on us. Those who politicize the pandemic are enablers of the pandemic.

If you want to be able to go to a restaurant or a church without having to be 6 feet away from other people, then get vaccinated. If you want your kids to be able to go to school without wearing a mask, then get vaccinated. If you want to prevent your health insurance premiums and Medicare taxes from increasing, then get vaccinated. If you want to see shuttered businesses re-open, then get vaccinated. But if you remain unvaccinated, then this pandemic is on you. The only conceivable reason to be unvaccinated in the United States at this point is cowardice. Wars are won by the patriots. Patriots who fought for independence won the American Revolution 238 years ago. Patriots who supported the U.S. war effort won World War II after Pearl Harbor was attacked 80 years ago today. In the war against the coronavirus, the patriots are the men, women, and children who got vaccinated.

December 7, 2021


Why COVID-19 Will Never Go Away

There are only three kinds of people: those who have been vaccinated for COVID-19, those who will survive COVD-19 infection, and those who will die of COVID-19 infection. Eventual exposure to the SARS-Cov-2 virus is inevitable and the virus will, in all likelihood, be with the human race for generations. The reason is because it is a unique zoonotic virus that infects so many different mammals.

A zoonotic infection is one that can be passed from animals to humans. Some of the most lethal pandemics in human history can be traced to zoonotic infections. The plague (Yersinia pestis) was carried by rats and transmitted to humans through the Oriental rat flee. Ebola is transmitted to humans from fruit bats that carry the virus without becoming sick. Hantavirus is carried by asymptomatic wild mice that can transmit it to humans. The 2009 H1N1 influenza strain (swine flu) came from pigs. Rabies, West Nile virus, Lyme disease… there are more than 250 infections that can be passed from animals to humans. The SARS-CoV-2 virus most likely jumped from horseshoe bats to other wild mammals and then to humans in the Wuhan region of China in late 2019.

Most zoonotic viruses are not easily passed from one human to another – think Zika, rabies, and hantavirus. These viruses can be largely prevented by avoiding contact with the animals that serve as viral reservoirs. Those few viruses that can be easily transmitted from one human to another are really scary – think about Ebola, for example. The reason SARS-CoV-2 is so unique among zoonotic viruses is that it is not only incredibly contagious between humans but it is also incredibly contagious from humans to other mammals that can then serve as a perpetual reservoir where it can then re-infect human populations. There is increasing evidence that these animal reservoirs exist today.

Mink farms. In April 2020, a farm worker in a Dutch mink farm came to work with a COVID-19 infection. Soon, minks at the farm were dying at an abnormally high rate and many of the minks were found to have nasal discharge. The SARS-CoV-2 virus had jumped from human to mink and was soon detected in 200 mink farms in nearby Denmark, most likely from feral cats roaming from farm to farm, stealing mink food and spreading COVID along the way. Not only did the virus spread among the minks like wildfire, but farm workers were soon becoming infected from the minks with a cycle of human to mink and back to human infection. As a consequence, the Danish government euthanized more than 17 million minks in November 2020. To make matters worse, viruses from mink corpses leached into the ground and infected human drinking water. In December 2020, an infected mink from a mink farm in Oregon escaped and soon, the SARS-CoV-2 virus was being detected in wild minks.

Whitetail deer. There are about 30 million whitetail deer in the United States (including this one in my backyard!). The U.S. Department of Agriculture collected samples from 481 deer in Illinois, Michigan, Pennsylvania, and New York between January 2020 and March 2021. In all, 40% of the deer had SARS-CoV-2 antibodies, indicating that they had been infected. A University of Pennsylvania study found that 30% of deer tested in Iowa between April and December 2020 had antibodies – however, a follow-up study found that by the period December 2020 through January 2021, fully 80% of Iowa deer tested had been infected. Genetic studies found that the strains of the virus in deer were the same as the viruses in circulation in Iowa causing human COVID-19 infection at the same time – strong evidence that the deer had become infected from human contact. The USDA Agricultural Research Service then experimentally exposed captive deer to the SARS-CoV-2 virus and found that the infected deer did not experience any overt sign of infection – in other words, the deer had asymptomatic infection. With the 2021 deer hunting season now beginning, it is likely that hunters and butchers will be exposed to infected deer, thus perpetuating the zoonotic cycle. Unfortunately, there is virtually zero chance of passing a law to require proof of COVID vaccination to get a trapping or deer hunting license in Ohio.

Zoos. Compared to wild animals, captive animals in our zoos are relatively easy to study due to the ease in collecting biological samples. The SARS-CoV-2 virus has been found in lions, tigers, gorillas, hyenas, and leopards. At least 4 snow leopards in American zoos have died of COVID-19 infection. In July 2021, Zoetis (a pharmaceutical company that makes medications and vaccines for livestock) donated 11,000 doses of its experimental COVID vaccine to 70 U.S. zoos. The Oakland Zoo was the first to get the vaccine and inoculated its bears, mountain lions, gorillas, chimpanzees, ferrets, and pigs. Fortunately, anti-vaxxers have not taken up protests against vaccine mandates for zoo animals. If animals in the zoo can get infected, then the same kind of animals in the wild are also getting infected.

COVID-19 is not going to go away

Although most data indicates that the SARS-CoV-2 virus originated in horseshoe bats in China, some people have suggested that the virus originated in a Chinese research lab. Whichever origin is correct is irrelevant to controlling the virus in the future. Because the virus has conclusively been shown to infect humans who then infect animals that then infect other humans, there is now a viral reservoir in the wild that can continuously seed the human race in the future. This means that even if we could magically eliminate all human cases of COVID-19 on a Monday, by Friday, some humans would have become infected from animals harboring the virus… and those humans would then infect other humans.

It all comes down to the ACE-2 receptor

The SARS-C0V-2 virus contains an outer glycoprotein called the spike protein. This is the protein that is encoded by the mRNA in the Pfizer and Moderna COVID vaccines. The spike protein on the coronavirus latches onto a receptor on human cells called the angiotensin converting enzyme-2 receptor (ACE-2 receptor). The part of the ACE-2 receptor that the coronavirus spike protein attaches to is called the S-protein binding site. Once attached to the ACE-2 receptor, the virus can then get inside of our cells and take the cells over to make more viruses, similar to the creatures in the movie “Alien” that grew inside the stomachs of the unfortunately infected humans before exploding through their abdominal walls.

All mammals have ACE-2 receptors on their cells. The more similar an animal’s ACE-2 S-protein binding site is to a human’s determines whether that animal is likely to become infected with SARS-CoV-2. For example, the ACE-2 S-protein binding site of mice is very different than that of a human’s and consequently, mice do not develop COVID infection. On the other hand, the ACE-2 S-protein binding site of hamsters is very human-like and indeed, hamsters are quite susceptible to developing COVID infection. Because so many mammals have ACE-2 S-protein binding sites that are similar to humans’, many mammals can develop COVID-19 infection – from domestic animals such as dogs and cats, to wild animals such as bats and deer.

When I was 5 years old, a bat flew into my bedroom and scratched my face while I was sleeping. I ended up getting vaccinated against rabies which at the time consisted of 14 daily intra-abdominal injections of rabies vaccine. I did not come down with a case of rabies but that life experience has shaped my respect for zoonoses. Humans were the vectors that disseminated SARS-CoV-2 to mammals throughout the world. And now, we are going to have to live with the consequences of  that dissemination for years to come. Today, I would have to worry about getting COVID-19 and not just rabies from my bat exposure. Going forward, unless an unvaccinated person lives their entire live in isolation lockdown, then COVID-19 infection is virtually inevitable – if not this year, then next year or the year after or the year after that. We have sown COVID-19 throughout the animal kingdom and we will have to reap its deadly harvest for years to come.

Children will be vectors

Varicella-zoster virus causes chicken pox and shingles. Like COVID-19, chicken pox is usually a relatively mild disease in young children but can cause severe infection in adults. Unlike COVID-19, you can only get chicken pox once and the initial chicken pox infection provides life-time immunity from re-infection. Before the varicella vaccine was first licensed in the United States in 1995, parents would hope that their children got chicken pox early in life, when it cause less severe infection. Some parents would hold “pox parties” to expose their pre-school aged children to an infected child in order to ensure early childhood infection. Attempting to draw from history, some adults have engaged in “COVID parties” in order to become infected and thus develop immunity – these efforts have been disastrous at best but often fatal at worst.

Since no COVID vaccines are currently approved for use in children under age 5, it is likely that the SARS-CoV-2 virus will continue to circulate among young children for the foreseeable future. In other words, children will be another viral reservoir for SARS-CoV-2 until COVID vaccines are approved for all ages. The only good news is that young children are less likely to die when they get infected with COVID than their adult parents are.

Vaccines are the only answer

Yesterday, I flew from Columbus to Las Vegas on a connecting flight while traveling to San Francisco. Behind me, an unmasked and sick 3-year-old coughed and sneezed constantly for the 4 hour flight. Across the aisle, a disruptive passenger tried to wear a mask with quarter-inch holes punched all through it and then when asked by the flight attendant to wear a normal mask, she refused to pull it up over her nose (she was ultimately escorted off the plane by an airport authority on arrival in Las Vegas while having a few loud choice words for the unfortunate flight attendant). This experience illustrates why behavior mandates will not bring an end to the pandemic. Behavior mandates protect the individual that complies but does not protect the human race – some parents will still bring their sick child onto a crowded plane and some anti-authoritarians will continue to refuse to wear masks in public areas. Similarly, travel bans are not the solution. Travel bans that worked in MERS, SARS, and Ebola outbreaks have proven to be ineffective with the initial COVID outbreak and again with the more recent omicron variant outbreak.

Had COVID occurred 30 years earlier in 1989 rather than 2019, then all humans would eventually have become infected and those who survived would have inherited the earth. However, COVID occurred at a unique time in our species’ history when science was able to rapidly invent effective vaccines. And so now, each of us humans have a choice – get vaccinated or get infected. Given the enormity of the mammalian reservoir for the SARS-CoV-2 virus, there really are no other choices. As I walked past rows of slot machines in the Las Vegas airport yesterday, I was struck by how similar COVID is to gambling: living on earth in the era of COVID is like playing Russian roulette with a loaded revolver. Getting vaccinated is like taking the bullet out of the gun.

November 30, 2021

Epidemiology Medical Economics

Should You Mandate Employee COVID-19 Vaccination?

“Individual freedom!” has been the rallying cry of a highly vocal but increasingly small minority of Americans who oppose COVID-19 vaccines. Most of these anti-vaxxers represent the intersection of ignorance, arrogance, and obstinance. But should you require them to get vaccinated if they are your employees? In a free market economy, businesses with vaccinated employees have a competitive advantage over businesses with unvaccinated employees.

COVID infection is costly

A study from the City University of New York found that the average direct medical cost of a symptomatic COVID-19 infection is $3,045. Infections that require hospitalization are considerably more expensive than those that can be managed as an outpatient. A report from CMS found that the Medicare payments for a COVID-19 hospitalization was $24,033 (this does not include co-pays that the individual is responsible for). A study in JAMA Open Network this week found that the average out-of-pocket co-pay for a COVID-19 hospitalization was $3,804. A report from the Kaiser Family Foundation found that the average cost of COVID-19 hospitalization for commercially-insured patients with pre-existing medical conditions is estimated to be $20,292 (commercially-insured patients are younger than Medicare patients, have fewer medical co-morbidities, and tend to have shorter hospital stays – all resulting in lower cost per hospitalization than Medicare patients).

In addition to direct medical costs, there is a cost of lost worker productivity during their infection. Recommendations by the CDC are persons infected with COVID-19 should not return to the workplace for at least 10 days from the onset of symptoms. Those persons who are immunocompromised or who require hospitalization for more severe COVID-19 infections should not return for 20 days. Asymptomatic persons who test positive for COVID-19 should not return to the workplace for 10 days from the date of the COVID-19 test. In total, COVID-19 absenteeism is quite costly to employers.

Unvaccinated employees cost more

Vaccines are effective in preventing COVID-19 infection. Overall, unvaccinated persons are 6.1 times more likely to test positive for COVID-19 than vaccinated persons. That means that unvaccinated persons are 6.1 times more likely to be absent from work for at least 10 days. They are 6.1 times more likely to incur the $3,045 direct medical cost of the average COVID-19 infection. The graph below shows the COVID-19 case rate per 100,000 for vaccinated and unvaccinated Americans of working age.

Vaccines are even more effective in preventing severe infection; most of the people hospitalized for COVID-19 infection are now unvaccinated. The CDC reports that unvaccinated COVID-infected persons are 12 times more likely to require hospitalization than unvaccinated persons. Preliminary data suggest that unvaccinated persons are 20-30 times more likely to require ICU admission for COVID-19 infection than vaccinated persons. The graph below shows hospitalization rates per 100,000 for vaccinated versus unvaccinated persons.

Older unvaccinated workers are even more likely to require hospitalization. The CDC reports that in August 2021, persons age 50-64 were 30 times more likely to require hospitalization if they are unvaccinated versus being vaccinated. Currently, the cost of those hospitalizations is being borne by commercial insurance companies and by Medicare. However, in the future, this will translate to higher health insurance costs and higher Medicare costs. These costs will then be transferred to employees by higher health insurance premiums and higher Medicare payroll taxes

Not only are vaccinated employees more likely to be hospitalized with COVID-19, but they are also more likely to die if they get COVID-19. In August, the overall death rate was 11.3 times higher in unvaccinated than vaccinated persons. Dead employees not only result in the cost of replacing them but they also generate life insurance payouts that then result in higher life insurance premiums for the business. The graph below shows the number of COVID-19 deaths per 100,000 in vaccinated versus unvaccinated people of working age. One implication of this graph is that it is safer for a company to hire a 70-year-old vaccinated employee than to hire a 30-year-old unvaccinated employee from a COVID-19 death risk standpoint.


Unvaccinated workers who are exposed to COVID-19 also incur higher lost productivity costs than vaccinated workers. Recommendations by the CDC are that unvaccinated employees exposed to COVID-19 quarantine at home for 14 days from the date of exposure. However, vaccinated employees do not need to quarantine and can continue to work as long as they wear a mask. These worker absences can be very costly to the employer who continues to pay the worker who is off work (“sick time”) and has to additionally pay someone else to do that worker’s job (often requiring expensive overtime pay). Because of the different quarantine requirements, it is far more costly to the employer if an unvaccinated employee is exposed to COVID-19 than if a vaccinated employee is exposed, even if the employee has no symptoms.

If vaccines save so much money, why don’t we just mandate them?

Vaccine misinformation has permeated the American public and has spilled over into American politics. Intuitively, one would have thought that Republicans would have been more pro-vaccine than Democrats given that Republicans historically were aligned with business and were in favor of policies that reduce business costs. Furthermore, Republicans historically opposed legislation that places constraints on the free market. Paradoxically, during the COVID-19 pandemic, Republicans have fought against vaccinations that could have lowered costs to businesses. Republicans have also introduced legislation that would prevent individual businesses from requiring employee vaccinations – even when businesses believe that having 100% employee vaccination can give them a free market competitive advantage over other businesses. As a consequence, when it comes to COVID-19 legislation, Chambers of Commerce have been aligning themselves with Democrats rather than their normal alignment with Republicans.

Most Americans are already vaccinated. As of this week, 66% of us have received at least one dose of a COVID-19 vaccine. Because many children are not eligible to be vaccinated, a better metric is the percent of adults who are vaccinated – currently 79% of Americans over age 18 have received a vaccine and 96% of Americans over age 65 have received a vaccine. The people who are vaccinated are not the ones who are vocally protesting against vaccine mandates – it is the minority of Americans who are not vaccinated that are making all of the noise. They are also the ones who are filling up our hospitals, increasing costs to employers, and increasing costs to Medicare and insurance companies. Getting these Americans vaccinated is not just good for our country’s health but it is good for our nation’s businesses. So, how to best get them vaccinated?

The mandate versus the nudge

A mandate is a directive requiring an employee to do something. A nudge is a more subtle means of influencing employee behavior without imposing a mandate. An example of a nudge applied to COVID-19 would be to make it easy for employees to get vaccinated by giving them paid time off work to get vaccinated. A nudge can be as simple as providing education about COVID-19 and vaccines in the workplace. Some employers use the nudge of paying their employees to get vaccinated and in Ohio, we have a free tuition lottery that vaccinated teenagers are automatically enrolled in. Public shaming can be a powerful nudge, for example requiring unvaccinated employees to wear masks at work but allowing vaccinated employees to work mask-free, making it clear to all who is and is not vaccinated. But perhaps one of the most effective nudges is to transfer the costs of COVID-19 to unvaccinated employees.

This was the approach taken by Delta Airlines which increased insurance premiums by $200 for unvaccinated employees. So far, 90% of Delta employees are now vaccinated and Delta projects that 95% will be vaccinated within the next month. On the other hand, United Airlines mandated vaccination and currently has 96% of its employees vaccinated with 3% having a medical/religious exemption to vaccination and only 1% of employees refusing vaccination. American Airlines and Southwest Airlines are also mandating vaccinations but their company policies are being stymied by a Texas law prohibiting businesses with headquarters in Texas from requiring vaccinations. This represents a fascinating social experiment: whether the mandate is more effective than the nudge. Over the next year, we will have an answer to this question and future economic analysis will show us which is the most cost-effective: the Delta Airlines strategy or the United Airlines strategy.

The difference between a mandate and a nudge is that a mandate eliminates choice but choice is inherent in a nudge. As a species, Americans rebel when being told what to do and are passionate about having the freedom of choice. In the song Growing Up, Bruce Springsteen said this better than anyone when he sang: When they said “sit down”, I stood up. The nudge can influence us to change our behavior without requiring us to change our behavior. But there are situations when the mandate is essential, for example, in the military on the battlefield.

When is the mandate better?

The danger of a vaccine nudge is that it may not be effective and if the business needs all of its employees to be vaccinated in order to be competitive, relying on the nudge could put the business at a competitive disadvantage. As an example, elective orthopedic hip replacement surgeries are very lucrative and are mostly performed in people over age 65. These older people have COVID phobia (which is why 96% of them have received a vaccine). The hospital that boasts that all front-line employees are vaccinated will be at a competitive advantage to attract people needing a hip replacement surgery compared to a hospital with unvaccinated nurses and doctors.

Many, if not most, businesses actually welcome legislated vaccine mandates. When the mandates come from the government, then the employer does not have to take responsibility for the mandate and can tell employees “Hey, this requirement is from the government, I’m just the messenger…”. Furthermore, with government mandates, a business does not need to worry about losing employees to its competition over vaccine requirements. If only one restaurant in town mandates vaccinations, there is a danger that the serving staff may quit and go work for a different restaurant rather than get vaccinated but if the State Health Department mandates that all restaurant employees in the state get vaccinated, then those serving staff will be unable to get a job anywhere if they remain unvaccinated.

In states with a high percentage of the population vaccinated, it is easier for employers to mandate vaccination because the pool of unvaccinated employees is relatively small to begin with. The implication is that if you have employees who quit rather than getting vaccinated, there will be ample other workers out there who are vaccinated and who you can hire to replace them. Thus, it is safer for a business owner in California to mandate vaccinations than for a business owner in West Virginia. The graphic below shows the geographic variation in vaccination status.

Similarly, within each state, there are regional variations in vaccination rates that can affect the worker pool and thus the willingness of a business to invoke a vaccine mandate. For example, in Ohio, it is more feasible for a restaurant owner in Delaware County, where 68% of the population has received a vaccine, to mandate employee vaccinations than in Holmes County, where only 15% of the population has received a vaccine. The restaurant owner in Holmes County will have a difficult time finding vaccinated applicants to replace unvaccinated workers who quit because of a vaccine mandate. In the graphic below, Delaware County is the darkest shade county in the middle of the state whereas Holmes County is the lightest shade county.

Another situation where vaccine mandates may be preferable is when mandates can mitigate personal injury litigation. Ever since COVID-19 vaccines have been available to all adults, there is a risk of getting sued if a customer becomes ill or dies from a COVID infection acquired at a business. In many situations, causality can be hard to prove. For example, it can be hard for a customer to conclusively prove that he acquired COVID-19 from an infected bartender at the pub that the customer was in for 45 minutes one evening. However, hospitals may be uniquely vulnerable since patients hospitalized for several days with non-COVID-19 conditions are as a group more susceptible to having severe COVID infections and hospitals have robust epidemiology measures in place that can effectively trace disease contacts. In the future, a hospital will likely be held responsible in civil court for patients who become infected from an exposure to an unvaccinated nurse with COVID-19.

When is the nudge better?

The danger of a vaccine mandate is that some recalcitrant anti-vaxxer employees may decide to quit. For many businesses, this may actually be a good thing if those individuals have a history of being disruptive or otherwise being problem employees in the past. But in other businesses, a large number of employees quitting because of a vaccine mandate can lead to worker shortages, reduced business production, and unfavorable public relations. The wise employer will find out which employees are unlikely to get vaccinated before the employer roles out a vaccine mandate. Strategically timing a vaccine mandate after researching employee vaccination status may provide the company with a rare opportunity to eliminate undesirable employees without having to deal with a protracted human resources battle over alleged unlawful job termination.

In some businesses, particularly those with a small number of employees, relentless education will eventually sway all but the most rabid anti-vaxxers. Once all of the existing employees are vaccinated, then the business can adopt a proof of vaccination requirement for all new employees, thus getting the benefits of the mandate without losing any employees.

Sometimes, the incremental nudge can be highly effective. With the incremental nudge, employee choice is preserved but over time, the consequences of choosing to be unvaccinated become incrementally more onerous for the employee. An example is as follows:

  • Step 1: Education about COVID-19 vaccination in the workplace
  • Step 2: Paid time off to get vaccinated and recover from any vaccine-related side effects
  • Step 3: Pay an incentive of $100 to every vaccinated employee
  • Step 4: Requirement that unvaccinated employees wear masks at work but vaccinated employees are not required to wear masks
  • Step 5: Requirement that unvaccinated employees get weekly COVID-19 nasopharyngeal swab tests
  • Step 6: Requirement that unvaccinated employees get daily COVID-19 nasopharyngeal swab tests
  • Step 7: Increase health insurance premiums for unvaccinated employees by $500 per year
  • Step 8: Increase life insurance premiums for unvaccinated employees by $500 per year
  • Step 9: Mandate vaccination

By the time the employer reaches step 8, only the most hardened anti-vaxxers will remain unvaccinated. This will be a relatively small percentage of employees and will mostly be disruptive employees that the employer would like to have an excuse to get rid of anyway. Therefore, step 9 could be mandating vaccinations and then terminating those few remaining unvaccinated employees. This allows the employer to time the mandate strategically in order to selectively cull the employment roster.

The future is right around the corner

In the very near future, there will be two kinds of people: those who are vaccinated against COVID-19 and those who either have had or will have COVID-19 infection. This pandemic is different than the SARS, MERS, and Ebola outbreaks – in those outbreaks, the virus was able to be contained locally until no new infections occurred. COVID-19 today is too widespread throughout the world and has long past the time when it could be locally contained. This pandemic is also different from the 1918 influenza pandemic and the 2009 H1N1 pandemic – in those pandemics, the inciting virus eventually disappeared and was replaced by other, less deadly strains of the virus. COVID-19 does not show any signs of going away or being replaced by a less deadly coronavirus.

Thus, it appears that COVID-19 is going to be with us for a long time and unless all nations can mount a universally successful vaccination campaign, as was done with polio, COVID-19 may be with us indefinitely. But it is clear that vaccination is the only way out of a perpetual pandemic. The good news is that the number of unvaccinated people is dwindling as the tolerance of the vaccinated for those who are unvaccinated also dwindles.

October 20, 2021