Ask an Infectious Disease Expert: Will a COVID-19 Vaccine Be Mandatory?

Makeda Robinson, MD, PhD, is an infectious disease specialist currently studying the differences in early immune responses between adults and children to COVID-19 at Stanford University. Dr. Robinson breaks down complicated COVID-19 topics and addresses pressing public health concerns.

As vaccine trials reach key clinical breakthroughs, a COVID-19 vaccine seems closer than ever. In fact, Pfizer and BioNTech just filed for Emergency Use Authorization (EUA) from the Food and Drug Administration (FDA) for their vaccine last week. As questions of vaccine efficacy are finally being answered, new questions regarding legislation and distribution are surfacing in their place. Experts are speculating on whether we can expect COVID-19 vaccines to become mandatory to enter places like offices and sporting events, or if they will be like flu shots, which are simply encouraged.

In the United States, most vaccine mandates come from the government. The Advisory Committee on Immunization Practices (ACIP) makes recommendations for both pediatric and adult vaccines, and state legislatures or city councils determine whether to issue mandates. How are these decisions made on a national level, and how do they impact smaller-scale legislative actions? Dr. Robinson spoke to Verywell about issues surrounding vaccine mandates.

Verywell Health: Legally, can COVID-19 vaccines be mandatory? Do public health experts think this can/should happen?

Dr. Robinson: While it is within the purview of the government to create a vaccine mandate to protect the public health of the nation, it is unlikely to be the approach that’s taken. The creation of a COVID-19 taskforce by the incumbent government is a good first step in developing a national standard and recommendations for vaccination. Having a united front leading into 2021 will be paramount as we aim to stop SARS-CoV-2 infections. 

The more likely outcome will be a targeted approach leading to a slow ramp up as opposed to a blanket mandate. This will likely protect the most vulnerable first, including the elderly and those living in communal living spaces such as nursing home settings. Additionally, those with comorbidities associated with disease severity—such as heart or lung disease, diabetes, and obesity—may have priority.

For the more general public, vaccination requirements will likely be implemented through employers and eventually schools. These entities have previously implemented vaccine requirements for attendance and employment, and therefore, can set a standard.

Given the risk of superspreader events related to this virus, vaccinating lower-risk people is also incredibly important to prevent spread.

Verywell Health: Is a vaccine mandate realistic?

Dr. Robinson: At this moment, the idea of a mandate is theoretical. There is currently no approved vaccine, and there are insufficient vaccine doses to distribute to the entire population.

The under-discussed supply chain issues should not be underestimated as a real bottleneck in vaccine distribution. The mRNA vaccines require extremely cold temperatures for transport (-70°C for Pfizer and -20°C for Moderna), which are difficult to maintain.

Two doses of the vaccine are required. This means those who have been vaccinated once will have to schedule a second visit several weeks later, which can lead to a drop-off in compliance.

Verywell Health: Could concerts or sporting events have their own mandates?

Dr. Robinson: This is an important time for public-private collaborations. Given the lack of clear national guidelines, some businesses began to make decisions independently. However, this has the potential to lead to misinformation, confusion, and frustration about the risks of certain activities and the trajectory of the pandemic.

As a larger percentage of the population gains access to the vaccine, we will see an increase in the number of people who are able to congregate in indoor or outdoor spaces. In the case of concerts or sporting events, restrictions could be put in place with some caveats to prevent unvaccinated individuals from entering into these higher-risk situations.

Ticketmaster has proposed using smart phones to verify vaccine status or testing status ahead of event entry. Decisions like these should not be made unilaterally and should include multiple stakeholders such as public health officials, government leadership, and citizens. These discussions will also bring up issues of equitable access to the vaccine.

Verywell Health: Regardless of what mandates look like, should we expect exceptions?

Dr. Robinson: There will be exempted groups that will not be included in the initial vaccine authorization. Pregnant and breastfeeding women were not included in the clinical trials and children were enrolled later in the Pfizer study, starting in October. These groups will have to be studied further to ensure the vaccine is safe and efficacious in them as well. It’s unclear if people who have compromised immune systems are going to have a robust enough immune response, so those people may not get the vaccine as it may not be useful to them. Other exemptions are also being discussed and there may be different regulations depending on the state.

Verywell Health: How do you think that proof of vaccination will be determined?

Dr. Robinson: While discussions of “immune passports” or “COVID cards” were popular early on in the pandemic, the idea fell out of favor as we learned about how different the long-term immune is from person to person. Madrid saw widespread pushback to the idea.

As the vaccine becomes more widely available and we have data validating lasting immunity after vaccination, a type of proof of vaccination could be a potential tool in reopening. However, the issues of access and equality would loom large in identifying a pathway for implementation.

Verywell Health: What are some other issues we need to consider?

Dr. Robinson: The development of these vaccines is something to be celebrated. They were developed in record time, and have an exceptional efficacy rate. Our initial efficacy cut-off was anything over 50% and we are now seeing upwards of 90% with the mRNA vaccines. Additionally, and just as importantly, the safety profiles are good. There have been no severe adverse events documented with the mRNA vaccines.

While we will have to continue to monitor safety, the longer out from vaccination someone is, the lower the likelihood of an adverse event; the majority of adverse events occur within one to two months after vaccination.

Lastly, the Moderna vaccine has shown not only an overall reduction in SARS-CoV-2 transmission, but also reduction in severity, which is important for those in at-risk groups. This is all great news! I know that many people are still fearful of vaccination, but I hope that we can start to embrace the potential benefits. As we move into the holiday season and struggle with making the decision to see our loved ones, we should have renewed hope that our future will be less fraught with these questions.

The information in this article is current as of the date listed, which means newer information may be available when you read this. For the most recent updates on COVID-19, visit our coronavirus news page.