Association Between State-Issued COVID-19 Vaccine Mandates and Vaccine Administration Rates in 12 US States and the District of Columbia

Abstract

Importance: Some US states have issued COVID-19 vaccine mandates; however, the association of these mandates with vaccination rates remains unknown.

Objective: To examine the association between announcing state-issued COVID-19 vaccine mandates that did not provide a test-out option for workers and the vaccine administration rates in terms of state-level first-dose vaccine administration and series completion coverage.

Design, setting, and participants: This cross-sectional study used publicly available, state-level aggregated panel data to fit linear regression models with 2-way fixed effects (state and time) estimating vaccine coverage changes 8 weeks before and 8 weeks after a state-issued COVID-19 vaccine mandate was announced. Mandates were announced on or after July 26, 2021, and were included only if they went into effect before December 31, 2021. Data were included from 13 state-level jurisdictions with a vaccine mandate in effect as of December 31, 2021, that did not allow recurring testing in lieu of vaccination (mandate group), and 14 state-level jurisdictions that allowed a test-out option and/or did not restrict vaccine requirements (comparison group).

Interventions/exposures: The event of interest was the announcement of a state-issued COVID-19 vaccine mandate applicable to specific groups of workers.

Main outcomes and measures: The outcome measures were state-level daily COVID-19 vaccine first-dose administration and series completion coverage, reported as mean percentage point changes.

Results: Of 5 508 539 first-dose administrations in the 8-week postannouncement period, an estimated 634 831 (11.5%) were associated with the mandate announcement. First-dose administration coverage among 13 jurisdictions increased starting at 3 weeks after the mandate announcement, with statistically significant differences of 0.20, 0.33, 0.39, 0.45, 0.49, and 0.59 percentage points higher than the referent category coverage of 62.9%. Increases in vaccine series completion coverage were observed from 5 to 8 weeks after the announcement, but statistically significant differences from the referent category coverage of 56.3% were observed only during weeks 7 and 8 after the announcement (both differed by 0.2 percentage points; P = .05 and P = .02, respectively).

Conclusions and relevance: The findings of this cross-sectional event study suggest that the announcement of state-issued vaccine mandates may be associated with short-term increases in vaccine uptake. This observed association may be a product of both a direct outcome experienced by groups governed by the mandate as well as the spillover outcome due to a government signaling the importance of vaccination to the general population of the state.

Figure 1.. Cumulative First-Dose Administrations by Time Since Vaccine Mandate Announcement Comparing Actual Doses Administered and Estimated Doses in the Absence of Mandates (Counterfactual Doses) in States That Issued Vaccine Mandates (July-October 2021)

End-of-week cumulative doses are shown for each period.

Figure 2.. Association Between State-Issued Vaccine Mandates Shown as Adjusted Average Percentage Point Changes of COVID-19 Vaccine First-Dose Administration and Series Completion in 13 States With a Vaccine Mandate Relative to 14 Comparison Group States (May-October 2021)

A, State-issued vaccine mandates were defined as requirements for a group of workers to (1) be vaccinated with no test-out option except for those with approved medical or religious exemptions, or (2) be vaccinated and undergo recurring testing (for the states in each group, see the Inclusion Criteria subsection in the Methods section). B, Percentage point changes and 95% CIs estimated from regression models were controlled for state and time (calendar date) fixed effects, previous week rolling 7-day average new cases per 100 000 population, percentage of the population fully vaccinated, and whether the observation occurred before or after the mandate effective date. Percentage point changes are relative to the average growth rates for the referent category (14 comparison group states and the referent period of 0- 2 weeks before the mandate announcement date in states that issued a mandate) denoted by the vertical reference line. For the first-dose administrations model, the model-estimated referent category coverage was 62.9%. For the series completion model, the model-estimated referent category coverage was 56.3%. Shaded areas indicate 95% CI.