In medieval days, “throwing down the gauntlet” was an invitation to a duel. The gauntlet itself was a glove of armor, and tossing it at the feet of an opponent was an insult of the highest order. The opponent’s only honorable response was to pick up the glove—take up the gauntlet, literally—and accept the challenge to engage in mortal combat.   

Today, in armorless times, “throwing down the gauntlet” refers to any type of provocative challenge or confrontation. In that sense, President Biden has thrown down the gauntlet in unveiling his six-point plan to improve lagging vaccination rates and tame, if not slay, the dragon of COVID-19.

The strategy enlists the hand (and arm) of the federal government in enforcing vaccine mandates throughout the executive branch and across healthcare facilities relying on Medicare and Medicaid funds. By leveraging federal sway over workplace safety, the plan also aims to establish get-vaccinated-or-get-tested policies in private businesses employing 100 or more workers.

This particular gauntlet lands at the feet of individuals and groups that are personally opposed or resistant to vaccines as well as those who are politically and philosophically opposed to vaccine mandates. The latter group includes numerous Republican governors, who have been quick to criticize the plan as an unconstitutional power grab and vowed to see the President not at the local immunization site but inside the local courthouse. State troopers, city firefighters and other public employees in Washington have already sued Governor Jay Inslee to challenge his vaccination mandate.

Some organizations of private employers have praised the mandate approach. The Business Roundtable, a national association of CEOs, said it “welcomes the Biden Administration’s continued vigilance in the fight against COVID… Over the past several weeks many companies have decided to implement a vaccine mandate for some or all of their employees, a decision we applaud.”

The National Association of Manufacturers, while not endorsing mandates, said that “we look forward to working with the administration to ensure any vaccine requirements are structured in a way that does not negatively impact the operations of manufacturers… It is important that undue compliance costs do not burden manufacturers, large and small alike.”

The American Apparel and Footwear Association, one of the first trade associations to achieve 100% vaccination of its staff, said it ”welcomed” the news “that vaccine mandates will go into effect for a large portion of the US workforce to fight against the spread of COVID-19.” The association, representing an industry that employs 3 million people, added that “it’s long past time for all Americans to get vaccinated.”

Others want more detail, and sooner rather than later. Consumer Brands Association president and CEO Geoff Freeman said the president’s announcement “prompts critical questions that require immediate clarification … As with other mandates, the devil is in the details. Without additional clarification for the business community, employee anxieties and questions will multiply.” Freeman added that increasing vaccination rates “hinges on federal agencies offering clear, detailed and timely guidance in hours, not weeks.” The CBA sent the president a letter on Monday posing a “sampling” of questions that are on the minds of their members, including the likes of Coca-Cola, PepsiCo, Kellogg, Campbell Soup, General Mills and Procter & Gamble.

In responding to the president’s announcement, the American Hospital Association reiterated its support for hospitals and health systems that adopt mandatory COVID-19 vaccination policies. At the same time, AHA president and CEO Rick Pollack said the government’s policy “may result in exacerbating the severe workforce shortage problems that currently exist.” Pollack called on the Biden administration “to work with us as partners in developing aggressive and creative strategies” to ensure that frontline workers can keep up the fight against COVID while providing all other healthcare for the communities they serve.”

The long-term care industry expressed gratitude for the administration’s decision to extend the vaccine mandate across all of healthcare, thus easing worries that nursing home and assisted living workers would bolt to jobs in hospitals or other health settings where mandates were not in place. However, as Kimberly Bonvissuto notes in McKnight’s Senior Living, LTC facilities are still awaiting billions in promised federal aid that can help them avoid a “pathway to bankruptcy.”

Overall, 60% of the public agrees with vaccine mandates for federal employees and companies with 100 or more workers, according to the Axios/Ipsos Coronavirus Index. Opinions skew heavily along party lines, with 80% of Democrats and 60% of Independents but just 30% to 33% of Republicans in favor.

In the University of Michigan’s National Poll on Healthy Aging, 80% of seniors said that COVID-19 vaccination of healthcare workers should definitely (61%) or probably (19%) be required, Diane Eastabrook reports in McKnight’s Home Care Daily.

Federal mandates are not the only game in town. The Los Angeles Unified School District, the country’s second largest, will require vaccination for students 12 and older attending in-person classes. The rule takes effect in January, but kids in extracurricular activities need to receive their second shot by October 31. No such mandate exists – yet – in the largest school system: In New York City, 1 million children returned on Monday for in-person learning, with no remote option.

The ultimate opponent here is the SARS-CoV-2 virus, which frankly doesn’t give a damn about constitutionality and is immune to politics. In the absence of a more comprehensive public consensus on vaccination, the virus and its variants will march on. Community transmission of COVID-19 remains high in 94% of counties in the U.S. and substantial in another 3%.

Mandates aside, the work of reaching out and persuading people who are unvaccinated for any reason (safety/side effects, distrust of government/big pharma, lack of easy access to vaccines), continues at the grassroots level. Conversations are taking place in doctors’ offices and community centers, in churches and barbershops, at family dinner tables, on the phone and on doorsteps. The CDC’s recent report that the unvaccinated are 10 times more likely than the fully vaccinated to be hospitalized with COVID-19 and 11 times more likely to die of the disease may resonate.

One arm at a time

•  Progress is slow, but it is progress. Somehow, someway, three quarters of a million COVID-19 shots are going into arms in the U.S. every day. Close to 75% of the vaccine eligible (ages 12 and up) in the U.S. have had at least one shot and 64% are fully vaccinated. The down side of that math is that tens of millions remain shotless; a score of 64% or 75% will give you a D or a C on a test where you are striving for at least a B.

•  The full equation, of course, takes into account the full population, including children under 12 who are waiting for a vaccine as they return to the classroom. It’s possible that Pfizer/BioNTech will submit data on vaccination of kids 5-11 years old sometime this month and that an emergency use authorization could be approved by the FDA by the end of October.  

•  The Allergy & Asthma Network added COVID-19 testing and vaccination to an initiative that offered free asthma screenings and patient education at Black churches, Eric Berger reports in PRWeek. According to Tonya Winders, the Network’s president and CEO, getting buy-in requires “a 20- to 30-minute trusted messenger conversation tailored to that individual’s concerns… and that takes a lot of effort and resources and time.”

•  About half the states (26) have fully vaccinated half of their populations, CNN reports, and three states—Massachusetts, Vermont and Connecticut—have fully vaccinated two-thirds.

•  One way to get more people vaccinated is to “lean into” local outbreaks. Public health researchers from Harvard and Emory University, writing in STAT, note that people are entering testing and contact tracing systems every day. “Surprisingly, there is no systematic effort to persuade the unvaccinated among them to get vaccinated… Vaccination information should be integrated into all aspects of the testing system.”

Source: Getty Images.

The challenges

•  Reaching the vaccine-hesitant and vaccine-resistant is a particular challenge because these groups are less likely to be politically engaged—more than 60% have no recent history of voting—and are not connected with mainstream media, Sabrina Sanchez reports in Campaign. Sara Fagen, CEO of performance analytics company Tunnl, suggests a social media campaign that “specifically speaks to the risk younger adults face from COVID and how that risk can be easily and safely ameliorated through vaccination.”

•  John Dick, CEO of unofficial Vaccine Project Newsletter pollster CivicScience, refers to the “pervasive role of political tribalism in nearly every aspect of our culture today.” He notes that only 17% of those supporting vaccine mandates in the workplace are Republicans and only 12% of those opposed are Democrats. “Companies and their workers may soon be as divisible by red and blue as our cable news networks and their audiences,” he notes.

•  A hospital in upstate New York may have to shut down its maternity unit after at least six nurses quit rather than comply with the hospital’s COVID-19 vaccination mandate.

•  The president is urging all states to join the nine that require vaccination of schoolteachers and staff.  A survey of 100 large school districts, including the biggest urban district in each state, finds that 90% require masks but just one in four require teachers to be vaccinated.

•  White House chief medical advisor Dr. Anthony Fauci told Axios that we have little chance of getting the virus under control until the count of new COVID-19 cases falls to less than 10,000 per day. The rolling seven-day average at the end of last week was 136,558 with a peak of 254,016 last January and a low of 11,613 in June.

The vaccine dashboard

•  The chief medical officers of the U.K. have recommended a single dose of COVID-19 vaccine for healthy youngsters 12 to 15 years old, Nick Bostock reports in GP. Children with underlying medical conditions, such as sickle cell disease, type 1 diabetes, congenital heart disease and poorly controlled asthma, should receive two doses. Children will likely receive their shots at school. 

•  The Food and Drug Administration’s Vaccines and Related Biological Products Advisory Committee will meet on Friday to consider booster doses of Pfizer/BioNTech’s COVID-19 vaccine, Comirnaty, in people 16 and older. Data from Moderna and J&J are farther back in the data submission queue.

•  The CDC’s Advisory Committee on Immunization Practices will also weigh in on boosters, but its next meeting is not scheduled until September 29 and the current agenda does not include COVID-19 vaccines.

•  Maryland Governor Larry Hogan is moving ahead on his own timetable and has authorized COVID-19 boosters for people 65 and older living in congregate care settings, including nursing homes, assisted living facilities, residential drug treatment centers and group homes for the developmentally disabled. Providers in Maryland are now seeking logistical details, Danielle Brown reports in McKnight’s Long-Term Care News.

•  Boosters will begin next week in the U.K. among vulnerable populations and people over 50, six months after the second dose.

•  A commentary in this week’s Lancet signed by 18 leading scientists argues against boosters for the general population. It argues that more lives will be saved by reaching the vast numbers of unvaccinated, who are “the major drivers of transmission and are themselves at the highest risk of severe disease.” The commentary warns that moving ahead with boosters without robust data “could adversely affect confidence in vaccines and undermine messaging about the value of primary vaccination.” The authors include six officials from the World Health Organization and two top vaccine reviewers from the FDA who are soon retiring or leaving the agency.

•  The National Comprehensive Cancer Network has identified the cancer patients who should receive priority for a third dose of COVID-19 vaccine. The list includes patients with new or recurring solid tumors who are being treated within a year of their first vaccine dose. Also: patients with active blood cancers, those who have received a stem cell transplant or engineered cellular therapy (such as CAR-T), ones who also have HIV or autoimmune disease and those who are taking corticosteroids or other immune-suppressing treatment for a condition other than cancer.

Source: Getty Images.

The rest

•  United Airlines is granting some employees religious exemptions to COVID-19 vaccination but will place those people on temporary unpaid leave.

•  While the headlines about the White House plan have focused on vaccine mandates, other planks in the platform include expanded COVID-19 testing (including affordable, rapid at-home tests), increased shipments of monoclonal antibodies to states by 50%, doubled fines for airline passengers who refuse to wear masks and a shot of adrenaline to the economy in the form of small business disaster loans of up to $2 million.

•  In Management Today, Amarat Bal of London’s PA Consulting identifies three essential leadership skills for a post-COVID world. First, agility, defined as the ability to make rapid and informed decisions amid uncertainty; second, an approach to staff that preserves the autonomy and flexibility that the pandemic allowed; and third, the ability to build inclusive and connected hybrid teams in a way that promotes communication, collaboration and innovation.

•  At least 13 western lowland gorillas at the Atlanta Zoo have tested positive for COVID-19, the AP reports, including Ozzie, who at 60 is the oldest male gorilla in captivity. Zoo officials believe that an asymptomatic, fully vaccinated employee may have transmitted the virus. The infected animals are receiving treatment with monoclonal antibodies. Ozzie is showing mild symptoms.

Parting shot

After going the made-for-TV route in 2020, Macy’s 95th Thanksgiving Day Parade is planning a return to the streets of New York City on November 25. The city government will arrange a number of public viewing sections along portions of the parade route. All volunteer participants and staff will be vaccinated. Keep your eyes peeled for Baby Yoda.

…and some songs, from the 2021 Video Music Awards

Good4u, Olivia Rodrigo

Shivers, Ed Sheeran

Been Like This and You Right, Doja Cat

Learn to Fly, Shame Shame and Everlong, Foo Fighters

LaLa (Unlocked), Alicia Keys and Swae Lee

Leave the Door Open, Bruno Mars, Anderson .Paak, Silk Sonic

How can we be halfway through September already? Thanks for joining us. Stay well and we’ll see you back here next Wednesday, the first day of autumn.