Vaccine mandates and vaccine injuries: An unexpected cost to the workers’ compensation system

Vaccinations have served to significantly reduce the spread of COVID-19 in populations with high take-up rates.¹ In the past months, many businesses and public entities have begun to require their employees to be vaccinated for COVID-19. Additionally, President Biden has recently proposed new legislation to require COVID-19 vaccinations for nearly 100 million Americans to further reduce the spread.² COVID-19 mandates have served to further increase vaccination rates and, as a direct result, reduce the spread of COVID-19 and also prevent serious illness.³ During periods of high community transmission of COVID-19, an employer vaccine mandate that increases vaccination rates for the general population will also reduce lost work time and medical treatment costs for employees who might otherwise file workers’ compensation claims. However, these mandates and increased vaccination rates also come with a cost—the very rare occurrence of vaccine injuries due to adverse reaction.

This paper estimates the future costs to the U.S. workers’ compensation system for these rare vaccine injuries as attributable to the employer mandates. We also provide a limited comparison of these costs to the estimated workers’ compensation system savings that can be achieved through vaccination. The estimates in this article are not intended to influence the decision of whether to require employees to be vaccinated for COVID-19, and should not be used as such. It was outside the scope of this article to model the reduction to the U.S. population in COVID-19 infection rates and resulting treatment costs attributable to increased vaccine take-up rates. We also did not attempt to estimate the potential costs of unvaccinated employees contracting COVID-19 on the U.S. workers’ compensation system.

We estimate that the U.S. workers’ compensation system losses to be incurred at the current rate of employer mandates prior to President Biden’s proposed plan would not be significant to the industry. However, if approved, President Biden’s proposed mandate legislation would generate proportionally higher and more significant levels of both additional treatment savings and vaccine injury costs for the workers’ compensation system. Additionally, as the Centers for Disease Control and Prevention (CDC) is expected to recommend COVID-19 vaccine boosters after the second dose, we could see further increases in these levels.

Background

As noted above, vaccinations have served to significantly reduce the spread of COVID-19. Since the height of the pandemic in January 2021, the daily number of cases had decreased from 300,000 per day to less than 20,000 per day in June 2021.⁴ The rollout of the COVID-19 vaccination program has also prevented approximately 279,000 additional deaths and 1.25 million additional hospitalizations.⁵ While the majority of adults in the United States are vaccinated, unvaccinated individuals are still contributing significant costs to the U.S. healthcare and workers’ compensation systems. In June and July 2021, COVID-19 hospitalizations among unvaccinated adults cost the U.S. healthcare system over $2 billion.⁵ Additionally, Milliman’s COVID-19 research estimates the average commercial allowed cost for a COVID-19 hospital admission is approximately $35,000.⁶ Due to the high medical costs among unvaccinated individuals, along with the number of deaths and hospitalizations prevented, over 1,700 private and governmental employers have now mandated that their employees must be vaccinated for COVID-19.⁷ This includes large corporations such as Disney, Facebook, and Tyson Foods, along with local municipalities.⁸ President Biden also recently announced a new plan requiring all federal workers and contractors, along with all employers with 100 or more employees, to be fully vaccinated against COVID-19. President Biden’s plan is estimated to affect roughly 100 million Americans.⁹

Even though an employer vaccine mandate is likely to further reduce COVID-19 treatment costs, prior to President Biden’s proposed vaccination mandate, legislation was enacted in Texas and nine other states (Arizona, Arkansas, Michigan, Montana, New Hampshire, North Dakota, Ohio, Tennessee, and Utah)¹⁰ to prohibit employer-mandated vaccinations. Specifically, Texas bill HB 4272 states that employers are prohibited from failing or refusing to hire, discharging, or otherwise discriminating against an individual with respect to compensation or the terms, conditions, or privileges of employment because the individual does not provide any proof of COVID-19 vaccination status. Whether legislation prohibiting employer vaccine mandates by these 10 states will be redacted following President Biden’s plan is still to be seen.

The three COVID-19 vaccines currently in use in the United States (Pfizer-BioNTech, Moderna, and Johnson & Johnson), while shown to be effective in treating the COVID-19 virus, still come with a rare (0.13%) chance of an adverse reaction. As of early August 2021, nearly 450,000 reports of adverse reactions to the three vaccines (defined as a “possible side effect”) have been reported in the Vaccine Adverse Event Reporting System (VAERS) sponsored by the U.S. Department of Health and Human Services (HHS), compared to over 350 million doses administered.

One of the standard employee benefits in the United States is the ability to file a workers' compensation claim. The typical claim requires three criteria to be met in order to be compensable:

1. There must be an injury or illness.
2. The injury or illness must arise in the course of employment.
3. The injury or illness must be caused by the employment.¹¹

If an adverse reaction were to occur to an employee of an employer mandating COVID-19 vaccines, then all these criteria would appear to be met, entitling an employee to receive workers' compensation benefits. In addition, according to Marsh, there are two other scenarios in which an employee with an adverse vaccine reaction could be entitled to workers' compensation benefits even if not mandated by the employer:

1. If the employer offers the vaccine optionally to its employees, an employee who suffers an adverse reaction would be entitled to workers' compensation benefits.
2. If the employer has no vaccine policy, an affected employee could file a claim but would still need to prove that the injury was work-related.¹²

Because these two scenarios seem much less likely to occur compared to the employer-mandated vaccine claims, we have excluded them from this article.

As of late August 2021, 68% of the U.S. adult working population (ages 18-64) has received one vaccine dose¹³ and approximately 58% is fully vaccinated.¹⁴ These rates vary by state—Alabama is the lowest, with 40% fully vaccinated; Vermont is the highest, with 73% fully vaccinated.¹⁸ An extremely small percentage of the vaccinated population (less than 0.002%) experienced severe adverse reactions such as anaphylaxis, myocarditis, and death. These types of severe adverse reactions have occurred for other vaccines as well. According to the report “Vaccination Adverse Outcomes and Costs of Vaccine Injury Claims (VICs): Past, Present, and Covid-19" by John Paull,¹⁵ the 30-year average settled claim for vaccine injuries has been $585,012 per claimant. Paull’s research is based on National Vaccine Injury Compensation Program (VICP) data, which is a program hosted by HHS. This program provides compensation to individuals found to be injured by certain vaccines, the most common of which is the influenza flu shot.

Under the Public Readiness and Emergency Preparedness (PREP) Act, U.S. vaccine manufacturers are immune to liability from adverse reactions,¹⁶ so the workers' compensation system will most likely be the first option injured employees will target to receive compensation. In conjunction with the PREP Act, the U.S. government included COVID-19 vaccines under the Countermeasures Injury Compensation Program (CICP). However, the CICP only covers compensatory awards and explicitly excludes attorney fees and costs. In order to receive compensation under the CICP, it must be proven that an injury is “the direct result of a covered countermeasure” and was not due solely to temporal association. Since 2010, when the first CICP claim was reported, only 29 claims have received compensation for a total amount of over $6 million,¹⁷ all but one of which are related to the H1N1 vaccine. Due to the stringent causality requirements and the exclusion of attorney expenses, the CICP appears to be a less frequent option for vaccine injury compensation, and only an option if the claim was not covered under the workers' compensation system.

Vaccine injury claims are novel to the workers' compensation system. For small mom-and-pop businesses that purchase workers' compensation from an insurance company, these additional costs will be assumed by the insurance carrier. However, in the United States the majority of large corporations use some form of self-insurance to save on their workers' compensation costs. Additionally, local municipalities and governmental organizations that may have the ability to mandate COVID-19 vaccinations for their employees either self-insure or buy insurance through a public entity risk pool. The potential additional insurance costs could be unexpectedly detrimental to these organizations.

Estimating the future costs to the U.S. workers' compensation system

Using publicly available information on vaccination rates, employment rates, vaccine injury claims, and other sources, we built a model to estimate the potential future costs (based on doses to be administered) that employer-mandated COVID-19 vaccines could have on the U.S. workers' compensation system.

We created our model on a state-by-state basis to identify differences in COVID-19 vaccination rates, employment rates, and state vaccine mandate legislation. We first estimated claim frequency. Our approach to estimating frequency is described in the following steps:

1. Using the adult (ages 18-64) COVID-19 vaccination rates by state from the CDC for both fully vaccinated individuals and those with one dose, along with the estimated number of U.S. adults working as of July 2021 from the U.S. Bureau of Labor Statistics (BLS), we derived the number of doses that still need to be administered for the entire U.S. working labor force to be fully vaccinated. Because the Johnson & Johnson (J&J) vaccine only requires one dose to be fully vaccinated, we reduced the estimated number of doses by its market share of 7.5% as of August 23, 2021, based on CDC data.
2. The next item to estimate was the chance for an adverse reaction, which we estimated separately for moderate claims (interferes with daily activity) and severe claims (death, life-threatening, required inpatient hospitalization or prolongation of existing hospitalization, or resulted in persistent disability/incapacity). For moderate claims, we used an estimated percentage of 5%, based on the Pfizer Clinical trials.¹⁸ For severe claims, we used an estimated percentage of 0.002%, based on the CDC-published ratio of specific severe COVID-19 vaccine adverse events (anaphylaxis, thrombosis, Guillain-Barre Syndrome, myocarditis/pericarditis, and death) to total COVID-19 vaccine doses as of late August 2021.¹⁹
3. Using the estimated number of doses to be administered and the chance for either a moderate or severe adverse reaction, the product of these values results in the estimated number of workers' compensation claims to be filed. However, this estimated number of claims represents the frequency where: 1) all employers required their employees to receive the vaccine; and 2) all claims were both filed and automatically compensable under state workers' compensation laws. To account for these two items, we incorporated two additional variables: a) the rate at which employers mandate the vaccine, and b) a claim compensability rate. For states that are prohibiting employers from mandating COVID-19 vaccinations, we set the employer mandate rate to zero. According to Gartner, 9% of employers are planning to mandate COVID-19 vaccinations in the workplace.²⁰ We note that these values may change significantly following the implementation of President Biden’s proposed vaccine mandate plan. For the compensability rate, we used an expected value of 50%, based on Paull’s study, in which vaccine injury cases are dismissed 52% of the time¹⁹ on average.
4. The product of the estimated number of claims to be filed, the percentage of employers planning to mandate the vaccine, and the workers' compensation compensability rate leads to the estimated compensable number of workers' compensation claims related to adverse reactions from employer COVID-19 vaccination mandates.

As an example of this methodology, the table in Figure 1 displays the calculation of claim frequency for California in the expected scenario.

Figure 1: Estimated California COVID-19 Vaccine Injury Frequency – Expected Scenario

Using this same methodology for the United States in total, the estimated number of workers' compensation claims related to adverse reactions from employer COVID-19 vaccination mandates is nearly 175,000 claims, of which approximately 60 are severe and the remainder moderate.

We additionally looked at the estimated number of successful COVID-19 vaccine claims filed for the United States in total at alternative employer mandate rates and compensability rates. For the employer mandate rate, we assumed a low frequency scenario of 5% and a high frequency scenario of 20%. For the compensability rate, we adjusted the expected value of 50% up and down by 25%. The resulting estimated number of claims is displayed in the table in Figure 2.

Figure 2: Estimated Number of Successful U.S. COVID-19 Vaccine Injury Claims

As displayed in Figure 2, the estimated number of claims is highly sensitive to the input assumptions in the model. If only 5% of employers were to mandate the COVID-19 vaccine and only 25% of those claims were compensable, then around 50,000 claims (16 severe) would be successful across the United States. On the other end, if 20% of employers were to mandate the vaccine and 75% of claims filed were compensable, then over 580,000 claims (196 severe) would be successfully filed, which is over 400,000 more claims than the expected scenario of 175,000 (59 severe).

After estimating the number of successfully filed claims to the U.S. workers' compensation system, we determined the average severity for each of these types of successfully filed claims. Moderate adverse reactions are reactions that have some interference with daily activity. We assumed that these claims would not be claims that would require medical attention, but rather only consideration for the potential lost income from being unable to work due to conditions such as fatigue, chills, vomiting, muscle pain, and joint pain. Thus, to account for the loss of income, we used the state average weekly wages (SAWW) for 2019 from the National Council on Compensation Insurance (NCCI), trended to 2021 levels using an inflationary rate of 3%. We then prorated this trended SAWW by two-fifths to account for an estimated average of two days out of work. Some states such as California and New York require employers to offer paid leave due to adverse events from COVID-19 vaccination. However, the amount of paid leave varies by state (California offers 80 hours²¹ and New York four hours²² of paid leave), and the interaction of these benefits with the workers’ compensation system is unknown, so we excluded them from our model. This could lower the estimated costs in the states that offer paid leave due to adverse reaction to the COVID-19 vaccine.

For severe claims, the severity associated with these claims is expected to be similar to previous vaccine injury claims from the VICP. As mentioned above, the average cost of a vaccine injury over the past 30 years is $585,012 (compensated awards and attorney costs combined). However, the annual frequency of the number of compensated awards began to increase significantly in 2011. This increase in frequency consequently led to a decrease in the annual severity. Thus, we relied on VICP data from 2011 forward. VICP data was also split between compensation awards and attorney fees and expenses. We estimated severities for each of these factors separately, using the compensation awards as a proxy for lost wages and medical costs.

In estimating lost wages and medical costs, we made two adjustments to the historical VICP data. We first trended the historical severities at an annual rate of 3% per year to account for inflation. VICP compensation awards also include vaccine injuries to children, which may have larger awards. Therefore, we multiplied the trended severity by approximately 72%, which is the percentage of compensable vaccine injuries that were caused by influenza flu shots (primarily administered to adults) from 2006 to 2019. We reviewed historical averages from these trended and adjusted severities, which ranged from $239,000 to $417,000. We also reviewed the 29 CICP awards mentioned above and trended them at the same 3% inflationary rate. This trended CICP value was approximately $250,000. Based on these results, we selected $250,000 as the lost wages and medical costs severity.

Our process was similar for estimating the average attorney costs per claim. However, we did not adjust the attorney costs based on the flu shot percentage, as we assumed that these costs would be similar for both adults and children. Based on the historical averages ranging from $31,000 to $37,000, we selected average attorney costs per claim of $35,000. Therefore, in total, we assumed the average severe vaccine injury severity to be $285,000.

For the expected scenario in which 9% of employers mandate the vaccine and 50% of claims are compensable, assuming average severities of the pro-rated SAWW for moderate claims and $285,000 for severe claims would result in total estimated losses to the U.S. workers' compensation system of approximately $99 million. Additionally, because the severity assumption is likely to be highly variable, we developed a range of 50% to 150% of the average severities. The table in Figure 3 describes the estimated losses at the different severities, along with the different compensability rates.

Figure 3: Expected Scenario: 9% of Employers Mandate the COVID-19 Vaccine, Estimated Losses ($ thousands)

As displayed above, estimated losses to the workers' compensation system vary between $25 million ($4 million severe) and $223 million ($38 million severe), depending on the assumptions. While even these loss levels are not likely to be significant to the industry, we also believe it is important to consider the benefit of costs avoided due to vaccinations.

Cost-benefit analysis of vaccine mandates

Cost savings can be achieved through COVID-19 vaccinations via reduced virus transmission rates and reduced hospitalization rates. We note that it is beyond the scope of this article to perform a detailed analysis of the estimated cost savings from COVID-19 vaccinations due to the lack of available data and the numerous variables to consider, such as transmission rates, compensability rates, COVID-19 presumption laws, percentage of employees working from home, impact of new virus strains, etc.

We have provided a simplified example to provide some context as to the savings that can be achieved. Prior to the rollout of the COVID-19 vaccines in March 2021, California averaged nearly 12,200 COVID-19 workers’ compensation claims per month from March 2020 to February 2021.²³ From March 2021 to July 2021, California averaged approximately 1,700 COVID-19 claims per month, for an average percentage reduction of 86%, or approximately 10,500 claims per month. The NCCI 2021 State of the Line presentation indicates that, for accident year 2020, private carriers and state funds had an average severity for COVID-19 losses of $6,000. Assuming a 100% vaccination rate and 100% vaccine effectiveness, this results in estimated monthly workers’ compensation savings on COVID-19 losses in California of approximately $63 million. Obviously there are many more variables at play that could significantly change this estimate, but the estimated monthly savings of $63 million in California alone are nearly two-thirds of the estimated COVID-19 vaccine injury losses of $99 million for the entire United States in total.

Additionally, to put the countrywide COVID-19 vaccine injury losses into perspective, for accident year 2020, NCCI’s data for private carriers and state funds had $260 million in losses for COVID-19 claims, with an average severity of $6,000 as noted above. These COVID-19 losses were primarily driven by frequency, where approximately 45,000 claims were reported. Frequency of small claims is also the driver of the estimated COVID-19 vaccine injury claims, where moderate claims represent $82 million (or 83%) of the $99 million expected estimate. While the NCCI data is not the best to compare for the entire U.S. workers' compensation system (as its data reflects private carriers and state funds only, excluding alternative forms of insurance), it is still useful as a frame of reference. Our overall estimated losses for COVID-19 vaccine injury claims of $99 million are over $160 million lower than NCCI’s COVID-19 claims estimate of $260 million. Because COVID-19 vaccine injury losses of $99 million only represent 0.4% of accident year 2020 losses (for private carriers and state funds only), COVID-19 vaccine injury claims are not likely to have a significant impact on the U.S. workers' compensation system. However, the costs could be significant for a smaller employer who self-insures.

What impact would President Biden’s proposed vaccine mandate plan have?

As mentioned above, President Biden announced an employer-mandated COVID-19 vaccination plan that would affect approximately 100 million U.S. employees. The estimated U.S. labor force as of July 2021 from the BLS is slightly over 151 million, implying President Biden’s plan will affect approximately 66% of the U.S. workforce. We decided to look at the impact of President Biden’s proposed legislation on vaccine injury costs. While it is unclear whether states that are currently prohibiting employer-mandated COVID-19 vaccinations will redact their legislation, for the purposes of comparing the results to the expected scenario we have assumed that these prohibitions will remain. The table in Figure 4 displays these results at different compensation rates and severities.

Figure 4: President Biden’s Proposed Plan: 66% of Employers Mandate the COVID-19 Vaccine, Estimated Losses ($ thousands)

In the case of a 50% compensability rate applied to the average severity, the value of $726 million ($123 million severe) represents 3.1% of the estimated accident year 2020 losses. The most conservative estimate in Figure 4 of $1.6 billion represents 7.1% of the accident year 2020 losses and 4.3% of 2020 written premium (for private carriers and state funds). These costs would be significant to the industry. Furthermore, if states redact their currently enacted employer vaccine mandate prohibitions, we could see further increases in the estimated costs.

Conclusion

COVID-19 has had a significant impact on the workers' compensation environment in the United States and on society as a whole. This impact includes changes in legislation pertaining to presumptions for the disease, along with changes in behavior, such as more employees working from home and businesses pivoting to a larger digital presence. In response to COVID-19 and the Delta variant, and due to the significant number of lives saved and reduction in healthcare and workers’ compensation costs, more and more employers are mandating that employees be vaccinated. With President Biden’s proposed employer COVID-19 vaccine mandate plan, we could even see a further increase in the lives and costs saved. COVID-19 vaccine injuries, similar to claims from employees contracting COVID-19, are expected to have a large number of small claims, and a small number of severe claims. As displayed in the results above, the losses at the current rate of employer mandates, while not insignificant, would not be enough to overload the workers' compensation system. Additionally, workers’ compensation cost savings in the reduction of COVID-19 claims through vaccination can be significant, as the reduction in frequency of COVID-19 claims has been shown to be substantial since the rollout of COVID-19 vaccines.

However, if more employers begin to require vaccinations for their employees following the implementation of President Biden’s plan, the frequency of vaccine injury claims would increase proportionally and raise costs. In contrast, the number of COVID-19 cases would decrease proportionally, leading to savings in treatment and lost worktime costs and lives saved. Additionally, as the CDC is expected to recommend COVID-19 vaccine boosters eight months after the second dose,²⁴ we could potentially see more vaccine injury claims but also more savings. While a lot is still unknown about COVID-19, its vaccines, and what percentage of employers will mandate the booster shots, carriers and self-insured corporations should be on the lookout for these trends.

¹CDC (July 27, 2021). Science Brief: COVID-19 Vaccine and Vaccination. Retrieved September 15, 2021, from https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/fully-vaccinated-people.html.

²Watson, Kathryn et al. (September 10, 2021). Biden announces COVID-19 vaccine mandates that will affect 100 million Americans. CBS News. Retrieved September 15, 2021 from https://www.cbsnews.com/live-updates/biden-covid-19-vaccine-mandates-announcement/.

³CDC, Science Brief, op cit.

⁴Galvani, Alison, et al. (July 7, 2021). Deaths and Hospitalizations Averted by Rapid U.S. Vaccination Rollout. Commonwealth Fund. Retrieved September 15, 2021, from https://www.commonwealthfund.org/publications/issue-briefs/2021/jul/deaths-and-hospitalizations-averted-rapid-us-vaccination-rollout.

⁵Amin, Krutika & Cox, Cynthia (September 14, 2021). Unvaccinated COVID-19 hospitalizations cost billions of dollars. Peterson-KFF Health System Tracker. Retrieved September 15, 2021, from https://www.healthsystemtracker.org/brief/unvaccinated-covid-patients-cost-the-u-s-health-system-billions-of-dollars/.

⁶Bazell, C., Kramer, M., Mraz, M., & Silseth, S. (June 2020). How Much Are Hospitals Paid for Inpatient COVID-19 Treatment? Milliman Report. Retrieved September 15, 2021, from https://www.milliman.com/-/media/milliman/pdfs/articles/how-much-hospitals-paid-for-inpatient-covid19-treatment.ashx.

⁷Andrea Hsu (August 17, 2021). Employers Want You to Get Vaccinated. This One Is Offering a $1,000 Bonus. National Public Radio. Retrieved September 15, 2021, from https://www.npr.org/2021/08/17/1027620914/to-mandate-or-not-employers-get-urgent-about-vaccinations.

⁸Andrew Mendez (August 7, 2021). These companies are requiring employees to get vaccinated. Los Angeles Times. Retrieved September 15, 2021, from https://www.latimes.com/business/story/2021-08-07/list-employers-with-covid-19-vaccine-mandates (subscription required).

⁹Watson, Kathryn et al., op cit.

¹⁰Hannah Mitchell (August 9, 2021). 11 bans on vaccine mandates — What states have them & which might soon. Becker’s Hospital Review. Retrieved September 15, 2021, from https://www.beckershospitalreview.com/workforce/11-bans-on-vaccine-mandates-what-states-have-them-which-might-soon.html.

¹¹Michael Stack (March 20, 2019). 3 Criteria Determine If a Workers' Comp Claim Is Covered. AMAXX. Retrieved September 15, 2021, from https://blog.reduceyourworkerscomp.com/2019/03/determine-if-a-workers-comp-claim-is-covered/.

¹²Marsh. COVID-19 Vaccines: Answers to Employers’ Most Pressing Questions. Research & Briefings. Retrieved September 15, 2021, from https://www.marsh.com/us/insights/research/covid19-vaccines-questions-and-answers.html.

¹³Cecelia Smith-Schoenwalder (August 2, 2021). Biden Reaches Goal of 70% of Adults Partially Vaccinated Against COVID-19 a Month Late. U.S. News. Retrieved September 15, 2021, from https://www.usnews.com/news/health-news/articles/2021-08-02/biden-reaches-goal-of-70-of-adults-partially-vaccinated-against-covid-19-a-month-late.

¹⁴CDC (September 14, 2021). COVID-19 Vaccinations in the United States, Jurisdiction. Retrieved September 15, 2021, from https://data.cdc.gov/Vaccinations/COVID-19-Vaccinations-in-the-United-States-Jurisdi/unsk-b7fc.

¹⁵John Paull (2020). Vaccination Adverse Outcomes and Costs of Vaccine Injury Claims (VICs): Past, Present and Covid-19. International Journal of Clinical and Experimental Medicine Research, 5(1), 1-5. DOI: 10.26855/ijcemr.2021.01.001.

¹⁶Public Health Emergency (April 13, 2021). PREP Act Immunity From Liability for COVID-19 Vaccinators. Retrieved September 15, 2021, from https://www.phe.gov/emergency/events/COVID19/COVIDvaccinators/Pages/PREP-Act-Immunity-from-Liability-for-COVID-19-Vaccinators.aspx.

¹⁷Health Resources & Services Administration (August 2, 2021). Countermeasures Injury Compensation Program (CICP) Data, Table 2. Retrieved September 15, 2021, from https://www.hrsa.gov/cicp/cicp-data#table-2.

¹⁸CDC. Local Reactions, Systemic Reactions, Adverse Events, and Serious Adverse Events: Pfizer-BioNTech COVID-19 Vaccine. Vaccines & Immunizations. Retrieved September 15, 2021, from https://www.cdc.gov/vaccines/covid-19/info-by-product/pfizer/reactogenicity.html.

¹⁹CDC (September 14, 2021). Selected Adverse Events Reported After COVID-19 Vaccination. Retrieved September 15, 2021, from https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/adverse-events.html.

²⁰Martha White (August 6, 2021). Mandating vaccines amid a worker shortage could spell trouble for corporate America. NBC News. Retrieved September 15, 2021, from https://www.nbcnews.com/business/economy/mandating-vaccines-amid-worker-shortage-could-spell-trouble-corporate-america-n1276213.

²¹California Department of Industrial Relations (March 29, 2021). 2021 COVID-19 Supplemental Paid Sick Leave. Retrieved September 15, 2021, from https://www.dir.ca.gov/dlse/2021-COVID-19-Supplemental-Paid-Sick-Leave.pdf.

²²NY Labor Law § 196-C. Leave Time for COVID-19 Vaccination.

²³California Workers’ Compensation Institute (August 13, 2021). Delta Variant Spurs New Wave of California Workers' Comp COVID-19 Claims. Retrieved September 15, 2021, from https://www.cwci.org/press_release.html?id=847.

²⁴CNBC (August 16, 2021). U.S. expected to recommend Covid vaccine booster shots 8 months after second dose, sources say. Retrieved September 15, 2021, from https://www.cnbc.com/2021/08/17/us-to-recommend-covid-vaccine-booster-shots.html.