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California today issued the first order in the nation that requires COVID-19 vaccinations for health care workers, allowing only for religious or rare medical exemptions.

Employees of hospitals, nursing homes, doctors’ offices, clinics and other medical facilities have until Sept. 30 to get at least one dose of the vaccination, under the new order issued by Dr. Tomás J. Aragón, California’s public health officer. In the meantime, they must either be vaccinated or undergo mandatory weekly testing, under the state’s previous order issued last week.

California also ordered visitors to hospitals, skilled nursing homes and facilities for the developmentally disabled to be fully vaccinated or show a negative COVID-19 test within 72 hours. The order applies only to indoor visits and goes into effect on Wednesday.

The new requirement for medical workers tightens Gov. Gavin Newsom’s move last week to require health care workers and state employees to be vaccinated or submit to weekly testing.

State health officials were not immediately available to explain why the requirements for health care workers won’t go into effect until the end of September.

The orders come as California — along with the rest of the nation — grapples with a surge of cases propelled by the highly contagious delta variant of the coronavirus, which represented about 86% of cases as of July 21, according to the California Department of Public Health.

“As we continue to see an increase in cases and hospitalizations due to the delta variant of COVID-19, it’s important that we protect the vulnerable patients in these settings,” Aragón said in a press release. “Today’s action will also ensure that health care workers themselves are protected. Vaccines are how we end this pandemic.”

The exemption for medical and religious reasons could prove to be problematic. California eliminated similar exemptions for childhood vaccines because of overuse by many parents.

More than 9,500 new COVID-19 cases were reported today, a sharp increase from mid-June when the state’s economy largely reopened and just over 1,000 daily cases were reported.

State health officials said recent COVID-19 outbreaks in health care facilities often are traced to unvaccinated employees — even though health workers were first in line to get the COVID-19 vaccines when they first became available in December.

A number of health workers, including certified nursing assistants, have been surprisingly reluctant to get vaccinated.

It’s difficult to know how many of California’s hundreds of thousands of health care workers remain partially or completely unvaccinated, but federal data analyzed by CalMatters provides a clue: About 23% of nearly 500,000 hospital workers in more than 350 California hospitals had not received a single dose of vaccine as of July 23.

As a result, Kaiser Permanente and other large health care systems have announced their own vaccine mandates for workers. Carmela Coyle, president and CEO of the California Hospital Association, an industry group, called the state order “an important step in a long battle we face.”

About 23% of nearly 500,000 hospital workers in more than 350 California hospitals had not received a single dose of vaccine as of July 23.

Unions representing health care workers have not been as outright supportive. Reluctant to visibly oppose officials’ vaccine mandates, one of the unions sent out a vague statement similar to those released last week.

“Workers must have a seat at the table as these decisions and their implementation are discussed,” Bob Schoonover, president of SEIU California and executive director of SEIU 721, which represents about 35,000 health workers, said in an emailed statement. SEIU spokesman Mike Roth declined to elaborate.

But another union leader voiced support for the state’s new, tougher mandate. “While this order will not be embraced by all of our members, it will save lives and protect the health of healthcare workers and patients enduring another COVID-19 surge that is being spread primarily by unvaccinated people,” Sal Roselli of the National Healthcare Workers Union said in an emailed statement.

Other states’ orders have not been as stringent. Massachusetts on Wednesday issued an order requiring nursing home employees to be vaccinated by Oct. 10, with exemptions only for religious or medical reasons. And Oregon announced a mandate similar to California’s original order, requiring health care workers to be vaccinated but allowing a testing alternative.

With slightly more than half of California’s eligible population fully vaccinated, nearly all new COVID-19 cases and deaths are occurring in unvaccinated people, state public health officials say, and hospitalizations have risen at an alarming rate.

More than 5,500 Californians are currently hospitalized for COVID-19, with about one-fifth of them needing intensive care.

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CALmatters.org is a nonprofit, nonpartisan media venture explaining California policies and politics.