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Four of Hawaii’s largest hospital systems — Hawaii Pacific Health, The Queen’s Health System, Kaiser Permanente and Adventist Health Castle — announced mandatory COVID-19 vaccination policies for their employees on Monday.

The decision came as the state reported 365 new cases and the seven-day positivity rate climbed to 6% Monday, largely due to the delta variant continuing to drive infections across the country.

According to the Hawaii Department of Health, nearly 570,000 Hawaii residents were vaccinated during the first quarter of the year, but that number dropped to 34,000 in the second quarter.

Officials have said most of the new cases are among unvaccinated people, prompting the hospitals and other organizations to offer incentives or impose requirements for employees to get the shots.

Hawaii Pacific Health Vice President Melinda Ashton said she believes that many unvaccinated employees were either on the fence or just hadn’t gotten around to it and would be swayed by the mandate.

“We’re going to help them get around to it,” she said. “We expect that our employees will respond appropriately to this announcement.”

The Healthcare Association of Hawaii, a nonprofit trade association representing more than 30,000 employees statewide, offered “overwhelming support” for mandatory vaccinations for health care workers, pending full FDA approval and assuming exemption accommodations apply.

While each hospital system’s policies differ, all are requiring vaccinations by the end of September or beginning of October.

The hospital systems’ representatives mentioned ramifications such as weekly testing or termination, but they did not disclose specific details. They also didn’t say if patients would be informed if their care provider is not vaccinated, although Queen’s Health System Senior Vice President Todd Allen said transparency is a high priority.

“Patients have a right to know,” Allen said. “We will also use the other tools in our toolbox for those who cannot get vaccinated, so that will include regular testing for the virus, and it will also include heavy adherence to PPE, masking and distancing.”

The included 222 on Oahu, 76 on the Big Island, 14 on Kauai, 44 on Maui and nine diagnosed out of state, according to the health department. That raised the state’s total to 43,227, with 537 deaths.

Lt. Gov. Josh Green said vaccine mandates are not the only tough calls on the horizon.

“It’s likely that restrictions will be on the size of gatherings,” Green said during an interview on the Honolulu Star-Advertiser’s “Spotlight” program. He noted that the Department of Health is likely to recommend that people go back to restricting gatherings to only 10 people.

“Most of the spread has been community spread,” he said, attributing 20% of community spread to returning unvaccinated residents who quarantine with their families instead of getting tested after traveling to COVID-19 hotspots.

Green said he’s proposed testing requirements for unvaccinated returning residents and more contact tracing across the state. However, he still does not support a vaccine mandate for state employees.

Dr. Darragh O’Carroll, an emergency medicine physician on Oahu, said he views vaccinations as a moral duty for health care workers who have pledged to “do no harm.”

“Many times we’re taking care of very immunocompromised patients who have just undergone chemotherapy, who have weakened immune systems, who have multiple comorbidities and who are really at risk,” he said.

“I think the medical community as a whole should greatly consider — and almost demand — vaccine mandates just because it’s going to keep ourselves, and more importantly our patients, safer.”

O’Carroll — who served as a medical consultant for the recent Netflix documentary series “Pandemic: How to Prevent an Outbreak” — noted that hospitals are seeing younger and mostly unvaccinated COVID-19 patients amid the current surge.

“It’s only natural to not really take things seriously until it affects you personally,” he said. “So put every piece of armor on that you can — and that includes vaccines.”