Employees of four of Hawaii’s major hospital systems, including Hawaii Pacific Health, Kaiser Permanente, The Queen’s Health Systems and Adventist Health Castle, are now required to get the COVID- 19 vaccine, according to mandates announced Monday by health care executives. The hospitals join a rapidly growing pool of health care employers nationally that are mandating the vaccine in light of the fast-spreading delta variant, which has caused COVID-19 cases to soar locally and nationally.

Health care officials indicated earlier this summer that they were reluctant to mandate the vaccine or were waiting for the Food and Drug Administration to grant full approval for at least one of the available vaccines. At the time, the number of COVID-19 cases remained low in Hawaii, and vaccination rates were steadily rising. But the decisions this week by top hospital officials to move forward without the full FDA approval reflect a landscape that has shifted dramatically in just two weeks.

As the highly contagious delta variant of the virus has taken hold, the state’s average daily case count has nearly tripled in just two weeks, rising from 117 new cases a day to about 317, according to the latest state data. While the vast majority of Hawaii’s most vulnerable population is now vaccinated, including nearly everyone over the age of 65, there has still been a rise in hospitalizations as the virus quickly spreads among the unvaccinated. On July 1 there were 40 confirmed COVID-19-positive patients who were hospitalized. On Monday there were 145 patients.

“The world has changed, the war has changed, as the CDC said, and so we are no longer waiting for FDA approval,” said Melinda Ashton, executive vice president and chief quality officer for Hawaii Pacific Health, which oversees Kapiolani Medical Center for Women & Children, Pali Momi Medical Center, Straub Medical Center and Wilcox Health on Kauai.

Ashton, who spoke during a news conference announcing the mandates, said 85% of Hawaii Pacific Health’s workforce was vaccinated, a figure she called good but “not good enough.”

“With the delta variant and the absolutely clear evidence that vaccination is protective, we think it is really important that we have our employees protected, that we have our patients protected and that we assist in the effort to fully protect the community,” she said.

Hawaii Pacific Health is requiring all employees to be fully vaccinated by Oct. 1, which means the last dose, or single dose of the Johnson & Johnson vaccine, must be administered by Sept. 16. It takes two weeks after the last dose for the vaccine to be considered fully effective.

The Queen’s Health System also has set an Oct. 1 deadline, while Adventist Health Castle and Kaiser are requiring employees to be vaccinated by Sept. 30.

More than 80% of Kaiser’s nonphysician staff in Hawaii is vaccinated, while about 95% of physicians are vaccinated, said Greg Christian, president of the Hawaii market for Kaiser Foundation Health Plan and Hospitals.

The hospitals are expected to provide limited exemptions to the vaccine mandates based on medical or religious reasons. It’s not yet clear, however, what the penalty will be for employees who refuse to get vaccinated and don’t receive such an exemption. Hospital executives stopped short of saying they would be fired. However, they could be required to undergo regular COVID-19 tests if they decline to be immunized.

The major hospital systems are not the first to announce vaccine mandates in Hawaii. Waianae Coast Comprehensive Health Center announced last week that staff must be vaccinated by Oct. 1, though conditioned it on full FDA approval of a vaccine.

“We did this to protect the health and safety of our patients and employees, and also to send a strong message to the community that this vaccine is strong, effective, and absolutely necessary,” Jacob Schafer, director of infection control and employee health for the Waianae health center, told the Honolulu Star-Advertiser by email.

The Leeward side of Oahu, which has some of the lowest vaccination rates in the state, has been hit particularly hard by the surge in COVID-19 cases. Between 35% and 45% of Waianae is vaccinated, according to state vaccination data that is broken down by ZIP code.

More health care providers are expected to announce mandates. The Healthcare Association of Hawaii, the state’s trade group for hospitals and nursing homes, also announced Monday its support for vaccine mandates, though conditioned it on full FDA approval of a vaccine.

While some health officials have expressed frustration that the FDA still hasn’t granted full approval, the federal agency is widely expected to do so by the end of the year. President Joe Biden said recently that such approval could come sometime between the end of August and October.

Following Monday’s announcements the Hawaii Health Systems Corp., which acts as a safety net for neighbor island acute care and long-term care, issued a statement saying that it supported mandatory vaccinations.

“We are assessing the necessary steps that will be required to ensure that all legal and contractual obligations are met prior to implementing a mandate,” the health care system said in a statement.

The push to mandate vaccines comes amid a sputtering pace of vaccinations in Hawaii. Currently, 60.3% of the population is fully vaccinated, while 67.2% of the population has received at least one dose of a vaccine. The vaccines are readily available to anyone 12 and older. The FDA has not yet authorized a vaccine for younger children, though it’s expected to in the coming months.

Jill Hoggard-Green, president and CEO of The Queen’s Health Systems, urged Hawaii residents during a legislative briefing Monday to get vaccinated amid the surge in cases — a message that health officials have now been repeating for months.

While a person infected with the original version of the coronavirus can spread it on average to two people, she said recent studies indicate that people infected by the delta variant are transmitting it to seven to nine people. The Centers for Disease Control and Prevention recently indicated that the delta variant is as contagious as chickenpox.

“Please get your vaccination, if not for you, for the people you love and particularly for our keiki,” said Hoggard-Green.