SACRAMENTO, Calif. (NEXSTAR) — California will require all of its roughly 2.2 million health care and long term care workers to be fully vaccinated against the coronavirus by Sept. 30.

Democratic Gov. Gavin Newsom said last month he would require health care workers to either be vaccinated or submit to weekly testing. But the new order issued Thursday by the California Department of Public Health does not give health care workers a choice.

It says all must be fully vaccinated by the end of September, with exceptions for people who decline the vaccine because of a religious belief or workers who cannot be inoculated because of a qualifying medical reason backed up by a note signed by a licensed medical professional.

The change comes as California is seeing the fastest increase in new virus cases since the start of the pandemic, averaging 18.3 new cases per 100,000 people a day. Most of the state’s new infections are caused by the delta variant, a more contagious version of the coronavirus that the state says “may cause more severe illness.”

The delta variant is causing most of the new infections.

“Increasing numbers of health care workers are among the new positive cases, despite vaccinations being prioritized for this group when vaccines initially became available,” said Dr. Tomás J. Aragón, California’s public health officer. “Recent outbreaks in health care settings have frequently been traced to unvaccinated staff members.”

The order represents a new hard line in public health leaders’ quest to convince the hesitant to receive the vaccine. Several states are focusing on health care workers, since they are around vulnerable patients.

But other states with similar requirements have carved out exceptions, like in Oregon, where health care workers can instead get regular COVID-19 testing. In Maryland, the vaccine mandate only applies to certain state employees, such as those who work in health care facilities under the state health department.

In California, vaccine mandates are perilous for Newsom, who is facing a recall election next month fueled in part by anger over his handling of the pandemic. Newsom has angered many parents by continuing to require masks indoors at all public schools, but he has not required all teachers and staff to be vaccinated.

Some California local governments are going beyond the new rule. In Los Angeles County, some 110,000 government workers have until Oct. 1 to be vaccinated under a new order issued by Board of Supervisors Chair Hilda L. Solis.

She noted that about 4 million of the county’s roughly 10 million residents remain unvaccinated. The Los Angeles order doesn’t specify penalties for employees who refuse to be vaccinated.

The city of San Jose in California’s Silicon Valley is also requiring an estimated 8,000 workers to be vaccinated or provide weekly proof of negative COVID-19 tests. It may eventually mandate vaccination, with exemptions for medical or religious reasons.

Meanwhile, a letter to the approximately 5,000 staffers of Los Angeles County Superior Court — the nation’s largest trial court system — ordered them to be fully vaccinated or be fired. The letter says workers must show proof of vaccination no more than 45 days after the federal Food and Drug Administration gives its final approval to one of the vaccines available in the U.S., the Los Angeles Times reported.

Both of those mandates provide exceptions for people on medical or religious reasons.

Currently, 63% of Californians ages 12 and older have been fully vaccinated, with another 10% partially vaccinated, according to health department statistics.

As of Thursday afternoon, California had tallied 64,620 COVID-19 deaths and 4,003,787 cases since the start of the pandemic, according to Johns Hopkins data.

The Associated Press contributed to this report.