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Mandatory Vaccinations And Spread Of Covid

Mandatory Vaccinations And Spread Of Covid

Due to shortages, many high-income countries have quickly shifted from difficult decisions about who may receive COVID-19 vaccines to equally difficult decisions about who must receive them. As long-term COVID-19 containment remains elusive, many countries, from Costa Rica to Austria to Turkmenistan, are turning to vaccination mandates of various kinds. 1 Mandates, on the other hand, are contentious in many countries. The proposed adult mandate in Austria, for example, sparked widespread opposition. Some objectors argue that mandates infringe on individual liberty. Others argue that mandates will not be an effective COVID-19 policy because many people will try to avoid them, and mandates may erode support for other public health measures such as mask-wearing.

In this Viewpoint, we examine the likely effectiveness of policies requiring COVID-19 vaccines in improving vaccine uptake and reducing disease in the United States based on evidence from previous vaccination mandates and unique aspects of COVID-19. There are two dimensions of effectiveness in terms of improving uptake: (1) target-group effectiveness (the extent to which a mandate improves vaccine uptake in the group covered by the policy) and (2) population effectiveness.

Vaccination mandates are requirements imposed by government or private educational institutions or employers that make access to an important benefit (typically school or employment) contingent on receiving a vaccine unless an exemption applies. Exemptions may be granted on religious or philosophical grounds but must also be granted for valid medical contraindications. Compulsory vaccinations are uncommon, with civil or criminal penalties for noncompliance. We distinguish mandatory and compulsory vaccination from policies that require unvaccinated individuals to submit to alternative measures to prevent disease transmission, such as disease testing.

Visit: Proof of the Effectiveness of Vaccination Mandates
Before the COVID-19 epidemic, substantial evidence suggested that vaccination mandates in the United States performed well on both dimensions of effectiveness. Cross-state comparisons show that school-entry mandates (for pertussis and measles, for example) improve vaccination coverage among schoolchildren and significantly reduce disease outbreaks in the United States. 2, 3 This has already resulted in COVID-19 vaccination mandates for schoolchildren in two states (California and Louisiana) and the District of Columbia.

The strictness and enforcement of school-entry mandates are important. States that have removed personal belief or religious exemptions (while retaining medical exemptions) have lower exemption rates and higher vaccination rates. Furthermore, vaccine-preventable disease outbreaks have occurred disproportionately in areas with higher exemption rates. 2, 3, 4 Based on such evidence, California, Connecticut, Maine, Mississippi, New York, Washington, and West Virginia have eliminated religious or personal-belief exemptions from some or all vaccination requirements. 5 Similarly, states that impose onerous procedures for obtaining exemptions, such as counseling, annual reapplication, notarization, or clergy attestation, have lower exemption rates and a lower risk of disease outbreak. Vaccination mandate laws with gaps or loopholes (e.g., delayed effective date) have prompted vaccine objectors to engage in strategic behavior. 6 Mandate laws can also spark debate about the vaccine’s specific targets. Following the first vaccine approval in 2006, an attempt to require adolescents to receive human papillomavirus vaccines sparked heated debate. Some questioned the need for a vaccine for a virus that cannot be transmitted through casual contact, although the virus can cause six different types of cancer. The perception that the vaccine manufacturer was involved in political efforts to enact mandates fueled further debate.

There is less evidence available for adult vaccination mandates than for childhood vaccination mandates. Many states and universities require meningitis and other vaccines for college students. Still, there needs to be more reliable data on how such requirements have affected vaccine uptake or disease outbreaks. Policies requiring influenza vaccination for healthcare workers increase vaccination rates, decrease inpatient influenza diagnoses, and lower influenza mortality for long-term care residents and the general population. 7, 8

COVID-19 vaccination mandates for healthcare workers, emergency first responders, federal workers, school staff, university students and staff, and other groups have garnered high levels of compliance, according to reports (though not systematic evaluations).

9, 10 Among US adults vaccinated between June and September 2021, 35% say one of the main reasons they got vaccinated was to participate in recreational activities that required proof of vaccination, while 19% say their employer’s requirement was a big reason. 11

Considerations that may reduce the efficacy of COVID-19 vaccination mandates
Several aspects of the COVID-19 pandemic raise doubts about whether COVID-19 vaccination mandates will produce the same results as school-entry mandates for other vaccines, particularly regarding population-wide effectiveness.

Political polarization and opposition
Resistance to COVID-19 vaccination mandates is significantly higher than resistance to other vaccination mandates.
12 Conservative media and political leaders’ political polarization and promotion of vaccine skepticism have fostered anti-vaccine views among an unusually high proportion of the population in some areas of the country. 13 This resistance jeopardizes the target group and population effectiveness of COVID-19 vaccination mandates for adults and children. Furthermore, government mandates could amplify anti-vaccine sentiment in general,14 fuel organized campaigns to repeal other mandates (which have already resulted in proposed legislation in some states), and reduce acceptance of other vaccines.

Another source of mandate resistance in the United States is the belief that those infected with the virus do not require vaccination, making mandates unnecessary. Evidence suggests that natural infection produces different levels of immunity in different people and that people who have previously been infected benefit from vaccination. 15 New variants undermine the case for previous infection’s sufficiency16 (although they could also mean reduced vaccine effectiveness, at least until vaccines can be reformulated).

Adoption with distinction
COVID-19 vaccination mandates are the responsibility of states, localities, and businesses, except for entities subject to federal regulation. Because of ideological differences, mandates will be implemented differently across the country. The areas with the lowest vaccination rates are the least likely to have vaccination mandates. Some states have passed legislation that makes some or all COVID-19 vaccination mandates illegal. 17 This phenomenon does not affect target-group effectiveness but reduces mandate population effectiveness.

Some potential COVID-19 vaccination mandates would be difficult to implement, undermining target-group and population efficacy. There are no powerful levers for enforcing a general-population mandate for adults. The primary available mechanism, a civil fine, is regressive, would be difficult to implement, and could exacerbate political opposition. College attendance, loans, and government benefits may be contingent on COVID-19 vaccination, but most people in the United States are not students. Many government benefits (for example, Medicaid coverage and unemployment benefits) help vulnerable people. Withholding them may jeopardize pandemic control and health equity.
Mandatory Vaccinations And Spread Of Covid
On the other hand, employer-based vaccination requirements are relatively simple to enforce through adverse employment consequences. Several large US employers have fired hundreds of employees for noncompliance. 18 Employer-based mandates, of course, only reach some. Furthermore, the cooperation of employers in enforcing them is common. Employers who disagree with vaccination requirements, face opposition from labor unions, or are unwilling to lose workers in a tight labor market may choose not to require vaccination. Concerns about the workforce have prompted some school districts and correctional institutions to add testing as an alternative to vaccination.

School entry mandates rely on mechanisms that work best at the start of the academic year (for example, administrative review of student registration data or completion of state reporting requirements). Imposing such mandates in the middle of the school year would mean that unvaccinated students would be moved to remote learning programs or forced to find another district willing to accept them in the middle of the school year, which would be an unwelcome prospect given the educational disruption children have already experienced. With the start of a new academic year, this enforcement issue will be alleviated.

Regarding the ultimate impact of school mandates on COVID-19 spread, the marginal reduction in cases from school mandates compared to voluntary vaccination combined with universal mask-wearing may be modest in areas with high vaccination coverage for adults and adolescents. Adult mandates can help reduce the need for school-entry mandates by lowering community prevalence. However, as mask mandates are lifted, and childhood COVID-19 vaccines are fully approved by the government, the case for including COVID-19 on the list of vaccines required for school entry will strengthen. Full licensure, which necessitates submitting additional evidence of vaccine efficacy and safety beyond the relatively small clinical trials that support emergency use authorization, could be possible by the start of the 2022-23 academic year.

A final concern about enforceability is legal challenges. COVID- The legality of 19 vaccination mandates adopted by public and private organizations is being heavily litigated, with the decisions issued thus far sending conflicting signals. The Supreme Court invalidated a federal requirement that large employers mandate vaccines on January 13, 2022, adopting a surprisingly narrow view of federal authority, but upheld a federal mandate for healthcare facility employees. Lower court decisions have also sent contradictory messages about the legal requirements for federal and state mandates. Individuals and organizations subject to mandates may postpone compliance in the hope that it will be optional in the end, jeopardizing target-group effectiveness. State and local governments and other organizations may delay implementing mandates until legal issues are resolved, reducing population effectiveness. Indeed, in the aftermath of the Supreme Court decisions, some employers backed away from mandate plans, although those decisions had no bearing on what private employers could require.

Evidence of security
Because safety is the primary concern among people in the United States who have not yet been immunized against COVID-19,19, the target-group effectiveness of vaccination mandates—as well as political support for mandates—are inextricably linked to assuring the public that the vaccines are safe, post-licensure safety data can boost confidence that a vaccine’s expected benefits outweigh its risks. During COVID-19, general administration in adults produced a large body of evidence supporting the vaccines’ safety, including evidence from active-surveillance studies. 20 Although early indications of vaccine safety for children have been positive, the evidence base is still evolving. Before school-entry mandates are implemented, additional analyses on the risk of adverse events should be conducted using active-surveillance data.

The public communication of studies demonstrating the safety of vaccines could be better. Vaccines’ associations with specific adverse events have received more attention in the media than their overall favorable benefit-to-risk ratio. These issues may reduce compliance with COVID-19 vaccination mandates without a concerted, sophisticated public education effort.

Proceed to: Conclusions
COVID-19 vaccines have demonstrated greater efficacy in preventing infection with some variants than others, but their importance in preventing severe illness and death is undeniable.
21 Mandates can help promote the use of these vaccines. Our review supports several specific conclusions.

First, there is ample evidence that school-entry mandates greatly increase childhood vaccine uptake. Second, current evidence on the safety of COVID-19 vaccines in adults is sufficient to justify mandates. Third, due to unique implementation challenges, the effectiveness of adult COVID-19 vaccination mandates in increasing vaccination uptake may be lower than the very high effectiveness observed in the past for other vaccinations. As a result, mandate policies cannot be the only approach, especially given the legal uncertainties surrounding them. Fourth, COVID-19 vaccine requirements will most likely be effective if employers and educational institutions enforce them. Fifth, school-entry mandates should be considered after a review of real-world safety data and full licensure of the vaccines for children, which could happen as soon as the start of the 2022-23 school year.

Finally, effective vaccination policies, including mandates, active surveillance for adverse events following immunization, and clear, sophisticated communication of findings to the public, are required. Imposing mandates does not eliminate the need for effective messaging to overcome vaccine apprehension. Giving appropriate weight to the major headline of the accumulating vaccine safety studies—that the vaccines are indeed safe—can help to cultivate more fertile soil for vaccination mandates to take root.

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