Mandatory Vaccination to rescuing the Economy in the Era of Vaccine Hesitancy and Skepticism

Public health measures often were mandated by governments to protect the wellbeing of individuals or communities. Such policies can be ethically justified, as they may be crucial to protect the health and wellbeing of the public. Although vaccines are one of the most effective tools for protecting people against COVID-19, vaccines alone won’t stop the community transmission and we need to ensure that people follow the public health measures. People need to continue to use masks consistently, be in ventilated spaces, practice hand hygiene and respiratory etiquette, physical distancing and avoid crowding. This continues to be extremely important, even if you are vaccinated, when you are dealing with on-going community transmission.

The World Health Organization (WHO) in its policy brief of April 2021 stated “ … because policies that mandate an action or behavior interfere with individual liberty and autonomy, they should seek to balance communal well-being with individual liberties”…. It further describes… “while interfering with individual liberty does not in itself make a policy intervention unjustified, such policies raise a number of ethical considerations and concerns and should be justified by advancing another valuable social goal, like protecting public health”.

In the last month and more so very recently the Covid-19 vaccination policy debates in Barbados and Eastern Caribbean Countries have shifted.  Some public and private businesses are ‘mandating’ employees to be vaccinated. These new workplace policies articulate direct or indirect threats of imposing restrictions in cases of non-compliance and require unvaccinated to produce a negative RT-PCR-test for SARS-Cov-2 at their own expense. The policies also state that the PCR-test must be taken on periodic intervals before resuming at their place of employment. This mandatory requirement of vaccination makes it a legal condition for continued employment i.e., enforced by threat or restrictions.

Dr. Yitades Gebre, PAHO/WHO Representative for Barbados and the Eastern Caribbean

Dr. Yitades Gebre, PAHO/WHO Representative for Barbados and the Eastern Caribbean

Such policies are not uncommon; although it should be noted that the World Health Organization (WHO) does not presently support the direction of mandates for COVID-19 vaccination, having argued that it is better to work on information campaigns and making vaccines accessible to all.

When to make vaccination mandatory?

SARS-CoV-2 infection of high-risk workers constitutes a transmission risk to other staff, consumers, and the community at large. According to the global health architecture, mandatory vaccination should be considered only if it is necessary for, and proportionate to, the achievement of an important public health goal (including socioeconomic goals) identified by a legitimate public health authority. As mandates represent a policy option that interferes with individual liberty and autonomy, they should be considered only if they would increase the prevention of significant Covid-19 risks of illness and death and/or promote significant and unequivocal public health benefits.

A study conducted by PAHO team in the Caribbean revealed that 23% of nurses and doctors are hesitant to take the Covid-19 vaccines. If important public health objectives cannot be achieved without a mandate – for instance, if a substantial portion of individuals are able but unwilling to be vaccinated and this is likely to result in significant risks of harm – their concerns should be addressed, proactively if possible. Even when the vaccine is considered sufficiently safe, mandatory vaccination should be implemented with no-fault compensation schemes to address any vaccine-related harm that might occur. A relevant body should pay compensation to a worker suffering injury, loss or damage secondary to a vaccine where vaccination has been made a condition of employment, with liability extending for the life of the worker even if the worker is no longer rendering services. Where employee vaccination is mandated, organizations may become liable for any adverse outcomes of vaccination. This is important, as it would be unfair to require people who experience vaccine-related harm to seek legal remedy from harm resulting from a mandatory intervention.

Vaccine safety 

WHO in its policy brief states, “if mandatory vaccination is considered necessary to interrupt transmission chains and prevent harm to others, there should be sufficient evidence that the vaccine is efficacious in preventing serious infection and/or transmission.” Alternatively, if a mandate is considered necessary to prevent hospitalization and protect the capacity of the acute health care system, there should be sufficient evidence that the vaccine is efficacious in reducing hospitalization. Policymakers should carefully consider whether vaccines authorized for emergency or conditional use meet evidentiary thresholds for efficacy and effectiveness sufficient for a mandate. We should not mandate vaccination of all employees without taking into consideration certain risk factors such as pregnancy, age of the worker, health conditions, valid medical reasons, etc. To date all seven WHO emergency use authorized COVID-19 vaccines have shown to be safe and efficacious in preventing transmission, severe disease and death, and it is clear that vaccine supply will continue to increase globally, albeit inequitably.

Vaccine supply

In the last seven months over 3.7 billion Covid-19 vaccine doses have been administered in 216 countries, areas, and territories. Pace highly inequitable, 1.6 doses per 100 persons in low-income countries and 91.6 does per 100 persons in high income countries. The absence of a sufficient supply and reasonable, free access would not only render a mandate ineffective in achieving vaccine uptake but would create an unduly burdensome and unfair demand on those who are required to be vaccinated but are unable to access the vaccine. Such a mandate would threaten to exacerbate social inequity in access to health care. Vaccination mandates for general adult populations are rare. In the absence of a sufficient, reliable vaccine supply that would permit every eligible member of the public to be vaccinated, a mandate for the general public would fail to address ethical consideration regarding sufficient supply. Even if there is a sufficient, reliable vaccine supply, policymakers should consider whether mandatory vaccination of the general population is necessary and proportionate to achieve intended public health goals. Vaccines should be prioritized in countries with limited supply for maximum public health impact, considering the most recent evidence on COVID-19 vaccines and on the ongoing supply constraint issues. Booster doses should also be taken into consideration.

Public trust

Legitimate public health authorities have a duty to carefully consider the effect that mandating vaccination could have on public confidence and public trust, and particularly on confidence in the scientific community and public trust in vaccination generally. If such a policy threatens to undermine confidence and public trust, it might affect both vaccine uptake and adherence to other important public health measures, which can have an enduring effect. Vaccine hesitancy may be stronger in such populations and may not be restricted to concerns of safety and efficacy, as mistrust in authorities may be rooted in histories of unethical medical and public health policies and practices as well as structural inequity. Such populations may regard mandatory vaccination as another form of inequity or oppression, making it more difficult for them to access jobs and essential services. Healthcare providers should engage in a friendly discussion with vaccine-hesitant individuals, soliciting their perspectives, acknowledging their worries, and explaining scientific rationales.

Policy makers should encourage voluntary vaccination against COVID-19 before contemplating mandatory vaccination. Efforts should be made to demonstrate the benefit and safety of vaccines for the greatest possible acceptance of vaccination. Vaccines work and are safe.

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