Vaccination Mandates

--- title: Vaccination Mandates tags: live-v0.1, policy, incentives, vaccines permalink: https://c19vax.scibeh.org/pages/vaxmandates --- {%hackmd 5iAEFZ5HRMGXP0SGHjFm-g %}  {%hackmd GHtBRFZdTV-X1g8ex-NMQg %} # The role of vaccination mandates [TOC] ## What are vaccination mandates? Vaccination Mandates refer to various ways in which people are legally compelled to be vaccinated. In the extreme case, mandates can be backed by criminal sanctions (people who refuse to vaccinate are subject to prosecution) or by limiting access to schools, services, and jobs (either by law or at the employers' discretion). Historically, [vaccination mandates are not a new concept](https://www.bbc.com/future/article/20211029-why-mandatory-vaccination-is-nothing-new), though it can be difficult to determine what counts exactly as a mandate ([Wynia, 2007](https://www.tandfonline.com/doi/full/10.1080/15265160701795809)). It is therefore important to understand when are vaccines mandated, whether mandates can be successful, whether the public accepts them, and whether they are ethical. ## What about "Vaccine Passports"? [At the height of the pandemic, many governments, organisations, and companies worldwide required some form of vaccine passport for a range of circumstances](https://www.theguardian.com/world/2021/sep/16/which-countries-enforcing-mandatory-covid-vaccination). In general, "vaccine passport" (or "COVID passport") is a term [used by the media to refer to documentation that one has had the vaccine](https://www.bbc.co.uk/news/explainers-55718553). This documentation could be digital or in hard copy. It could be used to allow access to venues, or travel. The terminology can be confusing as it has often been used interchangeably with "COVID certification" that includes other measures such as whether one has tested negative or previously recovered from COVID-19. :::warning Disinformation actors have also used the term "vaccine passport" in a derogatory way to propagate misinformation. Read more about [how to counter myths about the COVID-19 vaccine with facts](https://c19vax.scibeh.org/pages/misinfo_myths). ::: ### Some examples of vaccine passports/COVID certification These are just some examples of situations and ways in which vaccine passports/COVID certification were rolled out to manage the pandemic. These were [often changing frequently over the course of 2021](https://www.adalovelaceinstitute.org/project/international-monitor-vaccine-passports-covid-status-apps/), but most countries lifted domestic requirements for vaccination or proof of recent infection in 2022.   Click on each section to expand the examples below. :::spoiler Travel * The European Commission proposed a [Digital Green Certificate](https://ec.europa.eu/commission/presscorner/detail/en/qanda_21_1187) to facilitate movement within the EU. The certificate covered vaccination against COVID-19, testing negative for COVID-19, or recovery from COVID-19, so it was not solely based on whether one has had a vaccine. * China mandated [vaccination with a Chinese-made vaccine as a condition of visa processing for travel into the country](https://fortune.com/2021/03/17/covid-vaccine-china-visa-entry-visitors-foreigners/). * Qantas Airways required [mandatory vaccinations for their passengers](https://www.traveller.com.au/qantas-starts-first-vaccine-passport-trial-ahead-of-border-reopening-h1ujun). * Cruise companies (e.g., [Saga](https://www.bbc.co.uk/news/business-55738918)) had a requirement that passengers must be fully vaccinated in order to travel.  ::: :::spoiler To access services, such as in the hospitality industry * Vaccination status verification was trialled [in Israel used](https://www.economist.com/science-and-technology/2021/03/11/are-vaccine-passports-a-good-idea).  * [Denmark introduced a "Coronapas" vaccine passport](https://www.bbc.co.uk/news/world-europe-56522408) to be used within the country. This required proof of vaccination, proof of earlier infection or a recent negative test to access services such as hairdressers, restaurants and cinemas. * [Italy, France, and Ireland introduced vaccine passes](https://www.theguardian.com/world/2021/jul/26/covid-more-eu-states-restrict-venue-access-unvaccinated-people?CMP=Share_iOSApp_Other) that were necessary to access certain public venues. * New York introduced a **voluntary** [pass](https://covid19vaccine.health.ny.gov/excelsior-pass) to show their COVID-19 vaccination status or a negative COVID test result to show to [venues requiring proof](https://covid19vaccine.health.ny.gov/excelsior-pass-what-you-need-know), including weddings and catered events, major stadiums and arenas. ::: :::spoiler As a requirement of employment * The UK government required staff working in care homes to be vaccinated against COVID-19. While this was also planned as a requirement for all those working in the National Health Service ([Dyer, 2021](https://www.bmj.com/content/373/bmj.n1576)), the mandate was [revoked before it came into force](https://www.gov.uk/government/news/regulations-making-covid-19-vaccination-a-condition-of-deployment-to-end). * Italy had a requirement for health workers, including pharmacists, to be vaccinated before treating patients ([Stokel-Walker, 2021](https://www.bmj.com/content/373/bmj.n1645)). * [Border workers](https://www.theguardian.com/world/2021/apr/12/ardern-new-zealand-border-staff-covid-vaccine?CMP=Share_iOSApp_Other) and [Defence Force staff](https://www.rnz.co.nz/news/national/441066/defence-force-service-members-told-to-get-vaccinated-or-face-being-fired) in New Zealand were required to be vaccinated as a condition of employment. * [Federal employees in the US](https://www.whitehouse.gov/briefing-room/presidential-actions/2021/09/09/executive-order-on-requiring-coronavirus-disease-2019-vaccination-for-federal-employees/) and members of the [US military](https://www.theguardian.com/us-news/2021/aug/09/us-military-covid-vaccine-mandate-military?CMP=Share_iOSApp_Other) were required to be vaccinated against COVID-19. * The Australian airline [Qantas](https://www.theguardian.com/business/2021/aug/18/qantas-mandates-full-covid-19-vaccination-for-all-its-employees?CMP=Share_iOSApp_Other) required its frontline staff to be vaccinated, with exemptions for documented medical reasons. * Some other businesses where staff interact frequently with customers [also introduced "no jab, no job" policies](https://www.bmj.com/content/373/bmj.n1645). ::: ## Are mandates ethical? The issue of the ethics of mandates has been extensively debated in the academic literature and legal fora. In the United States, the Supreme Court has ruled that mandates are constitutional provided they are reasonable (in [Jacobson v. Massachusetts](https://en.wikipedia.org/wiki/Jacobson_v._Massachusetts) in 1905). More recently, the European Court of Human Rights ruled on 8 April 2021 that [compulsory vaccination](https://www.dw.com/en/echr-rules-obligatory-vaccination-may-be-necessary/a-57128443) may be necessary in democratic societies and is not in contravention of human rights law. This was in the context of child vaccinations (which are mandated in the Czech Republic), and protecting the best interests of children to be protected against serious disease. The ruling sets a precedent that obligatory vaccination is not against the European Convention of Human Rights, but does not mean countries will necessarily mandate a COVID-19 vaccine. [Navin & Attwell (2019)](https://onlinelibrary.wiley.com/doi/10.1111/bioe.12645) suggest that the ethics of vaccine mandates should be considered with respect to the harms an responsibilities associated with the disease. For example, they differentiate between vaccinating for measles---a highly contagious disease where an infected individual likely has little control over whether they spread it to others---vs. HPV, which is transmitted through sexual activity, and thus there is some level of responsibility an infected individual can take to reduce disease spread. Recent academic work that has examined the ethics of mandates has similarly endorsed mandates, at least in some circumstances ([Schachar & Reiss, 2020](https://dx.doi.org/10.1001/amajethics.2020.36)). In Europe, the Ethics and Vaccination working groups of the European Academy of Paediatrics similarly issued qualified support for mandates ([Hadjipanayis et al., 2019](https://doi.org/10.1007/s00431-019-03523-4)). Other recent recommendations have also urged care in the application of mandates and suggested that other variables---ranging from making vaccines easily available to improving communication by healthcare professionals---be explored first ([Omer et al., 2019](https://dx.doi.org/10.1038/d41586-019-02232-0)). ### Existing examples of vaccine mandates that are considered appropriate There are existing circumstances where vaccinations are mandated in order to protect workers in roles where they may be exposed to risk of disease. For example, [healthcare workers who are directly involved in patient care (e.g., doctors, dentists, midwives, and nurses) must provide evidence that they are up to date with routine immunisations such as the MMR vaccine](https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/147882/Green-Book-Chapter-12.pdf). This is to avoid staff transmitting measles or rubella infections to vulnerable groups they work with. Travellers to certain countries with high disease risk are also required to have evidence of vaccinations, for example [inoculation against yellow fever](https://www.who.int/ith/ith_country_list.pdf) is required to prevent the spread of the disease in countries where this risk is present. ### What about the ethics of COVID-19 vaccine mandates? In the context of COVID-19, mandatory vaccination of healthcare professionals may be justified to ensure they can fulfil professional responsibilities such as caring for older and immunocompromised individuals ([Parker, 2021](https://www.bmj.com/content/374/bmj.n1903)). There is a duty of care here to patients who would be seriously harmed should their carer transmit the virus to them. Unfortunately, vaccine hesitancy among healthcare workers may stem from damaged trust in the systems due to their poor treatment during the pandemic (e.g., lack of adequate protective equipment). Vaccination mandates in the absence of providing other necessary protections (e.g., because employers assume workers have immunity and thus they do not need protective equipment) is ethically questionable ([Gur-Arie et al., 2021](https://gh.bmj.com/content/6/2/e004877)). It is also necessary to consider vaccine mandates in the context of existing vaccination rates among staff, and the level of risk posed by the remaining unvaccinated staff ([Bedford et al., 2021](https://www.bmj.com/content/374/bmj.n1903); [Hayes & Pollock, 2021](https://www.bmj.com/content/374/bmj.n1684); [Shemtob et al., 2021](https://www.bmj.com/content/374/bmj.n1975)). In the same vein, companies may wish to [appease customers and shareholders](https://www.economist.com/business/2021/03/06/how-companies-should-handle-vaccines) who believe unvaccinated employees are unnecessary risks for the business. Indeed, [58% of UK managers](https://www.theguardian.com/business/2021/mar/17/covid-19-jabs-for-staff-should-be-our-call-say-58-of-uk-managers?CMP=Share_iOSApp_Other) responded in a poll that their firms should be allowed to mandate vaccinations for staff. Yet, in the UK, when Covid certification was proposed, possibly for accessing hospitality services, the proposal faced [backlash from company owners](https://www.theguardian.com/business/2021/apr/06/pubs-and-clubs-attack-uk-covid-passport-scheme?CMP=Share_iOSApp_Other) who believed such measures would harm their business. It is unclear whether mandatory vaccination for employees would be [considered discriminatory under employment laws](https://www.theguardian.com/politics/2021/mar/22/tuc-says-covid-vaccine-efforts-hindered-by-lack-of-paid-time-off-for-jab?CMP=Share_iOSApp_Other). In the US, employers may legally exclude an employee from the workplace if an unvaccinated individual would pose a "direct threat to the health of safety of individuals in the workplace"---for example, if an unvaccinated individual exposes others to the virus [US Equal Employment Opportunity Commission, 2020](https://www.eeoc.gov/wysk/what-you-should-know-about-covid-19-and-ada-rehabilitation-act-and-other-eeo-laws). Finally, narrow vaccination mandates that exclude people due to inability to get specific vaccines are also controversial. For example, China's requirement for travellers to have a Chinese-manufactured vaccine ignored the fact that [these vaccines are not available in most of the world](https://www.theguardian.com/world/2021/mar/17/china-to-allow-foreign-visitors-who-have-had-chinese-made-vaccine) and could be seen as [politically motivated](https://fortune.com/2021/03/17/covid-vaccine-china-visa-entry-visitors-foreigners/). ## Vaccine mandates and inequalities The UK Royal Society proposed [12 criteria](https://royalsociety.org/-/media/policy/projects/set-c/set-c-vaccine-passports.pdf?la=en-GB&hash=A3319C914245F73795AB163AD15E9021) that a "passport" should satisfy in order to be feasible and ethical. In these criteria, a core ethical concern is whether passports certification is inclusive, shares only minimal data required and protects personal data and anonymity, and avoids discriminating against certain groups or exacerbating inequalities in society. The latter is especially concerning for several reasons. Requiring vaccination for specific circumstances (e.g., for travel and work in specific industries) may be justified without vaccination becoming a mandate for the population---people arguably have choices about whether they wish to undertake these activities. However, the use of "passports" quickly crosses the line into vaccination mandates if they are required for many other societal activities. For example, it is clear that requiring vaccines for essential activities such as buying food, accessing health services, and using public transport is effectively a vaccination mandate. With common everyday activities that may not be essential to survival (e.g., going to a restaurant or a clothing store), requiring vaccines for such activities would also effectively act as a vaccine mandate. As Stephen Reicher of the UK SAGE Advisory Panel [writes](https://www.theguardian.com/commentisfree/2021/apr/07/covid-passports-good-idea-government-damaging?CMP=Share_iOSApp_Other): "Once people begin to see vaccines as compulsory for everyday social participation (going to the pub, even going to work), two things follow. Those who aren’t vaccinated are, in effect, excluded from society. They will view the threat of such exclusion as a means of controlling them and forcing them to get a jab." Perceptions that vaccines are about control can also play into anti-vaccination misinformation that relies on this narrative ([Leask, 2020](https://www.nature.com/articles/d41586-020-02671-0)). Because vaccine hesitancy is [higher among certain groups for various reasons---especially from structural inequalities](https://c19vax.scibeh.org/pages/vaxculture)---_effective_ mandates through requiring certification for common activities could easily exacerbate societal divisions. Where vaccines restrict access to societal activities, it could even amount to [unlawful discrimination against people with protected characteristics](https://www.theguardian.com/world/2021/apr/14/covid-status-certificates-may-cause-unlawful-discrimination-warns-ehrc?CMP=Share_iOSApp_Other), especially if they are not able to receive a vaccination (e.g., it has not been made available to them). Proposals to start excluding people from common activities based on COVID status are [also an especial concern if they come into force before vaccines have been offered to the majority of most countries' populations](https://www.theguardian.com/politics/2021/jun/07/scientists-urge-caution-after-tony-blair-backs-uk-covid-pass?CMP=Share_iOSApp_Other). It would be unfair to effectively exclude groups from common societal spaces if they were not prioritised for vaccination (e.g., younger adults) and therefore could not be vaccinated even if they wanted to. ## Does the public accept mandates for COVID-19 vaccinations generally? Responses to mandates can be mixed. In France, mandates for health workers to be vaccinated and the introduction of a vaccine health pass (limiting access to services like restaurants and trains) were [met with protests](https://www.theguardian.com/world/2021/jul/15/france-protests-clashes-with-police-on-bastille-day-amid-anger-at-tighter-covid-rules)---but also a [large uptake in vaccinations](https://www.theguardian.com/world/2021/jul/15/france-protests-clashes-with-police-on-bastille-day-amid-anger-at-tighter-covid-rules). In the US, when federal employees were required to be vaccinated against COVID-19, an Axios-Ipsos nationally representative poll in September 2021 found that 60% of 1,065 respondents supported the vaccine mandate. A review of public attitudes towards vaccination certificates (current in preprint stage) found that people were generally in favour of COVID-19 vaccinations required for travel, but against vaccines being required for access to work and other activities, with a significant minority being opposed to any use of vaccine certificates ([Drury et al., 2021](https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-021-11166-0)). Another paper also corroborates these findings, where respondents were less inclined to be vaccinated if vaccine passports were to be introduced for domestic use ([de Figueiredo et al., 2021](https://www.thelancet.com/journals/eclinm/article/PIIS2589-53702100389-8/fulltext)). A German study suggested that mandates for COVID-19 control measures, including vaccinations, would be in general better supported if they were voluntary rather than mandated ([Schmelz, 2021](https://www.pnas.org/content/118/1/e2016385118)). However, attitudes varied across measures: there was less aversion to mask mandates, but more aversion to mandates for vaccination and smartphone tracing applications. A poll conducted in May 2021 by [Generation Lab/Axios](https://www.generationlab.org/post/how-to-vaccinate-young-people) among younger adults (aged 18-29) in the US found that 74% believed people should have to be vaccinated to return to work or University campus, and 37% would refuse to return if vaccinations were not mandated. The poll also found that 66% of respondents would get the COVID-19 vaccine if it were mandated for work/study. A study conducted in September 2020 with a representative sample of nearly 3,000 American adults found that a plurality (48%) found mandatory COVID-19 vaccinations for children attending school acceptable, compared to 38% who found it unacceptable. For adult mandates the pattern was reversed, with 45% finding them unacceptable compared to 41% who approved ([Largent et al., 2020](https://dx.doi.org/10.1001/jamanetworkopen.2020.33324)). More generally, a systematic review of research on public attitudes [(Gualano et al., 2019)](https://dx.doi.org/10.1080/21645515.2018.1564437) across different vaccines revealed that, in general, the majority of the population in many countries is in favour of mandatory vaccinations. However, there is also considerable variability between countries and vaccines. Even in countries like Brazil, which mandates a number of vaccines (e.g., for Hepatitis B), proposals to mandate the COVID-19 vaccine were met with [protests against authoritarianism](https://www.reuters.com/article/us-health-coronavirus-brazil-vaccine-idUSKBN27H1TE). Previous acceptance of vaccination mandates may therefore not indicate definite acceptance in the future. In Israel (which had a "green pass" linked to vaccination), 31% of 503 individuals surveyed said the offer of a green pass and the associated benefits would possibly or definitely persuade them to get vaccinated, whereas 46% said that incentives would not persuade them ([Wilf-Miron et al., 2021](https://jamanetwork.com/journals/jama/fullarticle/2777686)). Of course, when considering public attitudes towards mandates, it is worthwhile noting that attitudes do not necessarily translate into behaviour. For example, while survey respondents may tell pollsters that they would quit their job if they are told to be vaccinated, [many do not actually do so when faced with the actual decision](https://theconversation.com/half-of-unvaccinated-workers-say-theyd-rather-quit-than-get-a-shot-but-real-world-data-suggest-few-are-following-through-168447). ## How successful are mandates? In the context of COVID-19, a study analysed vaccine uptake data across 6 countries in Europe that introduced COVID-19 passes in 2021 (which included vaccination but also other forms of immunity such as recent negative tests and proof of recovery). [Mills & Rüttenauer (2021)](https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(21)00273-5/fulltext) compared these countries against countries that did not, and found that introducing the COVID-19 passes helped to increase uptake if vaccination rates were below average to begin with and had greater effect on younger age groups, particularly when they were a condition of access to specific venues like nightclubs . However, passes did not have an effect on uptake in populations that already had average or higher vaccination rates (e.g., Germany) or when the limiting factor was supply. This analysis quantifies the experience of France with requiring a "vaccine pass" to access services suggests these can spike an increase in uptake, despite objections by a minority: vaccination rates [increased substantially](https://www.theguardian.com/society/2021/jul/15/france-achieves-record-covid-jabs-with-macrons-big-stick-approach?CMP=Share_iOSApp_Other) once the pass was announced. A [similar increase in vaccinations was observed in British Columbia, Canada](https://www.cbc.ca/news/canada/british-columbia/why-hesitant-people-now-getting-vaccinated-1.6210266), when the provincial government there announced a vaccine passport for non-essential settings, and some states in the USA, which [reported boosts in vaccination rates after vaccines or weekly tests were required for employees](https://popular.info/p/why-more-than-half-of-taco-bell-workers). However, these COVID-19 passes were not a vaccine mandate per se: vaccination was not compulsory, and one could still access services and public venues with a negative test or other proof of immunity (although in some countries those became harder to acquire when the pass came into force). Furthermore, the passes were less effective in situations where there were other barriers to vaccination---be it access or simply [support from employers, for example in the form of time off to get a vaccine or for side effects](https://popular.info/p/why-more-than-half-of-taco-bell-workers). **More broadly, is there evidence from past vaccination efforts to suggest mandates would be successful?** A review of the efficacy of vaccination mandates for measles and pertussis in European countries has linked the existence of mandates to significantly higher uptake [(Vaz et al., 2020)](https://dx.doi.org/10.1542/peds.2019-0620). The review also linked mandates to reduced incidence of measles (but not pertussis) in countries without nonmedical exemptions for mandates. The figure below summarises existing mandates for a selection of vaccines and target populations in some European countries. ![](https://i.imgur.com/pxxlT7N.png) Mandates also have a proven track record in increasing uptake of the influenza vaccine among health care professionals [(Dubov & Phung, 2015)](https://dx.doi.org/10.1016/j.vaccine.2015.03.048). For example, in Finland the new Infectious Diseases Act of 2016 has required health care professionals to be vaccinated against the flu. The high uptake rate (86.2% vaccinated) in a sample of healthcare professionals ([Karlsson et al., 2019)](https://dx.doi.org/10.1371/journal.pone.0224330) indicates widespread compliance with the act. The Finnish uptake rate is higher than among healthcare professionals in other European countries in which mandates are more relaxed or absent. Mandates are most likely to be useful when they match social norms most closely (e.g., if vaccination is already highly favoured by the population) and if there is high confidence in vaccine safety and effectiveness ([Brewer et al., 2018](https://journals.sagepub.com/doi/10.1177/1529100618760521)). Otherwise, mandates could make people angry and more susceptible to anti-vaccination messages ([Brewer et al., 2018](https://journals.sagepub.com/doi/10.1177/1529100618760521)). ## Conclusion On the positive side, there is considerable evidence that mandates work if vaccine uptake is the target measure of interest. They are also broadly---though not universally---accepted by the public for some circumstances (e.g., travel), but less so for others (e.g., visiting a restaurant). On the negative side, mandates do not boost people’s competence or improve calibration of their risk perception, or deal with any of the other multitude of factors that determine hesitancy ([Betsch et al., 2019](https://dx.doi.org/10.1007/s00103-019-02900-6)). There is also evidence that mandates may stimulate "reactance" ([Brehm & Brehm, 1981](https://books.google.co.uk/books?hl=en&lr=&id=6ZxGBQAAQBAJ&oi=fnd&pg=PP1&dq=Psychological+reactance:+A+theory+of+freedom+and+control.&ots=lbEgIpXNa1&sig=QBQfSFz3XbDeIcxR9cccuHxR3ZU#v=onepage&q=Psychological%20reactance%3A%20A%20theory%20of%20freedom%20and%20control.&f=false)). Reactance involves anger at the reduction of choice, accompanied by a desire to reassert the constricted freedom. In the context of vaccinations, it has been shown experimentally that selective mandates—operationalized as a compulsory decision to be vaccinated in a simulated scenario—can induce reactance in participants whose attitudes towards vaccinations were neutral or negative. In consequence, those participants were less likely to agree to another, voluntary vaccination afterwards than a control group that was not exposed to a mandate ([Betsch & Böhm, 2016](https://dx.doi.org/10.1093/eurpub/ckv154)). Research involving surveys in 24 countries identified trait reactance---i.e., a person’s dispositional tendency to resent infringements of their freedoms---as the second-most important variable driving anti-vaccination attitudes generally (the first being [conspiratorial ideation](https://c19vax.scibeh.org/pages/misinfo_conspiracytheories); [Hornsey et al., 2018](http://dx.doi.org/10.1037/hea0000586)). Ultimately, autonomy in decision-making is important. A mandatory vaccination policy could backfire and cause some people to become vaccine resistant ([World Economic Forum, 2021](https://www.weforum.org/agenda/2021/02/disinformation-covid19-vaccine-attitudes/)). Mandatory vaccination also does not solve other problems such as unequal access or constraints such as lack of time to get a vaccine. Mandates need to be considered carefully alongside [other incentives and ways to facilitate and encourage vaccination](https://c19vax.scibeh.org/pages/vaxuptake). ---- Page contributors: Stephan Lewandowsky, Dawn Holford {%hackmd GHtBRFZdTV-X1g8ex-NMQg %} {%hackmd TLvrFXK3QuCTATgnMJ2rng %} {%hackmd oTcI4lFnS12N2biKAaBP6w %}