Global Ethical Considerations Regarding Mandatory Vaccination in Children

Herd immunity to endemic diseases: Historical concepts and implications for public health policy

BACKGROUND

"Herd immunity" became a contested term during the COVID-19 pandemic. Although the term "herd immunity" is often used to refer to thresholds at which some diseases can be eliminated (e.g., due to mass vaccination), the term has multiple referents. Different concepts of herd immunity have been relevant throughout the history of immunology and infectious disease epidemiology. For some diseases, herd immunity plays a role in the development of an endemic equilibrium, rather than elimination via threshold effects.

METHODS

We reviewed academic literature from 1920 to 2022, using historical and philosophical analysis to identify and develop relevant concepts of herd immunity.

RESULTS

This paper analyses the ambiguity surrounding the concept of herd immunity during the pandemic. We argue for the need to recapture a long-standing interpretation of this concept as one of the factors that leads to a dynamic endemic equilibrium between a host population and a mutating respiratory pathogen.

CONCLUSIONS

Informed by the history of infectious disease epidemiology, we argue that understanding the concept in this way will help us manage both SARS-CoV-2 and hundreds of other seasonal respiratory pathogens with which we live but which have been disrupted due to sustained public health measures/non-pharmaceutical interventions targeting SARS-CoV-2.

Moving the Needle: A Qualitative Exploration of the School Nurses' Experience with Virginia's Human Papillomavirus Mandate

In all US localities, students provide proof of compliance with vaccination requirements to attend school. Despite benefits, vaccine legislation remains contentious. The human papillomavirus (HPV) vaccine is recommended for adolescents and prevents cancer, but its inclusion in school immunization requirements is challenged. Virginia was the first state to mandate HPV vaccination. HPV is the only required vaccine in VA that allows caregivers to elect out. School nurses are trusted members of communities and enforce vaccine compliance. This study aims to understand Virginia school nurses' practice in implementing the HPV vaccine mandate through the exploration of their subjective experiences. Semi-structured interviews were conducted. Thematic analysis using the socioecological model guided data analysis. Factors that influence nursing practice were identified at all socioecological model levels The data from this study is intended to provide an understanding of school nursing practice so that interventions to improve HPV vaccination rates can be developed.

Vaccine Mandates and Cultural Safety

The issues and problems of mandatory vaccination policy and roll out in First Nations communities are unique and do not concern the safety and effectiveness of vaccines. These issues are also independent of more specific arguments of mandatory vaccination of healthcare workers as a condition of employment. As important as these issues are, they do not consider the complex politics of ongoing settler colonialism and First Nations community relations. In this paper, we also set aside the very real problems of disinformation, hesitancy, scientific and health illiteracy, and other concerns that drive vaccine hesitancy and refusal. These affect all communities, including First Nations communities. We, instead describe the dominant arguments in favour of mandatory vaccination and critique them in terms of the disputed legitimacy of Settler-Colonial decision-making as it impacts First Nations communities. We contend cultural responsiveness and safety-not state compulsion-must remain the first principles of any engagement-including vaccination-with First Nations Peoples, families, and communities.

Ethical considerations of the vaccine development process and vaccination: a scoping review

BACKGROUND

Various vaccines have been developed and distributed worldwide to control and cope with COVID-19 disease. To ensure vaccines benefit the global community, the ethical principles of beneficence, justice, non-maleficence, and autonomy should be examined and adhered to in the process of development, distribution, and implementation. This study, therefore, aimed to examine ethical considerations of vaccine development and vaccination processes.

METHODS

A scoping review of the literature was conducted based on the Arkesy and O'Malley protocol to identify eligible studies published until November 2021. We searched Web of Science, PubMed, Scopus, and SciELO databases. The search was conducted using combinations of Medical Subject Heading (MeSH) search terms and keywords for Ethics, COVID-19, and vaccines in abstract, keywords, and title fields to retrieve potentially relevant publications. We included any study that reported one of the four principles of medical ethics: autonomy, justice, non-maleficence, and beneficence in the COVID-19 vaccine development and distribution and implementation of vaccinations. Letters, notes, protocols, and brief communications were excluded. In addition, we searched gray literature to include relevant studies (ProQuest database, conferences, and reports). Data were analyzed using framework analysis.

RESULTS

In total, 43 studies were included. Ethical considerations concluded two themes: (1) production and (2) distribution and vaccination. The production process consisted of 16 codes and 4 main Categories, distribution and vaccination process consisted of 12 codes and 4 main Categories. Moreover, the ethical considerations of special groups were divided into four main groups: health care workers (HCWs) (five codes), children and adolescents (five codes), the elderly (one code), and ethnic and racial minorities (three codes).

CONCLUSION

Due to the externalities of pandemics and the public and social benefits and harms of vaccination, it is not feasible to adhere to all four principles of medical ethics simultaneously and perfectly. This issue confronts individuals and policymakers with several moral dilemmas. It seems that decision-making based on the balance between social benefit and social harm is a better criterion in this regard, and the final decision should be made based on maximizing the public benefit and minimizing the public harm.

Ethical Challenges Involved in COVID-19 Vaccine Mandates for Children: A Systematic Review

The new COVID-19 pandemic has affected day-to-day life, creating various ethical dilemmas. COVID-19 vaccination is seen as an effective way to halt the pandemic. Ethical challenges can arise when the vaccines are mandated for all ages, but more so when mandated for children. This systematic review discusses the pros and cons of the COVID-19 vaccine mandate for children. The primary objective of this study is to summarize exclusively the various ethical conflicts, impacts, and requirements that arise as a result of the COVID-19 vaccine mandate laws on children. The secondary objective is to analyze the reasons for parents refusing to allow their children to be given the COVID-19 vaccine sand the effective strategies to increase vaccine uptake among children. The study involved a systematic review, identification of relevant literature and reviews following the PRISMA-ScR recommendations. The keywords ‘COVID-19 vaccine mandates on children’ were used to mine the literature from PubMed and WHO COVID-19 Research Database. Limitations placed on the original searches were: English language, humans, ethics, and children. Out of 529 studies, only 13 satisfied the selection criteria. The sample included studies with a wide, diverse range of methods, settings, research, authors, and journals. COVID-19 vaccine mandates on children need to be scrutinized. Implementing the COVID-19 vaccination drive in a scientific way is acceptable. As children are the fastest-growing population and have the highest life expectancy, it is important to take into account that the vaccines do not disturb their growth and development.

Political Partisanship and Trust in Government Predict Popular Support for COVID-19 Vaccine Mandates for Various Professions and Demographic Groups: A Research Note

Due to the slow rate of COVID-19 vaccine uptake and the spread of the highly contagious Omicron variant, governments are considering mandating COVID-19 vaccination for specific professions and demographic groups. This study evaluates popular attitudes toward such policies. We fielded a survey of 535 registered voters in South Dakota to examine popular attitudes towards vaccine mandates for five groups-children 12 and older, K-12 teachers, medical staff, nursing homes staff, and police personnel. We estimated a series of logistic regression models and presented predicted probabilities to find the primary determinants of these attitudes. Results revealed that political partisanship and trust in government are strong predictors of support for vaccine mandates across all models. Should government and public health officials wish to increase the proportion of people vaccinated for COVID-19, they must recognize the limitations of current public health campaigns, and reshape their efforts in congruence with scientific findings.

ChatGPT Output Regarding Compulsory Vaccination and COVID-19 Vaccine Conspiracy: A Descriptive Study at the Outset of a Paradigm Shift in Online Search for Information

BACKGROUND

Being on the verge of a revolutionary approach to gathering information, ChatGPT (an artificial intelligence (AI)-based language model developed by OpenAI, and capable of producing human-like text) could be the prime motive of a paradigm shift on how humans will acquire information. Despite the concerns related to the use of such a promising tool in relation to the future of the quality of education, this technology will soon be incorporated into web search engines mandating the need to evaluate the output of such a tool. Previous studies showed that dependence on some sources of online information (e.g., social media platforms) was associated with higher rates of vaccination hesitancy. Therefore, the aim of the current study was to describe the output of ChatGPT regarding coronavirus disease 2019 (COVID-19) vaccine conspiracy beliefs. and compulsory vaccination.

METHODS

The current descriptive study was conducted on January 14, 2023 using the ChatGPT from OpenAI (OpenAI, L.L.C., San Francisco, CA, USA). The output was evaluated by two authors and the degree of agreement regarding the correctness, clarity, conciseness, and bias was evaluated using Cohen's kappa.

RESULTS

The ChatGPT responses were dismissive of conspiratorial ideas about severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) origins labeling it as non-credible and lacking scientific evidence. Additionally, ChatGPT responses were totally against COVID-19 vaccine conspiracy statements. Regarding compulsory vaccination, ChatGPT responses were neutral citing the following as advantages of this strategy: protecting public health, maintaining herd immunity, reducing the spread of disease, cost-effectiveness, and legal obligation, and on the other hand, it cited the following as disadvantages of compulsory vaccination: ethical and legal concerns, mistrust and resistance, logistical challenges, and limited resources and knowledge.

CONCLUSIONS

The current study showed that ChatGPT could be a source of information to challenge COVID-19 vaccine conspiracies. For compulsory vaccination, ChatGPT resonated with the divided opinion in the scientific community toward such a strategy; nevertheless, it detailed the pros and cons of this approach. As it currently stands, the judicious use of ChatGPT could be utilized as a user-friendly source of COVID-19 vaccine information that could challenge conspiracy ideas with clear, concise, and non-biased content. However, ChatGPT content cannot be used as an alternative to the original reliable sources of vaccine information (e.g., the World Health Organization [WHO] and the Centers for Disease Control and Prevention [CDC]).

How Mandatory Can We Make Vaccination?

The novel coronavirus (SARS-CoV-2) pandemic has refocused attention on the issue of mandatory vaccination. Some have suggested that vaccines ought to be mandatory, while others propose more moderate alternatives, such as incentives. This piece surveys a range of possible interventions, ranging from mandates through to education. All may have their place, depending on circumstances. However, it is worth clarifying the options available to policymakers, since there is sometimes confusion over whether a particular policy constitutes a mandate or not. Further, I illustrate a different kind of alternative to mandatory vaccination. Rather than seeking less coercive alternatives to a mandate, we might instead employ an alternative mandate, which requires people to do something less than get vaccinated. For instance, we might merely require people to attend an appointment at a vaccine clinic. Whether this mandatory attendance policy is justified will depend on specific circumstances, but it represents another way to promote vaccination, without mandating it. In some cases, this may represent an appropriate balance between promoting public health goals and respecting individual liberty.

The (Un)fairness of Vaccination Freeriding

For contagious diseases like measles a successful immunization program can result in herd protection. Small outbreaks may still occur but fade out soon, because the possibilities for the pathogen to spread in the 'herd' are very small. This implies that people who refuse to participate in such a program will still benefit from the protection it offers, but they don't do their part in maintaining protection. Isn't that a case of freeriding-and isn't that unfair towards all the people who do collaborate? If so, that might be considered an additional ground for making vaccination mandatory or compulsory. In this paper I argue that vaccination refusal can be considered as freeriding, but that this might not be unfair. The public good of herd protection is a peculiar public good because it supervenes on private benefits that are enjoyed by all who do opt for vaccination. For vaccinated individuals, the additional benefit of herd protection comes about, as it were, for free, and hence they can't complain that others benefit without sharing in the burdens. There are however still other grounds for making vaccination compulsory or at least for seeing refusal as a morally wrong choice.

Do we need to vaccinate every child against COVID-19: What evidence suggests-A systematic review of opinions

It is still debatable whether all children should receive the COVID-19 vaccine. The comparatively mild cases and low risk of COVID-19 in children compared to adults, as well as the lack of clarity on the relative effects of the disease and vaccine, indicate that the risk-benefit ratio of vaccination in children is more nuanced. To consider and highlight the complexity of policy decisions regarding COVID-19 vaccination in children, we outlined the points regarding for and against vaccination of children against COVID-19 in this systemic review. Using Medical Search Headings (MeSH) terms and keywords, we searched PubMed, PubMed Central, Scopus, and Google Scholar. The primary search term was COVID-19 vaccination (all synonyms), factors (all synonyms), and among children (all synonyms). A total of 367 articles were searched. Finally, 64 articles met the inclusion criteria and were included in the review. The major theme/tone of 28 (43.75%) articles was in favor of children's COVID vaccination, and they were highlighting the positive factors, whereas the major theme/tone of 20 (31.25%) articles was against it. Approximately 16 (25.0%) articles were in a neutral position. Major factors highlighted by articles in favor of childhood COVID vaccination were as follows: the increasing rate of disease burden (29 articles), prevention of interruption of academic activities of children or school reopening (24 articles), and a role in defense against COVID infection (21 articles). Major factors against childhood vaccination were as follows: mild infection among children (27 articles), ethical concerns and legal problems regarding the consent of minors (17 articles), and vaccine hesitancy among parents for childhood vaccination (11 articles). Whereas, factors of uncertainty were the role in the reduction of community transmission (19 articles), protection against MIS-C (10 articles), and defense against long COVID (7 articles). Considering all the factors of COVID-19 disease progression among children, a cautious approach will be essential before proceeding with COVID-19 vaccination in children.

Should COVID-19 Vaccines Be Mandated in Schools? - An International Caregiver Perspective

Objectives

Caregiver attitudes toward mandating COVID-19 vaccines for their children are poorly understood. We aimed to determine caregiver acceptability of COVID-19 vaccine mandates for schools/daycares and assess if opposition to mandates would result in removal of children from the educational system.

Study Design

Perform a cross-sectional, anonymous survey of adult caregivers with children ≤ 18 years presenting to 21 pediatric emergency departments in the United States, Canada, Israel, and Switzerland, November 1st through December 31st, 2021. The primary outcome was caregiver acceptance rates for school vaccine mandates, and the secondary outcomes included factors associated with mandate acceptance and caregiver intention to remove the child from school.

Results

 Of 4,393 completed surveys, 37% of caregivers were opposed to any school vaccine mandate. Caregiver acceptance was lowest for daycare settings (33%) and increased as the child’s level of education increased, college (55%). 26% of caregivers report a high likelihood (score of 8–10 on 0–10 scale) to remove their child from school if the vaccine became mandatory. Child safety was caregivers’ greatest concern over vaccine mandates. A multivariable model demonstrated intent to vaccinate their child for COVID-19 (OR = 8.9, 95% CI 7.3 to 10.8; P < 0.001) and prior COVID-19 vaccination for the caregiver (OR = 3.8, 95% CI 3.0 to 4.9; P < 0.001) had the greatest odds of increasing mandate acceptance for any school level.

Conclusions

Many caregivers are resistant to COVID-19 vaccine mandates for schools, and acceptance varies with school level. One-fourth of caregivers plan to remove their child from the educational system if vaccines become mandated.

Providing children with COVID-19 vaccinations is challenging due to lack of data and wide-ranging parental acceptance

Aim

Vaccines are vital to ending the COVID‐19 pandemic and we reviewed the data on vaccinating children, and including them in clinical trials, as most of the activity has focused on adults.

Methods

English and Chinese databases, including PubMed, Elsevier Scopus, Web of Science, CNKI and CQVIP were searched, along with websites such as the World Health Organization and the University of Oxford.

Results

We identified 44 papers and 16 news items about vaccinating children against the virus, published from 10 February 2020 to 14 July 2021. Child vaccination has been slow and only a few countries have included children in Phase II or III clinical trials. The data on children were much more limited than on adults, but most children were asymptomatic or had mild symptoms and some deaths had been recorded. More clinical trials are needed to assess the safety and efficacy of vaccinating children, as higher vaccination levels can help to build up herd immunity. The percentage of parents willing to vaccinate their children against the virus ranged from 48.2% to 72.6%, with much lower rates for letting them participate in clinical trials.

Conclusion

Vaccines should be offered to children as soon as their safety and efficacy are established.

The Ethics of Selective Mandatory Vaccination for COVID-19

With evidence of vaccine hesitancy in several jurisdictions, the option of making COVID-19 vaccination mandatory requires consideration. In this paper I argue that it would be ethical to make the COVID-19 vaccination mandatory for older people who are at highest risk of severe disease, but if this were to occur, and while there is limited knowledge of the disease and vaccines, there are not likely to be sufficient grounds to mandate vaccination for those at lower risk. Mandating vaccination for those at high risk of severe disease is justified on the basis of the harm principle, as there is evidence that this would remove the grave public health threat of COVID-19. The risk–benefit profile of vaccination is also more clearly in the interests of those at highest risk, so mandatory vaccination entails a less severe cost to them. Therefore, a selective mandate would create fairness in the distribution of risks. The level of coercion imposed by a mandate would need to be proportionate, and it is likely that multiple approaches will be needed to increase vaccine uptake. However, a selective mandate for COVID-19 vaccines is likely to be an ethical choice and should be considered by policy-makers.

An ethical analysis of vaccinating children against COVID-19: benefits, risks, and issues of global health equity

COVID-19 vaccination of children has begun in various high-income countries with regulatory approval and general public support, but largely without careful ethical consideration. This trend is expected to extend to other COVID-19 vaccines and lower ages as clinical trials progress. This paper provides an ethical analysis of COVID-19 vaccination of healthy children. Specifically, we argue that it is currently unclear whether routine COVID-19 vaccination of healthy children is ethically justified in most contexts, given the minimal direct benefit that COVID-19 vaccination provides to children, the potential for rare risks to outweigh these benefits and undermine vaccine confidence, and substantial evidence that COVID-19 vaccination confers adequate protection to risk groups, such as older adults, without the need to vaccinate healthy children. We conclude that child COVID-19 vaccination in wealthy communities before adults in poor communities worldwide is ethically unacceptable and consider how policy deliberations might evolve in light of future developments.

An ethical analysis of vaccinating children against COVID-19: benefits, risks, and issues of global health equity

COVID-19 vaccination of children over 12 has begun in various high-income countries with regulatory approval and general public support, but largely without careful ethical consideration. This trend is expected to extend to other COVID-19 vaccines and lower ages as clinical trials progress. This paper provides an ethical analysis of COVID-19 vaccination of healthy children. Specifically, we argue that it is currently unclear whether routine COVID-19 vaccination of healthy children is ethically justified in most contexts, given the minimal direct benefit that COVID-19 vaccination provides to children, the potential for rare risks to outweigh these benefits and undermine vaccine confidence, and substantial evidence that COVID-19 vaccination confers adequate protection to risk groups, such as older adults, without the need to vaccinate children. We conclude that child COVID-19 vaccination in wealthy communities before adults in poor communities worldwide is ethically unacceptable and consider how policy deliberations might evolve in light of future developments.

Uptake of Non-Mandatory Vaccinations in Future Physicians in Italy

In 2017 in Italy, a number of vaccinations became mandatory or started to be recommended and offered free of charge. In this study, we aimed at assessing the coverage rates for those vaccinations in the pre-mandatory era among students at the School of Medicine of Padua University studying the degree course in medicine and surgery (future physicians) on the basis of the vaccination certificates presented during health surveillance. The vaccinations considered were those against pertussis, rubella, mumps, measles, varicella, Haemophilus influenzae type b (which became mandatory in 2017), pneumococcus, meningococcus C and meningococcus B (only suggested and offered for free since 2017). The study enrolled 4706 students of medicine and surgery. High vaccine uptake was observed, especially in younger students (born after 1990), with vaccines against pertussis, rubella, mumps and measles. Good completion for Haemophilus influenzae type b and meningococcus C was also observed. Very low coverage rates (all under 10%) for vaccination against varicella, pneumococcus and meningococcus B were observed. In conclusion, uptake for some non-mandatory vaccines was below the recommended threshold, although younger generations showed a higher uptake, possibly as a results of policy implemented at the national level. Our findings support the idea to consider health surveillance visits also as an additional opportunity to overcome confidence and convenience barriers and offer vaccine administration.