Ethical Issues in Mandating COVID-19 Vaccination for Health Care Personnel

Ladders and stairs: how the intervention ladder focuses blame on individuals and obscures systemic failings and interventions

Introduced in 2007 by the Nuffield Council on Bioethics, the intervention ladder has become an influential tool in bioethics and public health policy for weighing the justification for interventions and for weighing considerations of intrusiveness and proportionality. However, while such considerations are critical, in its focus on these factors, the ladder overemphasises the role of personal responsibility and the importance of individual behaviour change in public health interventions. Through a study of vaccine hesitancy and vaccine mandates among healthcare workers, this paper investigates how the ladder obscures systemic factors such as the social determinants of health. In overlooking these factors, potentially effective interventions are left off the table and the intervention ladder serves to divert attention away from key issues in public health. This paper, therefore, proposes a replacement for the intervention ladder-the intervention stairway. By broadening the intervention ladder to include systemic factors, the stairway ensures relevant interventions are not neglected merely due to the framing of the issue. Moreover, it more accurately captures factors influencing individual health as well as allocations of responsibility for improving these factors.

Ethical and Legal Debates on Vaccine Infodemics

Over the course of three and a half years, the global toll of coronavirus disease 2019 (COVID-19) has claimed the lives of millions of individuals. Scientific breakthroughs, exemplified by mRNA vaccines, have emerged as crucial tools in saving numerous lives and fortifying our defenses against future pandemics. However, the battle against the virus has been complicated by the dissemination of misleading political and ethical information, resulting in avoidable fatalities. Recognizing this phenomenon, the term 'infodemics' has been coined to denote the proliferation of false or misleading information that hinders effective social responses. Given the historical prevalence of infodemics surrounding vaccinations, this discussion delves into the ongoing ethical and legal deliberations concerning vaccination mandates, an indispensable health intervention in the face of pandemics. Governments bear the responsibility of safeguarding their citizens, acknowledging the social requirements imposed by the collective well-being. The protection of both citizens and healthcare workers becomes paramount, considering the potential risks of infection and mortality associated with individuals refusing vaccination. Historically, governments have played a pivotal role in eradicating pandemics through the implementation of vaccine mandates. However, the contemporary landscape is marked by the infusion of political and misleading misinformation, presenting new challenges. Governments are now confronted with an ethical duty to ensure that citizens possess the necessary information to make informed decisions and safeguard their well-being. While grappling with the realization that extraordinary circumstances demand extraordinary responses, the lessons from past pandemics underscore the imperative of prioritizing public health, especially in the context of the high numbers of casualties worldwide. This discourse explores the ethical and legal dimensions surrounding vaccine mandates, with particular emphasis on their relevance to healthcare workers.

Vaccine conspiracy association with higher COVID-19 vaccination side effects and negative attitude towards booster COVID-19, influenza and monkeypox vaccines: A pilot study in Saudi Universities

Conspiracies regarding vaccines are widely prevalent, with negative consequences on health-seeking behaviors. The current study aimed to investigate the possible association between the embrace of vaccine conspiracies and the attitude to booster COVID-19, seasonal influenza, and monkeypox (mpox) vaccinations as well as the perceived side effects following COVID-19 vaccination. The target population involved academic staff and university students in health colleges in the Kingdom of Saudi Arabia. A self-administered questionnaire was distributed in January 2023 to collect data on participants' demographics, self-reported side effects following each dose, willingness to get booster COVID-19, seasonal influenza, and mpox vaccinations, as well as an evaluation of vaccine conspiracies and attitude to mandatory vaccination. Among the 273 participants, the willingness to receive yearly booster COVID-19 vaccination was observed among 26.0% of the participants, while it was 46.9% and 34.1% for seasonal influenza and mpox vaccinations, respectively. Multinomial logistic regression analyses demonstrated a significant correlation between endorsing vaccine conspiracies and higher frequency of self-reported side effects following uptake of the second and third doses of COVID-19 vaccines. Vaccine conspiracies were also correlated with attitude toward booster COVID-19, influenza, mpox, and mandatory vaccination. The findings of this pilot study highlighted the potential adverse impact of the preexisting notions and negative attitudes toward vaccines, which could have contributed to heightened perceived side effects following COVID-19 vaccination. The study also highlighted the ongoing divisions concerning mandatory vaccination policies, emphasizing the need for cautious implementation of this strategy as a last resort for public health benefit.

Unraveling the association between vaccine attitude, vaccine conspiracies and self-reported side effects following COVID-19 vaccination among nurses and physicians in Jordan

Background

The negative impact of vaccine conspiracies is linked with negative health behavior. The aim of the current study was to examine the association between attitudes toward booster COVID-19, influenza, and monkeypox (mpox) vaccinations with post-COVID-19 vaccine side effects, vaccine conspiracies, and attitude towards mandatory vaccination among nurses and physicians in Jordan.

Methods

A structured closed-ended questionnaire was used to collect data on demographics, COVID-19 history, COVID-19 vaccine type and doses received, self-reported side effects post-COVID-19 vaccination, acceptance of booster COVID-19, seasonal influenza, and mpox vaccinations, attitudes towards mandatory vaccination, and beliefs in vaccine conspiracies.

Results

The study sample comprised a total of 341 participants. Acceptance of yearly booster COVID-19 vaccination was expressed by 46.6% of the sample, while 73.3% accepted seasonal influenza vaccination, and only 37.0% accepted mpox vaccination. A higher frequency of self-reported side effects following the first COVID-19 vaccine dose was associated with embrace of vaccine conspiracies and vaccine type. For the second vaccine dose, a higher frequency of self-reported side effects was associated with the embrace of vaccine conspiracies, older age, and affiliation to private sector. In multinomial logistic regression analyses, the lower embrace of vaccine conspiracies was associated with lower odds of reporting side effects post-COVID-19 vaccination. The lower embrace of vaccine conspiracies and favorable attitude towards mandatory vaccination were associated with the willingness to get COVID-19, influenza, and mpox vaccinations.

Conclusion

The study findings highlighted the negative impact of embracing vaccine conspiracies on health-seeking behavior among nurses and physicians. The findings indicated that the willingness to get vaccinated was associated with lower endorsement of vaccine conspiracies. Additionally, the lower embrace of vaccine conspiracies was associated with a lower frequency of self-reported side effects following COVID-19 vaccination. These results emphasize the importance of addressing vaccine misinformation and promoting accurate information to ensure optimal vaccine uptake and public health outcomes.

Impact of the COVID-19 vaccination mandate on the primary care workforce and differences between rural and urban settings to inform future policy decision-making

INTRODUCTION

Little is known about the impact of mandated vaccination policies on the primary care clinic workforce in the United States or differences between rural and urban settings, especially for COVID-19. With the continued pandemic and an anticipated increase in novel disease outbreaks and emerging vaccines, healthcare systems need additional information on how vaccine mandates impact the healthcare workforce to aid in future decision-making.

METHODS

We conducted a cross-sectional survey of Oregon primary care clinic staff between October 28, 2021- November 18, 2021, following implementation of a COVID-19 vaccination mandate for healthcare personnel. The survey consisted of 19 questions that assessed the clinic-level impacts of the vaccination mandate. Outcomes included job loss among staff, receipt of an approved vaccination waiver, new vaccination among staff, and the perceived significance of the policy on clinic staffing. We used univariable descriptive statistics to compare outcomes between rural and urban clinics. The survey also included three open-ended questions that were analyzed using a template analysis approach.

RESULTS

Staff from 80 clinics across 28 counties completed surveys, representing 38 rural and 42 urban clinics. Clinics reported job loss (46%), use of vaccination waivers (51%), and newly vaccinated staff (60%). Significantly more rural clinics (compared to urban) utilized medical and/or religious vaccination waivers (71% vs 33%, p = 0.04) and reported significant impact on clinic staffing (45% vs 21%, p = 0.048). There was also a non-significant trend toward more job loss for rural compared to urban clinics (53% vs. 41%, p = 0.547). Qualitative analysis highlighted a decline in clinic morale, small but meaningful detriments to patient care, and mixed opinions of the vaccination mandate.

CONCLUSIONS

Oregon's COVID-19 vaccination mandate increased healthcare personnel vaccination rates, yet amplified staffing challenges with disproportionate impacts in rural areas. Staffing impacts in primary care clinics were greater than reported previously in hospital settings and with other vaccination mandates. Mitigating primary care staffing impacts, particularly in rural areas, will be critical in response to the continued pandemic and novel viruses in the future.

COVID-19 Disease in Under-5 Children: Current Status and Strategies for Prevention including Vaccination

Since the coronavirus disease (COVID-19) pandemic hit the globe in early 2020, we have steadily gained insight into its pathogenesis; thereby improving surveillance and preventive measures. In contrast to other respiratory viruses, neonates and young children infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) have a milder clinical presentation, with only a small proportion needing hospitalization and intensive care support. With the emergence of novel variants and improved testing services, there has been a higher incidence of COVID-19 disease reported among children and neonates. Despite this, the proportion of young children with severe disease has not increased. Key mechanisms that protect young children from severe COVID-19 disease include the placental barrier, differential expression of angiotensin-converting enzyme 2 (ACE-2) receptors, immature immune response, and passive transfer of antibodies via placenta and human milk. Implementing mass vaccination programs has been a major milestone in reducing the global disease burden. However, considering the lower risk of severe COVID-19 illness in young children and the limited evidence about long-term vaccine safety, the risk-benefit balance in children under five years of age is more complex. In this review, we do not support or undermine vaccination of young children but outline current evidence and guidelines, and highlight controversies, knowledge gaps, and ethical issues related to COVID-19 vaccination in young children. Regulatory bodies should consider the individual and community benefits of vaccinating younger children in their local epidemiological setting while planning regional immunization policies.

COVID-19 vaccination: is it mandatory or optional?

In Indonesia, controversy about the COVID-19 vaccination is still going on, there is a group of people who believe in this vaccine, and another group chooses not to believe. There are those who support this as mandatory, but there are also those who think that this is optional. Hopefully through this letter, we can all respect the decisions of every human being who has free will and has full rights over their own life.

Effects of perspective switching and utilitarian thinking on moral judgments in a sacrificial dilemma among healthcare and non-healthcare students

During the COVID-19 pandemic, healthcare professionals have often faced moral challenges, which required them to choose between endorsing self- or other-sacrifice for the greater good. Drawing on the altruistic rationalization hypothesis and trait-activation theory, this study investigates (a) whether healthcare students' endorsement of utilitarian solutions to sacrificial moral dilemmas varies when they are confronted with the minority group, majority group, or third-person perspective on the given dilemma and (b) whether individual differences in utilitarian thinking, as measured by the Oxford Utilitarianism Scale (both instrumental harm and impartial beneficence), predict endorsement of utilitarian solutions to moral dilemmas. The study population was divided into a group of healthcare students and a group of non-healthcare students. It was found that the members of both groups expressed a stronger pro-utilitarian position when making moral dilemma judgments from a majority perspective than from the two other perspectives. However, a difference was observed with healthcare students being more reluctant to endorse the utilitarian action than their non-healthcare counterparts in the self-in-majority context. The instrumental harm component was a significant predictor of utilitarian judgments in the healthcare group, but impartial beneficence significantly predicted utilitarian judgments in the non-healthcare group in the self-in-majority context.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12144-023-04380-z.

Fear of Illness and Convenient Access to Vaccines Appear to Be the Missing Keys to Successful Vaccination Campaigns: Analysis of the Factors Influencing the Decisions of Hospital Staff in Poland concerning Vaccination against Influenza and COVID-19

The COVID-19 pandemic has lasted for two years as of 2022, and it is common knowledge that vaccines are an essential tool to mitigate the health, economic, and social fallout. Unfortunately, vaccine hesitancy is still a serious global problem, both in the general population and among healthcare workers. The authors used an original questionnaire to conduct an anonymous survey study in the University Clinical Hospital in Wrocław, Poland, in April and May of 2021 after acquiring consent from the Medical University of Wrocław, Poland Bioethical Committee. The study results demonstrate that, to a significant extent, the decisions concerning vaccinations are based on factors that are difficult to change with rational argumentation, including people’s personal opinions or beliefs concerning vaccinations and their earlier experiences with vaccinations. The study results suggest that the impregnating effect of one’s own opinions, beliefs, and experiences can be surmounted if vaccines are dispensed free and conveniently while the pathogen is irrationally and emotionally perceived as untamed and possibly severe and life threatening. It makes a significant difference as in such cases that the percentage of participants whose decisions concerning vaccination are influenced by the risks to life or health of one’s own or others rises by about 27 and 36 percent points, respectively. Therefore, in order to succeed, campaigns for vaccinations need to include strong subjective and emotional communication, appealing to negative emotions and exploiting the public’s fear of the unknown while stressing tangible and personal threats possibly resulting from acquiring a vaccine-preventable infectious disease.

SARS-CoV-2 Omicron Variant: Exploring Healthcare Workers' Awareness and Perception of Vaccine Effectiveness: A National Survey During the First Week of WHO Variant Alert

Background

As the SARS-CoV-2 Omicron variant spreads in several countries, healthcare workers' (HCWs) perceptions and worries regarding vaccine effectiveness and boosters warrant reassessment.

Methods

An online questionnaire among HCWs in Saudi Arabia (KSA) was distributed from Dec 1st-6th 2021 to assess their perceptions, vaccine advocacy to the Omicron variant, and their perception of the effectiveness of infection prevention measures and vaccination to prevent its spread, their Omicron variant related worries in comparison to the other variants, and their agreement with mandatory vaccination in general for adults.

Results

Among the 1,285 HCW participants, two-thirds were female, 49.8 % were nurses, 46.4% were physicians, and 50.0% worked in tertiary care hospitals. 66.9% considered vaccination to be the most effective way to prevent the spread of the Omicron variant and future variants. The respondents however perceived social distancing (78.0%), universal masking (77.8%), and avoiding unnecessary travel (71.4%) as slightly superior to vaccination to prevent the spread of SARS-CoV-2 variants. HCWs aging 55 or older agreed significantly with vaccine ineffectiveness to control Omicron spread, while those who believed in non-pharmacological infection prevention measures agreed significantly with vaccination for that purpose. Male HCWs had a significant agreement with mandatory vaccination of all eligible adult populations. On the other hand, unwilling HCWs to receive the vaccine had strong disagreements with mandatory vaccination.

Conclusions

The current study in the first week of Omicron showed that only two-thirds of HCWs felt that vaccination was the best option to prevent the spread of the Omicron variant, indicating the need for further motivation campaigns for vaccination and booster dose. HCWs had a strong belief in infection prevention measures to contain the spread of SARS-CoV-2 variants that should be encouraged and augmented.

COVID-19 Vaccination Willingness and Vaccine Uptake among Healthcare Workers: A Single-Center Experience

Healthcare workers (HCWs) are at higher risk of developing COVID-19 due to their professional exposition to the SARS-CoV-2 virus. This study assesses the intention of vaccination against COVID-19 before the vaccines were approved, and the rate of vaccine uptake during the first nine months of immunization among HCWs. A cross-sectional seroprevalence study was carried out during July 2020 in University Clinical Hospital Center Bezanijska Kosa in Belgrade, Serbia that included 62.8% of all HCWs. Besides serological testing for IgG antibodies, data about HCWs' intention to accept COVID-19 vaccination if a vaccine became available were collected. This cohort of HCWs was followed up until the end of October 2021 to assess the number of vaccinated and PCR-positive staff. In the cross-sectional study, 18.3% HCWs had positive SARS-CoV-2 IgG antibodies without difference with IgG-negative HCWs regarding age, gender, profession type, and years of service. Before vaccines became available, a significantly higher percentage of IgG-positive HCWs compared to IgG-negative HCWs was unsure whether to be vaccinated (62.5% vs. 49.0%), and significantly fewer stated that they would not be vaccinated (16.7% vs. 25.1%). When the vaccines became available in Serbia, among IgG-negative HCWs, those who stated clear positive (yes) and clear negative (no) attitude toward vaccination before the immunization period had begun were vaccinated at 28% and 20%, respectively, while 51% of unsure HCWs received a vaccine (p = 0.006). Among IgG-positive HCWs, there was no statistical difference in vaccine uptake regarding those with previous negative, positive, and unsure opinions about vaccination (p = 0.498). In multivariate analysis, independent factors associated with uptake were being female (OR = 1.92; 95%CI: 1.04-3.55), age of 30-59 years, previously vaccine-unsure (OR = 1.84; 95%CI: 1.04-3.25), and those with previous positive vaccine attitudes (OR = 2.48; 95%CI:1.23-5.01), while nurses were less likely to become vaccinated (OR = 0.39 95% CI: 0.20-0.75) These findings indicate a positive change in attitudes of HCWs towards COVID-19 vaccination.