Lessons We Can Learn from Mandatory Vaccine Policies in Europe
Lewis First, MD, MS, Editor in Chief, Pediatrics
January 16, 2020


We focus a lot of attention on articles that deal with ways to increase vaccination rates in the United States. We do so because our vaccine rates are suboptimal for a variety of reasons, many of which are related to unsubstantiated risk. What can we do to improve vaccination rates? Europe may offer us an answer. Did you know for example that there are 7 countries in Europe that mandate vaccination and only 2 of these allow nonmedical exemptions? In addition, 6 of these 7 countries will inflict financial penalties to families who do not immunize their children. So what are the vaccination rates in these countries and what about the incidence of vaccine-preventable diseases like pertussis and measles?

Vaz et al (10.1542/peds.2019-0620) evaluated these questions in new study being early released in our journal. The authors used data from the European Centers for Disease Control and Prevention and the World Health Organization to look at European countries that do and do not mandate vaccine administration to children in regard to vaccination against measles and pertussis, as well as the annual incidence of these two diseases in these countries. The results are interesting and perhaps not exactly what you might expect. On the good side, mandatory vaccinations did result in statistically significant increases in childhood vaccination against pertussis and measles. The interesting news is that only when a country did not allow nonmedical exemptions did the mandatory vaccine policy result in a significant decrease in measles, but not for pertussis. Why?

We asked Drs. Sean O’Leary (University of Colorado) and Yvonne Maldonado (Stanford) (10.1542/peds.2019-2436) to weigh in with an accompanying commentary. They draw some interesting lessons about vaccination mandates and changes in disease burden and bring to light other important considerations related to financial penalties and vaccination mandates. One important takeaway is that vaccine policies are uniform across each specific European country instead of the patchwork that exists across states. There is a lot of great information injected into the pages of this important study—so take a shot at reading both this study and commentary and then share with parents who will hopefully be even more convinced about why vaccination should be mandatory for their child. If state legislators read this study and commentary, perhaps vaccination policy, including mandates, will be made stronger.


Copyright © 2020 American Academy of Pediatrics

Mandatory Vaccination in Europe and Epidemiology of Vaccine Preventable Diseases 
 https://pediatrics.aappublications.org/content/145/2/e20190620?utm_source=TrendMD&utm_medium=TrendMD&utm_campaign=Pediatrics_TrendMD_0

VIDEO
https://ajp.psychiatryonline.org/doi/pdfplus/10.1176/appi.ajp.2020.20030272

Vaccination Policies and Disease Incidence Across the Pond: Implications for the United State

Sean T. O’Leary and Yvonne A. Maldonado
Pediatrics February 2020, 145 (2) e20192436; 

DOI: https://doi.org/10.1542/peds.2019-

2436https://pediatrics.aappublications.org/content/pediatrics/145/2/e20192436.full.pdf

Abbreviation:CI — confidence interval

In this issue of Pediatrics, Vaz et al report the results of their study, “Mandatory Vaccination in Europe."1 Although this study analyzed vaccination and vaccine-preventable disease trends in Europe, the policy implications are timely and relevant to US vaccination practices given the ongoing measles outbreaks in the United States and the legislative responses playing out in state capitols across the United States.

In this study, the authors examined the associations between vaccination mandate policies and subsequent vaccination coverage and measles and pertussis incidence in 29 European countries. Stated another way, the authors wanted to know if having a stricter vaccination policy resulted in higher vaccination rates and a lower incidence of 2 highly contagious vaccine-preventable diseases.

We already know that in the United States, a stricter state-based vaccination policy leads to lower rates of nonmedical exemptions2,3 and lower rates of vaccine-preventable diseases,4,5 but before the study by Vaz et al,1 these questions had not been examined among European countries. We can think of 3 main reasons this study is highly relevant to US vaccine policy: First, it demonstrates that the impact of such policies is not country specific, offering guidance to countries throughout the world on strategies to increase or maintain high vaccination rates. Second, some of the policies used in Europe are strategies that have not been tried previously in the United States and may offer US policy makers strategies to consider. Third, and most important, vaccine-preventable diseases are a worldwide problem; they know no borders, and therefore, it is in the interest of all of us to study and understand how to best achieve high vaccination coverage throughout the world. Indeed, many US measles outbreaks in the last decade have been a result of cases imported from Europe, (most recently and visibly, the Clark County outbreak in Washington state).6

To examine these questions, the authors used data from the European Centre for Disease Prevention and Control and the World Health Organization to examine the relationship between country-level vaccination policies and measles and pertussis vaccination coverage and the annual incidence of these diseases in 29 European countries. To try to assess the specific impact of the vaccination policies, the authors used regression models to examine these associations, adjusting for numerous country-level covariates likely to have an impact on vaccination coverage or disease incidence, such as education, urbanicity, income, and age of the population.

The authors found that mandatory vaccination was associated with 3.00 percentage points higher prevalence of measles vaccination (95% confidence interval [CI], 0.35–5.64) and 2.14 percentage points higher prevalence of pertussis vaccination (95% CI, 0.13–4.15) compared with countries that did not have mandatory vaccination. Mandatory vaccination was associated with decreased measles incidence in countries that did not allow nonmedical exemptions (adjusted incident rate ratio = 0.14; 95% CI, 0.05–0.36), although there was no significant association between mandatory vaccination and pertussis incidence. The authors also found that incorporating financial penalties for not vaccinating increased vaccination uptake. In countries with such policies, every €500 increase in the maximum possible penalty was associated with an increase of 0.8 percentage points for measles vaccination coverage (95% CI, 0.50–1.15; P ≤ .0001) and an increase of 1.1 percentage points for pertussis vaccination coverage (95% CI, 0.95–1.30; P ≤ .0001).

In Europe and other parts of the world, policy makers have (to varying degrees) employed financial penalties for parents who choose not to vaccinate. Policy makers in the United States have for the most part shied away from such policies. This study should make us reconsider this approach because it appears to be effective. In Hungary, for example, parents could face a financial penalty of up to ∼€1600 (∼$1800) if they fail to comply with vaccination requirements; this has resulted in high vaccination coverage and essentially no measles or pertussis cases. Importantly, these types of financial penalties may also be fair because it is clear that persons unvaccinated by parental choice place an unneeded financial burden on our health care system.7–9

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Canada's COVID-19 travel vaccine passport: Canadian government reveals standardized, national proof of vaccination

IT TOOK AN ELECTION TO GET THEM TO DO THIS 


Travelers wearing face masks walk out of the arrivals hall at Toronto Pearson International Airport in Mississauga, Ontario, Canada, on July 5, 2021. Starting from Monday, "fully vaccinated" Canadians and permanent residents can enter Canada without undergoing quarantine

. (Photo by Zou Zheng/Xinhua via Getty Images)


Elisabetta Bianchini
Thu, October 21, 2021, 9:26 AM·3 min read

Prime Minister Justin Trudeau announced Thursday that provincial and territorial governments across Canada will move forward with a standardized proof of COVID-19 vaccination certificate.

"All provinces and territories have confirmed that they will be moving forward with a standardized, national proof of vaccination," Trudeau said at a press conference on Thursday.

The prime minister highlighted that Saskatchewan, Ontario, Quebec, Nova Scotia, Newfoundland, Yukon, Nunavut and the Northwest Territories have put in for use of the national standard for proof of vaccination, with the remaining provinces "working hard to come online."


He added that the federal government will be "picking up the tab" for this standardized certificate.

The information on the proof of vaccination includes:


Full name and date of birth


A "neutral, factual" account COVID-19 vaccination history, including the dates of vaccination, the number of doses, vaccine type(s), product name(s) and lot number(s)


A QR code that includes the vaccination history and may include "additional information on the COVID-19 vaccines received"

The federal government has indicated that this proof of vaccination complies with the SMART Health Card standard, recognized by a number of international travel destinations.

Canada COVID-19 proof of vaccination (Government of Canada)
How to get your Canadian COVID-19 proof of vaccination?

If you live in a province or territory using a COVID-19 proof of vaccination system locally, like Ontario, you may already have the Canada COVID-19 proof of vaccination.

You have the Canadian COVID-19 proof of vaccination if the document:


Says “COVID-19 Proof of Vaccination” at the top of the document


Includes the official logos for your province or territory, the Government of Canada (the word “Canada” with the Canadian flag above the last “a”)


Has your full name and date of birth


Shows your COVID-19 vaccination history, including the number of dose(s), the vaccine type(s), product name(s) and lot number, the date(s) you got your vaccination(s), a SMART Health Cards QR code


Is a bilingual document

This proof of vaccination document can be accessed as a file on a mobile device, computer or mobile wallet, or printed.

While the federal government highlights that "many international destinations may accept the Canadian COVID-19 proof of vaccination," it is also stressed that "each destination makes the final decision on what they accept as proof of vaccination."

"There are many different standards being looked at around the world, Europe has one, we are using the SMART Health Card format that many places in the United States and elsewhere around the world are using," Trudeau said.

"We are very confident that this proof of vaccination certificate, that will be federally approved, issued by the provinces, with the health information for Canadians, is going to be accepted at destinations worldwide as proof of vaccination."

For Canadians returning to Canada, their proof of vaccination document can be uploaded to the ArriveCAN app up to 72 hours before arrival in the country.
Mixed COVID-19 vaccine doses

As of Nov. 8, Canadians vaccinated with any combination of authorized COVID-19 vaccines will be considered fully vaccinated by the U.S. government.

"The Government of Canada is actively engaging other countries and international partners to encourage them to recognize those who have received mixed vaccine schedules or extended dose intervals as being fully vaccinated," information from the Canadian government reads.

"Initial outreach has focused on the ongoing exchange of technical and scientific information to advance this time-sensitive work."
Travel within Canada

Effective Oct. 30, individuals travelling within Canada, age 12 and older, need to show proof of vaccination to board a plane, train or cruise ship.

This includes air passengers flying on domestic, transborder or international flights departing from airports in Canada, rail passengers on VIA Rail and Rocky Mountaineer trains, and marine passengers on non-essential passenger vessels, including cruise ships on voyages of 24 hours or more.

There will be a transition period where travellers will be able to go on their journey if they show a valid COVID-19 molecular test within 72 hours of travel, until Nov. 30.

Current vaccine approach not enough to eradicate measles

New study models the feasibility of eliminating measles and rubella

Peer-Reviewed Publication

UNIVERSITY OF GEORGIA

Current vaccination strategies are unlikely to eliminate measles, according to a new study led by faculty at the University of Georgia. 

The paper, which published today in The Lancet Global Health, explores the feasibility of eliminating measles and rubella using predominant vaccination strategies in 93 countries with the highest disease burden.

Despite marked reductions in the number of new measles and rubella cases worldwide, gaps remain between current levels of transmission and disease elimination. 

“Measles is one of the most contagious respiratory infections out there, and it moves quickly, so it’s hard to control,” said lead author Amy Winter, an assistant professor of epidemiology and biostatistics at UGA’s College of Public Health. 

The basic reproduction number (R0) for measles, which represents the number of people that one infected person is likely to transmit that disease to in a fully susceptible population, is roughly 18. By comparison the R0 for the original SARS-CoV-2 virus is estimated to be around three.

In 2017, the World Health Organization director general requested a report on the feasibility of measles and rubella eradication. One component of this report was to use transmission models to evaluate the theoretical feasibility of eradication of the two viruses given different vaccination strategies.

The assessment was a collaboration with the WHO Strategic Advisory Group of Experts Measles and Rubella Working Group, the World Health Organization, the U.S. Centers for Disease Control and Prevention, and five modeling groups.

Using four national disease transmission models and one sub-national model, the modeling groups projected the annual case rates for measles and rubella for two vaccination scenarios.

Both vaccination scenarios use the two predominant vaccination approaches of routine vaccination as part of childhood immunization schedules and nationwide vaccination campaigns.

The first “business as usual” vaccination scenario continues vaccination coverage and campaigns into the future. The second “intensified investment” vaccination scenario optimally improved vaccination coverage over time. This scenario also included vaccination campaign cessation criteria – a stopping point for when campaigns are no longer deemed necessary because a large enough proportion of the population has been inoculated.

The models show that current vaccine strategies could eliminate rubella and congenital rubella syndrome in all 93 counties, but not measles. 

“The current strategy that we use, which is focused on improving routine vaccination coverage and supplementing it with nationwide vaccination campaigns until routine vaccination is high enough, that alone is not going to be sufficient to reach measles elimination. We need novel approaches,” said Winter. 

The authors evaluated two strategies that could help move a country to elimination faster and reduce the probability of measles outbreaks: One, improve how supplemental vaccine campaigns are delivered to ensure they are reaching children who are not receiving routine vaccinations.

Two, improve vaccine coverage equity by focusing routine and supplemental vaccination on sub-regions with the lowest vaccination coverage first to get them up to par.

“A world that is permanently free of measles and rubella would be an incredible achievement for humanity. Our work suggests that to reach this goal, we need to make vaccine coverage much more equal,” said co-author Mark Jit, professor of vaccine epidemiology at the London School of Hygiene & Tropical Medicine.

“In other words, we need to work even harder to bring measles and rubella vaccination to the most underserved people around the world.”

The final strategy the authors present is a reconsideration of cessation criteria. Currently, most countries stop supplementing routine vaccines with vaccination campaigns once they reach elimination status, said Winter, but the models suggest that outbreaks are still likely to occur if countries rely on routine vaccines alone.

It’s critical, Winter warns, to remain vigilant to surveil for rubella and measles cases and rapidly respond to potential outbreaks even after elimination is achieved.

“We have a globally connected world, so there’s this constant pressure of importations of the viruses in places where it’s already eliminated,” she said. “That’s why keeping vaccination coverage high and continuing to improve surveillance for these diseases is important.”

---

JOURNAL

The Lancet Global Health

ARTICLE TITLE

Feasibility of measles and rubella vaccination programmes for disease elimination: a modelling study

ARTICLE PUBLICATION DATE

13-Sep-2022

Parents were fine with sweeping school vaccination mandates five decades ago – but COVID-19 may be a different story


James Colgrove, Professor of Sociomedical Sciences, Mailman School of Public Health; Dean of the Postbaccalaureate Premedical Program, Columbia School of General Studies, Columbia University

Fri, October 22, 2021

Children and parents lined up for polio vaccines outside a Syracuse, New York school in 1961. AP Photo

The ongoing battles over COVID-19 vaccination in the U.S. are likely to get more heated when the Food and Drug Administration authorizes emergency use of a vaccine for children ages 5 to 11, expected later this fall.

California has announced it will require the vaccine for elementary school attendance once it receives full FDA approval after emergency use authorization, and other states may follow suit. COVID-19 vaccination mandates in workplaces and colleges have sparked controversy, and the possibility that a mandate might extend to younger children is even more contentious.

Kids are already required to get a host of other vaccines to attend school. School vaccination mandates have been around since the 19th century, and they became a fixture in all 50 states in the 1970s. Vaccine requirements are among the most effective means of controlling infectious diseases, but they’re currently under attack by small but vocal minorities of parents who consider them unacceptable intrusions on parental rights.

As a public health historian who studies the evolution of vaccination policies, I see stark differences between the current debates over COVID-19 vaccination and the public response to previous mandates.
Compulsory vaccination in the past

The first legal requirements for vaccination date to the early 1800s, when gruesome and deadly diseases routinely terrorized communities. A loose patchwork of local and state laws were enacted to stop epidemics of smallpox, the era’s only vaccine-preventable disease.

Vaccine mandates initially applied to the general population. But in the 1850s, as universal public education became more common, people recognized that schoolhouses were likely sites for the spread of disease. Some states and localities began enacting laws tying school attendance to vaccination. The smallpox vaccine was crude by today’s standards, and concerns about its safety led to numerous lawsuits over mandates.

The U.S. Supreme Court upheld compulsory vaccination in two decisions. The first, in 1905, affirmed that mandates are constitutional. The second, in 1922, specifically upheld school-based requirements. In spite of these rulings, many states lacked a smallpox vaccination law, and some states that did have one failed to enforce it consistently. Few states updated their laws as new vaccines became available.

School vaccination laws underwent a major overhaul beginning in the 1960s, when health officials grew frustrated that outbreaks of measles were continuing to occur in schools even though a safe and effective vaccine had recently been licensed.

Many parents mistakenly believed that measles was an annoying but mild disease from which most kids quickly recovered. In fact, it often caused serious complications, including potentially fatal pneumonia and swelling of the brain.

With encouragement from the Centers for Disease Control and Prevention, all states updated old laws or enacted new ones, which generally covered all seven childhood vaccines that had been developed by that time: diphtheria, pertussis, tetanus, polio, measles, mumps and rubella. In 1968, just half the states had school vaccination requirements; by 1981, all states did.

Smiling boy rolls up his sleeve to get a shot from a nurse

Expanding requirements, mid-20th century

What is most surprising about this major expansion of vaccination mandates is how little controversy it provoked.

The laws did draw scattered court challenges, usually over the question of exemptions – which children, if any, should be allowed to opt out. These lawsuits were often brought by chiropractors and other adherents of alternative medicine. In most instances, courts turned away these challenges.

There was scant public protest. In contrast to today’s vocal and well-networked anti-vaccination activists, organized resistance to vaccination remained on the fringes in the 1970s, the period when these school vaccine mandates were largely passed. Unlike today, when fraudulent theories of vaccine-related harm – such as the discredited notion that vaccines cause autism – circulate endlessly on social media, public discussion of the alleged or actual risks of vaccines was largely absent.

Through most of the 20th century, parents were less likely to question pediatricians’ recommendations than they are today. In contrast to the empowered “patient/consumer” of today, an attitude of “doctor knows best” prevailed. All these factors contributed to overwhelmingly positive views of vaccination, with more than 90% of parents in a 1978 poll reporting that they would vaccinate their children even if there were no law requiring them to do so.

Widespread public support for vaccination enabled the laws to be passed easily – but it took more than placing a law on the books to control disease. Vaccination rates continued to lag in the 1970s, not because of opposition, but because of complacency.

Thanks to the success of earlier vaccination programs, most parents of young children lacked firsthand experience with the suffering and death that diseases like polio or whooping cough had caused in previous eras. But public health officials recognized that those diseases were far from eradicated and would continue to threaten children unless higher rates of vaccination were reached. Vaccines were already becoming a victim of their success. The better they worked, the more people thought they were no longer needed.

In response to this lack of urgency, the CDC launched a nationwide push in 1977 to help states enforce the laws they had recently enacted. Around the country, health officials partnered with school districts to audit student records and provide on-site vaccination programs. When push came to shove, they would exclude unvaccinated children from school until they completed the necessary shots.

The lesson learned was that making a law successful requires ongoing effort and commitment – and continually reminding parents about the value of vaccines in keeping schools and entire communities healthy.
Add COVID-19 to vaccine list for school?

Five decades after school mandates became universal in the U.S., support for them remains strong overall. But misinformation spread over the internet and social media has weakened the public consensus about the value of vaccination that allowed these laws to be enacted.

adults and kids with signs protesting COVID-19 vaccines

COVID-19 vaccination has become politicized in a way that is unprecedented, with sharp partisan divides over whether COVID-19 is really a threat, and whether the guidance of scientific experts can be trusted. The attention focused on COVID-19 vaccines has given new opportunities for anti-vaccination conspiracy theories to reach wide audiences.

[Over 115,000 readers rely on The Conversation’s newsletter to understand the world. Sign up today.]

Fierce opposition to COVID-19 vaccination, powered by anti-government sentiment and misguided notions of freedom, could undermine support for time-tested school requirements that have protected communities for decades. Although vaccinating school-aged children will be critical to controlling COVID-19, lawmakers will need to proceed with caution.

This article is republished from The Conversation, a nonprofit news site dedicated to sharing ideas from academic experts. It was written by: James Colgrove, Columbia University.

Read more:

Half of unvaccinated workers say they’d rather quit than get a shot – but real-world data suggest few are following through

Shutting down school vaccine clinics doesn’t protect minors – it hurts people who are already disadvantaged

James Colgrove has received funding from the National Library of Medicine, the Greenwall Foundation, the Milbank Memorial Fund, and the William T. Grant Foundation.

Vaccines bring us closer

Eurosurveillance issue marks European Immunization Week 2021

EUROPEAN CENTRE FOR DISEASE PREVENTION AND CONTROL (ECDC)

Research News

 

IMAGE: WORLD HEALTH ORGANIZATION (WHO) MEMBER STATES AFFIRMATIVELY REPORTING NATIONAL ADULT IMMUNISATION PROGRAMMES, BY WHO REGION AND WORLDWIDE, 2018 view more 

CREDIT: EUROSURVEILLANCE, WHO

Effectively and safely protecting against disease--this is what makes vaccines a vital and successful public health tool that saves lives and safeguards health and well-being. Today, vaccines shield us from more than 20 life-threatening diseases.

Each year, between 2 to 3 million lives are saved by immunisation against diseases like diphtheria, tetanus, pertussis, influenza or measles [1]. However, several vaccines such as the one against measles can only reach their full potential--protecting not just those who are immunised, but also those who might not be eligible for vaccination--if the vaccination coverage in a population is high enough [2].

Looking at immunisation programmes' successes and remaining challenges, this week's issue of Eurosurveillance is published on the occasion of European Immunization Week (EIW), from 26 April to 2 May 2021. The campaign, observed annually in the last week of April, was established by the World Health Organization (WHO) Regional Office for Europe in 2005 and aims to highlight the benefits of routine immunisation and to support national immunisation systems.

This year's EIW slogan, 'Vaccines bring us closer', embraces coronavirus disease (COVID-19) vaccines as an integral part of the response to end the ongoing pandemic and ease the physical distancing measures that have been implemented to help control it [3].

Thanks to routine vaccination--which has helped to eradicate for example smallpox and to protect against other diseases with potentially serious health consequences [4]--we know that vaccines work. Yet, WHO estimates that around 20 million children worldwide do not receive the vaccines they need or miss out on vaccination later in life [5].

Vaccines are most often administered to infants and children as part of routine national vaccination schedules. But immunisation protection reaches further than childhood and is important for people in all stages of life, from teenagers to adults and elderly people. Providing such lifelong protection poses further challenges for vaccination programmes, including ensuring equitable access to vaccines [6].

The editorial in this Eurosurveillance issue outlines the lessons learnt since the outset of the coronavirus disease (COVID-19) pandemic, with regards to rapid vaccine development, authorisation, procurement, distribution and administration in large vaccination campaigns. It looks at the key considerations for national vaccine decision-making--during a pandemic or otherwise--and the role that National Immunisation Technical Advisory Groups (NITAGs) or equivalent bodies play when they advise their governments on how to best use new vaccines or design national immunisation programmes.

Also in this issue, Williams et al. documented and quantified immunisation programmes for adults across 194 WHO Member States in order to assess existing infrastructures' suitability for COVID-19 vaccine deployment. Looking at five vaccines licensed for adult immunisation (hepatitis B, herpes zoster, influenza, pneumococcal conjugate and pneumococcal polysaccharide vaccines), the authors found that of the 194 WHO Member States, 120 (62%) reported having at least one adult vaccination programme in 2018, and that 59% of countries had adult vaccination programmes for influenza.

High- or upper-middle-income countries were found to be significantly more likely to report adult immunisation programmes, with country income serving as the most strongly associated factor overall in a multivariable analysis. Other significantly associated factors in a bivariable analysis included meeting National Immunisation Technical Advisory Group (NITAG) basic functional indicators, having introduced new or underused vaccines and having achieved paediatric vaccine coverage goals.

Based on their assessment, Williams et al. conclude that almost 40% of the assessed countries have no infrastructure for adult immunisation and that even the presence of a national adult vaccination programme does not guarantee extensive use of vaccines in the adult population [7].

One target group for adult vaccination is healthcare workers, given that they are exposed to vaccine-preventable diseases like measles, mumps, pertussis and varicella at work and can also transmit these to patients.

In their article, von Linstow et al. detected immunity gaps mainly among young healthcare workers. In addition, considerable proportions of healthcare workers in the study reported that they were unsure about their vaccination status (22-32%, depending on the disease) and possible previous infections (11% for varicella and 41% for pertussis). According to the authors, this demonstrates the need for more targeted measures like screening and a vaccine strategy to address these gaps in healthcare workers [8].

Specifically for measles and its related elimination goal, coverage and uptake of routine childhood immunisation programmes have to improve in many European countries in the same way that immunity gaps in adolescents and adults need to be addressed [9].

In their paper, Rohleder et al. examine a possible relationship between socioeconomic deprivation and measles incidence in Germany, taking into account demographic, spatial and temporal factors [10]. They conclude that the risks for measles infections are higher and more concentrated in areas with the highest socioeconomic status.

In a study of 6,423 healthcare workers in Italy who received the Comirnaty vaccine (BNT162b2, BioNTech/Pfizer, Mainz, Germany/New York, United States), Fabiani et al. found that the effectiveness of preventing SARS-CoV-2 infection was 84% (95% confidence interval (CI): 40-96) 14-21 days after receiving the first dose and 95% (95% CI: 62-99) at least 7 days after the second dose. According to the authors, these results could support the ongoing COVID-19 vaccination campaigns with evidence for targeted communication [11].

Vaccination may be receiving more attention than usual right now, as many adults worldwide are currently being vaccinated or awaiting their opportunity to receive protection against COVID-19. Topics around vaccine safety and efficacy, ethical and equity considerations, as well as logistics are being discussed more widely and more intensely. In this context, EIW serves to highlight the ongoing need to increase efforts to achieve better vaccination coverage for all vaccine-preventable diseases, in order to prevent disease and protect individuals beyond the COVID-19 pandemic.

###

References

1. World Health Organization (WHO). Vaccines and Immunization. Geneva: WHO; 2021. Available from: https://www.who.int/health-topics/vaccines-and-immunization#tab=tab_1

2. European Vaccination Information Portal (EVIP). Benefits of vaccination for the community. Stockholm: European Commission, European Centre for Disease Prevention and Control, European Medicines Agency; 2021. Available from: https://vaccination-info.eu/en/vaccination/benefits-vaccination-community

3. World Health Organization Regional Office for Europe (WHO/Europe). European Immunization Week. Copenhagen: WHO/Europe; 2021. Available from: https://www.euro.who.int/en/media-centre/events/events/2021/04/european-immunization-week

4. European Vaccination Information Portal (EVIP). Benefits of vaccination for individuals. Stockholm: European Commission, European Centre for Disease Prevention and Control, European Medicines Agency; 2021. Available from: https://vaccination-info.eu/en/vaccination/benefits-vaccination-individuals

5. World Health Organization (WHO). World Immunization Week 2021 - Vaccines bring us closer. Geneva: WHO: 2021. Available from: https://www.who.int/news-room/events/detail/2021/04/24/default-calendar/world-immunization-week-2021

6. World Health Organization (WHO). Immunization Agenda 2030: A Global Strategy to Leave No One Behind. Geneva: WHO; 2020. Available from: https://www.who.int/teams/immunization-vaccines-and-biologicals/strategies/ia2030

7. Williams S, Driscoll A, LeBuhn H, Chen W, Neuzil K, Ortiz J. National Routine Adult Immunization Programs among World Health Organization Member States: an assessment of health systems to deploy future SARS-CoV-2 vaccines. Euro Surveill. 2021; 26(17). https://doi.org/10.2807/1560-7917.ES.2021.26.17.2001195

8. von Linstow M-L, Yde Nielsen A, Kirkby N, Eltvedt A, Nordmann Winther T, Bybeck Nielsen A, Bang D, Poulsen A. Immunity to vaccine-preventable diseases among paediatric healthcare workers in Denmark, 2019. Euro Surveill. 2021; 26(17). https://doi.org/10.2807/1560-7917.ES.2021.26.17.2001167

9. European Centre for Disease Prevention and Control (ECDC). Who is at risk for measles in the EU/EEA? Identifying susceptible groups to close immunity gaps towards measles elimination. Stockholm: ECDC; 2019. Available from: https://www.ecdc.europa.eu/en/publications-data/risk-assessment-measles-eu-eea-2019

10. Rohleder S, Stock C, Bozorgmehr K. Socioeconomic deprivation is inversely associated with measles incidence: a longitudinal small-area analysis in Germany, 2001-2017. Euro Surveill. 2021; 26(17). https://doi.org/10.2807/1560-7917.ES.2021.26.17.1900755

11. Fabiani M, Ramigni M, Gobbetto V, Mateo-Urdiales A, Pezzotti P, Piovesan C. Effectiveness of the Comirnaty (BNT162b2, BioNTech/Pfizer) vaccine in preventing SARS-CoV-2 infection among healthcare workers, Treviso province, Veneto region, Italy, 27 December 2020 to 24 March 2021. Euro Surveill. 2021; 26(17). https://doi.org/10.2807/1560-7917.ES.2021.26.17.2100420

Disclaimer: AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert system.

CANADA

 Mandatory vaccination for health care workers: an analysis of law and policy

Colleen M. Flood, Bryan Thomas and Kumanan Wilson

CMAJ February 08, 2021 193 (6) E217-E220; DOI: https://doi.org/10.1503/cmaj.202755

• Article
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KEY POINTS

• An effective vaccine provided to all health care workers in Canada will protect both the health workforce and patients, reducing the overall burden of coronavirus disease 2019 on services and ensuring adequate personnel to minister to people’s health needs through the pandemic.

• Provincial governments should put in place rules for mandatory vaccination of health care workers that cut across all public and private settings, and should not leave this to the discretion of individual employers.

• If individual employers were to require vaccination among their staff, the legality of these mandates would likely be determined via labour law that considers the “reasonableness” of the employer’s directive, as is evident from case law related to mandatory influenza vaccination.

• Government mandates for the vaccination of health care workers may be challenged under the Canadian Charter of Rights and Freedoms, but these challenges, on the extant evidence, likely will not succeed if provisions are made for those who cannot receive the vaccination because of underlying health issues and for those who object to vaccination on bona fide religious or conscientious objection grounds.

• Challengers may argue that health care workers have the right to wear personal protective equipment (PPE) in lieu of receiving vaccination, which means that governments must support vaccine surveillance and keep abreast of emerging evidence of the effectiveness and safety of the various severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines relative to evidence of the effectiveness of PPE in reducing transmission of SARS-CoV-2.

With the approval of vaccines for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the vaccination of Canada’s health care workers who come in direct contact with patients is a top priority.1 The important question arises of whether governments, public health care organizations and private actors, such as the companies that own and administer long-term care facilities, should consider taking the controversial step of making SARS-CoV-2 vaccination mandatory, whether by direct regulation or under terms of employment. The rationale for taking such a step is that vaccination will protect individual health care workers, and the patients for whom they care, from acquiring SARS-CoV-2. Preventing coronavirus disease 2019 (COVID-19) in those who are vaccinated will also ensure that the health workforce does not become dangerously depleted. However, mandatory vaccination policies may be challenged. Historically, policies on mandatory influenza vaccination have been contested under labour law, and in theory might be challenged under human rights law and the Canadian Charter of Rights and Freedoms.2 We discuss legal precedents emerging from attempts to mandate influenza vaccines for health care workers and whether they translate to the context of the SARS-CoV-2 vaccination, and explain how both governments and individual employers (e.g., public hospitals or private long-term care homes) may legally justify SARS-CoV-2 vaccinations of health care workers.

Does case law on influenza vaccination apply to SARS-CoV-2 vaccination?

Much of the extant law relating to influenza vaccination for health care workers comes from labour arbitrator decisions (not courts) that resolve disputes between different employers (e.g., public hospitals) and health care workers’ unions. Agreements reached in the labour-law context do not limit choices by Canadian governments or employers with respect to SARS-CoV-2 vaccinations. For example, an agreement reached between the British Columbia government and nurses in December 2019, leaving it to individual nurses whether to have the influenza vaccination, does not mean that going forward, the British Columbia government, public hospitals or long-term care homes are similarly limited in requiring SARS-CoV-2 vaccinations. Moreover, law developed in the context of influenza vaccinations will not be applied indiscriminately to the COVID-19 context: law is adaptive to changing scientific evidence. An example of relevant evidence is that, compared with the various influenza strains, SARS-CoV-2 is both more transmissible and has a higher case fatality rate.3,4

The relatively short time frame of SARS-CoV-2 vaccine development (less than a year) is also relevant; for some this may heighten concerns about safety and effectiveness of the vaccines, yet it bears mentioning that different influenza vaccines are administered every year.5 As we write, it is also not clear whether emerging vaccines will prevent transmission of all SARS-CoV-2 strains or whether trial estimates will be borne out in nontrial settings. The evidence on safety, effectiveness, reduction in infectivity and duration of immunity for the different vaccines will evolve as vaccination programs roll out. All these factors will be considered when assessing legal issues. Because the evidence is limited regarding the extent to which SARS-CoV-2 vaccination programs prevent transmission, one question relevant to legal disputes is whether other measures, such as masking, could be sufficiently effective and obviate the need to mandate vaccination.

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