Global Ethical Considerations Regarding Mandatory Vaccination in Children

Abstract

Whether children should be vaccinated against coronavirus disease-2019 (COVID-19) (or other infectious diseases such as influenza) and whether some degree of coercion should be exercised by the state to ensure high uptake depends, among other things, on the safety and efficacy of the vaccine. For COVID-19, these factors are currently unknown for children, with unanswered questions also on children's role in the transmission of the virus, the extent to which the vaccine will decrease transmission, and the expected benefit (if any) to the child. Ultimately, deciding whether to recommend that children receive a novel vaccine for a disease that is not a major threat to them, or to mandate the vaccine, requires precise information on the risks, including disease severity and vaccine safety and effectiveness, a comparative evaluation of the alternatives, and the levels of coercion associated with each. However, the decision also requires balancing self-interest with duty to others, and liberty with usefulness. Separate to ensuring vaccine supply and access, we outline 3 requirements for mandatory vaccination from an ethical perspective: (1) whether the disease is a grave threat to the health of children and to public health, (2) positive comparative expected usefulness of mandatory vaccination, and (3) proportionate coercion. We also suggest that the case for mandatory vaccine in children may be strong in the case of influenza vaccination during the COVID-19 pandemic. Whether children should be vaccinated against coronavirus disease-2019 (COVID-19) (or other infectious diseases such as influenza) and whether some degree of coercion should be exercised by the state to ensure high uptake depends, among other things, on the safety and efficacy of the vaccine. For COVID-19, these factors are currently unknown for children, with unanswered questions also on children's role in the transmission of the virus, the extent to which the vaccine will decrease transmission, and the expected benefit (if any) to the child. Ultimately, deciding whether to recommend that children receive a novel vaccine for a disease that is not a major threat to them, or to mandate the vaccine, requires precise information on the risks, including disease severity and vaccine safety and effectiveness, a comparative evaluation of the alternatives, and the levels of coercion associated with each. However, the decision also requires balancing self-interest with duty to others, and liberty with usefulness. Separate to ensuring vaccine supply and access, we outline 3 requirements for mandatory vaccination from an ethical perspective: (1) whether the disease is a grave threat to the health of children and to public health, (2) positive comparative expected usefulness of mandatory vaccination, and (3) proportionate coercion. We also suggest that the case for mandatory vaccine in children may be strong in the case of influenza vaccination during the COVID-19 pandemic. We are in the midst of a global pandemic. Many countries are pinning their hopes on a coronavirus disease-2019 (COVID-19) vaccine as the solution. There are 247 vaccine candidates being tested at the moment, 10 of which are in phases II or III.1London School of Hygiene & Tropical MedicineVaccine tracker.https://vac-lshtm.shinyapps.io/ncov_vaccine_landscape/Google Scholar When a safe and effective vaccine becomes available, the focus will be on who should receive it and how it will be rolled out both nationally and internationally.2Department of Health and Social CareDistributing vaccines and treatments for COVID-19 and flu.https://www.gov.uk/government/consultations/distributing-vaccines-and-treatments-for-covid-19-and-fluGoogle Scholar, 3Giubilini A. Savulescu J. Wilkinson W. COVID-19 vaccine: vaccinate the young to protect the old?.J Law Biosci. 2020; 7: lsaa050Crossref PubMed Scopus (66) Google Scholar, 4World Health OrganizationAccess to COVID-19 Tools (ACT) accelerator.www.who.int/publications/m/item/access-to-covid-19-tools-(act)-acceleratorGoogle Scholar, 5Emanuel E.J. Persad G. Kern A. Buchanan A. Fabre C. Halliday D. et al.An ethical framework of global vaccine allocation.Science. 2020; 369: 1309-1312Crossref PubMed Scopus (0) Google Scholar One issue that will be hotly debated is whether the vaccine should be mandatory and whether it should be mandated for children. Some ethicists have already made a general case for mandatory COVID-19 vaccination, without arguing specifically for child vaccination, given certain assumptions about availability and risk profile of the vaccine, and suggested that there would be very few legal barriers to it in the US.6Reiss D. Caplan A.L. Considerations in mandating a new Covid-19 vaccine in the USA for children and adults.J Law Biosci. 2020; 7: lsaa025Crossref PubMed Scopus (19) Google Scholar Mandatory vaccination for children might be required if vaccine uptake will not be high enough or if governments have reasonable grounds to believe so. Because the timely implementation of effective vaccination policies save lives, there might be a case for considering mandatory vaccination, including for children, before less coercive policies. We provide an ethical assessment of possible mandatory COVID-19 vaccination policies targeting children, focusing on COVID-19 and influenza vaccines. We use a comparison with influenza vaccination policies to emphasize the risks and benefits of the 2 vaccines, both for children and for the public, and to assess the ethics of mandatory child vaccination. The public health importance of both the influenza vaccine and future COVID-19 vaccines cannot be underestimated, considering the number of deaths both vaccines will be able to prevent. With many countries having to face the influenza season in the midst of the COVID-19 pandemic and without a COVID-19 vaccine, adequate influenza vaccine uptake is going to be particularly important for public health this year. We first define what is meant by “mandatory” vaccination. We then provide an ethical assessment of mandatory vaccination policies, on the basis of considerations about risks of a vaccine for the targeted group, in this case, the COVID-19 vaccine for children. We identify 3 ethically relevant criteria: (1) whether the diseases are a grave threat to public health, (2) the positive comparative expected usefulness of mandatory vaccination, and (3) proportionate coercion. We examine how these concepts apply to influenza vaccination and to future COVID-19 vaccination policies. With the escalation in antivaccination activity, misinformation and conspiracy theories, COVID-19 vaccines may not achieve high enough uptake, with between 60% and 80% coverage needed to reach the herd immunity threshold. To date, low adult intention to refuse COVID-19 vaccines has been reported in Australia (7.6%), compared with data from the US (20%-27%)7Asscoiated Press National Opinion Research CenterExpectations for a COVID-19 vaccine. The Associated Press-NORC Center for Public Affairs research poll.https://apnorc.org/projects/expectations-for-a-covid-19-vaccine/Google Scholar and France (27%).8COCONEL GroupA future vaccination campaign against COVID-19 at risk of vaccine hesitancy and politicisation.Lancet Infect Dis. 2020; 20: 769-770Abstract Full Text Full Text PDF PubMed Scopus (391) Google Scholar These estimates will fluctuate over time with the phases of the pandemic, with 49% of adults in the US stating that they would refuse a COVID-19 vaccine in September 2020.9PEW Research CenterU.S. public now divided on whether to get COVID-19 vaccine.www.pewresearch.org/science/2020/09/17/u-s-public-now-divided-over-whether-to-get-covid-19-vaccine/Google Scholar Those refusing vaccination for themselves are of course very likely to refuse it for their children as well. Mandatory vaccination is already being discussed in Australia to facilitate high COVID-19 vaccine uptake amongst the key target groups, that is, frontline healthcare workers and people with medical risk factors. Children will not be initial targets of a COVID-19 vaccination program, but will be offered the vaccine according to the prioritization schedule over time. However, ensuring public confidence in vaccine safety and effectiveness will be crucial to facilitate uptake and introducing mandatory vaccination too early may threaten this. But what does “mandatory” mean and what needs to be considered before it is introduced? Mandatory vaccination means that some form of coercion is used to get people to vaccinate themselves and/or their children. Vaccine mandates are fundamentally about restricting individual or parental liberty for the public good or for a child's own good. Coercion means that threats of penalties are used to restrict a person's options, by making certain options (eg, vaccine refusal for oneself or for one's child) significantly more costly. Note that religious or ideological exemptions from vaccination requirements do not necessarily mean a policy is not mandatory. If, as is often the case for example with military conscription, the “conscientious objector” is required to provide some alternative and sufficiently burdensome contribution to the collective good, then the policy would still count as mandatory.10Giubilini A. An argument for compulsory vaccination: the taxation analogy.J Appl Phil. 2020; 37: 446-466Crossref Scopus (42) Google Scholar What conscientious objectors often want, though, is to costlessly refuse vaccination for themselves or their children in the name of freedom of choice or of conscience. Vaccination mandates with opt-out procedures might be seen as a form of mere nudging policy (which is not coercive) or as a form of coercion, depending on the cost of the exemption procedure. Mandatory vaccination for children is already employed in some parts of the world, In the US, for instance, children cannot be enrolled in state schools if their vaccination schedule is not up to date, unless they have a valid medical exemption. Many states allow nonmedical exemptions for personal moral or religious reasons, but some states have started to remove nonmedical exemptions (eg, California with the SB277 bill) or to make them particularly burdensome to obtain (eg, Michigan), for example by requesting objecting parents to attend immunization education courses.11Navin M.C. Largent M.A. Improving nonmedical vaccine exemption policies: three case studies.Public Health Ethics. 2017; 10: 225-234Google Scholar In Australia, financial assistance payments, including the childcare benefit, a childcare rebate, and family tax benefit Part A end-of-year supplement, are withheld when families do not fully vaccinate their children according to the National Immunization Program schedule (“No Jab, No Pay”) or access to early childhood education including Kindergarten is withheld (“No Jab, No Play”). Italy introduced a form of mandatory vaccination in 2017 that includes fines up to 500 euros for the parents of unvaccinated children who attend school.12D’Ancona F. Damario C. Maraglino F. Rezza G. Ricciardi W. Iannazzo S. Introduction of new and reinforcement of existing compulsory vaccinations in Italy: first evaluation of the impact on vaccination coverage in 2017.Euro Surveill. 2018; 23: 1800238Google Scholar Coercion or the severity of the penalty can take a number of different forms from relatively mild (making a parent go through an education program) to moderate (fines, withholding financial or childcare, Kindergarten, or school exclusion), or severe (large fines or imprisonment). We call all these measures mandatory, although terms like mandatory and compulsory are used inconsistently or interchangeably in the vaccination debate; some reserve the term mandatory for policies that threaten to withdraw or and compulsory for policies that vaccine refusal as a with legal M.C. 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