On July 12, France made it mandatory for healthcare workers to get vaccinated. Beginning September 15, all unvaccinated healthcare workers in France will not receive salary or be allowed to work.
Likewise, Greece and Italy too have made vaccination mandatory for healthcare workers from fall this year. In the U.K., care home workers would be required by law to have the COVID-19 vaccination.
Virologist Dr. Shahid Jameel, Director of the Trivedi School of Biosciences at Ashoka University, cites mandatory smallpox vaccination in several European countries. In 1853, smallpox vaccination became compulsory in England; Italy and Sweden made smallpox vaccination mandatory before England could. Germany made it mandatory in 1874. “Regions with mandatory vaccination proved to have substantially fewer deaths from smallpox than those that relied on voluntary vaccination,” Dr. Jameel says in an email.
Similarly, polio vaccination was made mandatory in several European countries. At this time childhood vaccination is mandatory in several EU countries and recommended in others, Dr. Jameel adds.
Wide exemptions
“Compulsory vaccination has never meant people should be vaccinated against their will. These provisions have always been implemented with fairly wide exemptions on religious, social and philosophical grounds,” says Dr. Chandrakant Lahariya, physician-epidemiologist in an email.
In France, it is not the healthcare workers alone who have been targeted. As per the announcement, all unvaccinated people will be denied entry into certain public places like theatres, sports venues and festivals involving more than 50 people in France from July 21, and cafes, bars, restaurants, shopping malls, and long-distance trains from August 1. Entry will be permitted only when unvaccinated people show a negative test result.
Age-old measure
Enforcing reasonable restriction in access to public places to prevent virus transmission appears fair and is an age-old public health measure. Individuals still retain the choice — whether to get vaccinated or not. “Such policies serve more of a nudge to get vaccinated. There is a qualitative difference between being denying entry to a venue and denying salary or refusal to allow to work, as this would impact their economic and social well-being and can have implications beyond the individual,” says Dr. Anant Bhan, global health and bioethics researcher.
“Denying salary unless vaccinated would be coercive as it puts an individual at disadvantage,” says Dr. Lahariya.
Dr. Giridhara Babu, Epidemiologist at the Public Health Foundation of India, Bengaluru is of the opinion that getting vaccinated is an individual's choice, and none can be forced out of their will to get the shot. “It is important to educate and have strong social mobilisation strategies to empower people to be aware and get vaccinated. In the case of healthcare workers, vaccination can be made an essential criteria for employment, which can be part of medical fitness after a pre-employment health assessment.”
Ways of protecting
In healthcare settings, there are other ways to ensure that an unvaccinated healthcare worker and the patients are protected — using a PPE kit, mask, face shield, other protective gears and redeployment of unvaccinated staff for services which do not require direct patient engagements, Dr. Babu says.
Dr. Jameel strongly disagrees. He says: “Healthcare professionals provide an essential service and work in a high-risk environment. They are at high risk to get infected and to pass infection to others. Therefore, when licensed vaccines are available, they must take them. No one in a hospital who is exposed to blood and other body fluids is allowed to work without hepatitis B vaccination. COVID-19 vaccination should be no different.”
Effect of nudges
Incidentally, two days after France announced its vaccine policy, 2.2 million people signed up to get vaccinated. It could suggest that nudges can play a role in health promotion, but it could also indicate fear or apprehensions about denial of access to key services or social opportunities which people value, says Dr. Bhan. According to Dr. Lahariya, a majority of those who signed up were in the 18-35 years of age group, who in all likelihood were willing but delaying their vaccination. The compulsion seems to have nudge people to prioritise their own vaccination. At the end of it, it is people who are making a choice about vaccination.
Though only less than 7% have been fully vaccinated in India, according to India's Health Ministry, nearly 80% of healthcare workers and 90% of frontline workers were already fully vaccinated by early July. Any attempt to make vaccination mandatory for healthcare workers in India will surely exacerbate the inequities of differential access to vaccines, says Dr. Babu. There is also the possibility that any coercion might lead to more fake vaccination certificate scams.
Inform and empower
“I am not for making it mandatory for any section or class. This will not only undermine the public support but will also be counterproductive and create newer problems where none exist. As per evidence, coercive measures are always counterproductive; they will only create further panic and fail to increase vaccine uptake,” says Dr. Babu. “The purpose of risk communication is to inform and empower people and respect individual choice. Mandating anything will fundamentally alter this dynamic by overriding personal autonomy.”
Dr. Lahariya says that prior to making any intervention compulsory, a few principles have to be adhered to. “The benefit of such an intervention should be scientifically supported. Vaccines should be easily available and accessible to every eligible citizen, and there should be reasonable exemptions. India does not fulfil one or more of these principles,” he says.
With demand outstripping supply, vaccine shortages have been reported by several States. Also, if the core argument of compulsory vaccination is to protect others and stop virus transmission, then the role of currently used COVID-19 vaccines in India is not backed by scientific evidence. Clinical trials have documented vaccine efficacy against moderate to severe disease, hospitalisation and deaths; there is limited data on their role in preventing virus transmission.
Breaking the chain
“It is clear that while those vaccinated can still get infected, they produce much less virus, thus reducing the chances of transmission. Further, they are protected from severe disease and in a pandemic situation you want your healthcare and frontline workers to be protected and available as much as possible,” says Dr. Jameel.
Dr. Bhan agrees that vaccination contributes to breaking of the transmission chain and case reduction even if it does not completely stop the possibility. This makes a strong case for promoting vaccination particularly among healthcare workers. “But this does not necessarily mean we should be exploring the mandatory vaccination route to push this,” Dr. Bhan adds.
Is there a possibility that any hesitancy among healthcare workers, who are among the most informed about vaccines and their benefits, might be to the vaccines currently available in India than against COVID-19 vaccines per se? “India has administered over 400 million doses of vaccines and the safety record is very good. Isn’t that proof enough for people in the healthcare business, who should understand this better than others?” asks Dr. Jameel.
