🖕🏻 🤷 🔧 Is vaccination mandatory a new reality? 🚣🏻 👩🏿‍🎤 🈸

In connection with the pandemic of a new coronavirus infection, the question of compulsory vaccination and tightening of control by the government is increasingly being raised. The introduction of vaccination and immunization passports is being discussed [ 1 ]. And it seems that by the time the effective vaccine against COVID-19 appears, many states will have to reconsider their policies on these issues. In this article, I propose to study the data of global studies of vaccination policy in different countries, as well as try to outline the main factors that can affect the effectiveness of various approaches.

Content

The first anti-vaccination movement
Vaccine. Salvation, Duty, Risk
Best policy
Pledge of trust
Discussion
List of sources

The first anti-vaccination movement

To begin with, a small but instructive excursion into history. Mandatory vaccination first appeared in the UK in the second half of the 19th century. Smallpox was raging in Eurasia at that time, transmitted by airborne droplets and by contact, this viral infection claimed up to 400,000 lives each year in the 18th century, deaths from infection ranged from 20% to 60%, and among children it could reach 80% , about a third of the surviving people lost their sight, and their skin remained disfigured by numerous scars for life [ 2 ].

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The first, relatively safe smallpox vaccine was developed by the British physician Edward Jenner in 1796, when he showed that if the patient was vaccinated with material from cows infected with smallpox, then the person subsequently acquired immunity from the deadly virus, and smallpox, people tolerated quite easily (at the moment, only two deaths are known [ 5 ]).
Jenner called the material taken from infected cows - vaccine, from the Latin word vacca - cow, and the vaccination process itself - vaccination [ 6 ].

The new vaccine almost immediately aroused a lot of skepticism, an example of which can be cited posters and those published at that time, on which vaccinators were depicted feeding cows to babies, and people who received the vaccine had grown bull faces.

Monster Vaccination Source

Another poster dating back to 1802

, Wellcome

However, despite skepticism, by the middle of the 18th century, the Jenner vaccine had proved its effectiveness and almost supplanted the practice of variolation, which prompted European governments to finance government programs for free voluntary vaccination.

1808 year. Jenner and two of his colleagues (right) drive out three variolators (left) who leave with curses, source: library in the collection of the Wellcome Foundation

But in 1853, after another epidemic, seeing that many people were in no hurry to get vaccinated, the British authorities passed a law requiring parents to vaccinate newborn children with smallpox with a new vaccine. And then in 1867, control was further tightened by introducing sanctions for avoiding vaccination in the form of serious fines of 20 shillings (about half the average monthly salary of that time) and imprisonment [ 7 ].

This tightening, against the background of not the highest safety and effectiveness of the first vaccine, caused massive discontent and a boycott of the law, and as a result, the first massive anti-vaccination action in history, which took place in Leicester in 1885. The Times news release, in its March 24, 1885 issue, wrote about these events:

“The broad movement against the compulsory application of the mandatory provisions of the Vaccination Act, which originated in Leicester, ended yesterday with a large demonstration, which was very successful. The position that city dwellers have taken on this issue is due to many reasons. Currently, more than 5,000 residents have been summoned for refusing vaccination. ”[ 8 ]

All this ultimately forced the authorities to weaken the law and after 4 years and the adoption of a new law, according to which anyone could refuse vaccination for "reasons of honor" [ 9 ].

Vaccine. Salvation, Duty, Risk

Since the Leicester demonstration, vaccines have become much more effective and safer, and smallpox has become the first disease to be completely defeated with their help (the last recorded case about 45 years ago [ 10 ]).

But although many infectious diseases have been practically eliminated, they still cannot be completely eradicated in all countries. For example, polio, although it was completely eradicated in the United States by 1979, and the number of cases in the world over the past 20 years has decreased by more than a thousand times (350 000 in 1988 to 33 cases in 2018), the virus is still continuing retained in the population, mainly due to regions with low vaccination coverage [ 11 ].

Decrease in child mortality from diseases against which there is a vaccine,source

Why is it so difficult to completely eradicate an infectious disease, even if an effective and safe vaccine exists? This sounds paradoxical, but the effectiveness of the vaccine may cause its not popularity. Epidemiologists have long noticed some patterns in how vaccines are perceived by people as the epidemiological situation changes. The whole process can be divided into several phases [ 12 ].

Phases 1-2. The growing popularity of vaccines. At first, when the incidence is at its peak, the vaccine that appears is seen as a lifeline and the coverage of the vaccinated population is growing rapidly.
3. . . . .
4. . .
5. . , , . . .

The image is adapted, the source

Although we still cannot declare the complete eradication of many infectious diseases, by keeping the vaccination level in the population above a certain critical value, we can keep the disease under control, avoiding epidemics and high mortality. This effect is called collective immunity. Simplified, this works as follows - if each infected person can transmit the infection to three more people, then if two of these three are vaccinated, the number of new cases cannot grow exponentially.

In reality, there are many other parameters, but the main indicators are the coefficient of infectivity R0 and the coefficient of coverage with vaccines. Accordingly, the higher the infection rate, the greater the percentage of coverage needed to restrain exponential growth. For most diseases, the safe level is in the region of 90-95 percent.

Calculation of critical vaccination levels for certain diseases depending on their infectivity, source: [ 13 ]

Best policy

To achieve the required critical level of vaccine coverage, different countries use a wide range of measures, from routine counseling and education, to introducing a list of mandatory vaccines and sanctions for refusing them. I propose to consider what approaches can be effective and under what conditions.

The Sabine Vaccine Institute, (named after Albert Sabin, the inventor of the oral polio vaccine) published in 2018 the results of a study of vaccination policies in 53 countries of the European region [ 14 ]. As a result, all countries were divided into groups according to their location in the spectrum, from a purely recommendatory policy to compulsory vaccination by law using monitoring and sanctions for non-compliance.

European Region Vaccination Policy Map, Source [ 14 ]

In some countries, tight vaccination control policies are bearing fruit. For example, in Italy, after adopting a list of 10 mandatory vaccinations in 2017, over the next two years, vaccination coverage among children increased from 87.3% to 94.1% [ 15 ].

But since 3 of the 8 countries with the lowest DTP vaccine coverage rates (Pertussis Diphtheria Stolbnyak) also have a mandatory vaccination policy, it seems that just introducing laws requiring people to be vaccinated is not enough.

An example of this is Ukraine, in which, despite the control of compulsory vaccination and the presence of sanctions, the lowest vaccination rate in the region is still maintained.

Immunization in Ukraine, according to the WHO

Wellcome Global Monitor 2018 global study conducted by the largest Wellcome Trust charity, reveals the importance of the influence of social factors on the effectiveness of vaccination policies. Fund employees interviewed more than 140,000 people from more than 140 countries to find out how people relate to science and medical achievements [ 16 ].
The data were very ambiguous, so in regions with most developed countries people with a high level of education were more likely to agree that vaccines are safe, but in regions where developing countries predominate, the picture looks exactly the opposite - the higher the level of education, the less confidence to vaccines.

Percentage of people in different regions by level of education who answered “strongly disagree” or “disagree somewhat” to the question: “Do you agree with the following statement: Vaccines are safe.”, Source: [ 16 ]

This can be seen even more clearly if we use the data from the table above and construct plots of confidence in vaccine safety as a function of educational level among a sample of residents of four regions of Western and Eastern Europe, as well as North America and South Africa.

Interestingly, such patterns are observed not only in relation to vaccines, the well-known economist Sergey Guriev and political scientist from Harvard University Daniel Traisman in their joint work “Informational Autocrats” released in 2019 [ 17 ] show similar trends in the distribution of opinions depending on education . Using the data of another global sociological survey Gallup World Poll [ 18] Researchers have built a graph of the difference in support of political leaders between sectors of society with different education, distributing the results of countries according to the degree of democratic political regime (Polity IV index).

Source [ 17 ]

The graph shows that in countries with non-democratic regimes (on the left), leaders enjoy more support among the population without higher education (the difference is negative), and in democracies, on the contrary, there is more support among educated people. The authors of the work explain this pattern by the fact that in countries with less democratic regimes, governments are forced to censor information, which creates a negative image and distrust among the most informed part of the population, which is able to notice such manipulations.

These observations are consistent with the results on vaccine confidence in the regions cited above, since there are many more democracies in North America and Western Europe than in South Africa and Eastern Europe.

Countries of the political regime with a rating of Polity IV. from -10 for full autocracy (red), to 10 for full democracy (green), source

And if you keep in mind what we have already learned about the phases of vaccine perception, as well as the mentioned political and social factors, then many things are on the map of global distribution levels of confidence in vaccine safety find their logical explanation.

Countries by share of people supporting vaccine safety statement, source [ 16 ]

For example, low confidence in vaccines in the territory of the post-Soviet space of Eastern Europe, with a high number of educated people and, as a result, low confidence in their not very democratic governments. And also one of the lowest levels of trust among the prosperous, in terms of health, the population of Japan, which seems to be in the third phase of a decrease in confidence in vaccines, or a record high level of confidence in vaccines among residents of Ethiopia and Bangladesh, where vaccination is only gaining its popularity.

Pledge of trust

A good solution to mitigate the effect of perceiving the risks of vaccination may be the introduction of a state system of compensation for the possible harm caused by vaccines. Indeed, the understanding that the government is ready to vouch for security gives additional confidence when deciding on vaccination. At present, about 25 countries that are part of the World Health Organization (in blue on the map) have compensation systems in case of undesirable effects of vaccination.

Source [ 19 ]

In June 2019, an article with statistics was published in Vaccine magazine, which showed that among countries with compensation programs, achievement of vaccination rates of 90% of the population is 4.5 times more likely than in countries without such programs (red line in table below). From which it can be concluded that such programs as a whole can also be a factor affecting the acceptance by people of a positive decision on vaccination [ 19 ].

Source [ 19 ]

A good example of a government vaccine reparation system exists in the United States. People’s massive lawsuits against vaccine companies in the 1970s and 1980s and, as a result, their withdrawal from the market, pushed the US Department of Health and Human Services (DHHS) to create the National Vaccine Harm Compensation Program (NVICP) in 1988. ) This program is funded by a tax that is charged on the sale of vaccines [ 20 ].

Thus, according to the reports of the National Program for the Compensation of Harm from Vaccines of the United States, over the period from 1989 to 2020, more than $ 4 billion was paid in compensation. But such a large amount is explained not by the mass number of cases of health damage, since about 7,252 appeals were rejected (5,527 rejected), but by the solid size of the average payment, which in 2020 amounted to, for example, 348 thousand dollars [ 21 ].

Fragment of the NVICP Compensation Report, Source [ 21 ]

At the same time, the indecisive policy of countries in relation to compensation may become an additional factor that reduces the trust of citizens in vaccines, as an example, the compensation system in Russia. In case of complications caused by the vaccine, a lump sum payment is 10,000 rubles ($ 143), and in case of death - 30,000 rubles ($ 428) [ 22 ].

Discussion

The effectiveness of vaccination policies depends on the interaction of many social and economic factors and is associated with a number of complex moral and legal dilemmas. The lack of vaccination in each individual person is increasingly becoming perceived as a threat to public health, which leads to discussion about the need for control by the government.

On the other hand, the introduction of a legislative requirement to be vaccinated is a restriction of rights, requiring that from their citizens, governments should also convey as clearly as possible the benefits that each person receives in return.
I would like to hope that most countries will take advantage of the accumulated experience and in resolving this issue they will go not along the path of tight regulation and enforcement, but along the path of building trust in public institutions, raising awareness and creating a system of social guarantees.

List of sources:

1. jamanetwork.com/journals/jama/fullarticle/2765835
2. pubmed.ncbi.nlm.nih.gov/9341063
3. www.nlm.nih.gov/exhibition/smallpox/sp_variolation.html
4. www.ncbi.nlm.nih.gov/pmc/articles/PMC1200696
5. emedicine.medscape.com/article/1131886-overview#a2
6. www.ncbi.nlm.nih.gov/books/NBK7294
7. en.wikipedia.org/wiki/Vaccination_Act
8. www.le.ac.uk/lahs/downloads/1967-68/1967-68%20(43)%2035-44%20Ross.pdf
9. www.ncbi.nlm.nih.gov/pmc/articles/PMC1628897/pdf/archdisch00727-0091.pdf
10. www.cdc.gov/smallpox/history/history.html
11. www.who.int/news-room/fact-sheets/detail/poliomyelitis
12. www.sciencedirect.com/science/article/pii/0264410X94903158
13. www.tandfonline.com/doi/full/10.4161/hv.18444
14. www.sabin.org/sites/sabin.org/files/zakonodatelnye_podhody_k_immunizacii_v_evropeyskom_regione.pdf
15. www.ncbi.nlm.nih.gov/pmc/articles/PMC6607737
16. wellcome.ac.uk/reports/wellcome-global-monitor/2018
17. www.jstor.org/stable/26796838?seq=1
18. www.gallup.com/analytics/232838/world-poll.aspx
19. pubmed.ncbi.nlm.nih.gov/31213377
20. www.historyofvaccines.org/index.php/content/articles/vaccine-injury-compensation-programs
21. www.hrsa.gov/sites/default/files/hrsa/vaccine-compensation/data/data-statistics-report.pdf
22. www.rosminzdrav.ru/documents/8007-federalnyy-zakon-157-fz-ot-17-sentyabrya-1998-g