Policy considerations for mandatory COVID‐19 vaccination from the Collaboration on Social Science and Immunisation

The benefits gained by vaccination mandates must be greater than the harms they may cause

Public attention has been intensely focused on how Australia can achieve the very high vaccination coverage needed for optimal control of the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Governments and businesses have already mandated coronavirus disease 2019 (COVID‐19) vaccination for workers in certain sectors, and vaccination is currently required for entry into many public venues in New South Wales and Victoria. International air travel without requiring an exemption is now possible for the fully vaccinated, as is the case in other countries. Outbreaks of COVID‐19, with their restrictive public health measures, have meant there is widespread support to mandate COVID‐19 vaccination in settings where people gather.

Mandatory vaccination policies impose individual consequences for non‐vaccination. They vary in the population subject to the requirement, the scale and type of consequences for non‐compliance, and accepted exemptions.1 Consequences for non‐compliance include change or loss of employment; a requirement to use masks; reduced access to money, goods or services; and inability to travel to another country. In some countries, more severe consequences may include fines or convictions and potential imprisonment.

Vaccine mandates are legitimised through reducing the risk of one person passing an infection to others. Requirements in occupational settings are often used to reduce risk of health workers infecting others, including those who are at higher risk of the disease and its severe effects. In general community settings, mandates may be used as a strategy to increase vaccination coverage more broadly. Because they are more coercive than other interventions to increase vaccination coverage, mandates demand stronger ethical justification. Policy makers should balance rights of individuals and the promotion of public good while carefully considering the epidemiological, programmatic and legal issues.

This article outlines the range of issues that need to be considered before, and when, making vaccination mandatory in any setting. It is intended for government policy makers, managers and executives. State and private sector mandates may differ in design, reach, purpose and implications. However, we provide guidance that is relevant for both, including outlining areas that are governments’ responsibility. We base our considerations on epidemiology, behavioural science and ethics, as well as policy and program issues learnt from other mandatory vaccination regimes.

The authors are members of the Collaboration on Social Science and Immunisation, Australia’s leading network informing immunisation policy and practice with high quality evidence from the social sciences. We initially contributed to a working paper in February 2021, which was updated in May. We then met to consolidate the normative position and structure for this article, and collaboratively refined the arguments through three meetings. A webinar was also held on 26 July 2021.2

Prerequisites for mandatory COVID‐19 vaccination

Mandates should only be implemented once a set of conditions relevant to the setting is satisfied. Below we set out these considerations.

The mandate should be legal

In most settings, mandatory vaccination must have legislative support.3 For occupational settings, the Fair Work Ombudsman provides general guidance (https://coronavirus.fairwork.gov.au/coronavirus‐and‐australian‐workplace‐laws/covid‐19‐vaccinations‐and‐the‐workplace). Broadly, employers can only require their employees to be vaccinated when a specific law requires it, when it is permitted by an enterprise agreement or other registered agreement or employment contract, or when it is lawful and reasonable to do so. The Fair Work Ombudsman divides work into four tiers of risk to facilitate case‐by‐case assessment: Tier 1, where employees are at higher risk of being exposed to COVID‐19; Tier 2, where employees work with people who are at higher risk of serious health impacts from COVID‐19; Tier 3, where interaction with others is likely; and Tier 4, where there is limited face‐to‐face interaction.

Burden of disease should be high enough to justify a mandate

The heavier the disease burden, the more justifiable mandates may be to increase coverage. In a setting that poses a higher risk of transmission, particularly to people more likely to experience serious harm, imposition on liberties may be more justifiable, at least while the background disease rates are high and transmission is more likely.

The mandated vaccines should be safe

Vaccines are an invasive intervention with risks of rare but serious side effects. Each required vaccine should have an acceptable safety profile, and where possible, the safest vaccine option should be available. Governments need to operate a no‐fault vaccine injury compensation scheme to compensate those required to vaccinate who experience a rare serious adverse event.4

The vaccines should reduce transmission

Ethically, it is difficult to justify requiring someone to do something for their own good alone. A mandate is, however, more justifiable when vaccinating one person helps protect others around them. COVID‐19 vaccines will prevent some degree of transmission because the vaccinated are less likely to acquire infection to begin with. In transmission studies, early evidence estimated a 40–50% reduction in risk of household transmission of the Alpha variant after at least one vaccine dose in an index case.5 Early evidence suggests that the current vaccines are less effective in reducing transmission from the Delta variant among those with breakthrough infection, and that this protection also wanes over time.6

Vaccine supply should be sufficient and easily accessible

Before a vaccine mandate, governments must ensure a stable vaccine supply, effective distribution, equity of access, and convenient services. Australia’s vaccine supply was limited for many months, and access remains a challenge for some, particularly those living in regional areas. People with disabilities have reported ongoing vaccine access challenges.7 Early inequities in access have affected certain groups disproportionately, such as Aboriginal and Torres Strait Islander communities and culturally and linguistically diverse groups. A penalty for not vaccinating when the government has not met its service delivery obligations is unjust and may be ineffective without addressing the access barriers limiting uptake.

Less restrictive, trust‐promoting measures should come first

Before a mandate is introduced, there should be sufficient time for voluntary acceptance. Non‐coercive measures targeting known causes of low vaccination should be exhausted (eg, on‐site vaccination, reminders and incentives),8 in concert with efforts made to understand and address other context specific barriers using available tools.

Establishing community trust and confidence is essential. People need opportunities to have their questions and concerns addressed.9 Since mandates can undermine trust in voluntary vaccination programs, those imposing them should invest in tailored communications well in advance.10

Procedural recommendations if a mandate is planned

The type of mandate chosen should not penalise the poor

Mandates should not compound disadvantage. Those involving loss of money, goods or services can disproportionately affect lower income earners. Crude financial penalties such as No Jab, No Pay impose a greater leverage on the poor and there is insufficient evidence that monetary sanctions improve uptake.11,12

Those mandating need to plan and support implementation

Reliable systems for documenting and retrieving evidence of vaccination are essential. Legislation now requires immunisation providers to record an individual’s vaccination status for “certain relevant vaccinations” on the Australian Immunisation Register. Governments must make it easy to correct recording errors, and retrieval systems should take into account privacy considerations.

Implementing mandates is logistically complex and time consuming for governments. In health care settings, managers have reported difficulties with identifying which staff are covered by the mandate and confusion as to why others are not included.13 Mandating mask use for unvaccinated people also creates challenges, as staff are then required to police subordinates or colleagues.

Those who implement and enforce requirements in any setting must be supported. For example, there can be conflict when a health professional determines a person is ineligible for a medical exemption, occasionally leading to verbal or physical threats. There need to be clear consequences for such actions.

Affected populations should be considered in planning

If mandates are considered necessary, those imposing them should develop and implement them transparently and in consultation with targeted groups. This will help ensure the most acceptable programs and communication strategies, maintain trust in agencies and vaccination programs, and guard against some groups being left worse off than others.

Mandatory vaccination should not result in the continuation of trauma or disadvantage for Aboriginal and Torres Strait Islander peoples arising from past state and territory health policies. Specific exemptions may be appropriate if governments develop them in consultation with communities.

Individuals who remain unvaccinated should be considered in planning. All mandates must include exemptions for those with a valid medical reason. Governments should design medical exemptions to enable suitably qualified practitioners to make clinical decisions, based on individual patient risk and inherent uncertainties with the new COVID‐19 vaccines. Clear clinical advice is needed for people who have previously had an adverse event following immunisation.

A proportion of the population will persistently reject vaccination on the basis of personal belief, even in the face of negative social or economic impacts.14 In October 2021, 7% of respondents to a national survey were not willing to be vaccinated against COVID‐19, even in the face of restrictions for the unvaccinated in some states.15 These populations should be accounted for in planning. In occupational settings with a mandate, the potential loss of workers should also be considered.

One option to offset such issues is to consider step‐down requirements such as mandatory documentation of a recent negative test result as an alternative for the unvaccinated. This maintains an avenue for trenchant refusers and the medically exempt to access privileges afforded to the vaccinated while still protecting the community. However, in situations of heightened occupational risk, such as health and aged care settings, it may not be appropriate to extend exemptions beyond medical ones, as organisations have responsibilities to ensure the safety of their staff and patients.

In some contexts, a personal belief exemption may be reasonable, and childhood vaccination mandates with personal belief exemptions can be as effective as requirements without them.16 Exemptions that are procedurally complex to acquire reduce the rate at which people seek them, compared with easily acquired exemptions.17 Provision of these exemptions can also maintain trust and engagement with medical services, public health officials and governments, reducing alienation and disenfranchisement. Regardless of the type of exemption, all should be organised and administered at a state or Commonwealth level (or both) and made accessible to private or public organisations considering or intending to introduce mandates.

Vaccine mandates, particularly without exemptions, can bring backfire effects among those more resistant to vaccination.18 Mandates have also intensified anti‐vaccination activism, as was seen in the 19th century with the smallpox vaccine. Political polarisation about mandates may increase organised political opposition, especially among minor party voters.19

In Box 1 and Box 2, we outline two worked examples of how the above considerations apply to specific situations where mandates have already been proposed or enacted.

Conclusion

Mandatory vaccination requires strong justification. If there are ways of achieving the same outcomes using measures that are less restrictive, they should be attempted. The benefits gained by mandates must be greater than the harms they may cause. These harms and benefits may be difficult to meaningfully compare.

A justifiable mandate must take into account the context and the goal of vaccination. Requiring vaccination for one group, or within one organisation, does not automatically make mandates acceptable for another.

A goal of vaccine mandates is to achieve a certain level of uptake in a population (eg, > 80%). However, all other avenues to increase uptake must first be exhausted and then certain ethical criteria satisfied. A general population mandate could cause resentment and mistrust in government and public health agencies, and undermine trust in vaccination more broadly and in other public health programs. Mandates cannot be ethically justifiable if they further entrench existing disadvantage, or if penalties will be experienced very differently by different populations (including between the rich and the poor). Different background risk levels — levels of COVID‐19 transmission, willingness to receive the vaccine — will mean the calculus around justifications for vaccine mandates could change quickly.

We have presented two worked examples using prerequisite criteria and procedural recommendations (Box 1 and Box 2). However, an overall guidance on thresholds for justifying mandates is beyond the scope of this article. Thresholds are value judgments that require stakeholders to consider what matters. Questions include: how high is “high enough” for the burden of disease? What levels of effectiveness are sufficient to justify the negative consequences of a mandate? How should we prepare for the inevitable backlash that will come from a policy of mandatory vaccination in any setting? The answers to these questions will differ over time and place and with the goal of the mandate. Addressing these considerations in ways that are procedurally just can ensure that outcomes are fairer and more trusted.20 Mandate decisions that are careful and responsive to context are more likely to avoid social harms while, ideally, helping to achieve a public good.

This article was published as a peer-reviewed Accepted Article (prior to structural editing and typesetting) on 12 September 2021.