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A vaccination policy is a health policy adopted in order to prevent the spread of infectious disease. These policies are generally put into place by State or local governments, but may also be set by private facilities, such as workplaces or schools.[1][2] Many policies have been developed and implemented since vaccines were first made widely available.
The main purpose of implementing a vaccination policy is complete eradication of a disease, as was done with smallpox. This, however, can be a difficult feat to accomplish or even confirm. Many governmental public health agencies (such as the CDC or ECDC) rely on vaccination policies to create a herd immunity within their populations. Immunization advisory committees are usually responsible for providing those in leadership positions with information used to make evidence-based decisions regarding vaccines and other health policies.
Vaccination policies vary from country to country, with some mandating them and others strongly recommending them. Some places only require them for people utilizing government services, like welfare or public schools. A government or facility may pay for all or part of the costs of vaccinations, such as in a national vaccination schedule,[3] or job requirement.[4] Cost-benefit analyses of vaccinations have shown that there is an economic incentive to implement policies, as vaccinations save the State time and money by reducing the burden preventable diseases and epidemics have on healthcare facilities and funds.[5][6][7]
Goals
Individual and herd immunity
Vaccination policies aim to produce immunity to preventable diseases. Besides individual protection from getting ill, some vaccination policies also aim to provide the community as a whole with herd immunity. Herd immunity refers to the idea that the pathogen will have trouble spreading when a significant part of the population has immunity against it, reducing the effect an infectious disease has on society. This protects those unable to get the vaccine due to medical conditions, such as immune disorders.[8] However, for herd immunity to be effective in a population, a majority of those who are vaccine-eligible must be vaccinated.[9]
Vaccine-preventable diseases remain a common cause of childhood mortality with an estimated three million deaths each year.[10] Each year, vaccination prevents between two and three million deaths worldwide, across all age groups, from diphtheria, tetanus, pertussis and measles.[11]
Eradication of diseases
With some vaccines, a goal of vaccination policies is to eradicate the disease – disappear it from Earth altogether. The World Health Organization (WHO) coordinated the effort to eradicate smallpox globally through vaccination, the last naturally occurring case of smallpox was in Somalia in 1977.[12] Endemic measles, mumps and rubella have been eliminated through vaccination in Finland.[13] On 14 October 2010, the UN Food and Agriculture Organization declared that rinderpest had been eradicated.[14] The WHO is currently working to eradicate polio,[15] which was eliminated in Africa in August 2020 and remained only in Pakistan and Afghanistan at the time.[16]
Individual versus group goals
The likely behavior of individuals when offered vaccines can be modeled economically using ideas from game theory.[17] According to such models, individuals will attempt to minimize the risk of illness, and may seek vaccination for themselves or their children if they perceive a high threat of disease and a low risk to vaccination.[18] However, if a vaccination program successfully reduces the disease threat, it may reduce the perceived risk of disease enough so that an individual's optimal strategy is to encourage everyone but their family to be vaccinated, or (more generally) to refuse vaccination once vaccination rates reach a certain level, even if this level is below that optimal for the community.[19][20] For example, a 2003 study predicted that a bioterrorist attack using smallpox would result in conditions where voluntary vaccination would be unlikely to reach the optimum level for the U.S. as a whole,[21] and a 2007 study predicted that severe influenza epidemics cannot be prevented by voluntary vaccination without offering certain incentives.[22]
Governments often allow exemptions to mandatory vaccinations for religious or philosophical reasons, but decreased rates of vaccination may cause loss of herd immunity, substantially increasing risks even to vaccinated individuals.[23] However, mandatory vaccination policies raise ethical issues regarding parental rights and informed consent.[24]
Fractional dose vaccination is a strategy that trades societal benefit for individual vaccine efficacy,[25] has proven to be effective in randomized trials in poverty diseases,[26][27] and in epidemiologic models[28] holds a significant potential for shortening the COVID-19 pandemic when vaccine supply is limited.[25]
Compulsory vaccination
At various times, governments and other institutions have established policies requiring vaccination with the aim of reducing the risk of disease. An 1853 law required universal vaccination against smallpox in England and Wales, with fines levied against people who did not comply.[29] These policies stirred resistance from a variety of groups, collectively called anti-vaccinationists, who objected on ethical, political, medical safety, religious, and other grounds.[30] In the United States, the Supreme Court ruled in Jacobson v. Massachusetts (1905) that states have the authority to require vaccination against smallpox during a smallpox epidemic.[31] All fifty U.S. states require that children be vaccinated to attend public school,[32] although 47 states provide exemptions based on religious or philosophical beliefs.[33]
Forced vaccination (as opposed to fines or refusal of services) is rare, and typically happens only as an emergency measure during an outbreak. This has been reported in parts of China.[34] Compulsory vaccinations greatly reduce infection rates for the diseases they protect against.[29]
Common objections included the argument that governments should not infringe on individuals' freedom to make medical decisions for themselves or their children, or claims that proposed vaccinations were dangerous.[30] Many modern vaccination policies allow exemptions for people with compromised immune systems, allergies to vaccination components, or strongly held objections.[35]
In 1904, in the city of Rio de Janeiro, Brazil, following an urban renewal program that displaced many poor, a government program of mandatory smallpox vaccination triggered the Vaccine Revolt, several days of rioting with considerable property damage and a number of deaths.[36]
Compulsory vaccination is a difficult policy issue, requiring authorities to balance public health with individual liberty:
Vaccination is unique among de facto mandatory requirements in the modern era, requiring individuals to accept the injection of medicine or medicinal agent into their bodies, and it has provoked a spirited opposition. This opposition began with the first vaccinations, has not ceased, and probably never will. From this realisation arises a difficult issue: how should the mainstream medical authorities approach the anti-vaccination movement? A passive reaction could be construed as endangering the health of society, whereas a heavy-handed approach can threaten the values of individual liberty and freedom of expression that we cherish.[30]
An ethical dilemma may emerge when health care providers attempt to persuade vaccine-hesitant families towards receiving vaccinations as this persuasion may lead to violating their autonomy.[9] Investigation of different types of vaccination policy finds strong evidence that standing orders and allowing healthcare workers without prescription authority (such as nurses) to administer vaccines in defined circumstances increase vaccination rates, and sufficient evidence that requiring vaccinations before attending child care and schools also does so.[37] There is also evidence that mandatory vaccination policies for healthcare workers, for instance for influenza shots, increase uptake.[38] One argument among public health professionals is that compulsory vaccination is necessary in severe circumstances, but that it should be approached carefully in order to avoid polarizing the population and decreasing trust in the long term.[39]
Many countries (Canada, Germany, Japan, and the United States) have specific requirements for reporting vaccine-related adverse effects; others (Australia, France, and the United Kingdom) include vaccines under their general requirements for reporting injuries associated with medical treatments.[40] A number of countries have both compulsory vaccination and national programs for the compensation of injuries alleged to have been caused by a vaccination.[41]
In November 2021, during a COVID-19 outbreak, Austria banned unvaccinated individuals from leaving their home apart from going to work, buying essential supplies, or exercise, in an effort to reduce the spread of disease.[42] During the fourth wave of the COVID-19 pandemic, with a low vaccination rate compared to the rest of Western Europe (79%), the Austrian government made vaccination mandatory.[43][42]
Parents' versus children's rights
Medical ethicist Arthur Caplan argues that children have a right to the best available medical care, including vaccines, regardless of parental opinions toward vaccines, saying, "Arguments about medical freedom and choice are at odds with the human and constitutional rights of children. When parents won't protect them, governments must."[44][45] However, government entities, such as Child Protective Services, can intervene only when the parents directly harm their child via abuse or neglect, considering a child does not have the ability to give or take away consent. Although withholding medical care meets the criteria of abuse or neglect, refusing vaccinations does not, as the child is not being harmed directly.[46]
To prevent the spread of disease by unvaccinated individuals, some schools and doctors' surgeries have prohibited unvaccinated children from being enrolled, even where not required by law.[47][48] Doctors who refuse to treat unvaccinated children harm both the child and public health, and may be considered unethical when parents are unable to find another provider.[49] Opinion on this is divided, with the largest professional association, the American Academy of Pediatrics, saying that exclusion of unvaccinated children may be an option under narrowly defined circumstances.[50]
One historical example is the 1990–91 Philadelphia measles outbreak, which led to the deaths of nine children in an anti-vaccination faith healing community. Court orders were obtained to have infected children given life-saving medical treatment, against the wishes of their parents, and also for healthy children to be vaccinated without parental consent.[51][52]
In schools and daycare
Vaccination requirements for access to daycare and schools increase vaccine uptake in the United States and there is evidence that these requirements may decrease disease.[53]: 661 However, the majority of studies of mandatory vaccination took place in the US and the cultural climate in United States is quite different from other industrialized nations.[53]: 665 A study shows that many Europeans countries have whooping cough vaccination rates as high as those in the United States despite no mandates.[54][55] Canada has a similar vaccination to the US despite 13 states having no vaccine mandates, which may in part be due to vaccination programs taking place in school in Canada.[53]: 664
Deliberate naturally acquired immunity through infection
In the United Kingdom, children are not vaccinated against chickenpox despite the availability of a vaccine since the 1990s. Modelling predicted that vaccinating children would increase the number of cases amongst adults due to the absence of natural boosting from exposure to chickenpox in day-to-day life. The Joint Committee on Vaccination and Immunisation were concerned that more pregnant women would become infected because immunity in the general population would decrease .[56]: 10
Planning vaccination policy
Vaccination committees
Vaccination policy is typically proposed by national[57][58] or supranational[59] advisory committees on immunization, and in many cases, is regulated by the government.[60]
Vaccination strategy models
Predictive vaccination strategy models[61] play an important role in predicting effectiveness of vaccination strategies at population level. The may, e.g., compare the sequence of age groups to be vaccinated and study the outcome in terms of caseload, deaths, length of a pandemic,[62] healthcare system load,[63] and economic impact.[64]
Evaluating vaccination policy
Vaccines as a positive externality
The promotion of high levels of vaccination produces the protective effect of herd immunity as well as positive externalities in society.[65] Large scale vaccination is a public good, in that the benefits obtained by an individual from large scale vaccination are both non-rivalrous and non-excludable, and given these traits, individuals may avoid the costs of vaccination by "free-riding"[65] off the benefits of others being vaccinated.[65][66][67] The costs and benefits to individuals and society have been studied and critiqued in stable and changing population designs.[68][69][70] Other surveys have indicated that free-riding incentives exist in individual decisions,[71] and in a separate study that looked at parental vaccination choice, the study found that parents were less likely to vaccinate their children if their children's friends had already been vaccinated.[72]
Trust in vaccination
Trust in vaccines and in the health system is an important element of public health programs that aim to deliver life-saving vaccines. Trust in vaccination and health care is an important indicator of government work and the effectiveness of the social policy. The success in overcoming diseases and in vaccination depends on the level of trust in vaccines and health care. The lack of trust in vaccines and immunization programs can lead to vaccine refusal, risking disease outbreaks, and challenging immunization goals in high- and low-income settings. Today, the medical and scientific communities obviously face a big challenge where vaccines are concerned, namely enhancing the trust with which the general public regards the entire endeavor. Indeed, earning the public's trust in public health is a big challenge. Accurately, studying the trust in vaccines, and understanding the factors that affect the reduction of trust, allows authorities to build an effective vaccine campaign and communication strategies to fight the disease. Trust is a key parameter to work with before and while undertaking any vaccine campaigns. The state is responsible for providing smart communication, and to inform a population about diseases, vaccines, and the risks of both. The WHO recommends that states work long-term, to build population resilience against vaccine myths and scares, to develop a strong campaign that is well prepared to respond to any event that may erode trust, and respond immediately to any event which may erode trust in health authorities.[73]
Cost-benefit: United States
The first economic analysis of routine childhood immunizations in the United States took place in 2001, and reported cost savings over the lifetime of children born that year.[74] Other analyses of the economic costs and potential benefits to individuals and society have since been evaluated.[75][76] In 2014, the American Academy of Pediatrics published a decision analysis that evaluated direct costs, such as program costs, vaccine cost, administrative burden, negative vaccine-linked reactions, and transportation time lost to parents.[76] The study focused on several communicable diseases, including diphtheria, tetanus, pertussis, measles, hepatitis A and B, and varicella (chickenpox), but did not include seasonal flu vaccines. Estimated costs and benefits were adjusted to 2009 dollars and projected over time at three percent interest.[76] Of the theoretical group of 4,261,494 babies, beginning in 2009, who had followed a standard childhood immunization schedule under the Advisory Committee on Immunization Practices guidelines "will prevent ~42,000 early deaths and 20 million cases of disease, with net savings of $13.5 billion in direct costs and $68.8 billion in total societal costs, respectively."[76] In the United States, and in other nations,[77][78][79] there is an economic incentive and "global value" to invest in preventive vaccination programs, especially in children as a means to prevent early infant and childhood deaths.[80] Socioeconomic disparities have been found to hinder reasonable access to vaccinations in the U.S., and it has also been found that even if such status is not a factor, "racial ethnic minority adults are less likely than whites to receive preventive care including vaccination".[81][82]
Cost-benefit for older adults
There is an economic incentive to establish vaccination programs for older adults as the general population is aging due to increasing life expectancy and decreasing birth rates.[83] Vaccinations can reduce the issues linked with both polypharmacy and antibiotic-resistant bacteria in the older demographic with comorbidities by preventing infectious diseases and decreasing the necessity of polypharmacy and antibiotics.[84][85] One 2016 study done in Western Europe found that the estimated cost of vaccinating one person over a lifetime against 10–17 potentially debilitating pathogens would be €443–3,395 (equivalent to €476–3,651 in 2021).[86] Another study found that if 75% of adults over 65 were vaccinated against seasonal influenza, 3.2–3.8 million cases and 35,000–52,000 influenza-related deaths could be avoided, and €438–558 million saved annually, solely on the European continent.[87]
International Organizations
In 2006, the World Health Organization and UNICEF created the Global Immunization Vision and Strategy (GIVS). This organization created a ten-year strategy with four main goals:[88]
- to immunize more people against more diseases
- to introduce a range of newly available vaccines and technologies
- to integrate other critical health interventions with immunization
- to manage vaccination programmes within the context of global interdependence
The Global Vaccination Action Plan was created by the World Health Organization and endorsed by the World Health Assembly in 2012. The plan which is set from 2011 to 2020 is intended to "strengthen routine immunization to meet vaccination coverage targets; accelerate control of vaccine-preventable diseases with polio eradication as the first milestone; introduce new and improved vaccines and spur research and development for the next generation of vaccines and technologies."[89]
By country
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