THE RECENT SPREAD of the highly infectious Delta variant of SARS-CoV-2 – the virus that causes Covid-19 – has highlighted the risk of continued circulation of the virus in unvaccinated individuals.

Data published by public health officials last week showed that Covid-19 incidence among younger age cohorts, many of whom have not yet been vaccinated, is increasing at a significantly higher rate than among older sections of the population.

Of course, more of those younger people will be vaccinated in the coming weeks as the HSE’s portal opens to them, protecting a larger share of the population from the effects of Covid-19.

But while the vaccination programme in Ireland is still underway, in a few months’ time we will have to address another problem: people who do not want to be vaccinated.

Could they pose a risk to society by facilitating the emergence of new variants that may be more infectious? And should vaccination be mandatory to prevent this?

It is important to appreciate that there are two reasons for someone be vaccinated: to protect yourself from a disease, and to create herd immunity that could eventually lead to the elimination of that disease.

The tetanus vaccine is an example of one that simply protects the individual. Humans are not the reservoir for the tetanus pathogen, so vaccination can ultimately have no impact on the existence of that pathogen.

On the other hand, polio is a pathogen that has largely been eliminated through mass vaccination programmes.

Evidence in relation to Covid-19 vaccines shows that if you are fully vaccinated, you are extremely unlikely to die if you get infected. As a result, it is not unreasonable to think that unvaccinated people are the only ones who will suffer, and that that’s their problem.

But that isn’t really the case.

If there are a sufficient number of unvaccinated people, Covid-19 will continue to circulate, which will inevitably lead to the emergence of new variants that may have more of an impact on those who are vaccinated.

Understanding non-vaccination

It helps to understand the different reasons for non-vaccination.

Many people are vaccine deniers who refuse vaccination on religious or political grounds. Examples of this are found in the US among certain faiths or members of the political groups.

Such anti-vaccine beliefs are not based on science, and the use of science to try and persuade people to get vaccinated will not impact them. No number of studies pointing to the safety and efficacy of Covid-19 vaccines will encourage them to get vaccinated.

Other people are vaccine hesitant, and typically they are concerned about the safety of the vaccines.

People in this group may be reluctant to accept mRNA vaccines on the basis that they are a new technology with no clinical experience, even though all clinical trials and the subsequent health outcomes of billions of people who have been vaccinated show that these vaccines are safe.

They may also be reluctant to take the AstraZeneca vaccine because of the risk of thrombosis, even though such events are incredibly rare and the chance of developing blood clots is higher from catching Covid-19. 

Unlike vaccine denial, this type of vaccine hesitancy is based in science, and there could be a willingness among people in this group to be vaccinated if the benefits and risks of doing so are explained clearly to them.

Then there is vaccine lethargy. Some people, especially younger people, have no problem being vaccinated but just don’t feel that there is a need for them to do so.

Given that huge numbers of older people are vaccinated and the mortality rate among younger populations is lower, they may feel that the worst thing that could happen if they contract Covid-19 is that they have flu-like symptoms for a few days.

They may feel that the risk to themselves is low, and that there is no real need for them to be vaccinated.

Much of this is based on flawed reasoning.

Young people can in fact get very sick and end up in hospital with Covid-19, or suffer the effects of ‘long Covid’.

Furthermore, no vaccine is 100% effective, so some of those who are vaccinated will still suffer the worst effects of Covid-19 if they end up catching the virus.

Vaccines protect more than just the individuals who receive them: they reduce transmission of Covid-19 to other people, thereby reducing the chance that Covid-19 will take its toll on sections of the older population who have already been vaccinated.

Ethical problems

So should we get around the problem of vaccine lethargy by compelling everybody to be vaccinated to prevent the spread of Covid-19, or would that violate an individual’s rights?

We already accept the principle that a patient can refuse treatment. For instance, Jehovah’s Witnesses are allowed to refuse blood transfusions despite the absence of any clinical data to support such a decision.

The difference is that this refusal by Jehovah’s Witnesses is a personal choice.

When it comes to vaccination, if an individual refuses, there is a potential impact on all of society.

But there are ethical problems with forcing people to be vaccinated, which will only reinforce the beliefs of the vaccine deniers.

Rather than coercing people to be vaccinated, a carrot-and-stick approach to enhance voluntary vaccination may be more appropriate and should certainly be tried before considering compulsory vaccination.

Information campaigns are currently at the centre of encouraging vaccine uptake, but it is necessary to have targeted campaigns for different groups.

Vaccine deniers do not respond to government-based campaigns and are more likely to have their stance reinforced by them, as they may believe that government control is behind mass vaccination programmes.

They are perhaps more likely to respond to advice from their family doctor or from religious or political leaders. Doctors and pharmacists should therefore engage with these patients and discuss with them the benefits of vaccination to them.

Key religious and political leaders who are relevant to this demographic should also be recruited to encourage vaccine uptake.

When it comes to those who are vaccine hesitant, publishing studies on the safety and efficacy of vaccines is more likely to encourage people to get vaccinated.

Evidence that the regulatory authorities are closely monitoring any adverse effects to the vaccines should also provide encouragement.

Campaigns that are directed specifically at younger people, which highlight the importance of vaccination for virus eradication, will be most effective at encouraging these groups.

While young people are unlikely to die from Covid-19, they can still get symptomatic infection that can lead to ‘long Covid’, and this needs to be emphasised in information campaigns.

Possible restrictions

However, although targeted information campaigns should help increase vaccine uptake, there will still remain those who are unconvinced.

It may be necessary to introduce restrictions on non-vaccinated people, as well as benefits for vaccinated people.

Drinking in a pub is not a human right, and it is possible to wait until Covid-19 is completely eradicated before going to a pub, although that is unlikely to happen unless everybody is vaccinated against the virus.

Social welfare could also be used as a tool to encourage vaccination.

The Pandemic Unemployment Payment (PUP) is currently in place to support people who have been unable to work due to Covid-19 restrictions.

If an eligible person has refused to register for a vaccine, they should no longer be eligible for the PUP, as the primary reason for their inability to work is their unwillingness to be vaccinated.

It is perfectly acceptable for employers to require their staff to be vaccinated, as it is necessary to protect their customers and other staff.

Finally, there could also be financial consequences for not being vaccinated.

If a non-vaccinated person becomes infected and requires hospitalisation, there will be significant costs for their treatment.

It is appropriate for the State to cover the medical costs of people affected by the Covid-19 pandemic, but the HSE has clearly established that vaccination is the most cost-effective strategy and there is no obligation for the State to fund much more expensive treatment.

Smoking-related diseases are a significant burden on the healthcare system. The State covers these costs in patients, but it levies a large tax on cigarettes and uses the money earned to offset the cost of the treatment of affected individuals.

If a person gets Covid-19 after refusing a vaccine, they should ultimately pay the bill for their medical treatment, as these are unnecessary costs incurred. There is no reason why the taxpayer should have to pay for those who refuse to be vaccinated.

Healthcare workers in particular are at high risk of contracting Covid-19 due to their exposure to large number of infected patients in hospitals and other healthcare settings.

Because of this, vaccination is essential for healthcare workers to protect themselves, their patients and others around them.

This is not unique to Covid-19 of course, and a similar example is seen in the case of laboratory researchers, who cannot work with blood unless they have been vaccinated against Hepatitis C. This is a health and safety requirement and is not optional.

There is clear benefit for vaccination, and there is no scope for healthcare workers to use non-scientific based approaches in their job. As a result, vaccination should be mandatory for healthcare workers.

If it is not mandatory, non-vaccinated healthcare workers should be restricted in their duties with no access to Covid-19 patients or vulnerable patients. It may also be necessary to have regular screening of non-vaccinated staff as well.

But most importantly, a strategy of building trust in vaccination through education and open discussions on the benefits of vaccines are the best approaches to encouraging uptake, because they still respect individual rights.

Ultimately, we really need to emphasise the importance of the benefit of vaccines to society.

Professor Dermot Cox is Associate Professor in Pharmacy and Biomolecular Sciences at the Royal College of Surgeons.