COVID-19 Vaccination: Striving to Vaccinate Everyone

The Libertarian tenant of John Stuart Mills holds that people are free to act as they wish as long as their actions do not cause harm to somebody else (The Ethics Centre, 2016). Basically, absolving people of criminal behavior for saying things that others find offensive, it does hold people accountable for direct injury to others, but not unto themselves. Spreading vaccine disinformation causes direct injury to others. However, in our society people have the right to decline the vaccine based on deliberation during the informed consent process. So, the onus remains with us to persuade, on the basis of strong epidemiology and the factual representation of real risks related to severe disease, that refusing a series of COVID-19 vaccines is not just a poor health choice, like eating a double scoop hot fudge ice cream sundae when an apple is available, but a potentially devastating one where the risk of vaccine-associated harm is far-outweighed by preservation of life through vaccination.

That can be a hard sell in pediatrics, especially when a young parent has not experienced the death of a close family member or friend from COVID-19, as many of us have. So, it is important to impress upon our patients that, though the risk of a severe consequence of a preventable event (in this case hospitalization and death) can certainly be stratified for COVID-19, catastrophes happen in any group. 

Let’s look for a moment at recommendations for the safety harnesses for construction workers working on high rise building scaffold. Some workers have years of experience and situational awareness that will personally reduce the benefit of a universal requirement to use a safety harness for that individual compared to someone new to the occupation, however a fall for either rookie or veteran would have devastating consequences for that individual regardless of how likely it is to occur; thus, the recommendation applies to everyone. Likewise, the majority of persons without risk factors for severe disease will survive COVID-19 with or without vaccination. So, not everyone will benefit personally, though some even without risk factors for disease progression will have been protected. Additionally, through vaccination many fewer in all risk categories will be exposed (Singanayagam et al., 2022). 

Remember, the goal of COVID-19 vaccine is not prevention of infection, but prevention of severe disease, hospitalization, and death as we move through all stages of our lives. Remember, also, that achievement of that goal may not require persistent levels of neutralizing antibody and might be achieved by appropriate priming of the T-cell arm of the immune system and induction of T cell memory, which scientists are hoping will prove to be a more durable response (Moss, 2022).

In our health care institution, we wrestled with a vaccine mandate for COVID-19. We did much on the front end to encourage employee vaccination. We educated, had town halls, revisited and presented data, answered employee concerns by email, and led from the front vaccinating ourselves. Many complied, but some did not.  So, a mandate was eventually issued. Our decision was based on the need to maintain a healthy, well-protected and able workforce to care for patients which is central to our institutional mission. Our mandate was also issued out of sincere concern for the welfare of our staff. We dealt with backlash. We handled many requests for exemptions. We lost beloved employees. However, the mandate pushed many slow adopters to act in a healthy way, by stepping up and finally becoming vaccinated.

How would we consider this strategy in the context of personal and public freedoms? Philip Pettit (Buckle, 2021) argued that freedom as we know it is as a result of the beneficence of our government which we give some power to dominate us,but may choose to not to do so. We accept that as real freedom (even though it is not) because we need a functional society, which requires that we give the government some power to constrain us for the good of one another. Throughout the implementation of COVID-19 vaccine at Cook Children’s we kept that in mind. We encouraged employee volunteerism first and observed compliance, waited for FDA approval, then grudgingly mandated the vaccine when less than optimal compliance became a threat to achieving our organizational mission. In any event, a little more than three years into the COVID-19 pandemic, we are still mourning. Many of us lost grandparents, parents, siblings, and some lost children due to COVID-19. Though deaths are less common at this point in the pandemic, we continue to lose beloved family, friends, colleagues, co-workers, and patients. Our work is not done. We must strive to vaccinate everyone who is eligible.

The odds of pediatric vaccine and young adult associated events (CDC, 2023):

• Anaphylaxis: 1:200,000 vaccine doses
• mRNA vaccine-associated myocarditis (most are cases are transient):
  • 12-15 years old: one in 14,144 vaccine doses (Pfizer-BioNtec)
  • 16-17 years old: one in 9,442 vaccine doses (Pfizer-BioNtec)
  • 18-24 years old: one in 19,084 (Pfizer-BioNtec) and 17,762 (Moderna) vaccine doses
• Thrombosis and thrombocytopenia syndrome and Guillain-Barre (J&J/Janssen): see CDC reference.
• Value of lives saved from COVID-19 severe disease: Priceless.

Marc Mazade, MD, Medical Director of Infection Prevention

References:

Buckle, T. (2021, October 21). Freedom as non-domination: Phillip Pettit. What is Freedom? Conversations with Historians, Philosophers, and Activists (New York, 2021; online edition, Oxford Academic), https://doi.org/10.1093/oso/9780197572214.003.0007

Centers for Disease Control and Prevention. (2023, February 13). Selected adverse events after COVID-19 vaccination. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/adverse-events.html

Ethics Center. (2016, October 27). Ethics explainer: The harm principle. https://ethics.org.au/ethics-explainer-the-harm-principle/

Moss P. (2022). The T cell immune response against SARS-CoV-2. Nature immunology, 23(2), 186–193. https://doi.org/10.1038/s41590-021-01122-w

Singanayagam, A., Hakki, S., Dunning, J., Madon, K. J., Crone, M. A., Koycheva, A., Derqui-Fernandez, N., Barnett, J. L., Whitfield, M. G., Varro, R., Charlett, A., Kundu, R., Fenn, J., Cutajar, J., Quinn, V., Conibear, E., Barclay, W., Freemont, P. S., Taylor, G. P., Ahmad, S., … ATACCC Study Investigators (2022). Community transmission and viral load kinetics of the SARS-CoV-2 delta (B.1.617.2) variant in vaccinated and unvaccinated individuals in the UK: a prospective, longitudinal, cohort study. The Lancet. Infectious diseases, 22(2), 183–195. https://doi.org/10.1016/S1473-3099(21)00648-4.