Will vaccinations be required? [Edited: Will you get a vaccine if legally mandated]

In My Humble Opinion
81

I worked in the accounting office at a hospital and a medical clinic. The requirement for employment for both was a TB test. I see this as related, as TB transmission is airborne as is Covid, so I can see a vaccination being a requirement, which I would receive anyway. I’d get a regular flu shot since they’re available right now, but just got one earlier this year when I did my TB test.

Interestingly, because I got a two part TB test (you go in for a reading twice, not just once to be sure you’re really not positive) prior this most recent one and was told it was all I would need for the rest of my life. However, I learned that (in Hawaii) health care workers had to get tested every year. However, since I worked in the office, I didn’t quality for the free annual testing. I got a paid one (covered by my health insurance) at CVS and got my flu shot at the same time.

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Warning - hijack from vaccines follows:

Something important to highlight from this interchange and then some studies I have to share that illustrate the points more.

I made a significant error when I repeated as fact something that has been passed down to me in lectures … but was then unable to support it with actual research. This is an error that gets made often (not just by me) and can have very significant impacts.

So first a better recent (but pre-SARS-CoV-2) review of what is and is not known about the transmission routes of respiratory viruses among humans and the methods used to study it for anyone who wants to crawl in the weeds with me. There have been those animal models done btw @puzzlegal … more with ferrets as the models - one of those to be shared downpost.

@iamthewalrus_3 one important bottom line to highlight from that review is that there is zero reason to assume that different respiratory viruses, even of the same family, or of similar symptom complex, share transmission routes, and we know much less than many seem to think we do.

Pertinent to discussions about SARS-CoV-2 is an implicit assumption made that nasal, upper respiratory tract (URT) viral load correlates with airborne (lumping together droplet and aerosol) transmission, rather than lower respiratory tract sources. There actually IS an elegant ferret study that shows such is likely true for influenza, at least in ferrets (not able to say if droplets or aerosols, just airborne), and human studies that show the small airways of the lung, the LRT, are the main source for aerosol particle formation during tidal breathing in general (not turbulence through nasal epithelium as is often assumed), and specifically for the portion of human rhinovirus transmission that IS aerosol, that the LRT, not the nose, is the source of aerosol particle formation. It is also clear that some people produce few aerosols at baseline and some are outlier super-producers.

From that last citation (bolding mine):

(What contributes to being a super-producer? It would be nice to know. One suspects but does not know that the volume of air expired each tidal breath has something to do with it …)

That ferret study is worth highlighting because its design shows the lengths that they went to determine experimentally that nasal mucosa was indeed the source of airborne (again not discriminating between droplets and aerosol particles) transmission of influenza in ferrets at least. They created genetically tagged variant pairs of influenza virus and then simultaneously infected ferrets with each in discordant sites, the upper respiratory and lower respiratory tracts, and were thus able to tell which site the germ came from. That is one amazing study.

All that long hijack aside, lumping all respiratory viruses together and presuming they all transmit similarly, is without any evidenciary basis, to the degree that small aerosols are the main transmission source it may be that nasal viral load correlates little with transmissibility risk, but determining lower respiratory tract load, and efficiency at aerosol production, is not so easily done.
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Back to mandating vaccines.

Fundamental question. Should the standard, the burden, be that removing individual choice requires convincing proof that it will result in major benefit, to society if not to the risk that the individual being forced to have the vaccine. Or should the standard be that without convincing proof that there are no such benefits individual choice should be eliminated? Up to now we’ve used the former as the standard, requiring evidence of substantial benefit, usually (not always) including to the risks to the one being vaccinated, before mandating a vaccine. Should it go the other way around? I don’t think so.

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The odd and confusing phrasing makes it difficult to be sure what you’re saying here.

There’s a strawman odor to the last sentence, if you are claiming that posters in this thread (or those at work on developing a Covid-19 vaccine) want to mandate a vaccine without convincing evidence of benefit to society.

Much of the resistance to anti-Covid public health measures (limits on public gatherings, requirements for masks and the prospect of being “forced” to take an as-yet nonexistent Covid vaccine) is founded on resisters’ conviction that they face little significant threat from the disease. They resent restrictions deemed dangerous to their freedom and/or health, that particularly benefit vulnerable members of society. The latter include the elderly and those people of varying ages with pre-existing medical conditions (including but not limited to cardiovascular conditions, respiratory ailments and congenital or acquired immunosuppression). In its uglier forms, this resistance degenerates into victim-blaming.

We can choose to cater to these sentiments, or rely on the same principles that apply to pre-existing vaccines.

Depending on when/if we get a Covid-19 vaccine with a satisfactory efficacy and safety profile, I think an effective case could be made for mandatory vaccination of schoolchildren, both to protect them (including the most vulnerable children) and the adults who will be in close, continual proximity to them in school and at home.
I’d have considerable sympathy for teachers and other school employees who may refuse to work unless kids are vaccinated.*

*and before anyone argues that it should be enough for such workers to be vaccinated themselves, consider that in a low but not insignificant percentage of healthy people, vaccination does not “take” sufficiently to generate an effective immune response, while still others cannot be vaccinated for health reasons. These are the folks protected by herd immunity, supplied by vaccination of others.

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No not posters, just one. You.

So to clarify that perhaps I misunderstand. Your position is like mine that a vaccine should only be mandated upon the unconvinced or hesitant after it has met a strong burden of convincing proof that doing such would result in significant societal and/or individual benefits?

Because my read, perhaps misread, of your case is that the burden of proof goes the other way: unless there is solid proof that mandating vaccine will be of no help, or even if risks of harms greater than its benefits, then a mandate forcing it upon the hesitant is indicated.

Glad if I got it wrong.

85

FTR, private schools, which is virtually all preschools in the US (the few public preschools are programs in public schools under PL 94-142 [spec ed], and Head Start programs) can do as they like. The preschool where I work requires all vaccinations according to APA (American Pediatric Association) guidelines. Children who are not vaccinated do not go to our school. NO EXCEPTIONS. That includes kids with medical exemptions. Allergic to an adjuvant? Sorry. Find a brand without the adjuvant, or you can’t come to this school. Have a sibling with cancer, and told not to get the vaccine? Sorry. Find another school.

Part of the reason for the hard-ass policy is that the school has a long waiting list. There are a lot of hard-ass policies, because the waiting lists have to be thinned somehow. But the vaccine policy is very important to the principal. She is old enough to remember the Rubella epidemic of 66-68.

In a preschool, at any given time, about 15% of the moms are pregnant. We need the kids not to be passing viruses along to pregnant women. Not to mention, that the principal is educated, and knows that measles, mumps, Hib, even chicken pox can have lasting consequences, or even cause death.

So you can bet as soon as a viable COVID-19 vaccine exists, it will be on our list.

86

I think that societal benefit should be enough, and we don’t need to prove strong benefit to every individual.

“Prove” is a strong term. How many decades did it take to prove cigarette smoking increases the risk of lung cancer? But I certainly think there should be very strong evidence favoring both the safety of a vaccine and its likely benefit before any mandate is considered.

I am nervous about the possibility of a vaccine making covid worse, even in a small fraction of cases. Because the less safe the vaccine the stronger the burden of proof of efficacy needs to be. And of course it’s possible that we can’t get a vaccine at all, because the risk of harm is greater than the likely benefit. But even if there is a strong net benefit, a vaccine with a significant risk of harm needs to be used with great caution.

Obviously, data like the case of the person who got sicker the second time they caught covid is evidence of a vaccine being dangerous.

We live in interesting times.

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A lot of people getting COVID-19 a second time, and being sicker the second time around, are sicker because it apparently takes many people a very long time to recover from lung damage. So getting it within a few months of recovery-- or maybe I should say “recovery,” because from what I understand, no one is sure if people really are getting it twice, or just apparently getting well, but actually just having the virus become dormant for a short time, then resurge-- is getting it before one is fully recovered. The first time you got it, you were healthy. The second time, you were not, and everyone knows people who are unhealthy get hot harder.

It’s also possible that people who experience a resurgence were infected either with a more virulent strain, or had an incomplete immune response to it, and the resurgence was of an even YET more virulent form, that overcame the resistance the body did offer.

There are other examples of viruses that clear in most people but in other people become dormant, and then resurge to cause terrible problems. HPV, the virus Gardasil prevents apparently clears in many people, but not all, and the one in whom it does not clear are the ones at risk for cancers.

There’s even some evidence that a few people have cleared HIV-- very rare, but there have been people who tested positive many times in a row over a few years, then tested negative, and continued to do so, and finally had a test for the presence of the actual virus, and none was found.

They tested positive back when the only test was for antibodies, not the actual virus, and since false positives do happen, but several in a row is unlikely, no one is quite sure whether the law of extremely large number has dictated that a few people will test positive falsely several times in a row, before testing negative, or these people actually had the virus, carried immunities for a while, then stopped making them once the virus had been gone for some time.

Vaccines are built out of parts of a virus anymore, and designed not to make you sick. The parts that trigger immunity, and the parts that trigger symptoms are teased apart, so that only the parts that trigger immunity are used in the vaccines (to oversimplify, but pretty much, that’s how most vaccines are made these days-- they used to be attenuated by being put through animal tissue, or by finding a way to administer them that didn’t make you sick).

The point being, there’s a big difference between recovering from an illness, and being vaccinated against one.

So no, data on people who got sicker the second time around is not “obviously” evidence of a vaccine being dangerous.

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Obviously may be too strong a word. But it’s evidence the vaccine might possibly trigger a dangerous overreaction to the virus. One of the ways this virus can be deadly is to overstimulate the immune system. And if that is more common if you catch it a second time, it might also be a side effect of a vaccine. So it’s a warning. It’s not a red flag, but it’s at least a yellow flag.

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Cite? I’m aware of the study showing an individual getting reinfected, but I have not heard of it happening on a large scale.

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It’s not. But the phenomenon of people recovering “in waves” seems to happen sometimes, and it’s not uncommon with a lot of infections that cause residual damage; it just means that a person can rally, then be unwell, rally, be unwell, for a few cycles.

It happens often enough with COVID that no one should be declared disease-free without a test, at least according to my cousin, the microbiologist.

But before there was a good test, a number of people were deemed “cured” based on symptoms alone, who then became unwell again-- they didn’t actually become sick again, though.

Don’t have a cite other than my cousin, who works in Texas for the institute that made the Ebola vaccine (she worked on it). Don’t want to say more without her permission, though

91

Why yes, my position has always been that vaccines should demonstrate convincing evidence of benefit to society. Nowhere in this thread or in any other vaccine-related threads on this board have I ever suggested otherwise.

Now that that strawman has been disposed of, what of the argument that a particular group should be exempt from a vaccine mandate, if the vaccine is perceived as not providing that group overwhelming benefits? You’ve studiously avoided addressing potential harms to teachers and other school workers exposed to masses of unvaccinated schoolchildren, as well as dangers to vulnerable kids with pre-existing conditions. Why is that?*

I included what is (to me, anyway) the highly offensive Del Bigtree position of blaming the elderly, obese and those with serious chronic conditions for subjecting the presumably healthy general population to Covid-19 restrictions (never mind the squalling from these people about the prospect of mandatory vaccinations, once a vaccine is released). Is saving a couple hundred thousand lives a year worth it if Del has to wear a mask in a store, or if a crowd of young people are prohibited from attending raves?** Should we never ask mature adults to get pertussis boosters to avoid infecting young children, since the benefit to adults is very tenuous in comparison?
There have been efforts supported by infectious disease/public health experts to mandate influenza vaccination for schoolchildren. This, even though there are relatively few deaths from the flu in this population (overlapping in some years with what we’ve seen from Covid-19 so far) and a main justification is preventing influenza spread to the general population which includes vulnerable adults. Should schoolkids be required to get flu shots to prevent a few thousand more grandmas and grandpas (as well as those with cardiopulmonary ailments and cancer patients on immunosuppressive therapy) from dying every year? It’s not a ludicrous idea.

These are not slam-dunk propositions, but they’re worthy of serious debate - not something to be sloughed off based on the assumption that we should balkanize vaccination policy to reflect perceived group and subgroup benefits.

*considering that in a previous thread you fiercely rejected the idea that there could be any risk from completely unvaccinated kids in a pediatrician’s office to vulnerable children in that practice, I probably shouldn’t be surprised. It’s depressing nonetheless.
**the young may consider themselves immortal, but apparently they are not immune to carbon monoxide.

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Vaccinations are not developed by Donald Trump. They’re developed by scientists, doctors, and statisticians, using remarkably tight safety protocols. If the government allows those protocols to be skipped you can find out exactly how they were skipped. If they don’t, you may rest assured the vaccine meets high standards of safety and efficacy study.

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Okay. As of yet there is no such evidence. Your argument that one cannot assume that there is no such benefit, and citing newspaper accounts of individuals stating that there MAY be, notwithstanding.

Because it has been amply covered in another thread, which I have pointed to many times. Multiple expert bodies have agreed that there is NO strong case that children in person in schools, in particular elementary school aged children, present a high risk to teachers, but that it is premature to state with certainty that they present an insignificant one. Hence the nuanced recommendations based on levels in the community and other statistics, given some specifics to metrics in Harvard’s Global Health Institute’s guidance, but again, agreed upon review of the whole body of evidence by multiple expert bodies.

The completely irrelevant to this discussion one?

And here is where we can maybe return to the OP!

Ask is one thing. The OP is about mandating by force of law and enforcement of those laws.

Should we make adult pertussis updates MANDATORY enforceable by punishment and/or exclusion from participation in public institutions? Should a COVID-19 vaccine be so MANDATED upon all citizens, similarly enforced?

What is your position?

(As to your asterixed misstatements of past discussions, in which I have argued that societal good is much better served by pediatric offices engaging with the vaccine hesitant, and by so doing successfully changing some of their minds, protecting all of society, and that the risk to compliers in that brief waiting room contact from that is extremely small in comparison. … I can’t say much about it that would not earn me a warning.)

The FDA is talking about rushing approval through before trials are complete on emergency use authorization.

It scares some.
https://www.sciencemag.org/news/2020/08/here-s-how-us-could-release-covid-19-vaccine-election-and-why-scares-some

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For all of society? No.

For people who work in nursery and elementary schools, and so come in contact with a lot of pregnant moms? Yeah, that might be worth it.

And that’s pretty comparable to school children who are in contact with their teachers all day.

The sort-of-good news is that I expect we will have a lot more data about teachers getting infected by kids, or not getting infected by kids, before we have a vaccine and it becomes a real question.

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One of my problems with vaccines is while they can be tested to be safe, now… what about the future? Could it cause other issues say 10 years from now?

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While we don’t have experience specifically with any coronavirus vaccine (or with some of the technology being used to develop Covid-19 vaccines), we do have decades of experience with many other vaccines against a wide variety of pathogens, none of which have been shown to cause unexpected, deleterious effects many years later (including the chronic conditions blamed on them by antivaxers). There are multiple systems currently in effect for monitoring vaccines indefinitely following licensure (including the widely misunderstood VAERS), and we can expect them and possibly additional monitoring efforts to ensure long-term Covid-19 vaccine safety.

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And you cut the second half of my quote in which I noted that if they do rush it, it’ll be a known thing. That cannot be hidden.

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Yes, we’re starting to see the rollout of a sort of national experiment to see how many adults working in schools (including those with pre-existing conditions that make them particularly vulnerable, a number that includes many schoolchildren as well) will be sickened and killed by school-derived Covid-19 outbreaks. I think it’s farcical to dismiss such concerns, but we shall see.*

I would add to an adult pertussis vaccine mandate those adults working in day care settings and doing babysitting jobs (infants and very young children are disproportionately affected by severe pertussis disease), as well as any and all health care workers in pediatric hospitals. Surprisingly, it’s difficult to find examples of a health care provider mandate in the U.S. for Tdap vaccination, which covers pertussis (required influenza vaccination is a lot more common). As of 2015 only around half of U.S. health care workers had received Tdap vaccination.

*Make no mistake, there’s a lot of pressure to reopen schools, not only from politicians but from parents for whom round-the-clock child care is a major economic and psychological burden (schools provide a welcome babysitting function). For those who believe teachers should like it or lump it when it comes to confronting contagion risk, I’ve been thinking about my all-time favorite grammar school teacher, Mrs. Coles, a gray-haired lady who probably seemed more ancient to me than she actually was, but was still within an age range that currently would make her high-risk for Covid-19. She was an extremely nice and competent homeroom and English teacher. If she and her class were transported to 2020, I don’t think it would be too much to ask for her students to be vaccinated with an adequately tested, safe and effective Covid-19 vaccine, as an alternative to her possibly winding up in an ICU or worse, or face early retirement in order to avoid the risk to herself and aged relatives.

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Perhaps it’s relevant that NYC has just announced a delay in opening schools in person due to a threatened strike by the teacher’s union. I think “risk to teachers” is extremely relevant to the question of whether to mandate childhood covid vaccinations.

fwiw, my doctor and my DIL’s mother (a pediatrician) have both told me that I will need to get a pertussis booster if my DIL gets pregnant, even though I am at extremely low risk from pertussis. In fact, I had it about 20 years ago, and while it was unpleasant, in the current WFH environment it wouldn’t interfere with my life at all. Is that the law? No, but there are logistical reasons why it makes more sense to mandate laws around “school children” than around “potential grandparents”.

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I appreciate the cite. Obviously there is a lot that is both known and unknown, and different viruses transmit more efficiently in different ways. When it comes to the point I started on, though, I’m not sure how relevant all this is to the question of whether schools are going to be major centers of infection.

Whether it’s most-efficiently transmitted via aerosols or droplets or fomites, kids are bad at all of those things because they are bad at hygiene and basic politeness. They don’t cover their coughs or sneezes. They yell a lot. They don’t wash their hands. They hit all the routes!

There may well be some other factor that makes kids not spread COVID very effectively, but I’m not convinced that either environment or behavior are likely relevant. Schools are pretty nasty environments for infection. Sitting in closed classrooms all day with a bunch of other people. Again, I’m not a doctor or an epidemiologist, but I went to school and got sick from my classmates plenty.