Inside the compulsory vaxx conundrum
As protests rage in Austria over mandatory Covid jabs, David Cox looks at why an established concept is causing such a backlash now
Austria’s Covid cases surged to a record high of more than 15,800 a day last week, prompting Alexander Schallenberg to take extreme steps. As well as introducing a new month-long lockdown, which began yesterday, the chancellor announced that Austria would become the first European country to make vaccination compulsory from February 1 next year.
The rationale behind Schallenberg’s decision is that ongoing vaccine hesitancy is thought to be one of the driving forces behind the country’s recent sharp rise in cases. Austria has a relatively low vaccination rate for western Europe: only 65.7 per cent of the population are fully jabbed, a rate lower than the UK (68.7 per cent), France, Italy, Portugal and Spain.
According to Andreas Bergthaler, a virologist at the Austrian Academy of Sciences, there appears to be a link between regions in Austria with low vaccine uptake and particularly high Covid-19 rates, such as the province of Salzburg, one of the hotspots of the current outbreak. “The vaccination rate in Salzburg seems to correlate at least partially with the high infection numbers,” says Bergthaler.
Over the next two months, the government will put into place a legal framework for the mandate. According to the latest reports, the authorities will first offer an appointment to anyone who has yet to be vaccinated, then penalties of up to 3,600 euros (£3,022) will follow if the offer is rejected. For those who are already double vaccinated, there will still be fines of up to 1,500 euros (£1,259), if they refuse to get a booster shot. Exemptions will only be offered to those who are able to prove, with a doctor’s certificate, that they cannot receive a jab on medical grounds, such as severe allergies to all currently available vaccines or those who had an adverse reaction to the first dose.
This decision has been prompted by the increasing urgency of the situation in Austria – in Salzburg, intensive care units are under such strain that some hospitals have been forced to consider turning away all but the worst patients. Yet it remains deeply controversial.
Only Indonesia, Micronesia and Turkmenistan have introduced full population Covid vaccine mandates, and the subject has become increasingly politically charged. In Vienna last weekend, protests turned violent as an estimated 40,000 people took to the streets to show their anger against the new mandate. Similar demonstrations were held in Rotterdam against a proposed law that would prevent unvaccinated people from entering businesses.
While intensive-care doctors in Austria are reportedly relieved by the news of the mandate, other scientists are not so comfortable with the idea.
“I think vaccines are really crucial and key, but I find it sad if we need mandatory vaccination because we cannot convince people otherwise,” says Bergthaler. “There might be certain parts of society where it would make sense, say, people working in healthcare and nurseries, who are dealing with vulnerable people on a daily basis. But in the long run, I think it would make more sense to invest in communicating and convincing people, rather than forcing them.”
Ethicists also remain unsure that the severity of the pandemic warrants compulsory vaccines at a population level. According to Dominic Wilkinson, professor of medical ethics at the University of Oxford, the ethical case for mandatory jabs is stronger for healthcare and care-home workers, than the wider public.
“If we had an outbreak of a disease that was like the bubonic plague or Ebola, that had devastatingly high mortality, and we had a massive threat to our health system and way of life, I think there would be a strong case for having a vaccine mandate,” he says. “I’m not convinced that this pandemic is sufficiently severe that it’s ethically proportionate to have compulsory vaccination for the general population.”
But while Austria and nations such as Romania and Bulgaria – which have double vaccination rates of just 34 per cent and 22 per cent respectively – have struggled to overcome widespread mistrust of the jabs, other European countries have been far more successful.
Portugal is among the world’s leaders in vaccinations with roughly 87 per cent of its population of
10.3 million fully inoculated, and the daily death rate dropping to single digit numbers. Like Austria, Portugal is politically divided, with the country run by a minority Left-wing government, and its citizens have also been exposed to a flood of vaccine misinformation on social media.
The issue of Covid vaccination may have become something of a political tug-of-war in Austria, but the Portuguese have deliberately kept their campaign almost completely separate from politics. Rather than being run by elected ministers, Portugal’s vaccine rollout has been orchestrated by former military officer Vice Admiral Henrique Gouveia e Melo, whose communication policy has prioritised building credibility and trust.
Scientists say that this apolitical approach has been the bedrock of Portugal’s success. “Vaccination has been politicised in many countries, which has undermined our response, attitudes and uptake,” says Daniel Salmon, who directs the institute for vaccine safety at Johns Hopkins Bloomberg School of Public Health. “We need science to drive public health to drive politics, not politics driving public health that drives science.”
Yet vaccine mandates are nothing new, and in recent centuries played a key role in eradicating smallpox, one of the deadliest diseases in human history. Smallpox vaccines were compulsory in the UK for nearly 150 years after English doctor Edward Jenner developed the first jab in 1796.
More recently, similar mandates have been used as a way of boosting vaccine uptake in schoolchildren in the wake of rising hesitancy among parents, a trend that the World Health Organisation described as one of the 10 gravest threats to public health in 2019.
In the US, all 50 states require schoolchildren to receive the MMR vaccine, as well as jabs for polio, tetanus, diphtheria, pertussis, and varicella. In the past five years, legislators in Australia, France and Italy have restricted school access for children who haven’t received the country’s recommended panel of vaccinations, such as MMR.
Australia has introduced a so-called “No Jab, No Pay” legislation, which withholds financial child support from the parents of unvaccinated children. In Italy, parents can also receive fines of up to €500 (£419) for sending children to school who have not been vaccinated against chickenpox, polio, measles, mumps and rubella, while children under six can be turned away.
Early data suggests that these mandates have succeeded in achieving their desired goals. In France, for example, the number of fully vaccinated children born after 2018 has increased significantly compared with those born in previous years, while childhood immunisation rates in Australia are now close to 95 per cent.
But such measures can backfire. Vaccine mandates have resulted in violent riots in Brazil, while some have linked them to the rise of the antivaccine movement in Europe. After California introduced legislation in 2016, which made it impossible legally for parents to avoid immunising their children on anything other than medical grounds, the number of unvaccinated children being home-educated quadrupled between 2016 and 2019.
Health experts fear that compulsory Covid vaccination will diminish trust in the healthcare system over time. The European Centre for Disease Prevention and Control has already called mandates a double-edged sword, fearing that overly draconian rules will induce an even greater number of sceptical anti-vaxxers.
“Making vaccines mandatory is unlikely to overcome anti-vaxx sentiments,” says Salmon. “It may increase the proportion of people getting vaccinated, particularly among those sitting on the fence. But the risk is that making it mandatory may cause some [to become] even more strongly opposed, as they now feel their autonomy is being infringed.”
Bergthaler would prefer governments to pursue greater engagement with the public on the issue, attempting actively to create an open dialogue with communities who are resistant to the idea of Covid vaccines.
“This is not even that specific to Covid,” he says. “We see it with the seasonal flu vaccines, where in Austria rates are really low – in the single digits. I think it needs a lot more communication, not just TV commercials but reaching out to people, having testimonials, finding peers among different layers of society. So not just making it one individual’s decision but trying to convey that this is getting us out of this situation together. That wasn’t politically seen as an attractive strategy, and I think it is haunting us now.”
Vaccine mandates are nothing new and played a key role in eradicating smallpox