COVID-19 vaccines and risk management
By Josephine Robertson and Dr. Sarah Chan
COVID-19 Actuaries Response Group – Learn. Share. Educate. Influence.
In this bulletin we consider the non-compulsory nature of the vaccination programme and the ethical and cultural implications of alternative approaches. Approaches to manage risk at individual and population level must be appropriate to the nature of the threat. We consider the impact on building or eroding social cohesion, a vital component in pandemic response.
The emergence of a number of clinically-proven vaccines against SARS-CoV-2 within 12 months of the start of the COVID-19 pandemic is a major breakthrough. The vaccines themselves, however, are only one of the components needed for successful disease control. To affect the spread of the disease, public health policy must also incorporate strategies to:
- promote and monitor vaccine distribution and uptake throughout the population;
- assess and publicise evidence of vaccine effectiveness; and
- understand how these factors intersect with social and behavioural components, including non-pharmaceutical interventions.
By now, national and international measures to control or limit individual behaviour are commonplace but will vaccination status also be considered? Will ‘vaccine passports’ to regulate travel, give access to public spaces, or enable employees to attend work become a requirement? If so, are these restrictions acceptable? Could this approach provide incentives to be vaccinated, and at what cost?
Through this vaccine roll-out and the long-term management of COVID-19, the approaches adopted require careful consideration. These approaches have ethical and cultural implications which can either build or erode social cohesion, a vital component in pandemic response.
Factors to consider: vaccine effectiveness, immunity duration and uptake
Vaccine effectiveness evidence has shown that vaccinated individuals are less likely to suffer from symptomatic COVID-19. Public health surveillance programmes are underway to provide evidence on vaccine effectiveness in reducing infection and transmission risk. A vaccinated individual poses a reduced risk of transmitting the disease to the community around them only if a vaccine provides benefits a and b (shown below).
Another aspect where evidence is yet to fully emerge is the expected duration of immunity (naturally acquired through infection and subsequent recovery or induced via vaccination). This depends on both a) the rate at which the body’s immune response develops and subsequently wanes and b) on the virus mutation rate. Although more stable than flu viruses (requiring a new vaccine each year), SARS-CoV-2 already has new variants causing concern over vaccine effectiveness. In addition, coronaviruses (such as those that cause colds) tend to produce shorter natural immunity. Evidence for the duration of effective immunity is so far limited to assessing natural immunity at up to 6-8 months. It is hoped that vaccination will produce a more robust and long-lasting form of immunity, even if the response wanes slightly.
The ongoing management of COVID-19 via vaccination may therefore require booster shots to maintain immunity, but how often? This depends on the extent to which new variants require vaccine adaptations to maintain effectiveness. A major contributing factor to the emergence of new variants is the extent to which the virus has the opportunity to replicate. Therefore, the continued transmission of COVID-19 is a material risk for the emergence of vaccine-resistant variants. A novel variant threatens the effectiveness of vaccine strategies not only within the country where it emerges, but beyond. Controlling the virus at a global level should therefore be an overarching objective of all pandemic response strategies.
Finally, the effect of vaccines on reducing COVID-19 risks depends on availability and vaccination take-up rates throughout the population. In the UK, a programme is underway to improve vaccine uptake across all communities, with tailored interventions for groups needing additional support to achieve target vaccination levels.
Compliance and coercion: vaccine passports may fail to deliver
Epidemiological data and statistics on the effectiveness of vaccines and rates of uptake can provide an indication of the risks at a population level, but do not accurately assess individual risk. The R-number, for example, is a statistic that represents not the risk from or to an individual, but the average level of onward transmission within a population under given circumstances. These circumstances include social and behavioural conditions particular to that socio-cultural context, as well as any public health measures in play, including vaccination and non-pharmaceutical interventions.
Interventions that propose to introduce differential treatment for individuals on the basis of personal risk status should be carefully and critically considered. While it might be sensible and proportionate to recommend that people especially at risk from COVID-19 ought to exercise more caution, mandating individual behaviour on this basis and requiring compliance (for example through imposing penalties) would not necessarily follow. Moreover, segmenting the population on the basis of differential risk status raises serious ethical concerns around reinforcing historically-grounded harm to marginalized groups, and risks entrenching existing social inequalities.
The issue of ‘vaccine passports’ is one that deserves particular scrutiny. Aspects of this approach are already being implemented or considered in various countries – Israel’s “green pass” is one notable example, with the EU considering a similar scheme. It has been suggested that the approach of “immunity passports” by granting more freedom to individuals who are putatively immune might mitigate some of the negative social and economic impacts of lockdowns (and similar approaches). At the same time, however, the ethical and social issues associated with such a proposal are significant and require attention.
Controlling individual behaviour on the basis of individually-determined risk status is difficult to justify. Moreover, the framing of such monitoring in terms of “passports” puts the emphasis for the management of personal and public health risks in the wrong place. It places the focus of pandemic response on the individual’s responsibility to be vaccinated and on individual actions, rather than on the structural approaches that might encourage the uptake of vaccination and other health-promoting measures across the population. This atomistic approach to public health has the potential to undermine solidarity as well as distracting from other, more worthwhile response efforts. It is well-understood in public health, and the course of the pandemic thus far has shown, that assigning blame and responsibility to individuals for protecting, or failing to protect, their own health and that of others is simply less effective than strategies that address structural factors and facilitate collective approaches to promoting public health.
Furthermore, in so doing, it is likely to widen inequalities, not just in terms of health but broader socio-economic terms. Vaccination rates are often lower in groups who already face disadvantages, such as those with chronic health conditions, minority ethnic groups or low-income communities (Bulletin 114, 112, 110). Further restricting the participation of these groups in society will increase this disadvantage.
Finally, the limited utility and validity duration of a vaccine passport scheme, in comparison to the technological, resource, implementation, surveillance and social costs it would entail, weighs heavily against the introduction of such a scheme. Our aim nationally and globally, now that vaccines are available, should be to make them widely available to reach the point where enough of the population is vaccinated to prevent the disease from spreading. Once enough of the population is vaccinated, it will be even less useful to force everyone to carry proof of vaccination status. This being the case, the use of public funds to commission a passporting scheme that, if all goes well, could be obsolete within the year, could be a poor use of resources. Furthermore, it might be considered a poor use of resources which distracts attention from other, more effective ways of addressing the pandemic and its broader effects.
Compliance and coercion: international travel and inequity at a global scale
The UK does not currently require compliance with immunisation programmes, and at a global level, mandatory vaccination remains a contentious idea for ethical reasons, and because of its questionable effectiveness. Where vaccinations are a condition of access to certain places or services, the applicability of this requirement is generally limited with various exemptions in place. Vaccination requirements imposed by US states as a condition of school attendance, for example, usually allow for a range of exemptions including religious and personal beliefs as well as medical reasons. From a public health law perspective, where it is proposed to limit fundamental rights such as liberty and freedom of movement in order to prevent the spread of infectious disease, the curtailment of these rights must be both proportionate in relation to the threat to public health, and essential to protect the public interest in preventing disease transmission. If the restrictions imposed on the unvaccinated are sufficiently severe, this may be a form of de facto coercion or mandatory compliance.
Some governments may require vaccination as a condition of entry to protect their residents from the putative risk of infection posed by visitors. A model for this requirement would be the International Certificate of Vaccination or Prophylaxis (ICVP) provided by a WHO approved center. To be administratively feasible, vaccination certificates should have validity for long periods, such as 10 years, which implies the need for a vaccine to have a lasting immune response.
One such scheme commonly referenced is the certification associated with Yellow Fever. Yellow Fever has an effective vaccine which provides lifelong protection for most people, and proof of vaccination is required for entry to a certain, relatively small subset of countries where the disease is prevalent. For those with contraindications, an exemption letter may be awarded. Such a scheme does not entail compulsory vaccination as such: a person retains the right to choose not to be vaccinated, but the consequence of this is that they may be denied entry to the country requiring proof of vaccination.
Given the longstanding acceptance of the Yellow Fever certification scheme, could introducing vaccine passports for COVID-19 as a requirement of international travel be similarly unproblematic? There are substantial differences between the two cases. Yellow fever affects a small number of countries where the disease is endemic, while in the rest of the world it is rare; COVID-19 is currently affecting all countries, even if not equally. As such, COVID-19 vaccine passports would present issues for international mobility generally, rather than entry to specific countries only.
Moreover, availability of COVID-19 vaccines is drastically unequal across countries, and demand will continue to outpace supply for some time to come, with disparities in access being a particular burden in populations in low-income countries. Such populations are already disadvantaged with respect to healthcare generally and further disadvantaged with respect to COVID-19 by having less access to vaccination. Therefore, imposing additional restrictions on freedom of movement could further compound this, resulting in significant perceived injustice.
Further issues arise when accounting for the existence of multiple different vaccines (and multiple routes to manufacture in different countries), which may have different efficacy and persistence. Moving away from one form of vaccine passport to different vaccine type-dependent passports may see certain countries accepting only particular passports potentially exacerbating “vaccine politics”. Recent moves by China to grant preferential immigration access to those who have received Chinese-made vaccines indicate the possibilities for new forms of vaccine nationalism and “vaccine diplomacy”.
Hard or soft coercion: passports as incentives?
It has been suggested that a benefit of introducing a vaccine passport scheme could be its effect in incentivising people to be vaccinated. This simplistic approach fails to engage with the much more complex and nuanced factors affecting vaccine decision-making. To begin with, such an approach assumes that whether or not a person is vaccinated is wholly a matter of their own, completely free choice, rather than dependent on other factors such as their ability to access the vaccine, or their pre-existing health conditions that may interfere with being vaccinated.
Furthermore, for people and groups who may have doubts about the vaccination, for whatever reason, using passports effectively as a means of coercion is liable to amplify mistrust and increase, rather than diminish, resistance. “Vaccine hesitancy” tends to be higher in minority and marginalised groups within society; introducing vaccination as a requirement for people to participate fully in society may deepen inequalities and fuel anti-establishment feelings, rather than promote trust and enable the wellbeing of these groups to be protected.
As seen with other interventions such as mask-wearing and lockdown restrictions, vaccination is already highly politicised. Public health behaviours can rapidly become aligned with ideological differences, and these differences can be amplified and polarised further by the nature of discussion, especially on social media. The implementation of a vaccine passport scheme, and so splitting the population into binary categories, may stigmatise the unvaccinated and restrict their rights. This is likely to lead to even greater polarisation and create deeper social divisions. Social cohesion enables the collective action and solidarity that are essentially required to meet the challenges of infectious disease. Actions which may erode social cohesion may not only dampen collective efforts in the current pandemic but also the next.
Contingencies: vaccination and employment
Similar ethical concerns may attach to employers imposing a requirement for employees to be vaccinated as a condition of work. If the alternative is not to be employed, such a requirement may effectively be a form of coercion, with the burden of that coercion falling particularly on those who are less advantaged. On the other hand, it seems appropriate to require that workers in certain roles involving contact with those particularly vulnerable to infection or high exposure risks to themselves, such as health and social care, should be vaccinated both for their own safety and that of others.
As a contingency of employment in a role, vaccination may form part of the employee health and safety policy. Under Health and Safety, “employers, employees and self-employed have specific duties to protect, so far as reasonable practicable, those at work and others who may be affected by their work activity, such as contractors, visitors and patients” For example, NHS employers may have a policy to reduce exposure to or the consequences of exposure to vaccine-preventable disease for both staff and patients through screening and vaccination. Requirements and recommendations are dependent on the characteristics of and risk posed by the infectious disease, and category of staff based on exposure risk. Framing COVID-19 vaccines in this way may enable us to realise the public health benefits of vaccination in certain industries and sectors while avoiding some of the ethical pitfalls associated with implementing a higher-level vaccine passport scheme across all of society.
When offered a vaccine, the decision-making involves a person “in effect performing complex cost-benefit analysis based on imperfect assumptions.”. The benefits of vaccination were set out in Box 1. The costs can include time, inconvenience, side effects, and money including travel, child minding, and lost work. To improve take-up is then to improve the understanding of the associated costs and benefits, and where possible reduce associated costs. These public health practices can be considered as nudges, reducing the threshold in the decision-making process so that the easier choice is aligned to the individual and collective benefit, while still respecting an individual’s right to choose.
For example, the NHS has a programme of incentives encouraging health and care staff to take up the annual flu vaccination, ranging from community acknowledgement to leadership praise. The COVID-19 vaccination roll-out in NHS England staff has been treated in a similar way to that for annual flu (where take-up is generally around 75%). NHS England has called for staff managers to have one-to-one conversations to improve understanding of the ‘powerful protective effects’ of vaccination.
Other employers are considering the provision of incentives for health promotion, such as gift certificates or a full-pay day off to reduce the associated cost of vaccine side-effects. For the self-employed the government could consider a one-off payment similar in concept, if not in value, to the payment for isolation. Again, such incentives should be carefully evaluated in terms of their potential for coercion and effects on inequality. Support to meet the costs of making a choice that benefits individual and public health is likely to help address inequalities; additional incentives, particularly if significant, may start to compromise the freedom of that choice. Even without provision of direct incentives, employers may still be able to assist with vaccine promotion through providing easy access to appropriate information or one-to-one discussions via occupational health services.
These nudging interventions can be focused at the individual level but there are also collective nudges such as public holidays to mark important moments in time (i.e. a level of vaccine take-up). Another collective intervention is education. A key issue affecting decision-making is misunderstanding of collective benefits and individual risk of infection. Not perceiving COVID-19 as a personal risk may tip the scales where prevalence or consequences of infection are not well understood.
Where there is less appreciation for the collective benefits, an individual may also be less inclined to take the associated costs (as mentioned above). A fundamental public health response is education as it enables individuals to make informed choices. It can also enable the robust critique required to disable misinformation, a threat to vaccine take-up. These interventions can take many forms such as school and university awareness, regular training for key workers, health & safety representatives, and society decision-makers such as local and national politicians. Not only does this improve our approach to this pandemic, but also the next.
Approaches to manage risk at individual and population level must be appropriate to the nature of the threat. Social cohesion is a vital component in pandemic response, and any actions being considered should have regard to this aspect. Simplistic vaccination passport strategies may be less effective than hoped in increasing vaccine take-up and reducing infectivity, while damaging social cohesion (with various undesirable longer-term and/or indirect effects). Encouraging vaccine take-up through ‘nudging’ strategies may be more effective.
28 April 2021
 Ganguli Mitra, A. et al. (2020) Segmenting communities as public health strategy: a view from the social sciences and humanities. Wellcome Open Research 5:104 https://wellcomeopenresearch.org/articles/5-104
 Brown, R. et al. (2020) Passport to freedom? Immunity passports for COVID-19. Journal of Medical Ethics 46:652-659.
 de Togni, G. et al. (2020) Imagining life with immunity passports: Managing risk during a pandemic. Discover society, https://archive.discoversociety.org/2020/06/01/imagining-life-with-immunity-passports-managing-risk-during-a-pandemic/
 See de Miguel Beriain, I. and Rueda, J. Immunity passports, fundamental rights and public health hazards: a reply to Brown et al. Journal of Medical Ethics 2020;46:660-661.
 https://www.southernhealth.nhs.uk/EasysiteWeb/getresource.axd?AssetID=73504&type=full&servicetype=Inline / https://occupationalhealthportsmouth.nhs.uk/occupational-vaccinations/ / https://www.workingwellglos.nhs.uk/wp-content/uploads/2017/02/Countywide-Staff-Screening-and-Immunisation-Policy.pdf
 https://www.shrm.org/resourcesandtools/legal-and-compliance/employment-law/pages/employers-offer-covid-19-vaccine-incentives.aspx / https://www.forbes.com/sites/edwardsegal/2021/01/16/covid-vaccination-incentives-the-risks-and-rewards-for-employers/?sh=3770c48a2d5b