Is it time to rethink vaccine mandates for dining, fitness and events?

This article by Liam Petterson Deputy Editor, Health + Medicine, The Conversation Australiawas originally published in The Conversation on February 4.

The requirement to show proof of two doses of a COVID vaccine to do things such as eat out, go to the pub and visit sporting events is still in place across parts of the country including Victoria, Queensland and Western Australia.

Part of the rationale for such mandates is to limit transmission of the virus, and therefore also protect vulnerable people who may be at risk of severe disease.

But the arrival of the Omicron variant has changed the COVID landscape in Australia. Emerging evidence suggests two doses of COVID vaccine provides little protection against infection against the highly-infectious Omicron variant – though they’re still effective against severe disease.

So we asked five experts, is it time to rethink vaccine mandates for dining, fitness and events?

Here is what they said:

Associate Professor Holly Seale, from School of Population Health at the University of NSW

YES. During our interviews with people who remain unvaccinated, participants expressed an overwhelming sense they continue to be’pressured’ and there is absolutely no balance in conversations about the COVID vaccination.

Perhaps unsurprisingly, the issues of mandates comes up. For those who remain unvaccinated, there are many reasons why they have chosen that path. Based on what we have heard during these interviews, mandates are certainly not going to incentivise or nudge the people towards vaccination. Probably it is more likely to nudge them to sit outside on the lawns at parliament in Canberra.

This concern is echoed in a recent article which suggested the potential unintended consequences of COVID vaccine policies can include erosion of trust and polarisation.

But does that mean mandates should be removed?

Just like any other public health intervention, there needs to be ongoing review and adjustments to account for changes in risk, burden of infection and potential (and often unintended) impact of the intervention.

Remembering Omicron won’t be the last variant, there also needs to be ongoing reflection about occupational risk (including to staff and those who frequently the venue / site) and engagement with those who are affected by mandates.

Associate Professor Katie Attwell, from The University of Western Australia’s School of Social Sciences

NO. Considerations about vaccine mandates need to be context-specific. That context includes the amount of disease in the community, the effectiveness of the doses of vaccine mandated against current strains, and the local political context (public opinion and acceptability of mandates).

Other factors matter too: what is the impact of adding, removing, or changing mandates on the population?

My views are also indelibly shaped by being a West Australian and our local situation.

Currently, COVID vaccines protect the individual against severe disease more effectively than they limit spread. Meanwhile, the strongest justification for mandates draws from the ability of vaccines to prevent the spread of disease to vulnerable people.

However, even a limited reduction in transmission reduces the risk of illness (and hence serious illness) for others.

Given the much higher effectiveness of adding in that third dose, we may need to consider re-defining what it means to be’fully vaccinated’. The WA government has already done this for workplace man dates.

Global lessons from childhood vaccination indicate we should remove mandates with care. Removal may send a message that vaccination is no longer important. Governments need to be very careful about introducing mandates precisely because they are so challenging to jettison!

If a third dose is added to mandates, governments will need to provide the population with a careful and considered communication campaign as to why this is necessary and legitimate.

My unpublished research indicates we should not assume people who have had two doses will be equally happy to keep having further doses.

Professor Catherine Bennett, Chair in Epidemiology at Deakin University

YES. Mandating vaccines for certain venues was introduced when most Australians had not been infected, so our immunity was primarily vaccine-induced. The dominant variant at that time was Delta and, while the protection from infection offered by the first two vaccine doses was known to wane , more than half our vaccinated adult population was still within the first few months of their second dose.

So they had good protection, with a 70-80% lower risk of symptomatic infection than an unvaccinated person. Opening venues with the virus still circulating by restricting them to fully vaccinated adults was arguable on epidemiological grounds.

But then two important things changed. First, unvaccinated people were over-represented among cases in the Delta outbreak and so the proportion of the population who have no acquired immunity from either vaccination or infection shrunk.

Then, Omicron emerged as an immune-escape variant with the first two doses offering less than 20% protection against symptomatic infection. Peak Omicron infection rates based on reported case numbers in New South Wales were 30 times higher than the Delta peak, further reducing the number of unvaccinated people without any immunity.

The booster restores protection against symptomatic infection with Omicron to over 60%, but given the small number in the population who either haven’t been infected or vaccinated, there is little to be gained from having vaccine mandates in place.

Professor Julian Savulescu, visiting professor in Biomedical Ethics at Murdoch Children’s Research Institute; Distinguished Visiting Professor in Law, University of Melbourne

YES. Arnold Schwarzenegger is reported to have interrupted actor Zach Braff’s workout to tell him,’You need to eat a lot of carrots.’

Imagine the government restricted entry to McDonald’s to overweight people telling them,’You need to go home and eat more carrots’. Even if a healthy behavior should be promoted and encouraged, a mandate is different.

There are two justifications for vaccine passports. Firstly, they stop transmission. They stop one individual harming another.

That does not apply to current COVID vaccines – they are relatively poor at preventing transmission, especially of the dominant Omicron strain. UK data puts effectiveness of two doses against symptomatic Omicron at 0-10% at six months.

Although the booster restores this, the effectiveness against symptomatic infection also appears to be waning in the time frame available.

Secondly, they stop too many people getting seriously ill at a time the health system is in crisis. If ICU is nearly full, one person requiring ICU may stop another person being admitted.

Whether this justifies COVID vaccine mandates turns on whether the health system is at breaking point.

Otherwise, it is like turning overweight people away from McDonald’s or stopping people drinking alcohol because they might put a burden on the health system. It is right to encourage and promote healthy behaviors. But to single out the unvaccinated for mandates, if there is not an extraordinary health system crisis, is to discriminate against them.

Even if the health system is in crisis, general vaccine mandates are unlikely to be justified. Hospitalisation risk increases substantially with age. The only vaccine mandates that are likely to be justified are selective mandates for the elderly – but they are likely to take the vaccine voluntarily because it is strongly in their interests.

Professor Tony Blakely, from School of Population and Global Health, The University of Melbourne

YES. Mandates should be used during times of severe infection but not on an ongoing basis.

Omicron infections are passing through, and the time for measures that flatten the curve of infections to prevent pressure on health systems is largely past in probably all states and territories other than Northern Territory and Western Australia (and New Zealand).

So we need to rethink and plan for what’s next.

But it’s up to chance how severe it will be. Hopefully any new variants will be more infectious, but not highly severe. – But we need plans for the worst case scenario of a variant that’s more infectious and more severe.A key part of that plan is having levers ready to pull, when we need them. Key levers include:

• vaccine passports and mandates. There should soon be a requirement for three doses. But in six months or so, it might be something like’having had at least one dose of a next generation vaccine that offers wider protection than previous vaccines’
• standard restrictions on mobility and social contact we are all too familiar with
• mass-masking – with higher quality N95 and KN95 masks
• mass deployment of rapid antigen tests.

Going forward we need structures and mechanisms in place and ready to go if we need them. That includes vaccine passports and mandates. But that does not mean vaccine passports and mandates are’turned on’all the time. Rather, they are just activated if we need them. Part of pandemic planning is to ensure we have those mechanisms ready to go, should we need them.

Back to today. It makes sense, in east Australia at least, to be cautious about school return. I doubt we will see much of a kick up in transmission of Omicron due to schools returning, but I support the four week plans of ventilation, twice weekly rapid antigen tests of children, and such like – to be sure.

Otherwise, we can soon ease off further on restrictions – and not even require vaccine passports – as Omicron passes. But we need to be ready to turn measures back on with a new variant.

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