Medical exemptions to mandatory vaccinations: The state of play in Australia and a pressure point to watch.

Australia's mandatory vaccination policies have historically allowed for non-medical exemptions (NMEs), but this changed in 2016 when the Federal Government discontinued NMEs for childhood vaccination requirements. Australian states introduced further mandatory vaccination policies during the COVID-19 pandemic for a range of occupations including healthcare workers (HCWs). There is global evidence to suggest that medical exemptions (MEs) increase following the discontinuation of NMEs; the new swathe of COVID-19 mandatory vaccination policies likely also placed further pressure on ME systems in many jurisdictions. This paper examines the state of play of mandatory vaccination and ME policies in Australia by outlining the structure and operation of these policies for childhood vaccines, then for COVID-19, with a case study of HCW mandates. Next, the paper explores HCWs' experiences in providing vaccine exemptions to patients (and MEs in particular). Finally, the paper synthesizes existing literature and reflects on the challenges of MEs as a pressure point for people who do not want to vaccinate and for the clinicians who care for them, proposing areas for future research and action.

Policy Feedback and the Politics of Childhood Vaccine Mandates: Conflict and Change in California, 2012-2019.

CONTEXT: In 2012, California instituted a new requirement for parents to consult with a clinician before receiving a personal belief exemption to its school entry vaccine mandate. In 2015, the state removed this exemption altogether. In 2019, legislators cracked down on medical exemptions to address their misuse by vaccine refusers and supportive clinicians. This paper explores these political conflicts using 'policy feedback theory,' arguing that personal belief exemptions informed the emergence and approaches of two coalitions whose conflict reshaped California's vaccination policies. METHODS: We analysed legal, policy, academic and media documents; interviewed ten key informants; and deductively analysed transcripts using NVivo 20 transcription software. FINDINGS: California's long-standing vaccination policy inadvertently disseminated two fundamentally incompatible social norms: vaccination is a choice; vaccination is not a choice. Over time, the culture and number of vaccine refusers grew, at least in part because the policy state-sanctioned the norm of vaccine refusal. CONCLUSIONS: The long-term consequences of California's 'mandate + PBE' policy - visible, public, and socially sanctioned vaccine refusal - undermined support for it over time, generating well-defined losses for a large group of people (the vaccinating public) and specifically for the parent activists whose experiences of personal grievance drove their mobilisation for change.

West Australian parents' views on vaccinating their children against COVID-19: a qualitative study.

BACKGROUND: Australian children and adolescents were among the last local cohorts offered COVID-19 vaccines. Despite promising initial uptake, coverage subsequently plateaued, requiring further efforts to improve access and build parents' recognition of the importance of COVID-19 vaccination. We sought to understand West Australian (WA) parents' willingness to vaccinate their children to inform strategies for improving uptake at the time in which they were becoming eligible. METHODS: We undertook in-depth qualitative interviews with 30 parents of children aged 5-17 years from June - December 2021. During this period, children aged 12-15 years became eligible for vaccination; children aged 5-11 years became eligible shortly thereafter. Data were thematically analysed in NVivo. RESULTS: Most parents intended on vaccinating their children once eligible. Parents sought to protect their children, to protect the community, to resume travel, and to get back to "normal". They reflected that vaccination against key infectious threats is a routine activity in childhood. Some were concerned about the vaccine, particularly mRNA vaccines, being new technology or impacting fertility. "Wait-awhiles" wanted to see what other parents would do or were delaying until they felt that there was a higher risk of COVID-19 in WA. Most parents of younger children wanted their child to be vaccinated at the general practice clinic due to familiarity and convenience. Parents were particularly eager for clear and consistent messaging about vaccination of children and adolescents, including safety, importance, scientific evidence, and personal stories. CONCLUSION: For future pandemic vaccinations pertaining to children, governments and health officials need to address parents' concerns and meet their preferences for the delivery of the vaccine program to children and adolescents.

Parents' COVID-19 vaccine intentions for children under 5 years: Brief reflections from a qualitative study.

AIM: Australian authorities made COVID-19 vaccines available for children aged under 5 years old with serious comorbidities in August 2022. There is presently no universal programme for young children, but crucial to any rollout's success is whether parents are motivated and able to vaccinate. By examining parents' vaccine intentions, this study aims to inform current and future COVID-19 vaccine roll-outs for children aged under 5 years. METHODS: As part of the mixed methods project 'Coronavax: Preparing Community and Government' we interviewed 18 Western Australian parents of young children about their intentions in late 2021. RESULTS: Two thirds intended to vaccinate if and when they could, with one third intending to delay for reasons including risk and safety perceptions, fears about side effects and influence from their social networks. However, even those choosing to delay were waiting rather than refusing. CONCLUSIONS: To improve uptake, targeted messaging should emphasise that COVID-19 can be a serious disease in young children, with such messaging drawing on the reputability and esteem of scientific and technical authorities. Such messaging should be oriented towards parents of children with serious comorbidities at the present time. It will be important to emphasise that government vaccine recommendations are based on supporting families to protect their children and keep them healthy.

Making salient ethics arguments about vaccine mandates: A California case study.

Vaccine mandates can take many forms, and different kinds of mandates can implicate an array of values in diverse ways. It follows that good ethics arguments about particular vaccine mandates will attend to the details of individual policies. Furthermore, attention to particular mandate policies-and to attributes of the communities they aim to govern-can also illuminate which ethics arguments may be more salient in particular contexts. If ethicists want their arguments to make a difference in policy, they should attend to these kinds of empirical considerations. This paper focuses on the most common and contentious vaccine mandate reform in the contemporary United States: the elimination of nonmedical exemptions (NMEs) to school and daycare vaccine mandates. It highlights, in particular, debates about California's Senate Bill 277 (SB277), which was the first successful recent effort to eliminate NMEs in that country. We use media, secondary sources, and original interviews with policymakers and activists to identify and evaluate three ethics arguments offered by critics of SB277: parental freedom, informed consent, and children's rights to care and education. We then turn to one ethics argument often offered by advocates of SB277: harm prevention. We note, however, that three arguments for mandates that are common in the immunization ethics literature-fairness/free-riding, children's rights to vaccination, and utilitarianism-did not play a role in debates about SB277.

'I'm provax': Pro-vaccination personal histories and socialities of older Australians in the COVID-19 pandemic.

Vaccination scholarship often explores how social networks foster vaccine refusal and delay, revealing how social and institutional relations produce refusing or delaying parents and un- or under-vaccinated children. It is likewise critical to understand the development of pro-vaccination orientations by researching those who want to be vaccinated since such attitudes and associated practices underpin successful vaccination programmes. This article explores pro-vaccination sociality, personal histories and self-understandings during the COVID-19 pandemic in Australia. We draw upon 18 in-depth interviews with older Western Australians, documenting how they articulate 'provax' identities in opposition to those they depict as 'antivax' others. Provax identities were clearly anchored in and solidified through social relations and personal histories, as interviewees spoke of 'likeminded' friends and families who facilitated each other's vaccinations and referenced childhood experiences of epidemics and vaccinations. Access barriers relating to the vaccine programme drove interviewees to reimagine their provax status in light of not yet being vaccinated. Thus, interviewees' moral and ideological understandings of themselves and others were interrelated with supply-side constraints. We examine the development of self-proclaimed 'provaxxers' (in a context of limited access); how they imagine and enact boundaries between themselves and those they deem 'antivax'; and possibilities for public health research.

Childhood vaccine refusal and what to do about it: a systematic review of the ethical literature.

BACKGROUND: Parental refusal of routine childhood vaccination remains an ethically contested area. This systematic review sought to explore and characterise the normative arguments made about parental refusal of routine vaccination, with the aim of providing researchers, practitioners, and policymakers with a synthesis of current normative literature. METHODS: Nine databases covering health and ethics research were searched, and 121 publications identified for the period Jan 1998 to Mar 2022. For articles, source journals were categorised according to Australian Standard Field of Research codes, and normative content was analysed using a framework analytical approach. RESULTS: Most of the articles were published in biomedical journals (34%), bioethics journals (21%), and journals that carry both classifications (20%). Two central questions dominated the literature: (1) Whether vaccine refusal is justifiable (which we labelled 'refusal arguments'); and (2) Whether strategies for dealing with those who reject vaccines are justifiable ('response arguments'). Refusal arguments relied on principlism, religious frameworks, the rights and obligations of parents, the rights of children, the medico-legal best interests of the child standard, and the potential to cause harm to others. Response arguments were broadly divided into arguments about policy, arguments about how individual physicians should practice regarding vaccine rejectors, and both legal precedents and ethical arguments for vaccinating children against a parent's will. Policy arguments considered the normative significance of coercion, non-medical or conscientious objections, and possible reciprocal social efforts to offset vaccine refusal. Individual physician practice arguments covered nudging and coercive practices, patient dismissal, and the ethical and professional obligations of physicians. Most of the legal precedents discussed were from the American setting, with some from the United Kingdom. CONCLUSIONS: This review provides a comprehensive picture of the scope and substance of normative arguments about vaccine refusal and responses to vaccine refusal. It can serve as a platform for future research to extend the current normative literature, better understand the role of cultural context in normative judgements about vaccination, and more comprehensively translate the nuance of ethical arguments into practice and policy.

Antibiotics online: digital pharmacy marketplaces and pastiche medicine.

The internet enables access to information and the purchasing of medical products of various quality and legality. Research and regulatory attention have focused on the trafficking of illicit substances, potential physical harms of pharmaceuticals, and possibilities like financial fraud. However, there is far less attention paid to antibiotics and other antimicrobials used to treat infections. With online pharmacies affording greater access, caution around antibiotic use is needed due to the increasing health risks of antimicrobial resistance (AMR). The COVID-19 pandemic has helped to normalise digital healthcare and contactless prescribing, amplifying the need for caution. Little is known of how antibiotics are consumed via digital pharmacy and implications for AMR prevention. To expand insight for AMR prevention policy in Australia and internationally, we use digital ethnographic methods to explore how digital pharmacies function in the context of health advice and policy related to AMR, commonly described as antimicrobial stewardship. We find that digital pharmacy marketplaces constitute 'pastiche medicine'. They curate access to pharmaceutical and information products that emulate biomedical authority combined with emphasis on the 'self-assembly' of healthcare. Pastiche medicine empowers the consumer but borrows biomedical expertise about antibiotics, untethering these goods from critical medicine information, and from AMR prevention strategies. We reflect on the implications of pastiche medicine for AMR policy, what the antibiotics case contributes to wider critical scholarship on digital pharmacy, and how medical humanities research might consider researching online consumption in future.

'Corona is coming': COVID-19 vaccination perspectives and experiences amongst Culturally and Linguistically Diverse West Australians.

BACKGROUND: Culturally and Linguistically Diverse (CALD) groups within high-income countries are at risk of being left behind by the COVID-19 vaccination rollout. They face both access and attitudinal barriers, including low trust in government and health authorities. OBJECTIVE: To explore perceptions and attitudes towards COVID-19 vaccination, as well as facilitators, barriers and strategies to promote uptake among CALD residents of Western Australia (WA), where there were almost no COVID-19 cases for 2 years. DESIGN AND PARTICIPANTS: Perth, WA's capital, was chosen as the state's study site because most of the state's CALD population lives there. Eleven semistructured in-depth interviews and three focus groups (with 37 participants) were conducted with CALD residents between August and October 2021. Thematic analysis was conducted, informed by the 'Capability', 'Opportunity', 'Motivation', 'Behaviour' model. RESULTS: CALD participants faced barriers including a lack of knowledge about COVID-19 and the vaccines, low self-rated English proficiency and education levels, misinformation, passive government communication strategies and limited access to vaccine clinics/providers. They were, however, motivated to vaccinate by the imminent opening of state and international borders, trust in government and healthcare authorities, travel intentions and the desire to protect themselves and others. CONCLUSIONS: Despite high levels of trust and significant desire for vaccines among CALD communities in Perth, current strategies were not meeting their needs and the community remains at risk from COVID-19. Tailored intervention strategies are required to provide knowledge, address misinformation and facilitate access to ensure uptake of COVID-19 vaccines-including for additional doses-amongst CALD communities. Governments should work with trusted CALD community members to disseminate tailored COVID-19 vaccine information and adequately translated resources. PATIENT OR PUBLIC CONTRIBUTION: The Wesfarmers Centre of Vaccines and Infectious Diseases Community Reference Group at Telethon Kids Institute consulted on this project in September 2020; Ishar Multicultural Women's Health Services consulted on and facilitated the focus groups.

Communication Is Not a Virus: COVID-19 Vaccine-Critical Activity on Facebook and Implications for the 'Infodemic' Concept.

In February 2020 the World Health Organization declared an 'infodemic' in relation to COVID-19. The label infers that people are being contaminated by 'misinformation' as they would be by a virus. However, this metaphor conveys a simplistic empirical understanding of communication, which may encourage 'information control' responses. This article argues for the importance of understanding the diverse factors that impact the effectiveness of communication - including the context in which it is received, and the emergent properties created through communication processes. Analyzing 'vaccine-critical' Facebook activity in Australia between 1 December 2020 and 28 February 2022, we find that controlling access to or censoring vaccine-critical misinformation does not lead to a reduction in vaccine-critical narratives. Rather, discussions continue based on more tenable political and social arguments. Further, bans antagonize vaccine-critical Facebook users and encourage them to move to other platforms where they may be radicalized. Crucially, recruitment to vaccine-critical sites accelerated following both bans of 'misinformation' and the introduction of vaccine mandates, suggesting that such responses can lead to increased discontentment. Accordingly, we call for researchers, policy makers and media platforms to engage with a more nuanced view of communication, acknowledging the powerful role of audiences' uses and gratifications in determining the effectiveness of public health messaging.

Imperfect Immunization Communication on School District Websites: A Mixed-Methods Review.

Schools and school districts are key to U.S. vaccination policies: They communicate immunization enrollment requirements and enforce them during registration. This article presents a mixed-methods study of how Michigan's 537 districts communicate about vaccine mandates through public-facing websites. It reports the results of a qualitative analysis (n = 50) of websites from Southeast Michigan and a quantitative analysis of all (n = 537) Michigan's district websites. School district websites engage in diverse health promotion practices surrounding immunization, from encouraging vaccination to neutral messaging and to encouraging exemptions. Most provide scant immunization information and few promote the importance of immunization for individual and community health. We recommend that school nurses, district staff, and health authorities collaborate to ensure that school district communication promotes immunization and does not promote nonmedical exemptions. This can lead schools to embrace immunization as an essential activity for their own functioning rather than as an unwelcome requirement imposed by outside agents.

We're all in this together, but for different reasons: Social values and social actions that affect COVID-19 preventative behaviors.

We examined how personal values, beliefs and concerns about COVID-19, and socio-demographics, relate to two important COVID-19 preventative behaviors: willingness to get vaccinated for COVID-19 and social distancing, in 1413 Australian adults. As expected, social focus values influenced the extent of compliance with these preventative behaviors, even when controlling for beliefs and concerns about COVID-19 and socio-demographics. We also examined the persuasiveness of four different value-expressive messages promoting social distancing, in a subsample of 737 Australian adults. We found that the message expressing self-transcendence values was ranked most persuasive by 77% of respondents. However, as hypothesized, personal values were related to message persuasiveness. As the importance ascribed to social focus values increased, the likelihood that the self-transcendence message was ranked as most persuasive increased. In contrast, the likelihood that the openness to change message was ranked as most persuasive increased for those who ascribed lesser importance to social focus values. Our findings can help the framing of government messaging around preventative behaviors, including maintaining social distancing in vaccinated populations who may still spread the disease, and preventing COVID-19 spread by or to vaccine refusers.

Designing a multi-component intervention (P3-MumBubVax) to promote vaccination in antenatal care in Australia.

ISSUE ADDRESSED: Coverage of maternal influenza and pertussis vaccines remains suboptimal in Australia, and pockets of low childhood vaccine coverage persist nationwide. Maternal vaccine uptake is estimated to be between 35% and 60% for influenza vaccination and between 65% and 80% for pertussis vaccination. Australian midwives are highly trusted and ideally placed to discuss vaccines with expectant parents, but there are no evidence-based interventions to optimise these discussions and promote maternal and childhood vaccine acceptance in the Australian public antenatal setting. METHODS: We gathered qualitative data from Australian midwives, reviewed theoretical models, and adapted existing vaccine communication tools to develop the multi-component P3-MumBubVax intervention. Through 12 interviews at two Australian hospitals, we explored midwives' vaccination attitudes and values, perceived role in vaccine advocacy and delivery, and barriers and enablers to intervention implementation. Applying the theory-based P3 intervention model, we designed intervention components targeting the Practice, Provider and Parent levels. Midwives provided feedback on prototype intervention features through two focus groups. RESULTS: The P3-MumBubVax intervention includes practice-level prompts and identification of a vaccine champion. Provider-level components are a vaccine communication training module, learning exercise, and website with printable fact sheets. Parent-level intervention components include text message reminders to receive influenza and pertussis vaccines in pregnancy, as well as online information on vaccine safety, effectiveness and disease severity. CONCLUSIONS: The P3-MumBubVax intervention is the first Australian antenatal intervention designed to support both maternal and childhood vaccine uptake. A pilot study is underway to inform a planned cluster randomised controlled trial. SO WHAT?: Barriers to vaccine acceptance and uptake are complex. The P3 model is a promising evidence-informed multi-component intervention strategy targeting all three levels influencing health care decision-making.

Childhood Vaccination Mandates: Scope, Sanctions, Severity, Selectivity, and Salience.

Policy Points We offer the first systematic conceptual framework for analyzing the operation of mandatory vaccination policies. Our multicomponent framework facilitates synthesis judgments on single issues of pressing concern to policymakers, in particular, how mandatory vaccination policies motivate people to vaccinate. We consider the impact of each component of our framework on persons who remain unvaccinated for different reasons, including complacency, social disadvantage, and more or less committed forms of refusal. CONTEXT: In response to outbreaks of vaccine-preventable disease and increasing rates of vaccine refusal, some political communities have recently implemented coercive childhood immunization programs, or they have made existing childhood immunization programs more coercive. Many other political communities possess coercive vaccination policies, and others are considering developing them. Scholars and policymakers generally refer to coercive immunization policies as "vaccine mandates." However, mandatory vaccination is not a unitary concept. Rather, coercive childhood immunization policies are complex, context-specific instruments. Their legally and morally significant features often differ, and they are imposed by political communities in varying circumstances and upon diverse populations. METHODS: In this paper, we introduce a taxonomy for classifying real-world and theoretical mandatory childhood vaccination policies, according to their scope (which vaccines to require), sanctions and severity (which kind of penalty to impose on vaccine refusers, and how much of that penalty to impose), and selectivity (how to enforce or exempt people from vaccine mandates). FINDINGS: A full understanding of the operation of a vaccine mandate policy (real or potential) requires attention to the separate components of that policy. However, we can synthesize information about a policy's scope, sanctions, severity, and selectivity to identify a further attribute-salience-which identifies the magnitude of the burdens the state imposes on those who are not vaccinated. CONCLUSION: Our taxonomy provides a framework for forensic examination of current and potential mandatory vaccination policies, by focusing attention on those features of vaccine mandates that are most relevant for comparative judgments.

Vaccine mandates, value pluralism, and policy diversity.

Political communities across the world have recently sought to tackle rising rates of vaccine hesitancy and refusal, by implementing coercive immunization programs, or by making existing immunization programs more coercive. Many academics and advocates of public health have applauded these policy developments, and they have invoked ethical reasons for implementing or strengthening vaccine mandates. Others have criticized these policies on ethical grounds, for undermining liberty, and as symptoms of broader government overreach. But such arguments often obscure or abstract away from the diverse values that are relevant to the ethical justifications of particular political communities' vaccine-mandate policies. We argue for an expansive conception of the normative issues relevant to deciding whether and how to establish or reform vaccine mandates, and we propose a schema by which to organize our thoughts about the ways in which different kinds of vaccine-mandate policies implicate various values.