My work as an emergency medicine physician has taken me to urban and rural areas on both coasts and in the middle of the country. No matter where I see patients, I hear excuses like these for not getting immunized against influenza:
- “Flu shots don’t work.”
- “I got the vaccination once and it made me sick.”
- “We don’t believe in vaccination.”
- “Vaccination is dangerous.”
It puzzles me, then, that they’ve come to the emergency department because they are feeling awful with fever, chills, cough, body aches, and fatigue — in other words, with the flu — expecting a fix for something that could have been easily prevented.
Indeed, 43% of Americans forgo getting vaccinated against influenza. That doesn’t bode well for the highly anticipated vaccine against coronavirus, something that President Donald Trump has said we might have by the end of the year, though others say it will take longer.
To achieve herd immunity, which makes it more difficult for an infectious disease to spread through a population, 80% or more of us need to be immune to Covid-19, either because we’ve been infected with the virus that causes it or we’ve gotten the vaccine against it.
I fear that many Americans will resist getting vaccinated against the SARS-CoV-2 coronavirus even after having been bombarded by news reports of the number of cases (more than 1.3 million in the U.S. as I write this) and the number of deaths (more than 80,000), or having seen images of refrigerated trucks in New York City storing the bodies of people who died of Covid-19.
To put this scourge behind us, I believe that our nation should, for the first time ever, require all Americans — or at least schoolchildren and workers in direct-contact jobs — to be vaccinated against this coronavirus.
Scientists are moving at “Warp Speed” to develop a coronavirus vaccine. Researchers at the University of Oxford intend to try one on 6,000 people by the end of May. The NIH has created a partnership with 16 pharmaceutical companies to speed vaccine development.
That means we need to develop vaccination policies and programs now, since they will take time to enact.
Here’s what I think we should do:
Create a federally mandated vaccination policy. No federal laws require vaccination, and states have a smorgasbord of policies.
A 1905 Supreme Court decision established the constitutionality of compulsory state vaccination laws to protect the public health. Although all 50 states and the District of Columbia now require diphtheria, tetanus, pertussis, polio, measles, rubella, and varicella vaccinations before attending public school, all also offer a variety of vaccine exemptions for medical, religious, and philosophical reasons. Only 11 states can override these exemptions in an outbreak. Court decisions, including from the Supreme Court, have upheld both state-imposed fines for refusing to be vaccinated and the exclusion of unvaccinated children from schools.
Because people often travel across state lines, we need a unified national approach, perhaps something like the military’s Army Medicine 2020 initiative, which requires vaccination but also allows for rigorously controlled exemptions that are medical (such as pregnancy), religious (in consultation with a chaplain), and administrative (such as plans to leave the military).
Test, test, test. The only way that individuals should be allowed not to get the vaccine against SARS-CoV-2 is to prove they’ve been infected with it. Testing for the presence of the virus, the antibodies to it, or both, will need to be proven, accurate, and available to everyone.
Make influenza and coronavirus vaccinations mandatory for public school children. Only five states — New York, California, Maine, Mississippi, and West Virginia — have eliminated religious and philosophical vaccination exemptions for children entering public kindergarten. This applies to the standard childhood immunizations only and does not include influenza. In fact, only one state, Connecticut, requires influenza vaccination for public school attendance. Only a few states require flu vaccination for day care and pre-K attendance. While I respect individual health care choices and acknowledge that some citizens will not avail themselves of the protection afforded by a vaccine, the enormity of the Covid-19 pandemic demands that the welfare of the community take precedence and all children be vaccinated against the virus that causes this disease.
Require vaccination for workers in direct-contact jobs. Health care workers are the only adults in the U.S. required either by state law or individual employers to be vaccinated against the flu, though they can file an exemption and instead wear a mask at work from October through March. (For coronavirus, that might mean wearing one year-round.) Requiring immunization for a broader range of people with direct-contact jobs, like those working in restaurants and food stores, flight attendants, hair stylists and barbers, nail salon workers, teachers, and others, would decrease the spread of infection and the resulting hospitalizations and deaths.
This is especially important for the coronavirus because it has a higher viral load in the nose, mouth and throat, making transmission more likely via a simple conversation or a sneeze. In one recent study, 71% of individuals who tested positive for Covid-19 but who had no symptoms had detectable levels of SARS-CoV-2 up to six days before becoming ill.
Make the vaccine easier to get. One key to widespread uptake of vaccination against SARS-CoV-2 is making it as easy as possible for people to get it, like buying groceries or filling up a gas tank. Here are a few ways to do that:
- Combine the coronavirus vaccine with another one (like influenza) and package them in a form that patients can take on their own.
- Allow it to be administered to individuals with low-grade symptoms. Tetanus immunization has been wildly successful in part because we administer the vaccination when someone is being seen for a wound, not weeks later when it has healed.
- Make coronavirus vaccination available in all health care facilities, physicians’ offices (no matter what the specialty), local health departments, and emergency or urgent care facilities. Make it clear that any physician or advanced practice provider can administer a vaccine.
- Offer vaccinations in workplaces, schools, pharmacies, and community organizations. That could mean visits from mobile teams (perhaps run by medical school students as part of their public health training) to provide immunizations.
- Make vaccinations inexpensive. Instead of costing as much as $70, the price tag for a high-dose influenza vaccination for seniors, the cost of a coronavirus vaccine should be affordable for all. Stores like Walmart, with its $4 medication list, could add immunizations and offer them as people come in to pick up their prescriptions.
To add one more incentive, health insurers should require either a test result showing immunity to influenza and coronavirus or proof of vaccination in exchange for full coverage. We all pay for those who eschew prevention but who then seek medical care when they become ill.
Finally, we should do a better job of teaching kids about the value of vaccination so they can make good choices. Misinformation is the enemy of good public health.
We can’t afford another pandemic with millions sick or dying, a health care system stretched beyond its limits, and a devastated economy. Immunization for all is a simple way to prevent that from happening.
Lauren S. Grossman is a physician, assistant professor of emergency medicine at the University of Colorado School of Medicine, and medical director of the university’s Integrative Medicine Center. The opinions expressed here are her own and do not necessarily represent those of the University of Colorado or UCHealth.