Dear Editor,

Despite the existence of a number of vaccines developed to prevent infection by coronavirus disease 2019 (COVID-19), the pandemic continues, having already claimed more than 4.5 million lives to date, even though 5.2 billion doses of vaccines have been administered.1 This suggests that vaccines alone cannot control COVID-19, and government-imposed stringency measures and policies, such as those related to social distancing and masking, are still needed.2 Stringency measures affect education, work, travel, and social events, all of which are intricately linked to personal freedoms. How can vaccinations and other measures such as masking be mandated while reducing the accumulation of stress and anxiety caused by their long-term imposition,3 and still respect personal freedoms and choices, including movement?

Social distancing might only be mandated in the absence of effective vaccine campaigns, i.e., lack of containment due to insufficient voluntary choice hampering the achievement of population immunity.4 Given that receiving a COVID-19 is not risk-free, and that there are vaccine-related deaths, and risks for those who may suffer allergic reactions, the socio-economic benefits of a vaccine still outweigh the risks.5 Even though a workplace-wide vaccination campaign among healthcare workers might offer a safer working environment for hospital staff and patients, congregation members in a religious setting, or business clients (e.g., in the hotel, restaurant, and travel industry), with exceptions based on valid religious or disability-related reasons, there are still legal and ethical considerations of mandating a vaccine, which becomes difficult to impose absent long-term safety data.6 In a school vaccination campaign, data related to immunogenicity, transmission, and morbidity is needed, as is acceptance by parents/caregivers, the community, and the public.7 A vaccine passport or COVID-19 vaccination certificate for access to an airplane, restaurant, or concert; for example, might be perceived by unvaccinated individuals as an unfair advantage to those who are vaccinated.8

Knowing that the SARS-CoV-2 continues to be transmissible makes it difficult to argue in favor of personal freedoms such as no masks or crowds in public places where the vaccinated and/or infected status of the surrounding individuals is unknown. It is also difficult to argue that personal freedom is superior to the health and well-being of another individual if a risk of transmission of SARS-CoV-2 exists. Such an attitude might be perceived as selfish. At the same time, there needs to be flexibility, respect, and understanding of both sides of the vaccination argument. Even if a vaccine is mandated in the workplace, schools, restaurants, or other private or public places where there is contact with other individuals in close proximity, there needs to be respect for those with valid health, religion, or other bases for vaccine exemption,9 provided that they too respect the health of vaccinated individuals surrounding them, e.g., by using masks. Yet, violation of mandates might also imply penalties that might invoke anger and resistance. Those resistant to or against vaccinations could be encouraged to get a vaccine through financial or freedom-related incentives,10 but they should also be aware of the consequences of mandate violations.

Even with a vaccine and mask mandate, one should not be expected to wear a mask on a lonely hiking trail. Nor should one expect partygoers or those at a music concert with thousands in a cramped space to be maskless. Ultimately, it boils down to practicality, common sense, but always giving respect to one’s own health and that of others. Education and public campaigns of appreciation and understanding are needed to build trust and dispel misinformation and unfounded fears about vaccines, but to also realistically note that such mandates are not risk-free.

references

1. 1. Johns Hopkins University & Medicine. Coronavirus resource center. COVID-19 Dashboard. [cited 2021 August 31]. Available from: https://coronavirus.jhu.edu/map.html.
2. 2. Our World in Data. COVID-19: stringency index. [cited 2021 August 30]. Available from: https://ourworldindata.org/grapher/covid-stringency-index.
3. 3. Teixeira da Silva JA. Corona exhaustion (CORONEX): covid-19-induced exhaustion grinding down humanity. Curr Res Behav Sci 2021;2:100014.
4. 4. Largent EA, Persad G, Sangenito S, Glickman A, Boyle C, Emanuel EJ. US public attitudes toward COVID-19 vaccine mandates. JAMA Netw Open 2020 Dec;3(12):e2033324.
5. 5. Klimek L, Jutel M, Akdis CA, Bousquet J, Akdis M, Torres MJ, et al. ARIA-EAACI statement on severe allergic reactions to COVID-19 vaccines - An EAACI-ARIA position paper. Allergy 2021 Jun;76(6):1624-1628.
6. 6. Gostin LO, Salmon DA, Larson HJ. Mandating COVID-19 vaccines. JAMA 2021 Feb;325(6):532-533.
7. 7. Opel DJ, Diekema DS, Ross LF. Should we mandate a COVID-19 vaccine for children? JAMA Pediatr 2021 Feb;175(2):125-126.
8. 8. Lacsa JEM. COVID-19 vaccine passports: a mandatory choice or a mere option? J Public Health 2021;fdab258.
9. 9. Rothstein MA, Parmet WE, Reiss DR. Employer-mandated vaccination for COVID-19. Am J Public Health 2021 Jun;111(6):1061-1064.
10. 10. Fradkin C. An incentive-based approach may be the only approach to achieve COVID-19 herd immunity. Ethics Med Public Health 2021;19:100686.