Saturday, September 25

Mandatory vaccination in Spain: a debate with many ethical drawbacks and little scientific quorum

Spain faces another stage of the pandemic and immunization in September. So far, efforts have focused on reducing the number of infected and increasing the number of vaccinated. But after the summer, when presumably 70% of the population has been reached with the full guideline, it is time to answer new questions. Is there any assumption that justifies mandatory vaccination? What happens to those who return to the offices without the certificate? And to schools? Can companies force or harm those who have not wanted to be vaccinated?

Spain had successfully circumvented the mandatory vaccination debate that many countries have had to face. While Italy, France, Greece or the United States were preparing strategies to pressure certain groups to inject the doses, in our country the rate of vaccination continued to grow, reaching world records. However, the last month has changed the board a bit. Outbreaks in nursing homes and the spike in infections among older age groups have led certain communities to demand that nursing home workers and health workers be vaccinated.

Galicia, Cantabria, Andalusia, the Basque Country or Murcia asked to use the Public Health Law of 1986 to establish an exceptional scenario that would force the vaccination of these professionals. “This law could protect it in very specific areas”, says Fernando García, coordinator of the Ethics and Data Protection group of the Spanish Epidemiology Society (SEE). “In public health we move by the principle of harm to third parties formulated by the Scottish philosopher Stuart Mill: we must respect the freedom of individuals as long as it does not harm third parties”, says the expert.

But in the case of Spanish residences and toilets, García assumes that it is rash to consider it right now. Health has refused and has instead proposed two mandatory PCRs every week for those who are not vaccinated and work in centers for the elderly. “From an ethical point of view, if restrictive measures of freedoms are taken, they must be taken as a last resort. And they are not necessary if persuasion achieves broad vaccination coverage”, defends the epidemiologist. In addition, “we lack data: we do not know how many toilets have not been vaccinated or how many nursing home workers, or what is their impact on current infections.”

From an ethical point of view, if measures restrict freedoms are taken, they must be taken as a last resort. And they are not necessary if persuasion achieves broad vaccination coverage

Fernando Garcia
– Coordinator of the Ethics group of the Spanish Epidemiology Society

According to calculations by the Spanish Geriatrics Society (SEGG), 85% of nursing home workers are immunized. “We cannot force that 15% to be vaccinated, but we must do a lot of pedagogy so that they understand that they are a vehicle of transmission between very vulnerable and fragile people,” their spokesman proposed.

“The fact that the denial movement has penetrated much less in our country makes this debate less necessary. But from the point of view of Public Health, I would have no doubt in proposing the obligatory nature of vaccination in workers in nursing homes,” he says. Daniel López Acuña, former director of the WHO. “We are drifting individualistic from the issue of vaccination and not analysis: they are caring for very vulnerable people and at high risk of disease and death,” he says. However, he acknowledges that “there is not a sufficient percentage of rejection in the care sector, the health sector or among the general population” to make it mandatory. “Better strategies must be considered,” says the epidemiologist. The experts are clear: the time has come to re-catch.

Repescar, an alternative to compulsory vaccination

Despite its cultural and geographical proximity to its European neighbors, Spain has been a territory resistant to the anti-vaccine movement. The experts are proud to say that it is a mixture of collective memory and a huge health structure based on contact with the family doctor and with Primary Care. “From the moment we are born, we begin to receive this product for free. It is true that we pay them with taxes, but in other countries there is usually an outlay. Public vaccination policies and our health system are powerful and enviable elements,” explained Amós García Rojas, president of the Spanish Association of Vaccination.

It is best understood by looking at the data. 30 million people have received a complete vaccination from a country of 47 and in less than eight months. The lowest percentages are found among groups from 12 to 39 years old and the rate has dropped in these summer months due to the decrease in lots arriving from abroad or internal mobility. In no case due to vaccine rejection, as has happened in Italy, France and the United Kingdom. “We cannot translate what happens in the US or in France, where society is politically very divided regarding vaccination. Despite the fact that the political environment in Spain is highly charged, it has not displaced vaccines” , believes Fernando García.

Vaccination, by age group, in each community

Percentage of the population of each age group that has received at least one dose of the Covid-19 vaccination or the complete schedule, out of the total population of that group

NOTE: in the case of the 20-49 age group, before June 21 includes 18 and 19 years


Source: Ministry of Health

However, there is a small percentage of the older population that has not received the second dose or neither. This is where the experts ask to put the focus now. In the “repeats”. 89.6% of people between 50 and 59 years old have received the complete guideline. It is not known if those that are missing are due to a matter of time, that they were infected with the first dose or that they refused to be vaccinated from the beginning. The same with 6% from 60 to 69 years old or 2% from 70 to 79 years old. “Most of the people who have not been vaccinated are not anti-vaccines or unconditionally opposed. Many of them have doubts or perhaps difficulty of access. We should put the focus there,” says the expert in bioethics.

“More than obtaining numerical percentages, the strategy of the Interterritorial Council should be to focus on the black holes of vaccination”, shares Daniel López Acuña. “Perhaps they did not receive information or they were caught at a bad time and now they can go to the repechage. It is necessary to identify the laggards to advance towards 85% or 90% of the vaccinated population,” the expert understands.

Against the obligation of companies

Another uncomfortable issue raised by the mandatory vaccination debate, experts say, is relevance. There are still millions of people to receive their appointment and their vaccine in Spain, and raising the obligation is currently “discriminatory.” But it is not only a question of age. “We cannot forget that there are pockets of the population that are far from the health system and that it is more difficult for them to access vaccination, such as homeless people and migrants,” says García.

There are differences in the obligation in those places with a high risk of infection and infecting offices, leisure or travel venues. A standard cannot be established that excludes unvaccinated people from a job or the possibility of moving

Daniel López Acuña
– Former director of the WHO

In the United States, large companies such as Google and Netflix have announced that they will require vaccination for their templates. And, without going so far, some job offers in Spain already pose it as a requirement to assess. “This debate changes the ethical criteria. We enter into discrimination against those who do not have the vaccine. We must differentiate the obligation in those places with a high risk of infection and infection, such as residences and health areas, offices, leisure or travel venues. A standard cannot be established that excludes unvaccinated people from a job or the possibility of moving, “says Daniel López Acuña.

“The possibility of demanding it should not be left in the hands of companies. Instead, there is the option of requesting periodic tests (two PCRs per week). They pose pressure because on the one hand there is the cost that the employee would have to assume and on the other , the signaling. This type of measures, which do not impose the obligation but exert pressure or an incentive, are intermediate “, bets the spokesman of the Spanish Society of Epidemiology. Regarding the obligation in the private sphere, “I do not see that it will be a feasible situation in Spain in the short term.”



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