Minor Consent for Vaccination: Ethically Justified, Politically Fraught.

Policies allowing some minors to consent to receive recommended vaccines are ethically defensible. However, a policy change at the federal level expanding minor consent for vaccinations nationwide risks triggering a political backlash. Such a move may be perceived as infringing on the rights of parents to make decisions about their children's health care. In the current post-COVID environment of heightened anti-vaccination activism, changes to minor consent laws may be unadvisable, and policy makers should proceed with caution.

Coercion and Its Discontents: The Promise and Peril of Increasingly Restrictive of Vaccination Mandates Comment on "Convergence on Coercion: Functional and Political Pressures as Drivers of Global Childhood Vaccine Mandates".

Attwell and Hannah present a cogent analysis of why policy-makers in four jurisdictions chose to use coercive approaches to increase vaccination rates between 2015 and 2017. Their study calls attention to the challenging political calculations that are necessary when choosing between coercion and persuasion to increase vaccine uptake. Further research is needed on the consequences of making a mandatory vaccination policy more restrictive, in order to better understand the backlash and resistance such a strategy may provoke. Although one reason that policy-makers may choose a coercive approach is that it is cheaper and easier to implement than a persuasive one, sociopolitical trends and backlash related to the COVID-19 pandemic may make coercive policies more politically risky in the coming years.

Freedom, Rights, and Vaccine Refusal: The History of an Idea.

We analyzed how activists opposed to vaccination have used arguments related to freedom, liberty, and individual rights in US history. We focused on the period from the 1880s through the 1920s, when the first wave of widespread and sustained antivaccination activism in this country occurred. During this era, activists used the language of liberty and freedom most prominently in opposition to compulsory vaccination laws, which the activists alleged violated their constitutionally protected rights. Critics attacked vaccination with liberty-based arguments even when it was not mandatory, and they used the language of freedom expansively to encompass individuals' freedom to choose their health and medical practices, freedom to raise their children as they saw fit, and freedom from the quasicoercive influence of scientific and medical experts and elite institutions. Evidence suggests that in recent years, vaccine refusal has increasingly been framed as a civil right. We argue that this framing has always lain at the heart of resistance to vaccination and that it may prove consequential for the rollout of COVID-19 vaccines. (Am J Public Health. 2022;112(2):234-241. https://doi.org/10.2105/AJPH.2021.306504).

France's citizen consultation on vaccination and the challenges of participatory democracy in health.

BACKGROUND: Confronted with a rise in vaccine hesitancy, public health officials increasingly try to involve the public in the policy decision-making process to foster consensus and public acceptability. In public debates and citizen consultations tensions can arise between the principles of science and of democracy. To illustrate this, we analyzed the 2016 citizen consultation on vaccination organized in France. This consultation led to the decision to extend mandatory vaccination. METHODS: The analysis combines qualitative and quantitative methods. We analyze the organization of the consultation and its reception using the documents provided by its organizing committee, articles of newsmedia and the contents of 299 vaccine-critical websites. Using methods from computational linguistics, we investigate the 10435 public comments posted to the consultation's official website. RESULTS: The combination of a narrow framing of debates (how to restore trust in vaccination and raise vaccination coverages) and a specific organization (latitude was given to the orientation committee with a strong presence of medical experts) was successful in avoiding legitimizing vaccine critical arguments. But these choices have been at the expense of a real reflection on the acceptability of mandatory vaccination and it did not quell vaccine-critical mobilizations. CONCLUSIONS: Public health officials must be aware that when trying to increase democratic participation into their decision-making process, how they balance inputs from the various actors and how they frame the discussion determine whether this initiative will provide meaningful information and democratic legitimacy.

The Two Faces of Fear: A History of Hard-Hitting Public Health Campaigns Against Tobacco and AIDS.

Fear is now commonly used in public health campaigns, yet for years ethical and efficacy-centered concerns provided a challenge to using fear in such efforts. From the 1950s through the 1970s, the field of public health believed that using fear to influence individual behavior would virtually always backfire. Yet faced with the limited effectiveness of informational approaches to cessation, antitobacco campaigns featured fear in the 1960s. These provoked little protest outside the tobacco industry. At the outset of the AIDS epidemic, fear was also employed. However, activists denounced these messages as stigmatizing, halting use of fear for HIV/AIDS until the 21st century. Opposition began to fracture with growing concerns about complacency and the risks of HIV transmission, particularly among gay men. With AIDS, fear overcame opposition only when it was framed as fair warning with the potential to correct misperceptions.

Why France is making eight new vaccines mandatory.

France is one of the countries with the highest prevalence of vaccine hesitancy in the world. In an attempt to raise vaccination coverages, the French government made on January 1, 2018 eight more vaccines mandatory in addition to the three required until then. The process that led to this policy choice is of particular interest. We describe how vaccines became contentious in France and how French authorities came to view mandatory vaccination as the solution to the rise in vaccine hesitancy. In a bold move, French public health authorities turned to a new type of institutional device grounded in the ideal of democracy and public participation to political decision-making: "a citizen consultation". This consultation anchored the idea that legal coercion could be the solution to France's crisis with vaccines. Time will tell whether the French extension of mandatory vaccination will reduce tensions around vaccines.

Message framing in the context of the national menu-labelling policy: a comparison of public health and private industry interests.

OBJECTIVE: We conducted a content analysis of public comments to understand the key framing approaches used by private industry v. public health sector, with the goal of informing future public health messaging, framing and advocacy in the context of policy making. DESIGN: Comments to the proposed menu-labelling policy were extracted from Regulations.gov and analysed. A framing matrix was used to organize and code key devices and themes. Documents were analysed using content analysis with Dedoose software. SETTING: Recent national nutrition-labelling regulations in the USA provide a timely opportunity to understand message framing in relation to obesity prevention and policy. SUBJECTS: We examined a total of ninety-seven documents submitted on behalf of organizations (private industry, n 64; public health, n 33). RESULTS: Public health focused on positive health consequences of the policy, used a social justice frame and supported its arguments with academic data. Industry was more critical of the policy; it used a market justice frame that emphasized minimal regulation, depicted its members as small, family-run businesses, and illustrated points with humanizing examples. CONCLUSIONS: Public health framing should counter and consider engaging directly with non-health-related arguments made by industry. Public health should include more powerful framing devices to convey their messages, including metaphors and humanizing examples.

A Tale Of Two States: Mississippi, West Virginia, And Exemptions To Compulsory School Vaccination Laws.

School-based compulsory vaccination laws have provoked debates over the legitimacy of government coercion versus the scope of parental rights. A key point of contention in these school vaccination laws are provisions known as exemption clauses that allow some parents to enroll their children in school unimmunized for reasons other than medical conditions. For more than three decades Mississippi and West Virginia stood apart as the only two US states that did not offer nonmedical exemptions to school vaccination laws. But other states seem to be moving in this direction, such as California, which in 2015 eliminated nonmedical exemptions following the Disneyland measles outbreak. The apparent shift creates an opportune moment to look at the experiences of Mississippi and West Virginia. Through a review of legislative histories, legal rulings, media accounts, and interviews with health officials in the two states, we consider the reasons for and consequences of their allowing only medical exemptions and the prospects their approach holds out for other states that may wish to emulate it. The experiences of these two states suggest that contrary to conventional wisdom, it may be politically tenable to limit exemptions to only medical reasons without damaging either the stature of public health or the immunization system.

Risky Business: New York City's Experience With Fear-Based Public Health Campaigns.

Fear-based public health campaigns have been the subject of an intense moral and empirical debate. We examined how New York City, under Mayor Michael Bloomberg, used fear-based appeals to confront three challenges to public health: high rates of tobacco use, obesity, and HIV infection. New York City's use of this type of messaging may have set a precedent. Other state and local health departments will have to navigate how and whether to use fear in a context where it is possible to assert that it can serve the interests of public health. But this will not reduce the need to carefully balance efficacy, uncertainty, stigma, marginalization, emotional burdens, justice, community participation, and scientific credibility.

Placebo use in vaccine trials: recommendations of a WHO expert panel.

Vaccines are among the most cost-effective interventions against infectious diseases. Many candidate vaccines targeting neglected diseases in low- and middle-income countries are now progressing to large-scale clinical testing. However, controversy surrounds the appropriate design of vaccine trials and, in particular, the use of unvaccinated controls (with or without placebo) when an efficacious vaccine already exists. This paper specifies four situations in which placebo use may be acceptable, provided that the study question cannot be answered in an active-controlled trial design; the risks of delaying or foregoing an efficacious vaccine are mitigated; the risks of using a placebo control are justified by the social and public health value of the research; and the research is responsive to local health needs. The four situations are: (1) developing a locally affordable vaccine, (2) evaluating the local safety and efficacy of an existing vaccine, (3) testing a new vaccine when an existing vaccine is considered inappropriate for local use (e.g. based on epidemiologic or demographic factors), and (4) determining the local burden of disease.

The politics of HPV vaccination policy formation in the United States.

This article explores the political dimensions of policy formation for the human papillomavirus (HPV) vaccine through case studies of six states: California, Indiana, New Hampshire, New York, Texas, and Virginia. Using thematic content analysis of semistructured key informant interviews with policy stakeholders, newspaper articles, and archival materials, we describe the trajectory of public health policy developments for HPV immunization and analyze key influences on policy outcomes through the theoretical lens of the Multiple Streams framework. Specifically, we examine factors influencing the extent to which HPV was perceived as a problem meriting policy action; political forces that facilitated and impeded policy adoption, including interest-group opposition and structural and ideological features of the states' political environments; and factors affecting which policy alternatives received consideration. We find that effective policy entrepreneurship played a critical role in determining policy outcomes. We conclude by discussing lessons from the case of HPV vaccination for future efforts to craft vaccination policies.

Pharmaceutical companies' role in state vaccination policymaking: the case of human papillomavirus vaccination.

OBJECTIVES: We sought to investigate roles that Merck & Co Inc played in state human papillomavirus (HPV) immunization policymaking, to elicit key stakeholders' perceptions of the appropriateness of these activities, and to explore implications for relationships between health policymakers and industry. METHODS: We used a series of state case studies combining data from key informant interviews with analysis of media reports and archival materials. We interviewed 73 key informants in 6 states that were actively engaged in HPV vaccine policy deliberations. RESULTS: Merck promoted school-entry mandate legislation by serving as an information resource, lobbying legislators, drafting legislation, mobilizing female legislators and physician organizations, conducting consumer marketing campaigns, and filling gaps in access to the vaccine. Legislators relied heavily on Merck for scientific information. Most stakeholders found lobbying by vaccine manufacturers acceptable in principle, but perceived that Merck had acted too aggressively and nontransparently in this case. CONCLUSIONS: Although policymakers acknowledge the utility of manufacturers' involvement in vaccination policymaking, industry lobbying that is overly aggressive, not fully transparent, or not divorced from financial contributions to lawmakers risks undermining the prospects for legislation to foster uptake of new vaccines.