PRO-VACCINE MANDATE: A LITERATURE REVIEW 1
Pro-Vaccine Mandate: A Literature Review
Lacey Jung, Amy Lanoue, Michelle Pruszynski and Timeka Williams
Siena Heights University
Contemporary Issues in Healthcare Administration-LDR 614
Dr. John Fick
August 14, 2023
PRO-VACCINE MANDATE: A LITERATURE REVIEW 2
Vaccination is the issuing of a secure surrogate-defined substance that brings about an immune
response in the body and generates immunoglobulins that produce protective immunity against the
comparable transmittable agent. Not all vaccinated persons are safeguarded by an antigenic, even with
the positive outcomes of vaccines; but regular childhood vaccination routines have provided worldwide
security from numerous transmittable diseases that at one time caused millions to die (World Health
Organization, 2020). Vaccinations have proven to be safe, effective, and serious adverse reactions are
not usual. The most successful population health approach to mitigating and managing illness has been
due to the success of vaccines and immunization.
The researchers of this review have studied current peer-reviewed data on vaccinations and the
benefit of supporting a vaccination mandate. The data will show the implications and support for the
implementation of a pro-vaccine policy. The analysis of the data will answer these questions:
1. How do vaccines and vaccine mandates impact vulnerable populations?
2. What are the potential benefits of implementing vaccine mandates as a strategy for
disease eradication and control?
3. How do vaccinations preserve healthcare resources?
4. What is the impact of public health on vaccine policies?
Protection of Vulnerable Populations:
Vaccinations have been a time-tested defense against illness and disease for vulnerable
populations across the nation. Vulnerable populations are those who have limited access to healthcare
resources due to barriers such as transportation, cost, or education. People in vulnerable populations
have healthcare needs that are “complex, and intersecting with the social and economic conditions they
experience” (Moran, 2021). Examples of vulnerable populations include pregnant women, the
immunocompromised, pre-term infants, and the elderly.
Vaccination mandates protect individuals in vulnerable populations because they bring attention
and awareness to illnesses and diseases in which they are most susceptible. Vaccine mandates ensure
PRO-VACCINE MANDATE: A LITERATURE REVIEW 3
that the greater amount of the whole population is protected, preventing the spread of life-threatening
illnesses to those who cannot protect themselves. Scientific data has proven certain vaccinations to be
beneficial in the prevention of certain life-threatening illnesses. Pregnant women are more susceptible
to influenza than the general population. In 2009, pregnant women contracted influenza more than
non-pregnant people by more than 9 times (Doherty et al, 2016). Women who contract influenza during
pregnancy risk premature birth, infants with reduced birth weights, and even the death of their unborn
babies. A couple of vaccinations that are recommended for pregnant mothers include influenza, tetanus,
and pertussis, also known as whooping cough (Doherty et al, 2016). In a vaccine effectiveness study
focused on prenatal vaccinations, data showed that the rate of babies who contracted prenatal tetanus
dropped 80% for those whose mothers received 2 out of 3 vaccine doses, and the mortality rate of this
illness also dropped 98% (Doherty et al, 2016). This shows that women who receive vaccinations during
pregnancy help prevent life-threatening illnesses for their unborn babies. Vaccines have also been
shown to help protect babies who were born early.
Preterm babies are more susceptible to illness than full-term babies due to the
underdevelopment of their immune systems. A study focused on pre-vaccination antibody
concentrations showed that full-term babies had higher amounts of antibodies for vaccine-preventable
illnesses than pre-term babies. However, pre-term infants who were vaccinated for pneumococcal at 2,
4, and 6 months of age had antibody counts that were still less than those of full-term unvaccinated
infants, but high enough to protect them from contracting pneumococcal (Doherty et al, 2016). Vaccines
help protect individuals with lower immune system functions, such as preterm infants, as well as
individuals with weakened immune systems such as those with chronic illnesses, and other
comorbidities. While data shows that vaccine mandates protect vulnerable people from illness, some
would argue that the negative consequences of vaccine mandates outweigh the protection and
prevention of these populations, such as political backlash and public mistrust.
PRO-VACCINE MANDATE: A LITERATURE REVIEW 4
Misinterpretations of mandates and data surrounding mandates promote distrust and
conspiracy throughout the nation (Bardosh et al, 2022). This distrust often comes from mandates and
regulations that are not clearly justified, confusing, or lack overall transparency. However, “being
transparent about negative vaccine information builds trust,” (Bardosh et al, 2022) and the Covid-19
pandemic was a good lesson for all on how to clearly write and communicate vaccine information in the
most transparent, and effective ways possible. It can be argued that vaccine mandates have been
implemented in the past to support discrimination against disadvantaged groups of people, such as
immigrants, the homeless, the elderly, the mentally ill, and those with differing political and religious
affiliations (Bardosh et al, 2022). However; previously written vaccine mandates have highlighted areas
where education is still needed to help further support and protect disadvantaged groups.
Disadvantaged groups often contain individuals who lack the proper means or ability to access the
healthcare they need. These individuals often have other comorbidities or lifestyles that support in
weakening of their immune systems and defenses. Immunocompromised populations are steadily
growing throughout the nation. Studies show that immunocompromised individuals are also the largest
population of under-vaccinated people in the United States due to cost of education, or lack of access to
resources (Doherty et al, 2016). Due to these circumstances, immunocompromised people are at the
highest risk for vaccine-preventable illnesses and infections.
Vaccine mandates help protect populations of people whose immune systems cannot fight
illness and infection at the highest efficiency, as well as those who are susceptible to the transmission of
illnesses, such as Influenza, HPV, and Hepatitis, that are associated with socioeconomic circumstances.
While mandates may have supported fear, mistrust, and discrimination in the past the opportunities
they provide for continued education, growth, and continued protection and prevention for vulnerable
populations continues to outweigh any unintended consequences.
PRO-VACCINE MANDATE: A LITERATURE REVIEW 5
Disease Eradication and Control
Smallpox once plagued the American colonies as a significant epidemic until a pivotal moment
occurred in 1796 when Edward Jenner unveiled a groundbreaking discovery. Through inoculation with
cowpox (vaccinia) lesion material, Jenner demonstrated a remarkable ability to safeguard against the
deadly smallpox virus. This seminal event marked the dawn of the vaccine era. As the twentieth century
unfolded, an impressive array of new vaccines emerged, each wielding a profound impact on disease
prevalence. In recognition of their transformative effect, the Centers for Disease Control and Prevention
(CDC) acknowledged vaccinations as one of the ten extraordinary achievements in public health during
the last century in their crucial role in disease eradication and control (Malone & Hinman, 2023). This
breakthrough relegated smallpox to a minor concern among the great epidemic diseases. However, as
the memories of its horrifying outbreaks faded, and a generation emerged with little exposure to its
victims, vaccination fell into neglect, leading to a rise in smallpox cases. From the 1830s, the intensity of
smallpox attacks gradually increased, and by the time of the Civil War, it became a serious problem once
more (Malone & Hinman, 2023).
One key characteristic of most vaccines is their ability to offer both individual and community
protection. Many of the diseases we vaccinate against are transmitted from person to person. When a
significant portion of individuals within a community is vaccinated, they act as a protective barrier,
reducing the likelihood of disease transmission within the community. This concept is known as "herd
immunity"(Malone & Hinman, 2023). As a result, this indirectly safeguards those who cannot receive
immunization and even individuals who received the vaccine but did not develop full protection (vaccine
failures).
Parents participate in a social contract by immunizing their children, not solely for individual
protection but also to contribute to the safeguarding of other children, and school vaccination laws play
PRO-VACCINE MANDATE: A LITERATURE REVIEW 6
a vital role in controlling vaccine-preventable diseases. The first school vaccination requirement was
introduced in the 1850s in Massachusetts to curb smallpox. By the early twentieth century, roughly half
of the states had implemented the mandate to vaccinate children before attending school (Fraser &
Neuss, 2022). When several individuals opt not to be vaccinated, the overall protection levels within the
community decrease, leading to a loss of the herd immunity effect. Hence, the risk of disease
transmission rises. In the United States, the incidence of most diseases has been reduced by 99% and
vaccines undergo rigorous studies that evaluate their safety and efficacy by the Food and Drug
Administration (FDA) (Malone & Hinman, 2023).
Vaccine Mandate Challanges
However, vaccine mandates have been subject to debate and controversy. While vaccines are
generally safe and effective, it's essential to recognize that they are not entirely without risks or
guaranteed effectiveness. Some individuals may experience adverse reactions after receiving vaccines,
while others may not achieve full protection. Certain individuals object to vaccination due to religious
beliefs, while others oppose it for various philosophical reasons. Additionally, some people may not be
against all vaccines but are opposed to the idea of mandatory vaccination or specific vaccine mandates.
Individuals who are against vaccination have utilized the Internet extensively to communicate their
beliefs. Moreover, the emergence of new adverse events linked to vaccines has fueled the ongoing
controversy surrounding vaccinations (Malone & Hinman, 2023). Throughout history, vaccine mandates
have been instrumental in controlling and even eradicating various diseases, such as smallpox and polio.
In the ongoing efforts to combat infectious diseases, vaccine mandates continue to protect public health
and achieve disease eradication and control goals (Fraser & Neuss, 2022).
Preserving Healthcare Resources
The influenza vaccine was the first to be mandated for many healthcare workers nearly 15 years
ago. Many hospitals in the United States have implemented policies requiring influenza vaccination as a
PRO-VACCINE MANDATE: A LITERATURE REVIEW 7
condition of employment. Mandated vaccine policies for healthcare workers aim to prevent the spread
of preventable infectious diseases and preserve healthcare resources.
For over three years since the beginning of the COVID-19 pandemic, America’s hospitals and health
systems have been on the front lines caring for patients, providing support for families, and helping
protect communities. COVID-19 presents several risks to healthcare workers, including exposure, mental
health challenges, increased workload, and lack of support from leadership. It has also caused the
disruption of the delivery of various health services, such as cancer treatment, dialysis services, and
maternal health services. Illness among healthcare workers can cause infectious spread in healthcare
settings, the wider community, and even within their own households. Vaccination for health care
workers is a key component to health care delivery.
Vaccine mandates for healthcare workers are important for their own safety. The morbidity and
mortality rates of COVID-19 surpass that of influenza. An investigation published in April 2021 by The
Guardian and Kaiser Health News found that nurses accounted for roughly one in three COVID-19
deaths (32%) in the pandemic’s first year. One in five (20%) of the deaths occurred among healthcare
support staff, while 17% of those who died were doctors (Banks, 2023). Globally, the World Health
Organization estimated last fall that 115,000 healthcare workers died from the pandemic. The WHO’s
analysis suggested the number of healthcare worker deaths worldwide ranged from a low of 80,000 to a
high of 180,000 (2021).
Vaccine mandates for healthcare workers are important for patient safety. Nosocomial
transmission of Covid-19 is common; asymptomatic and pre-symptomatic cases contribute to
transmission and may prove critical in healthcare settings where high-risk groups receive healthcare (Wu
et. al., 2021). A study conducted in three university medical centers (2304 outpatient HCP) with
mandatory influenza vaccination policies and four Veteran Affairs healthcare systems (1759 outpatient
PRO-VACCINE MANDATE: A LITERATURE REVIEW 8
HCP) with no mandatory influenza vaccination policies over three influenza seasons (2012–2013 through
2014–2015) found that mandatory influenza vaccination policies significantly increased vaccine uptake
rates while HCP symptomatic absenteeism diminished as rates of influenza vaccine uptake increased
(Frederick et al., 2018). In practice, COVID-19 vaccination prevented almost seven out of ten episodes of
absenteeism among healthcare workers and significantly reduced the length of absence from work
(Maltezou et al., 2021).
Vaccination is extremely important for hospitals and health systems from a public health
perspective. “Do no harm is a core ethic for all those who care for the sick and injured. I think that
physicians and, frankly, all those working in the health care system, have a fundamental obligation to
patients by getting vaccinated for preventable diseases such as COVID-19,” said Audiey Kao, MD, PhD,
the AMA’s vice president of ethics (Lubell, 2021). COVID-19 vaccines have prevented nearly 280,000
deaths and 1.25 million hospitalizations in the U.S. according to estimates from researchers at the Yale
School of Public Health (Greenwood, 2021). Vaccine mandates are the only course of action healthcare
organizations can take to address the enormous economic implications of health care workers
contracting Covid-19 infections and we have the moral obligation to protect both them and their
patients during infectious outbreaks.
Vaccination and Population Health Protection
The area of population health science has risen to accurately deal with its deficiencies. The
documented undertaking of public health is to guarantee the state in which individuals maintain their
well-being (Azarpanah, et al., 2021). The task of public health is defined by a panel of an Institute of
Medicine in 1988 as, “assuring the conditions in which people can be healthy” Population health
management requires following the course of outcomes for every individual, even if an individual does
not seek care (Zimmerman, 2021).
PRO-VACCINE MANDATE: A LITERATURE REVIEW 9
Public health has seen an increasing contention in recent years with resistance to vaccinations.
This opposition to vaccines is in large part to vaccine safety and adverse reactions. The most recurrent
reactions likely to happen are slight, such as injection site redness (4.29%), fever (3.66%), and swelling
from the injection (3.21%). In eight years, 94.5% of outcomes are not detrimental and the most common
population-based injurious information was 25.3 per 1 million in the population. According to the
Strategic Advisory Group of Experts (SAGE) on immunizations, vaccine hesitancy is, “a delay in
acceptance of refusal of vaccines despite availability of vaccination services” and has always been a
public health risk (Azarpanah et al., 2021).
Doubts about vaccine protection and adverse reactions contribute to uncertainties in
vaccinations. Comprehension and perception points about religion, culture, gender, socio-economic,
and vaccine-specific factors create a wide range of elements affecting vaccine resistance. Apart from
this, having practical information on vaccine safety increases confidence and ultimately tolerance.
Independently, several elements such as prior understandings, awareness of dangers, vagueness, loss,
understandings acquired, and details such as feelings and subject matter, construct biases (Azarpanah et
al., 2021).
The U.S. Vaccine Adverse Events Reporting System (VAERS) database collects voluntary
information from individuals who report adverse events (AE) and serious adverse events (SAE) from
vaccinations. This creates an abundant reference base for information on adverse reactions and vaccine
safety. The results from a VAERS report from 2011 to 2018, indicated there were 866,842 occasions of
adverse events, 60,040 reported no adverse event, and 75,155 of them reported medication or device
errors and occurrences. VAERS (SAE) reports totaled 293,609 and 16,130 (5.5%) were serious adverse
events. Even so, VAERS reported that 94.5% of the adverse events following immunizations were not
serious (Azarpanah, 2021).
PRO-VACCINE MANDATE: A LITERATURE REVIEW 10
In contrast, it is impractical to deduce a medication or vaccine could not have deleterious
effects. Is there a connection between autism and vaccinations? Some providers and parents do not
subscribe to the “vaccines do not cause autism, SIDS, or infertility”. It is difficult to verify this as a
general fact, and a basis for causation cannot be determined. A review of SAE following vaccinations in
children purported the available facts were insufficient to rule out a causal association between the
vaccine and any effects (Orient, 2019).
There is a plethora of research on vaccine hesitancy, refusal, and the viewpoints of parents who
hesitate or are anti-vaccination. Indeed, outbreaks of vaccine-preventable diseases are resurging in
communities around the world. Research shows vaccination estimates should be about 95% to protect
societies. For medical reasons, some people cannot be vaccinated, and some children remain
unvaccinated due to geographical challenges. To preserve mass immunity and population health
protection most communities need non-vaccinated numbers to remain low (Attwell & Navin, 2019).
Vaccine hesitancy reflects the public’s skepticism of public health entities and the healthcare systems
(Orient, 2019).
References
Attwell, K., & Navin, M. C. (2019). Childhood vaccination mandates: Scope, sanctions, severity,
selectivity, and salience. The Milbank Quarterly, 97(4), 978–1014.
Azarpanah, H., Farhadloo, M., Vahidov, R., & Pilote, L. (2021). Vaccine hesitancy: Evidence from an
adverse events following immunization database, and the role of cognitive biases. BMC Public
Health, 21(1), 1686. https://doi.org/10.1186/s12889-021-11745-1Links to an external site.
Bardosh, K., de Figueiredo, A., Gur-Arie, R., Jamrozik, E., Doidge, J., Lemmens, T., Keshavjee, S., Graham,
J. E., & Baral, S. (2022, May). The unintended consequences of covid-19 vaccine policy: Why
mandates, passports and restrictions may cause more harm than good. BMJ global health.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9136690/
Banks, M. A. (2023, February 6). Study shows deadly toll on MDS of Pandemic’s early wave. Medscape.
https://www.medscape.com/viewarticle/987902?form=fpf
PRO-VACCINE MANDATE: A LITERATURE REVIEW 11
Doherty, M., Schmidt-Ott, R., Santos, J. I., Stanberry, L. R., Hofstetter, A. M., Rosenthal, S. L., &
Cunningham, A. L. (2016, November 18). Vaccination of special populations: Protecting the
vulnerable. Vaccine. https://www.sciencedirect.com/science/article/pii/S0264410X16310611?via
%3Dihub
Fraser, E. M., & Neuss, M. J. (2022). Who Calls the Shots? A Legal and Historical Perspective on Vaccine
Mandates. Chest, 162(3), 659–663. https://doi.org/10.1016/j.chest.2022.04.142
Frederick J., Brown A.C., Cummings D.A., et al. Protecting healthcare personnel in outpatient settings:
the influenza of mandatory versus nonmandatory influenza vaccination policies on workplace
absenteeism during multiple respiratory virus seasons. Infect Control Hosp Epidemiol.
2018;39:452–461.
Greenwood, M. (2021, July 9). U.S. vaccination campaign prevented up to 279,000 covid-19 deaths.
YaleNews. https://news.yale.edu/2021/07/08/us-vaccination-campaign-prevented-279000-
covid-19-deaths
Lubell, J. (2021, July 27). Why covid-19 vaccination should be required for health professionals.
American Medical Association. https://www.ama-assn.org/delivering-care/public-health/why-
covid-19-vaccination-should-be-required-health-professionals#:~:text=%E2%80%9CIncreased
%20vaccinations%20among%20health%20care,Bailey%20added.
Malone, K. & Hinman, A., (2023). Vaccine mandates: The public health imperative and individual rights
(Control and Prevention Chapter 13). Centers for Disease Control and
Prevention.https://www.cdc.gov/vaccines/imz-managers/guides-pubs/downloads/
vacc_mandates_chptr13.pdf
Maltezou, H. C., Panagopoulos, P., Sourri, F., Giannouchos, T. V., Raftopoulos, V., Gamaletsou, M. N.,
Karapanou, A., Koukou, D.-M., Koutsidou, A., Peskelidou, E., Papanastasiou, K., Souliotis, K.,
Lourida, A., Sipsas, N. V., & Hatzigeorgiou, D. (2021, November 26). Covid-19 vaccination
significantly reduces morbidity and absenteeism among healthcare personnel: A prospective
multicenter study. Vaccine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8556541/
Moran, M. (2021, June 23). What are vulnerable populations?. Statistics Solutions.
https://www.statisticssolutions.com/what-are-vulnerable-populations/
Orient, J. M. (2019). Vaccine controversies: The case for freedom and informed consent. Journal of
American Physicians and Surgeons, 24(3), 68-74.
World Health Organization. (2021, October 20). Health and care worker deaths during COVID-19. World
Health Organization. https://www.who.int/news/item/20-10-2021-health-and-care-worker-
deaths-during-covid-19
PRO-VACCINE MANDATE: A LITERATURE REVIEW 12
Wu P, Liu F, Chang Z, et al. Assessing asymptomatic, pre-symptomatic and symptomatic transmission risk
of SARS-CoV-2. Clin Infect Dis 2021 Mar 27;ciab271. doi: 10.1093/cid/ciab271. Online ahead of
print.
Zimmerman, F. J. (2021). Population health science: Fulfilling the mission of public health. The Milbank
Quarterly, 99(1), 9–23.
