COSSI Webinar: Mandatory Covid-19 vaccination YT Video Transcript https://www.youtube.com/watch?v=nDZ8wTcmlgQ 1,600 views Jul 27, 2021 This webinar was recorded on Monday 26 July 2021. Vaccination against COVID-19 is the main tool for bringing the world out of the COVID-19 pandemic. Mandatory vaccination has been debated as a strategy to get high vaccination coverage and protect individuals in certain settings. This webinar considered the policy, behavioural, ethical and epidemiological aspects of mandating COVID-19 vaccination. In this webinar: find out what vaccination mandates are, who they may be used for and how they could be delivered hear about the governance and political aspects of vaccination mandates - hear about epidemiological, behavioural and social considerations of mandates including effectiveness hear about ethical considerations of vaccine mandates for adults Speakers: Dr Katie Attwell Associate Professor James Wood Professor Julie Leask Dr Jane Williams Moderators: Associate Professor Margie Danchin (Chair of COSSI) Associate Professor Holly Seale (Deputy Chair of COSSI) Start of Autogenerated TubeYou Transcript With Timestamps 0:00 Start Prof MD: ..you to join but oh. uh I'd like to welcome everyone today to the COSSI webinar exploring mandated Covid-19 vaccinations. I'm Dr Margie Danchin. I'm a pediatrician and immunization researcher at the Murdoch Children's Research Institute and I'm the current chair of COSSI and I warmly welcome you today. But before we get started I would like.. 0:27 ..to acknowledge the traditional owners of the lands on which we are all meeting today. Which for me is the Wurundji people of the Kulin nation and to pay my respects to their elders past, present and emerging. So we have a really exciting webinar uh.. 0:45 ..for you all today on Covid uh mandatory vaccination. And of course mandates for Covid vaccines including vaccine passports after vaccination or with presumed immunity and incentives are currently under consideration or already implemented in several public and private settings both in Australia and globally. And mandatory vaccination continues to be debated.. 1:10 ..hotly as a strategy to get high vaccination coverage and to protect individuals in the community. So these are some of the themes that we're going to be covering today; including the social, ethical and epidemiological implications and considerations. So just to give you a broad outline of the webinar today... 1:33 ..the whole session will run for about 90 minutes so we aim to finish at around 3:30 not 4pm as originally indicated. And in the first hour we're going to have uh, four separate speakers and then uh, in the 30 minutes at the end we're going to have a moderated question and answer session by myself and uh the Deputy Chair of COSSI - Associate Professor Holly Seale who is familiar.. 1:59 ..to many of you. She's a leading Infectious Diseases Social scientist at UNSW and she will also do a wrap up for us at the end of the session. 2:10 So without further ado i would like to introduce our first speaker Dr (inaudible) and while I'm introducing Katie she can share her slides. So Katie is an Australian Research Council discovery early career research ah award fellow and one of the world's leading experts on mandatory childhood vaccination which is actually the topic of her ARC funded fellowship. Katie's also leading.. 2:36 ..the interdisciplinary project Coronavax in WA which is looking at preparing the community and government for Covid-19 vaccines and she's also conducted research on community attitudes regarding Covid-19 vaccine mandates as well. Katie's going to talk to us about the governance and political aspects of mandates so over to you Katie and a warm welcome. Dr KA: Thank you Margie I just like to confirm that you can all see a proper slideshow not just an ugly kind of Powerpoint file? Is that right? 3:09 Prof MD: thats perfect Katie Dr KA: Okay, a world of win. Let's go. All right. So I've entitled my presentation Covid-19 Vaccine Mandates: Who, What and How. Um I'd also like to start by acknowledging that I'm on Noongar land today um and pay my respect to elders past and present and encourage all of you to think about the land that you're on and the traditional owners of that land as well.. 3:33 ..okay. So. Mandatory vaccination slash vaccine mandates: what exactly are we talking about? The first thing I wanted to convey to you is that this idea has actually really only started to cohere in the last few years. Um, there's been a lot of talk.. 3:52 ..about vaccine mandates in particular contexts where people then generally regard their country's version to be sort of self-evident. But to kind of do the global consent, comparative and conceptual work has only become something that's happened much more recently. Um and certainly mandates are poorly.. 4:10 ..understood by the general public. And that's very true for recent work that my Coronavax team in Western Australia has done with regard to Covid-19 mandates; where people throw around words like mandates or incentives or compulsory without really um having a lot of clarity about what they mean or indeed having a lot of overlap um in what we would regard those concepts to be... 4:34 ..and this is a quote from Harry which really, really summarizes that 'it shouldn't be mandatory but they could encourage people by like blocking their tax refund or blocking their Centrelink.' So what Harry regards to be an encouragement or an incentive um and many of our participants use those words um.. 4:51 ..I would actually regard to be a vaccine mandate. So if we unpack vaccine mandates a little bit more and kind of try and work with um getting a concept and a definition going. A mandate is a policy intervention that imposes consequences for non-vaccination. So something happens to you if you don't comply with the government requirement for you to vaccinate or indeed as we will discuss.. 5:17 ..it perhaps a private requirement. And mandates aren't new for vaccination. Um governments have historically imposed them in various settings in our own Australia, uhm at a federal and state level we've got the no jab policies applying to childhood vaccination limiting access to family financial entitlements and child care subsidies. For adults and indeed for anybody traveling to certain areas um, yellow fever vaccine requirements are in.. 5:47 ..place for some governments. And we would be familiar as well that if you work for a health employer, you might have to have certain vaccines before you start in the job or demonstrate immunity and you might be required to have the flu vaccine annually. 6:04 And this is one of the things that's a bit complex or tricky when talking about vaccine mandates. It may include a consequence that um, that the person interpreting it might think of as an incentive like I talked about in that quote that i shared. 6:18 Um, in Australia we had the maternity immunization allowance um for many years for childhood vaccination which strictly was an incentive, um but if this was to be removed from somebody who chose not to vaccinate it would likely feel like a punishment if it was a form of money that everybody else was getting and you weren't. 6:37 So although some would say we should be very clear about the distinction between an incentive and a mandate, I think we also need to carefully consider that certain incentives might feel like a punishment if everybody doesn't get them. Or indeed if the thing you're in being incentivized to do and there you then.. 6:53 ..you miss out on is something like travelling interstate or internationally. Um, certainly in the context of Covid, what I want to suggest to you today is that mandates may also include something that I refer to as a collective requirement. Which I'll come back to but is the idea that um perhaps a mandate may not apply to me personally so Katie Atwell.. 7:16 ..if you're not vaccinated you can't get on that plane or you can't go and visit somebody in that nursing home. But rather West Australians where I am, collectively if you as a population don't get 70% of you covered by a Covid-19 vaccine, you as a group may not be allowed to come and go freely and travel in Bali which is all West Australians ever seem to do. So it might be that governments use.. 7:43 ..collective requirements to motivate individual behavior but based on the idea that collectively we will be allowed or not allowed to do certain things. 7:54 Finally a mandate with exemptions or opt-outs is still a mandate, but it may be less salient. And I'll explain what I mean by that in a moment. I just first I want to touch on this question of why are we mandating. And to get us thinking about who are the target population of vaccine mandates. So at a population level we can think about there being two under vaccinated groups; those who have.. 8:22 ..access barriers that mean that the system is not reaching them appropriately or it's not easy enough for them to overcome complacency or busy lives or complex factors making life difficult to go and get vaccinated. And then of course the one that gets all the headlines which is acceptance barriers. So this includes vaccine hesitancy and refusal. So these two different groups of people who may be under vaccinated can both be.. 8:47 ..reached and affected by vaccine mandates. But we would want to think about which group is perhaps being targeted by them. Within the acceptance subgroup sorry within the acceptance group there are two further subgroups. There are those who are very determined that they're not going to vaccinate and there are those who are hesitant. And the idea of a mandate for these people is you might manage to change their behaviour even if they don't really want you to. Um you might be able to push some of.. 9:16 ..these people over the line using a mandate. And finally to note that when thinking about this access and acceptance distinction, we want to think about the lever of the mandate and ask ourselves 'is it being aimed at basic social compliance?' kind of getting everybody over the line. Or is this actually about saying 'no if you refuse, something bad is going to happen to you' because you don't deserve to have good things happen.. 9:42 ..if you choose not to participate in this vaccination program. So I did some conceptual work a few years ago with an American scholar called Mark Navin and it uses this idea of The Five S's. I'm going to briefly talk you through that now in the context of Covid-19 kind of updating some of these ideas. So The 5s's refer to; scope, sanctions and their severity and selectivity which I'll briefly unpack now. So the scope is which vaccines are mandated. Now obviously in this context, derrrr it's Covid-19 vaccines. But still which ones? 10:18 Right? You know which specific vaccine? Um and obviously internally we know that right now if, if we were to have mandates they would apply to the vaccines that we currently have approved and available in our population. But if we're thinking about mandates applying to people coming into the country for example, we might have to think about the vaccines we haven't.. 10:36 ..approved. And what do we think about those as uh, as being included or not included in the status of being vaccinated? The other crucial point here is which populations. Are we talking about mandates for the general public or are we talking about mandates for aged care workers; for a subset, for a specific population group. Sanctions: this is seemingly one of the most crucial questions at the moment when mandates are talked about. What happens to people who don't vaccinate? What is the consequence associated with the mandate and relatedly how severe is that? Because for example if the consequence.. 11:12 ..was a fine. Is it $50 or is it $50,000? Selectivity is the question of how to enforce or exempt people from Sanctions. So there will always be people who don't have to follow the vaccine mandate - but who? and how? 11:28 And if you put those things together into the cauldron what you come up with is Salience. Which when we're talking about a specific vaccine mandate, how do all of these factors come together to determine how burdensome it is if I don't vaccinate. Like how much is that actually going to impact my behavior? And in this I would really note that the local context matters. So.. 11:50 ..what this looks like in one place will be different from what it looks like in another. And what's novel in the context of Covid-19 is that we have new private sector actors and agents applying or potentially applying mandates like this - arguably for the first time. 12:09 So Sanction design I mentioned is really perhaps one of the key focuses at the moment one of the most important things. And what I'm going to just run through is a theoretical kind of view of what some of the sanctions could be. The ones up this end I think we're very unlikely to see in this country. But you know forced vaccination is on the books in some places it's on the books in some American states. 12:32 It's generally left in the box but it's something that States do have at their disposal. Certainly in Australia it's not something that could form part of a routine vaccination program, uh and it's not something governments could do in a policy sense. Criminalize non-vaccination - the idea of fines and imprisonment - is something that's historically been used for childhood vaccination in other settings. Again it's not something we're associating here in Australia with our policy history. What we do have instead is the idea of.. 13:02 ..losing financial entitlements if you don't fully vaccinate your kids. And also this idea that you might be excluded from public spaces where the collective gathers. And again in the childhood space, our state governments have done this for child care, American states do it for schools. Um, other countries do it for schools but for the first time we're seeing that businesses might say this to their clients now which again would be a very novel thing to do. Restrictions on travel is obviously.. 13:31 ..another hugely important area where mandates may apply. Within a state, between states and between Australia and overseas. People also being unable to do certain types of work and this is obviously um government may say, oh you know if you work in um a particular industry, whether it's working for us the government or working for somebody else you have to be vaccinated. Um it may be.. 13:56 ..an employer doing it um, with what's within the law and within um, the agreements that um govern the way that we work. Ah but Queensland um, for a short time did a very weird version where they said 'okay businesses will empower you to exclude um, you know unvaccinated people if you want to' um, which Queensland has some form for doing in the childhood setting as well.. 14:18 ..um and anyway they rolled it back and replaced it with something more conventional. Um now, I've put incentives in here and I want to be very clear that these are not mandates and certainly the way we're seeing incentives operate at the moment - ideas of lotteries or the famous joints for jabs in Washington - these are not mandates. However if we were to look at something like a cash incentive that was $500 for everybody that goes and gets.. 14:44 ..vaccinated, you could very quickly see people developing a narrative whereby that would start to feel like a mandate for those for example who are reliant on money from the state and who are impoverished. So I'm wanting us to think carefully about incentives but I do want to be clear that in general incentives are not classed as mandates. 15:04 I've already mentioned collective requirements so that's something else to throw in the mix. What might government say to a group of us? Perhaps a state or a country? About collectively what we might need to get to in order for our freedom to change in order to things, do things like travel. Now exemptions are.. 15:23 ..a key aspect of mandates and so here I just want to talk through a few of the key features of them. Um, it's pretty much a given that medical exemptions will apply. Um, but the big questions here is who designs them and who governs them and I and other experts would argue that it's best if it's a government thing, So even if we're talking about my local Chinese restaurant introducing a mandate and saying 'if you're not vaccinated you're not coming in for a dinner,' um it would be better if they're not actually then having to decide who would be medically exempt from that. It's governments who have that technical.. 15:59 ..capacity and they should be deciding um, what you know, following the advice of technical experts, what medical contraindications should exist and should apply. And again experts would be arguing that we actually need a bit of scope, a bit of wiggle room for special exemptions to allow discretion in certain scenarios. 16:19 Much more controversial perhaps is what we should do with people who don't want to vaccinate in the event of mandates being applied. And what's been done um, formerly in Israel and now is being introduced in France and Italy is this idea that you have to be vaccinated. You have to demonstrate proof of vaccination in order to participate and enter in certain public spaces. But you can actually also get into those spaces if you can show that you have antibodies to Covid- 19 or a negative recent test. Now it's noteworthy that when Israeli officials brought this policy in, they explicitly constructed this as the.. 16:56 ..opt-out for vaccination and they were mindful of the fact of designing it in a way that was burdensome, and in fact more burdensome than the alternative of getting vaccinated. And for those of us who are involved in behavioral science and vaccination - we would know that that's actually the kind of optimum way to design a mandate. 17:15 You want to have its exemption available but you want it more difficult than the default setting you're seeking. And of course it will be a political issue and question for people as to whether they're willing to tolerate those um, opt-outs but certainly governments can draw strength from them. And certainly we found this in our study here in WA.. 17:34 ..that people link this to the kind of restrictions they're already used to. They're used to being not allowed in public space because they might spread disease so they would see not being allowed in public space without being vaccinated as an extension of that. But I note that the UK is saying that won't be enough for nightclubbing, you.. 17:53 ..will actually have to have been vaccinated. So you know watch this space. Um, also in terms of travel mandates, um some of us in Australia have discussed the idea that perhaps if you don't want to be vaccinated and you still want to travel, then at your destination you may have to fund your own mandatory quarantine if you're not fully vaccinated against Covid-19. Um.. 18:16 ..in a, in again again in that risk mitigation perspective, so that you're not actually spreading the disease, um if you're choosing not to be vaccinated when you travel. So this has been a whistle-stop tour by me of some of the policy and governance implications of mandates and i very much now look forward to handing over to my esteemed colleagues who are presenting today around the other aspects of mandates and returning to all of you in the question time. So that's me signing off for now. Thanks for your attention. 18:48 Dr MD: Thanks so much Katie. That was really excellent. Um, certainly a lot of food for thought there. Ah I forgot to say at the start please put any questions or comments for Katie into the q and a session. I think a couple of people are already doing that which is fantastic and obviously we'll get to all of those at the end of the four talks. 19:06 So I'm going to introduce our next speaker now, uh who is uh,Dr James Wood. And James while I'm introducing you please go ahead and share your slides. So James is an associate professor in the School of Population Health at UNSW in Sydney and he has specific expertise in Epidemiology and Modeling, for vaccine preventable diseases. And he's a current member.. 19:31 ..of uh the first ATAGI working group on vaccine prioritization and uh f, for population. So James is going to talk to us now about some of the critical epidemiological considerations for Covid mandates. Thanks James and over to you. Dr JW: Maggie, can I just check is.. 19:49 Dr JW: ..are my slides showing properly? Prof MD: you pop them into presenter view? That's perfect. Dr JW: Okay perfect. All right thanks. Um, Hi everyone. Um, so I'm going to just try and talk through some of the epidemiological considerations for, for Covid-19 mandates.. 20:06 ..um, and I guess I, I'm speaking this, as a capacity as a sort of eh, infectious epidemiologist and modeler, uh who's involved also in, um vaccination work quite heavily. So just while I get my, sorry. 20:22 So just the basic considerations, I've got quite a bit of text on my slides but I'm just going to step through this quite simply, and you can read as you go along. Um, So when we're thinking about reasons why you might want to impose a mandate, or you know, enhance coverage, uh firstly I guess we think about the burden of disease and.. 20:41 ..I think we know that Covid is a severe infection. Um, I guess the other thing is we expect it to be extremely common if we relax restrictions, and so that eventually maybe everyone will become exposed to Covid. A third point which i just will comment on a little bit more on the next slide is just that also there's quite varied outcomes for Covid. So you've got specific groups which are a high risk of.. 21:01 .. um severe events but also other groups that might be more important in terms of transmitting Covid and this also potentially bears on questions about um, things like mandates. Um, Secondly, what do vaccines do? Do they uh, stop you getting sick or do they also um, prevent.. 21:19 ..transmission? And we have evidence from the the randomized clinical trials that uh, the Covid vaccines are very effective against uh, symptomatic disease. And since then from observational studies in countries.. 21:31 ..that have had you know, very large population coverage, we know that there's very high protection against hospitalization and death. But also good protection against infection itself. And if you do.. 21:43 ..become infected as a vaccinated person, that you're less likely to transmit to others. Okay so there's good evidence of what we call indirect protection: the ability for, for the Covid vaccines to interrupt transmission. Um, I should note that the Delta variant is a sort of a new feature here. Um, it ehh, sort of somewhat reduces the.. 22:02 ..ability of the vaccines to protect against infection. But it they still interrupt transmission against the Delta variant so these, these sort of points still apply for for Delta. Um, finally, I guess that and the key point.. 22:15 ..is that the reduction in transmission due to vaccines is proportional to vaccination coverage in the population. So the more coverage you have, the more you interrupt transmission. And therefore there is err, a kind of a.. 22:28 ..um, this weighs on the, the question about whether you should be aiming for particular coverage targets or whether you should be taking steps to trying to ensure higher coverage. So I'm going to focus on the overall um, population level where most of the data is. But um, you can think about uh, I think Katie.. 22:45 ..touched on this area such as workplaces where um, you might have close tong, contact with vulnerable individuals as workers. Or you might be thinking um, how you, you know workplaces where, the loss of work time might be very costly and so there might be economic reasons to think about.. 23:02 ..and have attaining high coverage in workplaces. So just to kind of um, talk about this balance between um, transmission and um, disease. I've just pulled some data from the Netherlands here. As of about February this year and sorry there's a bit of Dutch on these slides um. But at the left I've just shown.. 23:21 ..evidence from their blood surveys about who gets infected in different age groups. And so, in the sort of this 18 to um, 24, 34 sort of age group, you have the highest rates of infection. 23:33 Okay. And it declines into older age. So about half as high in people of sort of 50 or 60 and a bit lower again in, in older people. Um, and of course this was in the context of some restrictions but not nearly as much as we've had here. Um, and then on the right here I've shown, I'm showing, um, what, what's hap what.. 23:51 ..happened with mortality. Okay. And you see that that's all concentrated in people over 50. Of course they did have deaths in people under 50. But ,you know the, the severe burden is very much in that older age group. So you've got.. 24:03 ..two different groups; one which you really want to protect through direct protection, and the other who might be responsible for uh, you know, exposing people to, to Covid. And so both these, these, these issues are sort of relevant in terms of thinking about... why we need potentially high crub.. 24:20 ..coverage and, and why it might be for different reasons in different groups. 24:25 Okay, so I, I wanted to talk through very briefly, um some of the evidence a little bit more detail about, um disease burden and sort of (inaudible) how the, how well vaccines work. Um, so just firstly I want to sort of note that the Delta strain has changed quite a bit of thinking about the level of vaccine coverage that's needed to open up. Um, it's, it's much more transmissible than the strains that we had last year. Um and, as you know, I'm in Sydney and I think probably a number of our audience are. Uh.. 24:58 ..we're struggling to contain this, even with a lock-down and very good contact tracing here. So this notion of maintaining Fortress Australia um, has sort of cracked a bit. So anyway there's all I'm saying is, is there's urgency around this. Uh, secondly um... you know, we know that vaccines, they provide very good protection against disease but they're not sterilizing. They don't.. 25:22 ..completely stop you getting infected. Um and like other respiratory viruses, we do expect that in the longer term, um we're going to be exposed and re-exposed to SARS-COV-2. We don't think it's going to go away, but the longer term is unclear. Is it going to be a benign infection like other human corona-viruses? Or is it going.. 25:43 ..to be something we're a bit more worried about, like flu? where you have seasonal peaks and so on that's unclear at the moment but we do.. 25:50 ..expect this to be a long-term um, you know, infection in our populations. So getting on to the um, the the evidence around um, vaccine efficacy there's this nice summary table that the UK puts out in its weekly uh, vaccine surveillance reports. Um, and I just sort of highlighted these lines around severe disease and infection. Uh, prevention of infection.. 26:15 ..and transmission here. Um, this largely reflects the Alpha variant so that was the, the one which caused the big wave um, over winter in, in the UK. So that there is emerging data around Delta but it's not contained in this table. 26:27 But just to show that um, you know f, for hospitalization and mortality the, the efficacy is really up around these sort of 95 percent or maybe even better. It's a little bit uncertain for the Astrazeneca um ,vaccine in this in this table but the more recent data for Delta suggests that the values are similar. So we're talking about being about, around.. 26:45 ..about 95 effective or better against hospitalization and death for the two vaccines we're using in Australia. 26:52 The effect, effect on infection is less, okay. So um, there's not a huge amount of data for second dose vaccines, particularly around uh, breakthrough infection. This was around sort of 50 to 70 percent uh, um, earlier on But now we're seeing with uh, the Delta strain, it's a little bit lower against protection against infection. 27:13 But when you look at the combined effect of reducing your chance of being infected and then uh, your chance of you know, if you get breakthrough infection, having a less severe course and being less likely to transmit to others, We still think that the, the vaccines are going to be about 85 to 95 effective at reducing transmission on a per person basis. I guess you know there's a lot of numbers there. What does that sort of mean? So I'm going.. 27:38 ..to get on to, uh some of that over the next few slides, including some examples of what we think different levels of coverage might mean in Australia. So um, but before I get to that I just want to bring up um, safety considerations. Because, you know, if you're thinking about rolling out vaccines um, to large numbers of people and.. 27:56 ..potentially if you're saying that they have to take, have, have to have the vaccines then safety is a of course a consideration. And we're all aware of some of the safety issues that have arisen with the vaccines that we're using in Australia. 28:08 So I'm not going to talk about minor side effects and, and anaphylaxis. Which of course is you know, is, is a serious concern but one we manage extremely well in Australia. Um, but with the Astrazeneca vaccine of course um, uh this issue of blood clots with low platelets. So TTS, um emerged, you know in Europe earlier this year and is one that ha, has been reacted to by Australian advisory groups in terms of the age, the preferential recommendations for different ages. Um, in terms of the data that we're seeing in Australia. So I think a lot of the focus has been on, um the, the incidents, and, and deaths.. 28:48 ..um and you don't see a huge change in incidents from younger people to older people. But it certainly declines. Uh, we don't have much data in people under 40 because we, we, we changed our recommendation quite early for that, for those groups. But the, the aspect which perhaps has been less well publicized is the change.. 29:05 ..in severity with age. So in, uh people under 50, um almost all the cases have been what we call this tier one classification which is where the, the clot occurs at an unusual location; whether it be in the brain or in the abdomen. At the sort of the key points and those tend to be quite severe. 29:23 Um, as you get into older people um, this rate really reduces. So by the time you're in the 60 plus group it's less than 30%. And so these two kind of things together are kind of what have governed, the sort of uh, recommendations around, uh age-specific use of this vaccine. Now all of this can't be taken in isolation if you're at high risk of being exposed to COVID.. 29:46 ..then in almost all age groups the, the, the benefits the vaccines still outweigh um, the uh, you know, the risks associated because of prevention of COVID. But just to point out that, you know, this, this does certainly makes it a.. 30:00 ..circumstantial kind of, something that where policy needs to be adapted to circumstance. And, and potentially offers some challenges in terms of mandated use of the Astrazeneca vaccine in for example workplace settings. Um.. 30:14 ..uh for the Pfizer vaccine um, there is some emerging evidence for the link between the Pfizer vaccine and Mycocarditis and Pericarditis. 30:22 Um, and this is sort of particularly after dose two in, in younger men. So ah, I, I believe under the age of 25 is sort of particularly the concerning area. Now this is still emerging and so it's not considered to be a proven link at present but has led to initial caution in the UK and other European countries in terms of recommending, uh vaccination of healthy children. Okay, so that's, that's sort of, some of.. 30:47 ..the safety considerations. At present, I should say at the moment we're a long way from um, having enough vaccine to be able to vaccinate children and the evidence around these uh, different uh, safety considerations we look stronger by the time we are. Um, So I want to get on to some examples of.. 31:03 ..how coverage influences restrictions. Um, and just to sort of make a couple of brief points ,we think that every person who's infect, on average each person infected with Delta, is uh infects about five others, with a lot of.. 31:17 ..variation between individuals. Um, and to get to herd immunity we would need four out of every five people to be immune. Um, we think the vaccines are pretty good at, at preventing onward transmission but um, only say 85 to 95 percent effective. So if we assume they were 90 effective, um yeah, we would need eight out of every nine people to be vaccinated. So 90% coverage. Um, I think this is optimistic. 31:44 So, um there are some questions about whether specific groups, you know, you don't need that across the whole population and you certainly wouldn't need that in children. But um, I, I guess the point I'm trying to er, get across here is that even if you don't get that high, um you know there are big differences between different levels of coverage. 32:03 So I'm going to go through some of that on the next slide. Um, so I've got three rough examples here which are based on some simplistic calculations that I, eh (inaudible), sort of behind the scenes. I, I should note that there are multiple groups in Australia producing modeling, uh you know, detailed modeling... 32:19 ..studies around this. Um, but also that, th, the outcomes are really quite sensitive to certain assumptions. So the first example is just thinking about, um if we got to 60% two dose coverage, ah, er ,of people over the age of 16. And in terms of high risk groups, so I'm thinking people who are.. 32:37 ..at most risk of, of severe illness getting to about 85% coverage. And I guess this is similar to what the USA has achieved thus far. Um, what we would find is that the um, transmission of the virus, it would fall below the sorts of levels we saw last year with the older strains. 32:56 But not that much below them. Okay? Just with this little level of vaccination. So, we would have a few different options.. 33:03 ..um, none of which uhh, are perfect. You know, so we continue to um, you know, maintain our low rates of.. 33:10 ..travel and eliminate the virus with, um, contact tracing and so on. We could do that. 33:16 Um, the other extreme would be to say, 'well, you know, this is as good as we're going to get. So let's just allow virus to spread. And the overall impact would be something of the order of three to five times as bad as a bad flu season, okay. In, in, in 2022. 33:32 After that it's really unknown as to what the future will be. I, I tend to think that this will be a sort of a more flu-like infection going into the future but that's that's really just speculation at present. So my second example is well what if we did a bit better? So what have we got to 70% two dose population coverage? And, and that's sort of, um you know, not far off what's been achieved in uh, in the UK at present. And also 90% coverage of those at high risk. So this would, um bring our uh, the transmission a fair bit below what we saw with um, the strains last year without vaccination. And it's likely that um, we, you know, we could, we could allow infection in our population and potentially have brief periods where we needed to impose some, ka, some controls in order to potentially protect the health system from having too many hospitalizations. 34:28 Um, if you didn't worry about doing that but use some public health measures maybe just at at sort of the peak of infections, the impact might be, you know, a bit worse than a, than a bad flu season but not terrible. Okay, so at that level of coverage does the potential to um, uh greatly change uh, how we approach um, COVID I suppose. Um, and then I've picked a sort of more optimistic example where we get as high as 80 percent and I don't know that um, any large country has, has achieved that as, as yet. Um, and 95 percent courage of those at high risk. 35:03 Um, and, um I realize I'm running out of time but I'm gonna, just gonna try and speed up a little bit. Um in that sort of situation you start to be in a uh, er situations like flu but ah uh, a milder season, okay? And so if you wanted to, uh stop transmission relatively mild restrictions will do it, you would only really consider border control if er, a problematic new variant emerged. And um, you know if you allowed the epidemic to spread um, your sort of impact would be more like a fff, a typical flu season. 35:35 So just a few implications of, of this that I, I'm going to try and get through quickly. Um, you know there, there are large differences to um, the potential burden, ah or, or the restrictions or freedoms, how if you want to look at it. Um.. 35:50 ..between good and excellent coverage. Um, and so it does argue for consideration of effective approaches to achieve high coverage and and mandates could be one of those potential, uh considerations. Um, a few caveats I've basically ignored the situation with children here. Who, who don't ah get infected as much or transmit as much. 36:10 Um, er, it is likely that younger adults are more important in transmission but then that's a challenge of how do you get high coverage in that group. Um, I'm not worrying too much here about waning of immunity because um, in play and new variants and also booster doses next year so there's a few things in the next 12 months that are important. Um, finally just to kind of make this point again... 36:35 ..Um, if you look at three different modeling studies they'll all have different coverage levels that they'll say you should get to. Um, and different consequences. And it all comes down to your assumptions really around how well a vaccine works against transmission and how well it works against hospitalization and death. Um and we just don't have really precise numbers on that so this allows this sort of variation between the different groups. So I'm going to stop there. Um, sorry for.. 36:58 ..going a little over time.. And er, I'll pass back to you Margie. Thanks. Dr MD: Thanks so much James. Gosh, you certainly make 80 coverage sound appealing. So back on to ah, ha ha, the argument for mandates. So I'm going to ah, um introduce our third speaker who is Professor Julie Leesk. Julie, go ahead and uh, share your slides. So Julie will be familiar to many if not.. 37:22 ..all of you. Uh, she's a social scientist who specializes in immunization and she's a professor at the Susan Wakil school of nursing and midwifery at the University of Sydney. Aah, and as many of you will be aware her research focuses on the social and behavioral aspects of vaccination uptake programs and policy. And she's going to talk to us about behavioral and social aspects of mandates. So over to you Julie. Prof Julie Leesk: Thanks Margie. The slide's showing properly? Prof MD: Yep, beautiful. Prof Julie Leesk: Great. Thank you. And um, Hi everyone. Um, great to have you join us, we've got 410 people now so that's fantastic 38:01 And I'd like to acknowledge um, the country I'm on which is Darrek (sp?) country and pay my respects to the elders; past , present and future. Tradigish, the traditional owners and any Aboriginal or Torres strait islander people uh, joining us today. So I'm going to.. 38:20 ..look at the behavioral considerations of mandatory vaccination but centriss on the fact that what we want from vaccination is thriving healthy societies, health for all, global health. We want families to be able to reunite like the, the family on the bottom right there, um, able to reunite with their young son recently. And we want to be able to get together with each other. I want to get together with my CO.. COSSI colleagues and see them after.. 38:53 ..far too long apart. So um, that's what we're on about. And we need to do a lot of things to increase uptake to those really high levels that we're gonna need for good control of COVID that James talked about. And these are the sorts of things that, that in, influence that. Now this has been put together by Angus Thompson and we summarized this in our COSSI um, document on getting high vaccination uptake for Covid-19 that we produced last October. So to get high coverage we need good access, supply. We need affordability of the services and the vaccine. People need to be aware of when a vaccine is recommended for them. 39:38 And how to get it. Um, there needs to be high acceptance and activation. And Katie um, has already outlined the acceptance and access bit. What activation means is that little final nudge over the line. The, the reminder, the thing that gets someone to finally just get their vaccine. And by the way i had my second Astrazeneca dose this morning. So I'm feeling very um, happy about that. 40:08 Mandatory vaccination can work. Um, it can increase vaccination uptake. This what I'm going to show is you is the evidence on what improves coverage according to the different kind of societal layers where you'll see interventions occur. Starting with public policy, mandates have been shown through systematic reviews.. 40:31 ..to improve uptake. So this is requirements. All the sorts of different requirements that Katie's talked about; incentives, reducing out-of-pocket costs, um and many other different things. So one of what I want to show you here is not just so much to read out all of these different things, but to show you that there are a whole lot of things that can improve vaccination coverage, including particularly things that occur at the service delivery interface. And um working on social norms. So social influence can make a difference. 41:08 And reminders for individuals - which is often how mandates work - because they act as that final activation, nudge, reminder to get people over the line, particularly when people are quite hesitant and kind of sitting on the fence. Um, what also interestingly education alone usually doesn't work, so it's not enough to just educate people about vaccination, you need all these other structures in place. But it's still very important. We, we need good communication as we all so well.. 41:42 ..know at the moment. So when we're thinking about mandates, you can kind of think about them as having two goals, particularly in relation to Covid-19 right now. One is to reduce transmission in high re, risk settings such as in health care or in um, international uh travel, plane travel or even domestic travel. I want to focus on health care and this is taking a, an old example from ah, Virginia Mason health center which is a large.. 42:16 ..tertiary referral hospital in Seattle, which managed to increase its influenza vaccination.. rates are quite markedly. It had been trying for some time. Then they had a shortage, then they planned this big campaign and they got very high coverage rates of their health care workers. And this is what they did; they had a.. 42:38 ..task force which had good, um support from the leadership from the CEO, they had a campaign and a mascot. They had incentives for people, they had very convenient services where you could drive through and get your vaccination. They had requirements and actually had medical and religious uh exemptions. The religious exemption you.. 43:03 ..had to get signed by a doctor or a nurse, so it wasn't easy to get the exemption. Um, so, Virginia Mason got higher coverage with a requirement, with a mandate and those other things and they are all essential. What about the second goal.. 43:20 ..where you're trying to increase population based coverage, right? so this is lesser eh lesser eh of it, it's more of an indirect strategy of getting really high coverage. 43:33 Well Israel as Katie mentioned, has done this with its so-called green pass which required vaccination and if not um immunity from Covid-19 or a negative test with some nuances around that. And you couldn't get into gyms cultural events stay at hotels, sit inside restaurants, unless you had your green pass. Now this was implemented variably but at least the impression that you had to get vaccinated did see.. 44:04 ..quite a steep rise in the vaccination coverage in Israel. And that figure there which is actually showing uh near close to 70 percent is the whole of the population, including children. So remember that's the denominator here so it's quite good for adults. Um, but the UK has managed to achieve also very high vaccination coverage. 44:28 And it hasn't had mandates. It's had other uh things in place to get very good delivery of vaccination to people. Neither of these countries have have yet the kind of coverage that James is talking about for um, the, the majority of the adult... 44:45 ..population but you will certainly see higher coverage rates in older adults where there's greater risk. Evidence from childhood vaccination shows that mandates are associated with higher coverage in some studies. So this is from um, theirs and colleagues, uh from the general.. 45:05 ..paediatrics which compared countries in Europe with mandatory vaccination um, over time, compared with those with no mandatory vaccination. And it does show a small difference with uh, an overall increase of 3.7 percentage points with mandatory vaccination. Um, in Australia we've kind of had, we've had vaccination requirements since 1999 for children.. 45:37 ..um, through the incentives program, where if a parent didn't fully vaccinate their child they had to um, provide a medical or so-called conscientious objection form. Now No-Jab No-Pay was the removal of that form and the tightening of the existing requirements. But in fact we saw the biggest increase.. 45:58 ..in our childhood vaccination rates, around this time when we simply tighten the due and overdue rules. So there was still a requirement - it was tightened - but they still had exemptions for er, ib uh, objectors. So, so far i want to say that we need.. 46:16 ..high coverage to control covert 19 well. That mandates can work but they're not a quick fix and you don't want to just have a showpiece mandate where the government has failed to deliver on other aspects of the program. 46:29 They don't solve access issues, although sometimes governments will recognize their obligation when they bring in a mandate and do some of that solving. They only work if combined with other strategies. They may be justified in certain high-risk settings and Jane's gonna.. 46:47 ..talk more about the ethics of this. This is me giving my views. Um, they raise population coverage, um but, um mandatory documentation may be as effective if you have exemptions that are hard to acquire. So that's the sort of um, summary so far. 47:07 Now i just want to quickly take you through Australia um, now. Uh, and say that we're increasingly feeling desperate to control Covid-19 and I say that from Sydney where we're in a hard lock-down and it's been going for four weeks, and.. 47:24 ..it will continue. Um, and it's hard to see how we're going to get our way out of this, uh except eventually through high vaccination coverage but maybe we will. So we need high coverage and this is what it looks like from national figures, where you've got.. there's a lot of data here but basically.. 47:45 ..if you're around 50 around 50 percent are vaccinated for a first dose, and then that rises to around 60 percent for um, the around 60s and the 70s it's around 70 percent. Um, right up to ah err, nearly 80 percent for the 85 year old males. Um, so you're seeing that we're doing, okay with older people in terms of initiation. 48:09 Which is an important figure because it's showing what people want to do and that they can get to a service. Um, vaccine intentions - we've got about 73 of people intending to. Now this group's important here on the left when it comes to.. 48:27 ..mandates because this is the group who are saying that they're not going to vaccinate. And if you have a hard mandate you've.. 48:33 ..got to figure out what you're going to do about them. Some of them will be tipped over but some of them will move further away from vaccination and dig in more and join the lock-down protesters in those kinds of groups. Um, and you're also in Australia, of the 66 of people who are not vaccinated at all, um some of them are waiting for a vaccine another vaccine i.e Pfizer.. 48:57 ..right they're the Astro-hesitant, 15 percent. 11 percent, um said the waiting time was too long and eight percent said they didn't know they were eligible. So there are these issues of convenience and confusion along with confidence that we're facing. So just keep that in mind when you think.. 49:16 ..about how mandates might work. And the fact that about two to four percent of people are against all vaccines which means they're likely to be the hardcore group that will not shift with any kind of requirement. And there will probably be some more as well. Including those who won't but also those who can't access vaccination for various reasons. 49:41 Um I want to just kwi, quickly go over the spillover effects and say that um, the obvious one is the imposition on people's rights to freedom of movement and privacy depending on what the consequences of your mandate are if for non-compliance. Some uh, are going to be unaffected, unf-heh, are going to be affected unfairly including those lacking access to vaccination or the documentation for it. If we particularly rely on sort of smartphone type systems, digital systems, and those affected by.. 50:16 ..vaccination recording error, where you can't correct the error, and that is a problem right now. There can be an impact on Aboriginal and Torres Strait Islander communities um, who will be affected by past injustices as well. So, those communities need to be considered when planning requirements. 50:36 There could be a conflict between the enforcer and the citizen or the worker. We saw that with No Jab, No Pay and that needs to be planned for as well. Mandate can reduce trust, it can backfire among the hesitant, um and it can intensify opposition movements and we saw this on Saturday.. 50:58 ..with these um, protests uh-eh. And we saw it with um, mandatory health care worker.. 51:04 ..vaccination in new south wales and the um anti-vax group uh-er, objecting to that. So i just want to also quickly point to Fair Work Australia which has some very useful information about vaccinations in the workplace if you want to read more about that. 51:21 And, finally say that um, in, in my view and this is after discussion with colleagues at COSSI, we've written a paper on this that's under review at the moment, that there could be some kind of graded approach. Where depending on what a person's risk to others is from higher to lower.. 51:43 ..um and depending on what the sector is, um the strength of requirement might vary; from a mandatory vaccination to mandatory documentation of protection, to a strong recommendation. This is just a, a rough, a rough sort of guidance and of course it will be subject to all sorts of variation, um depending on the context. But we all continue to need all of these other public health measures in place for the foreseeable future. 52:13 Um, in finishing I want to say that um.. a good vaccination mandates policy, um to me looks like a suspension bridge which is strong and supportive but also has the necessary flexibility that is one of the strengths of af, a suspension bridge they have to be a bit flexible they can't be too rigid. So i think that's kind of a helpful analogy when thinking about good policy around improving vaccination coverage. Thanks Margie. Prof MD: Thanks Julie. That was absolutely brilliant. So much to think.. 52:48 ..about there and I love that um, visual of the suspension bridge with that really firm mandate but with a bit of give there. So now we're going to go to our last speaker um, who is um, Dr Jane Williams and Jane's really going to round out the presentation now and focus on the ethical considerations for vaccine mandau.. 53:08 ..mandates in adults. And just while Jane sharing her slides, just introduce Jane briefly. So Jane is an apprised post-doctoral researcher at Sydney Health Ethics in the school of public health at the university of Sydney. And broadly her research focus is public health ethics with recent work including projects on quarantine and vaccination in infectious disease emergencies and I'm really looking forward to your talk. So Thanks Jane, Dr Jane Williams: Thank you. Uh, can you tell me if you're.. 53:38 ..seeing presenter, uhh moa..? Prof MD: Yeah just go to presenter mode..yep uh no. To full screen. Dr JW Sorry Prof MD: .. to display settings again, right? Dr JW: I'm just going to try again. sorry about that because we practiced earlier ,right? it always happens.. 54:04 Prof MD: And thank you everyone for putting your comments and questions into the q and a. There's some fantastic questions there which i know Holly is moderating and I'm uh, really looking forward to asking some of these questions to our speakers. Um. Dr JW: Do you have do you have my slide set? Prof MD: I do. You want me to, I can try and sh.. Dr JW: just gonna try again? but something funny has.. Prof MD: Do you want me to, I can try and share them for y.. Dr JD: Just gonna try.. Prof MD: Oh perfect. Well done Jane, that's great. 54:34 Prof MD: That's full screen. Dr JD: Okay. Prof MD: Go ahead. Dr JD: And how about now, still going? Prof MD: Perfect. Yep. Dr JD: All Right, tsherr hurr. Prof MD: Well done. Dr JD: Um, okay. Thanks everybody for having me. Sorry about that, um.. Okay, So I can't see my slides. This is too weird. Prof MD: You can't see them? Dr JD: I can't see my slides. 55:01 Dr JD: Anyway, um. Prof KA: Jane, go to view at the top right. See if that'll show that. Dr JD: Let me see. I, I think I know what's going on. Okay. As long as you can and are you still seeing them and presented now. Prof MD: Yep, and we're on the title slide. Dr JD: Sorry about this everybody. Okay, thank you very much. 55:18 Dr JD: Um, so I would like to... start by saying that I'm living and working on gadigal land that was never ceded. Um, and I'd like to acknowledge the traditional custodians of the land and pay my respect to elders past and present. Okay. So, uh today I'm gonna talk about.. 55:39 ..two broad areas related to how mandates could be justified ethically. So, I'll start by talking about what I've called prerequisites. Uhh, and those are conditions that are based on the disease and the vaccine. And then later I'll move on to some more substantive and procedural things that are just as important. Um, this first set of ideas is largely about weighing benefits and harms. 56:04 So, some of these have been mentioned by the other speakers. Uh, So what I've called proportionality here is what James was talking about when he talked about the burden of disease. So, um, proportionality is the idea that the disease has to be a significant threat to the population being considered for protection. By a mandate. So ethically we can't ask someone to undergo an invasive public health intervention unless there's a really good reason for it. Uh, so essentially it boils down to the risks posed by the disease have to be greater than the risks and burdens associated with the vaccine. Um, so with effectiveness uh, we.. 56:51 ..need to know that the vaccine works. Uh, and in order to mandate it and James talked about this as well, we also need to know that it prevents some level of transmission and that's because it's really hard to make an argument that somebody has to do something purely for their own good. Um.. 57:08 ..in terms of safety, there needs to be sufficient evidence of safety in the population who will be vaccinated under a mandate. And no vaccine can ever be totally safe, so there needs to be a compensation scheme for vaccine injury because we're asking people to take on a very small risk, but to benefit the wider population. The safety is also an interesting one,.. 57:32 ..like as we've seen in Australia this year safety is not a fixed idea. So it changes according to proportionality. Um, the TGA might approve something you know, assess it scientifically as being safe for use in the population. 57:49 Thanks.. But what we consider or perceive to be safe changes in response to the perceived seriousness of the threat of disease, for better or for worse. 58:00 Okay. And, finally there needs to be enough of the vaccine for everyone who would be covered under a mandate. So not only enough, but it needs to be very easily accessible. Availability and accessibility aren't the same thing. And I think it's um, probably fair to say that this prerequisite isn't really satisfied in Australia yet. 58:23 Uh, so Maggie's doing my uh slides. Next slide please. Maggie, sorry about that. 58:30 Um, so it's really important to note that the background circumstances change the ethical assessments of these prerequisites. So all of the things that i mentioned in the previous slide are going to shift over time.. uh, or according to whatever circumstances are going on. So as we all know, I'm also in Sydney, uh.. 58:51 ..the risk of Covid harm is different in Sydney today than it was six months ago. Uh, we, in terms of safety, we didn't know about some of the rare vaccine harms when the vaccines were provisionally approved. Uh, evidence of effectiveness changes with different strains and according to, to real-world situations. Our supply here has been uncertain, but that should improve. But all of these change the way change the kind of calculus that we have to do. Um, to think about how justifiability of a mandate is considered. So i think.. 59:26 ..there are three important things to um, take away from this. So first, there need to be mechanisms in place to trigger adjustments of advice around mandates when background context changes. And we see this um, in a slightly different scenario at the moment. Uh, where we're getting changing recommendations from ATAGI, it's important to do this for mandates as well. Because we need to be able to adjust decisions if they're no longer appropriate for the background context. 59:59 Related to that, changing advice can be really, really difficult for people to understand. So communications need to be prioritized and they need to be really, really top-notch. And the third thing about this is mandating a vaccine now in an emergency doesn't necessarily justify an ongoing mandate. 1:00:19 Okay, so there are, you know, this is what Julie uh, spoke about it as well. There are real risks of further disadvantaging some groups, usually along socially patent lines, if we have ongoing mandates for like, regular life. Um, next slide please Margie. And there are some other things, uh, to think about. Even if you think that the evidence and.. 1:00:45 ..supply conditions are met. So mandates need to foster mutual trust and trust isn't a one-way thing. So that's people trusting government, trusting public health agencies and so on. Uh, but it's also government and public health agencies trusting the publics. Okay, so if it's decided that mandates the best way to achieve a particular vaccination goal they have to be white done.. 1:01:10 ..in ways that demonstrate trust, uh and respect. And I'm going to give an example here that, that just happened this morning actually. So, well part of it happened this morning. So, threatening or announcing mandates in Australia. Now with vaccine access the way it is really risks giving the impression of political blame shifting. So making it about individuals not getting vaccinated rather than about rolling out a vaccine in the most equitable and appropriate way. So that everyone who needs it or wants it can actually get it. 1:01:42 So the federal government announcement about mandates, mandates for aged care staff has reportedly led to anger and that industry about lack of information like who needs to be vaccinated. Uh, In terms of people working in aged care facilities; lack of supply, they don't know where to get it and one of the CEO, a CEO of one of the large aged care providers said that his staff want to get vaccinated but they're still waiting and as he put it they said that they've been condemned by the government and the media for not acting fast enough So in contrast this morning uh in this.. 1:02:22 ..morning's New Southwells uh, press conference Kerry Chant responded to a journalist question about whether it was time for mandates now by saying, I'm going to read this quote, she said: 'We've been working closely with industry groups and to be fair there's not a lot of resistance in the community to vaccination. We have a very supportive community. It's sometimes about making access easy and making sure that people have the right information. We're very keen to provide access to those critical workers that are required to keep Sydney running." I thought this is a terrific demonstration of trust: basically that people want to do the right thing that we hear quite often. And that the responsibilities of government and public health agencies are probably more important than the responsibilities of the individuals. 1:03:09 So a mandate might work. It might provide some public health benefit but it also risks angering or alienating people who feel singled out for blame and stigma. So the way this is done is really important. And that's a social harm uh, that should be factored into how mandates are considered. 1:03:29 Um, we've seen some fairly intense politicizing of the pandemic and vaccination vaccine mandates, depressingly. Uh, there's a real risk that people who feel resentful or stigmatized by announcements of vaccine mandates will become politicized in ways that don't benefit social cohesion. Uh, and potentially don't benefit public health because they could lead to people disconnecting from public health advice or even vaccination more broadly if they lose trust in leadership and evidence. 1:03:58 So trust and respect have to be foundational when a mandate is being considered because there are harms associated with ignoring that. Okay this um, ties in with justice. So procedural justice is how decisions are made and uh, and how mandates are carried out. Uh, this should be transparent should be widely consultative ,uh and people for whom vagn uh, vaccine will be mandated, excuse me, shouldn't be hearing about this for the first time on the news. They shouldn't be surprised by it. So another justice uh, consideration is distributive which um Julie and Katie have touched on.. 1:04:36 ..partic, this is particularly if you're talking about a whole of population mandate because penalties shouldn't affect some groups more than others. And they shouldn't further bur uh, burden groups who are already burdened. 1:04:48 So for example financial penalties make it much easier for people with plenty of money to avoid vaccination than those who can't afford to take a financial hit and this means that some groups effectively have more choice than others, and this happens again in socially patent ways, so it's not ideal. It should be avoided if we can. 1:05:06 I've called this last one autonomy but what i mean by this is the importance of giving everyone the meaningful opportunity to get vaccinated when it's their choice, you know. So before it's mandated, before they're threatened with job loss, uh or something like that. And I mentioned this earlier when I said that availability and access aren't the same thing. Uh, so access doesn't really mean what we've got now you know, when you go.. 1:05:29 ..online and like using Brad Hazzard's words here, you know 'you Hunger Hames your way to an appointment.' Before even thinking about a mandate, vaccines should be provided in all sorts of incredibly convenient locations, like at the workplace for example. People should be provided with assistance to get appointments which might mean having a person you can ring up and talk to. Um, in different languages. 1:05:55 Um, paid leave to get vaccinated if you need it paid sick leave if that's needed. Um all of these things can support people getting vaccinated by choice. There's a sort of liberty-focused idea about less restrictive means where you admi, basically it means you try everything else. Everything in your arsenal before you make something compulsory. So offer alternatives if they're effective, um. 1:06:20 I don't know if this would be as effective and I don't recommend it but some ,you know daily testing and compulsory masking if somebody's really, really, really opposed to getting vaccinated. Although I don't know that that's valid. 1:06:34 We need really excellent diverse communications. Truly easy access. Incentives are something to try before a mandate. Um, I'm one of those people, I personally would uh differentiate between incentives and disincentives. I think incentives generally are a positive thing, uh rather than something you take away. Basically we want as many people as possible to do it because they want to do it. Uh, I do understand that this represents a huge effort required on the part of government and public health agencies and that's not easy. 1:07:10 But um, next slide please Margie. Ah, as you've heard from uh Katie, there are different kinds of mandates to support different kinds of public health goals. And just to end I'm going to talk briefly about how two of these differ in terms of their ethics considerations. So work mandates differ depending on whether they aim to provide indirect protection for a specific vulnerable group, such as aged care workers. Or whether they aim to reduce transmission by providing direct protection for workers in high exposure settings, like quarantine. So in the first strategy indirect you're asking people.. 1:07:51 ..to take on burden and risk for the primary benefit of another group. And of course like those individuals who are getting vaccinated might also benefit if they come into contact with COVID but the mandate's premised on them protecting others. So, you're using one group for another's ends. And this might be fine. It's not necessarily a bad thing but it's important to keep in mind that that's.. 1:08:13 ..what you're asking someone to do. That that mandate is less about protecting the person getting vaccinated and more about the people they interact with. Also uh, with a second there with the quarantine worker, though those people are taking on the burden of vaccination In the anticipation that they that themselves.. 1:08:32 ..might benefit if they come into contact with COVID. So, in that quarantine scenario the point of the mandate is to protect the worker themself. So the aim of population mandates, where you might be looking to hit a target, is uh to drive up overall vaccination levels. This is, you know.. 1:08:49 ..usually framed about, being about community protection or herd immunity but particularly with covert as you've heard there are so many possible public benefits beyond that, you know. Freeing up health care resources that might be scarce because they're taken up with, ah looking after people with COVID. Freedom of movement so maybe one day the.. 1:09:09 ..borders will open. Uh, so on. So there need to be really strong and tangible benefits so that people under a population mandate don't feel incredibly resentful if they're told to get vaccinated and.. they're not feeling it. Uh, that situation could lead to social uh, to diminish social cohesion and trust. Uh, which is harmful. And finally my last.. 1:09:35 ..slide, I feel like I've whipped through this. I just want to leave you with three key takeaways. Uh first there is no one-size-fits-all approach to mandates: it's really important to think about the context. Second, any mandate should be designed with the hard to reach or the most heavily burdened people in mind: make it as easy and appealing as possible. 1:09:57 And finally, exhaust everything that you can to get people want to be vaccinated first. Thank you. Prof MD: Thanks so much Jane and well done overcoming the slide issues. DR JW: Yeah, thanks sorry about that. Prof MD: I really loved what you said about you know really making sure that we optimize communication and overcome access barriers and try incentives. You know, before we start looking at um, at mandates and there's so much to consider there. 1:10:24 Um, now I note we're just going to um, open the, the Q and A now Holly and I, I noticed there's already been around 21 questions answered, which is fantastic so thank you so much to the panelists. Um, but I thought as the chair's prerogative I might start with the first question because Helen Bedford has joined us from the UK.. 1:10:43 ..which is just extraordinary, thank you so much Helen, I don't know what time it is there. But welcome. And I'm going to start with your question and I think Katie's going to answer this question for you. So, Helen has really um, focused on: With mandates, how can we assess, uh what is actually working? Uh, Is it the mandate or is it things that are introduced at the same time? Such as other um, campaigns or publicity reminders or other, ah things that might improve access? So it's a brilliant question.. 1:11:13 ..So Katie, I might throw that to you. Dr KA: Thanks Maggie and Helen. Yeah it is a great question Helen. And i think, you know, in complex um in complex interventions which mandates end up often being because as noted they'll be accompanied by communication campaigns potentially even if it's just communications on how to comply with the mandate. But sometimes as well around actually encouraging the population to accept the.. 1:11:37 ..vaccines. Um, communication in the media, you know, covering the events that are happening. Political communication by leaders, bureaucrats talking about it. We can't easily separate the impact of the policy change itself, um from those surrounding interventions which may also just be things that happen to occur at the same time independently of that policy change. So it is really difficult to do. Um, I don't think we can easily tease out the impact of that policy change um alone. Prof MD: Yeah, no. Thanks Katie, that's excellent. 1:12:08 Okay Holly over to you. I hope you've been moderating. I've got some great questions if you.. Holly: Yeah, thanks Margie. And I apologize for looking across at my screen I've been trying to scramble and answer them as quickly as i can. Uh, just a couple of um, points there was someone raised a question about not being able to see the answered questions. There are three different um, err, click boxes at the top of the Q and A um, section. And so you should be able to see some of the answered questions that way if you look across. But um, Margie and, and i think this may be something directed at you and, and to others on the call. But, you know, this um.. 1:12:48 ..keeps coming up in conversations and in the media about the long-term safety. And how do we, you know, introduce mandates in that setting. Uh, so maybe if you could talk to that and maybe clarify about what we know about safety. Um, and events with vaccines, please? Prof MD: Yeah that's a great question around vaccine safety. And James touched on some of the safety issues that we've already faced in the roll out around, with the.. 1:13:11 ..Astrazeneca vaccine and the, um TTS uh, or clotting syndrome. And now more, more recently with the Pfizer vaccine and Myocarditis. And i think what we can say in Australia is we have one of the most robust vaccine safety surveillance systems in the world. Um, that is able to uh, monitor.. 1:13:28 ..both, you know, for, for sort of more um, expected and common adverse events and for some of the rarer events. Um, and that is through text messages, through primary care and through linking data, for hospital admissions. So safety surveillance is ongoing. Um, but in terms of this concern that is often raised around the, uh potential for long-term side effects, we don't generally tend to see that very often with vaccination beyond that sort of six-week period or so. And of course there is ongoing surveillance happening in the community fa.. 1:14:00 ..for longer term events. And of course we have the opportunity to learn from the safety data globally. Um, and we have data now since December last year. So long-term safety surveillance is certainly ongoing but generally does not um, tend to be an issue with the introduction of a lot of new vaccines. Um, but safety is obviously critical. We need to be able to reassure the public that the vaccines are safe and I think someone actually made a comment around.. 1:14:27 ..the fact that they didn't believe that the Astrazeneca vaccine would be mandated. Um, but I haven't actually seen any documentation around that. But certainly with the current um, issue with the clotting syndrome particularly for people under the age of 60, I think you couldn't, eh, er, it would be difficult to mandate Astrazeneca vaccine across the population. I don't know if you want to comment on that James, with,with your knowledge around safety and, and.. 1:14:54 Prof JW: I don't (inaudible) think you've answered the question really well, Margie. I don't, I don't have a lot to, to add. I mean I, I just think that um, generally speaking it's quite difficult to, I would think it would be difficult to introduce a mandate in younger age groups. I mean for in, for instance United Kingdom, they moved fairly quickly to not providing or to a preferential recommendation in people under 40, even when they had quite a lot of COVID. So I, I just don't see us being in that sort of position here. Prof MD: Absolutely and of course lots of complexity around you know, even talking about mandates for children. Which is not the focus of today. 1:15:31 So back over to you Holly. The next question. Holly: James, while we've got you on the, on the um, screen there, there was another question just regarding the data you presented. I think someone would like to have seen.. 1:15:44 ..just um, where that information came from? But, uh, the also was about the safety um, concerns. So, you know looking at the current um, rates of clots and death rates, you know. And how do we bring this in now? With, you know I suppose what's happening in, in Sydney versus other settings.. 1:16:03 ..um, into future discussions. Prof JW: Yes, so um. I guess in terms of the vaccine efficacy data, um. The, the place that I used yea.. ah, so where I draw that the, that, table from for example, err, it is actually on the slides but it's from these weekly coverage reports from public health England. Um, and Public Health England has a monitoring of vaccine effectiveness, uh website which has links to most of the published articles that talk about, for instance efficacy against infection, against transmission. Uh, and some of these newer data around the delta variant that I think came up also in in some of the chat. Um, just in terms of these sort of risk - benefit uh, considerations in.. 1:16:46 ..in, say Sydney at the moment. Um, ATAGI did produce, uh in collaboration with NCIRS as a, as eh sort of a document around weighing up the risks and benefits. Uh, I mean all of these, these, these are always difficult ethic eh, exercises and every person, you know approaches this in a slightly different way. But, that, I might just put the link for that into, um. Let's see. How am I best to share that? In by the chat, is it? 1:17:12 Prof MD: We can forward that later James, later if you like. Prof JW: Okay. I'll put it in the chat and then we can um, forward that later but.. Prof MD: mmmmmmmm Prof JW: ..let's say, that there is a document there. And it provides comparisons to experiences in um, sort of wave one last year, and in Melbourne er, during their Lockdown period. 1:17:28 At the moment in Fairfield, for instance. Uh, the, the cumulative incidence so far has been higher than the average in Melbourne last year. Um, the other question is, you know if the lock down doesn't hold, you know, cases could go up rapidly. So at the moment we're kind of keeping it around level but if we fail to do that, you know rather than hundreds of cases a day you're dealing with thousands. And, and it, it calculus changes for everyone. 1:17:52 Prof MD: Yeah. Than.. thanks James. And just to comment as well that those, um, uh resources around weighing the risks and the benefit are quite useful because there's pictorial representation of, you know preventing um, severe disease in terms of hospitalization and death um, when there's higher disease in the community weighed against the risk of the clotting syndrome. So, that is very useful and you can find all of that on the, the Commonwealth Department of Health website and the ATAGI, um guidelines. Um, so back to you Holly. Holly: Yeah thank you. Uh, so uh to Julie, can I.. 1:18:21 ..please throw uh, a question over to you, uh, so uh from.. are there any cultural differences, um in terms of acceptance, uh of mandates of any sorts? Um, do we have any past, uh data that we can draw on in terms of variations in populations around using mandates or accepting mandates? Prof JL: Uh, actually I think this is better answered by Katie, but.. Holly: ..Ok, so.. Prof JL: ..very briefly, Uh yes. I actually thought.. 1:18:52 ..that question was about um, cultural differences in acceptance of vaccination. And there definitely are and particularly from um, for example, minority groups in the U.S affected by past injustice. Uh, there are issues around trust and acceptance of vaccination. And then of course you've got your kind of left right um, far-left, far-right um, polarization around vaccination that you're certainly seeing quite a lot of in the U.S but Katie Dr KA: Yeah. So just to add to that, the.. 1:19:29 ..polarization around mandates of course rather than just vaccination is even more extreme in the United States. But you could probably say in general as a culture that's a culture that um, is resistant to governance in general, resistant to being governed more than many other populations. Um. Australians are.. 1:19:47 ..you know, we consent to pretty high levels of governance. We're highly supportive of childhood vaccination and of childhood vaccine mandates. Um, we also have majority support for COVID-19 uh, vaccine mandates although with um, obviously lower support than for um, childhood vaccine mandates. Um, the United Kingdom has.. 1:20:05 ..much lower support for vaccine mandates and again you can link these to the policy history of these countries. So UK hasn't had vaccine mandates since smallpox. Um, it's been proudly voluntaristic um, till now. So that's the difference there. Um, in places like Italy and France, we see um, again it's almost not just the attitudes of the population that matters, it's the attitudes to government. 1:20:28 So the attitudes of government about their populations and certainly some recent work I did on Italy and the policy makers attitudes there. There was a sense that the Italian population needed to be told what to do. That they couldn't be trusted to make the right decisions to uh, wade.. that but also a kind of paternalistic sense that they, um they were having to wade through information that was too complex. The social media was kind of running rampant. But of course what that butts up against again is, well has government really got out there into the court of public opinion and prosecuted the case for vaccination? Before they decide that the population, you know isn't up for the job and it better just be mandatory. Prof MD: Yeah, thanks Katie. And actually it'd be.. 1:21:09 ..great to, to dovetail that answer into a question by Eve Urban where she asked, um whether positive reinforcement works better than punishment. And, and I think you're implying there that in fact in many situations government eh, are making that decision for their population. Uh, wha, in a, in the case of Italy, whe, in, d, you know before even trying positive um, reinforcement strategies.. 1:21:32 Dr KA: Absolutely. I think anyone who's ever parented a child knows that positive reinforcement strategies um, are a way of getting, getting the outcomes we desire without having as much heat or as much um, generation of reactants. Um, and certainly positive reinforcement um, is, is great as well because it can work.. 1:21:50 ..with voluntary um, motivations or it can work with a range of motivations in fact. So, absolutely I think um, I d.. I don't think a presenter here or a um, moderator would disagree with the fact that mandates shouldn't be something that you kind of reach for as a sort of, as a lazy option or as an easy option. 1:22:08 It is better if you can motivate people. If you can draw, especially if you can draw on people's intrinsic motivations. Um and connect to their values and beliefs and what matters to them, then you're able to instigate behaviour change in this case acceptance of COVID-19 vaccines that is lasting and meaningful and that can help people overcome barriers even relating to access. Prof MD: mmmmm. Fantastic, thanks.. 1:22:30 ..Katie. Over to you Holly. Holly: Yeah. Thanks Margie. Um. I.. I'm actually just going to draw back on some questions that we received prior to the session, um from uh, the attendees. Um, and really to bring in probably, you know, multiple members of the, the panel including Jane. Um, you know, an.. and your thoughts about, you know if mandates were to go forward, you know where do we sit in terms of the um, compensation system. And should it.. 1:22:57 ..be introduced side by side to um, any sort of mandatory policy? Jane, do you wanna, tack.. tackle that? Dr JW: Yeah. Did, did you mean the, the no fault compensation? Holly: Yep. Prof KA: Yeah. Dr JW: Yeahss, is probably much better coming from Julie. Because uh, she is, this is her baby. Holly: She's nodding. Okay Julia, over to you. Dr JL: Well I think this is a few of our babies that um, yeah. Ee.. It's, it's so, one of the things that we um, the group, um, in discussing this have agreed is that and, and everyone does it's logical that if you're going to require vaccination or even strongly encourage it, then it's beholden on you as government to make sure that the people who um, the very very small number of people who uh, receive a serious side effect from a vaccine that may need compensation receive that compensation without having to fight it out in the courts which itself requires resources. And uh, all of this um, an.. and COSSI in general, strongly endorse um, the need for no fault vaccine and injury compensation. We don't have it in Australia. The government have been asked to bring it in for now decades. I heard of someone in 1989 who um, had been aheruh.. asking government and worked within government. And uh, fortunately we have some positive signs afoot at present where, um the Health Minister Greg Hunt has announced earlier in July that this um indemnity scheme for providers would include a.. a scheme um, whether intertwined or in parallel I don't know, that would compens.. would enable individuals to access compensation. Now.. 1:24:48 ..we don't know much about this and I think they're still planning the details. But, um, there are hopeful signs afoot but when the um, policy detail comes out, we need to pay strong attention to it because we don't want just a showpiece compensation. We want real compensation, particularly for those.. 1:25:07 ..who have um, um, experienced compensatable impacts from TTS. 1:25:17 Prof MD: Back to you Holly. Holly: Thanks Margie. Um, again drawing on some questions.. 1:25:23 ..posted previously. Um, you know, oo.. n.. in past historically we've thought about mandates often in the public sector and with governments or health departments implementing them. But you know, we now may be thinking more in about this in a private setting and, you know, what kind of, you know, what needs to be.. 1:25:42 ..considered you know, by the private sector in terms of moving forward more here? You know, wh..what can they be drawing on as, as first steps and.. Prof MD: I think that's for Katie. Dr KA: So, um. I think the idea of the private sector mandating vaccines is.. 1:26:01 ..is really problematic. And I argued this in a piece in the New york Times with Mark Navin that listeners are welcome to, or viewers are.. 1:26:07 ..welcome to google and read. But basically, the private sector is not.. 1:26:12 ..set up to do the complex work around exemptions in particular. But also around privacy and around 1:26:18 enforcement. So it's one thing for government to put the burden of um, implementing a mandate on the private sector. That may be legitimate, that may be um, acceptable if government then sufficiently resources the private sector to implement that. But for um, for, for business, and look there could be very.. 1:26:38 ..good reasons, you know. Somebody in a, working in a small business might be going through cancer treatment and can't be vaccinated. And so they might have a very strong reason to either want their employees or their customers to be vaccinated. 1:26:51 So, I'm not saying that these aren't issues that um, that would be really pressing. But I.. 1:26:56 ..think I would just say at a headline level, it's optimal that governments be the one deciding on um, what industries would need mandates and in what context and how they would be implemented. Also because um, governments are the only ones who are democratically accountable to the citizens. So, we um, you know, we give this responsibility and power to, to the people making decisions to implement policies on our behalf. To consider technical advice, to consider the kind of normative and philosophical perspectives that have.. 1:27:25 ..been explored today. As well as the behavioral ones. As well as the policy design. As well as the epidemiology underpinning this all. Um, these are decisions that are going to be very difficult for businesses to make. And I think that, um, like I said I think the government's job is to think hard about this and to have the difficult conversations with the population if that's what it involves. 1:27:46 Uh, but for businesses I would say, go with care. And if you do go, then go with um, what is available. So for example the Commonwealth is, i.. is you know, is developing um, a conscience, not a, sorry. A medical exemption that would apply to COVID-19 vaccination. Um and so thinking about you know the.. 1:28:04 ..resources there and using, utilizing resources that would be available rather than just kind of going it yourself. Because, industry just doesn't have the resources or the technical know-how to manage that equitably and appropriately. 1:28:18 Prof MD: mmmmm. Thanks Katie. And I just want to quickly add in terms of um, medical exemptions. obviously that is a critical thing to consider and have been a few comments around that. Medical Exemptions are traditionally quite narrow um, in terms of when they can be applied and there's often a need for special medical exemptions and as you say, vital that there are pathways, you know.. 1:28:37 ..for consideration around different types of exemptions so that people are not unfairly penalized. I think that's a really excellent point. Well we're sort of getting towards the end of our half hour. Um, I don't know if there any last.. 1:28:50 ..pressing.. Holly: Uh, can we sneak in one more? I thought this is quite interesting question. Um, as experts in your field, do you feel the government is listening to your recommendations? Is that a bit controversial to finish on but um i thought that.. Prof JL: Depends on it depends on who in government. Um, you know there are some, there are, there are lots of very competent people in government, wh.. who, who in departments, who have been running.. 1:29:17 ..vaccination programs for decades. And, hats off to those people who.. are working in a very.. challenging environment. But the government is in um, our leaders at a national level are not listening enough to the expertise in this field. And um, we are you know, always here. We have been providing our inputs from earlier on. And unfortunately 1:29:44 ..I think in my personal view, there's an over-reliance on external consultants which conceive a vaccine um, uptake as being framed around uh, advertising campaigns and one-way communication. Uh, but having said that there are instances where there has been um, engagement and, and, um more engagement.. 1:30:09 ..than that as well. So generally, it's a difficult question to answer because there are areas where the government is listening and ve.. very strongly such as modeling. Um, but ah.. areas such as social science where there's a lot of corporate memory. Um, they are not listening enough. And in my view. Prod MD: Yeah. I agree Julie. All right. Well look I think we have reached the end. So Holly, I'm going to throw to you, for a nice succinct wrap up and then we'll, we'll finish the webinar. 1:30:39 Holly: Yeah, look thank you Marg. And thank you to all of our speakers today. That has been a really interesting session. And I appreciate that everybody has given up there, this amount of time to, to listen to this important topic, you know and stayed with us throughout this um, this webinar. Uh I there, has been questions raised about whether or not a recording will be available and we will speak to the uh, presenters of the session to seek their permission about whether or not their slides and/or the recording will go out. So if it does go out, it will be made available uh, via an email out to all of the registered participants, um.. 1:31:14 ..on the call. Also raised was about whether or not it was possible to get a certificate of attendance? I, uh, I understand that, that can't be automatically sent to all um, participants. And if you do need one to please reach out to the NCIRS team, uh, who are facilitating this webinar today. And if you don't have their details and of course please connect through to Margie and myself and we'll try and facilitate that for you. So that was my housekeeping. Um, there have been others who have raised.. 1:31:45 ..the issue about why the questions weren't all.. all addressed. Look we um, we received even more questions than what was posted on today. And many of these questions actually are critical, um and, and really do need to be addressed. But of course we've.. today's session was about mandates and focusing on that. And.. 1:32:03 ..what we would do is we will, you know, take down these questions, you know, look across them and to see whether or not they will mm... um, you know, we'll do future webinars about them or um addressing me in other ways via public, publications or reports. So you know, this is what we aim to do as part of COSSI. Um, I.. 1:32:21 ..we didn't get the slide up there. But for those on the call who are not uh, COSSI members and would like to do. We, we welcome you, to join our collaboration in our network. if you read.. if you have a look at the NCIRS website, there is a page dedicated to COSSI where you can see the um, details about joining our mailing list. Uh.. 1:32:43 ..okay. I think, oh there we go. Spoke to you soon, thanks Margie. Prof MD: there we go, just very quickly. Holly: We can leave that up, um for.. 1:32:50 ..those to take down the um, date down the details. And you can see the kind of who the network is open to. So please we, we welcome you to join. But really in, in, in wrapping up this session, I've taken so many notes and taken so many photos and I think I, I really just want to pull to three key.. 1:33:07 ..messages that I think were echoed across all of the presentations. The first being context. That, you know, whilst we do have you know, a history of mandates in some sectors. Uh, you know, it is critical that we draw on the current situation and what we know of what is happening when we think about the strategies going forward. Whether or not that includes mandates or it includes other uh, interventions or you know, focusing in other areas that um, Julie spoke to. And, and you know, I really liked that, um what James said about policy adapted to.. 1:33:43 ..circumstance. And i think that was, a also echoed by Jane. That we must adapt and adopt, you know these policies and these strategies to to what we know works. Um in, in each of the different population groups that we are trying to target. We need to keep the hard to reach in mind. We have a lot of ongoing issues.. 1:34:03 ..about access. And this has certainly been raised with the mandates that we introduced around aged care facility workers. That it, you know, if we don't get access right. If we don't ensure that the strategies are in place to, you know, support understanding and confidence in the vaccine then you know, we can't go forward with that mandate. And so, you know, designing with the hard to.. 1:34:26 ..reach group means that we need to have their voice as part of this um strategy and that we need to bring them in as part of the design teams. We don't want them disconnecting from public health. Um, and we want to make sure that this isn't an imposition on the rights to freedom. You know, that we many, you know, many, many people in our community want to go back out to travel and to meet and greet with family members. And so, you know, this is what we need to consider.. 1:34:52 ..with um, with going forward with this. That not everybody can equally access these vaccines right now. Um, and so drawing on this, you know, w.. what Katie said about the five s's. You know, there are, you know, we, we need to be grounded in all of this. Whether or not we're coming from government or from the private sector.. 1:35:12 ..we need to draw back on what we know works with improving vaccine uptake. And, and, keep considering those um, the who, what, and how. Um, all the time with with moving forwards. So, mandates won't be a quick fix. They, you know, that we've got still plenty more to do when it comes to communication. Plenty more to do to support access and uptake. Um.. 1:35:35 ..amongst that, you know, proportion of people who, you know, quite, you know, at the moment just are not sure whether or not they, um would like to receive the vaccine or whether or not they're eligible, you know. That is, that comes down to focusing on promoting and supporting understanding and motivation. So... Prof MD: Great. 1:35:54 Thanks so much Holly. I think we're going to have to stop there. I did tell everyone it was going to be 90 minutes. I would just like to sincerely thank our panelists who really gave outstanding presentations. So thank you so much to Katie.. 1:36:06 ..uh. To James and to Julie and to Jane. Really so much food thought there. I think the take-home message is this is complex and we know that we want to attain high vaccine coverage in the community and there's a long way to go. But, we need to absolutely mandate with care. Um, ah.. 1:36:22 ..I would like to also thank um, James Green and the NCIRS team for uh, organizing the webinar today and providing brilliant support. They're also going to send out an evaluation survey. So, our sincere thanks to all of you for tuning in. I think we had over 420 people at one point and now obviously people need to get on with their afternoon. But thank you very much and thank you to our amazing panel. 1:36:46 Take care everyone. See you.
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