Vaccination Requirements Research Articles

Effect of School HPV Vaccination Requirements on Pediatricians’ Recommendations

Background/objectives: Pediatrician recommendations are highly influential in parents’ decisions to vaccinate their children against HPV. Unqualified, presumptive, and bundled recommendations (UPBRs) are associated with increased HPV vaccine uptake and are considered best practice. This study analyzes pediatricians’ self-reported data to assess changes in UPBR use and the psychosocial determinants of UPBR use as a result of the implementation of a multi-level intervention, the Adolescent Vaccination Program (AVP). Methods: We surveyed pediatricians across 51 clinics in the Houston area. Baseline surveys (n = 137) were distributed in 2015, and follow-ups (n = 120) in 2019. Results: Pediatrician UPBR use significantly increased as a result of AVP implementation. Change in the provider belief that it is necessary to tell parents that HPV vaccination is not required for public school attendance significantly predicted UPBR use at follow up. This belief was also a significant mediator of increased use of UPBRs at follow-up. Conclusions: AVP was successful in increasing pediatricians’ use of UPBRs. Change in UPBR use is related to one critical psychosocial determinant: beliefs about communication regarding the non-mandatory nature of HPV vaccination for school enrollment. HPV vaccine promotion efforts should devote focus to changing pediatricians’ beliefs about the necessity of disclosing the non-mandatory nature of HPV vaccination for school attendance.

A systemic evaluation of COVID-19 vaccination drives in LICs, LMICs, UMICs, and HICs: Preparedness for future pandemics

ABSTRACT Introduction: The COVID-19 pandemic has significantly impacted global healthcare systems. Vaccination is an effective strategy to battle the disease. Policies and distribution frameworks have varied widely across countries. The paper aims to highlight the global vaccination trends in these nations, based on their economic classification, which will illuminate key takeaways that will allow for better pandemic management policies. Methods: A list of the most populated countries across each income slab was drawn up, and information on their vaccination campaigns was collected from national government portals and official health department websites of these countries in a structured manner. Data collected for the attributes was qualitatively described and converted into binary responses for quantitative analysis. ANOVA test, Chi-square test, and regression models were employed. Results: A consistent decreasing trend was noted in the percentage of the population vaccinated as the spectrum from higher-income countries to lower-income countries was traversed for all dose statuses. Fewer types of vaccines were available in the lower-income countries. Though compliance with the CDC vaccination strategies guide was largely noted, a linear regression univariate analysis of vaccination drive parameters carried out for single-dose vaccination yielded statistically significant results for medical provider vaccine standardization (P-value = 0.002), vaccination requirements (P-values <0.001), and provider recommendation. (P-values <0.001) Vaccine hesitancy was not dependent on economic status. Conclusion: Concerted global initiatives like vaccine donation would assist efforts in mitigating disease spread. Prompt busting of baseless anti-vaccine narratives and strengthening healthcare infrastructure to meet national requirements should be given due importance.

The Impact of Disease X on Potential Travelers’ Travel Decision

This study used ANCOVA models to investigate how pandemic characteristics—spreading speed, severity, and vaccination requirements—affect travel intentions. The results reveal that these factors explain 31.7% of the variance in travel decisions, with disease-spreading speed and severity being the most significant determinants. While vaccination requirements are relevant, they play a secondary role compared to the immediate threat of disease characteristics. The interaction effects between these factors further demonstrate their combined impact on travel reluctance. Demographic variables, such as gender and the presence of children, also influence decisions in specific contexts. These findings contribute to the understanding of risk perception during health crises, reinforcing the role of perceived severity in shaping cautious travel behavior. Practical implications for the tourism industry include the need for transparent communication, tailored health protocols, and demographic-specific marketing strategies. Future research should explore broader factors and adopt longitudinal approaches to capture evolving travel intentions during pandemics.

Political Affiliation, Policy Measures, and Intention to Receive COVID-19 and Influenza Vaccines

Our study aimed to assess the impact of political affiliation, personal beliefs, and policy measures on the intention to receive routine COVID-19 and influenza vaccines in the coming year. A cross-sectional study of 1256 individuals at Minnesota State and County Fairs was conducted to assess their intention to receive COVID-19 booster and influenza vaccines in the coming year. The association between vaccine intention and political affiliation, belief in collective responsibility, and workplace/school vaccine requirements were analyzed using multinomial logistic regression. Vaccine intention in the coming year was high among our participants; 65% intended to receive both vaccines, 11% intended to receive only the influenza vaccine, 7% intended to receive only the COVID-19 vaccine, and 17% planned to receive neither. Political affiliation was strongly associated with the intention to receive both vaccines. Republicans were far more likely than Democrats to report plans to receive neither vaccine (aOR: 12.8; 95% CI: 6.2–26.6), or only the influenza vaccine in the coming year (aOR: 8.7; 95% CI: 4.2–17.9). Additionally, those who planned to receive both vaccines were significantly more likely to view vaccines as a collective responsibility. This study highlights the significant influence of political affiliation and beliefs in collective responsibility on vaccine intentions.

Analysis of historical data to accelerate deletion of Abnormal Toxicity Test requirement for biologicals and vaccines

Abnormal Toxicity Test (ATT) is performed as quality control test by manufacturers and National Control Laboratory (NCL) to ensure safety of biologicals. However, stakeholders are in general consensus that extraneous toxic contaminations are extremely unlikely where Good Manufacturing Practices (GMPs) and consistent production have been established. This test requiring mice and guinea pigs is still a regulatory requirement for the batch release of biologicals in several countries although it has been deleted by some National Regulatory Authorities (NRAs) and Pharmacopoeias while some are still working on its elimination. Therefore, ten years historic data of ATT performed at National Institute of Biologicals (NIB), India on 4813 batches of biologicals including blood and related products, enzymes, hormones and vaccines by using 33637 animals was analyzed. As per Indian Pharmacopeia (IP), 4783 batches of these biologicals passed the test. The test had to be repeated in 30 batches, all of which were blood products and the repetition rate was 0.62 %. Further, after repeat testing, all these 30 batches also passed the test. This data will help the regulatory authorities of countries where ATT is still a requirement, take appropriate decision regarding its deletion. The elimination of ATT from specific monographs of these biologicals will help save many thousands of animals being used globally for this test.

Legal Frameworks for HPV Vaccination: A Doctrinal Analysis of Mandates and Exemptions

This paper analyzes the legal orders that concern HPV vaccination requirements and medical exemptions with an emphasis on how the implementation of such requirements and exemption takes into account rights of liberty such as consent and belief including that of parents. On this premise, knowledge of the legal and ethical issues about vaccination as an intervention against the detected cervical carcinogenic HPV strains cannot be overemphasized as the incidences continue to rise. Evaluating the data and analyzing the problems that are connected with HPV vaccination policies and the courts’ decision-making in relation to vaccination requirements is the purpose of the present research. To this end, the study adopts doctrinal analysis as a research method to review and analyze legal documents and public health regulations from the different jurisdictions of the world. From this analysis, the authors establish the legal factors, ethical dilemmas, and social perception of HPV vaccination. In addition, it assesses the standard that defines medical and religious low WI exemptions and philosophical considerations and discusses the meaning of these exemptions in public health policy. This gives us the roles of the courts in explaining vaccinations laws' meaning, including variations in mandates and exemption application. The issue of low vaccine uptake, vaccine hesitancy, and lack of equal access to vaccines, informed consent as an ethical issue come out prominently as figures of vaccination. The results emphasize the role of increasing legal regulators’ coherent and comprehensible language, engaging the community in order to prevent the spread of fake news, and the need for better distribution of vaccines among marginalized communities. In conclusion, it is stressed that promising approaches to HPV vaccine policies should consider the high relevance of the public health priorities to be achieved in equal regard to the values of people’s rights. Through linking positive effective population health interventions with positive legal constructs, stakeholders can increase barrier vaccination, decrease HPV related cancers, and enhance healthy communities. The policy implication of this study will be useful to policymakers and public health officials to develop multi pronged strategies on HPV vaccination mandates.

School-Entry Vaccine Policies: States' Responses To Federal Recommendations Varied From Swift To Substantially Delayed.

School-entry immunization requirements are a valuable strategy to reduce the spread of vaccine-preventable diseases. This research examined the temporal relationship between recommendations issued by the federal Advisory Committee on Immunization Practices (ACIP) and corresponding school-entry requirements adopted by states for adolescent meningococcal ACWY (MenACWY) and tetanus, diphtheria, and acellular pertussis (Tdap) vaccines. A legal epidemiological review of statutes, regulations, and state agency guidance identified school-entry policies across fifty states and Washington, D.C. Researchers measured the number of months between the date of an ACIP recommendation and the effective dates for state policies that were in place through the 2023-24 school year. All fifty-one jurisdictions had school-entry requirement policies for Tdap vaccination, and thirty-six had school-entry requirements for MenACWY vaccination. The average period between ACIP's recommendations and state policy adoption was 4.94, 9.61, and 8.24 years for Tdap and for MenACWY first and booster doses, respectively. This analysis found diverse timelines and notable delays for both Tdap and MenACWY school-entry requirement policies. This heterogeneity and patchwork of state requirements underscores the need for ACIP to evaluate the role of these policies in reducing vaccine-preventable diseases across the United States.

Nowhere to Go

This article examines epidemics and disease prevention within the War Relocation Authority camps for Japanese Americans during World War II. Although scholars and activists have noted the limits and inadequacies of medical care within the camps, little attention has been given to the actions of camp administrators in curtailing outbreaks of deadly diseases such as polio and tuberculosis, including universal vaccination requirements and the use of quarantine orders. Disease in the camps resulted in cases of social isolation and ostracization and further exacerbated the stresses of life among the confined. Meanwhile, this article explores the use of the camps as sites of scientific study. Administrators and anthropologists documented cases of camp epidemics and published their results in journals on public health.

Coverage with Selected Vaccines and Exemption Rates Among Children in Kindergarten - United States, 2023-24 School Year.

In the United States, states and local jurisdictions set vaccination requirements for school attendance, conditions and procedures for exemptions from these requirements, grace periods for submitting documentation, and provisional enrollment for students who need more time to be vaccinated. States annually report data to CDC on the number of children in kindergarten who meet, are exempt from, or are in the process of meeting requirements. Data reported by 49 states and the District of Columbia (DC) for the 2023-24 school year were used for national- and state-level estimates of the following measures: complete vaccination with required doses of measles, mumps, and rubella vaccine (MMR), diphtheria, tetanus, and acellular pertussis vaccine (DTaP), poliovirus vaccine (polio), and varicella vaccine (VAR); exemptions from vaccination; and school attendance while meeting requirements. The 2023-24 kindergarten class became age-eligible to complete most state-required vaccinations during the COVID-19 pandemic, after schools had returned to routine in-person learning. Compared with approximated national coverage levels across all reported vaccines for the 2019-20 (95%) and 2022-23 (93%) school years, coverage dropped below 93% for the 2023-24 school year, ranging from 92.3% for DTaP to 92.7% for MMR. Exemptions increased to 3.3%, compared with those during the 2022-23 (3.0%) and 2021-22 school years (2.6%). Coverage with MMR, DTaP, polio, and VAR decreased in 35, 32, 33, and 36 jurisdictions, respectively, compared with the 2022-23 school year. Exemptions increased in 41 jurisdictions, with 14 reporting that >5% of kindergartners had an exemption from one or more vaccine. Efforts by health departments, schools, and providers are needed to ensure that students begin school fully vaccinated.

Using regression tree analysis to examine demographic and geographic characteristics of COVID-19 vaccination trends over time, United States, May 2021–April 2022, National Immunization Survey Adult COVID Module

Using data from the nationally representative National Immunization Survey (NIS), we applied conditional linear regression tree methodology to examine relationships between demographic and geographic factors and propensity of receiving various doses of COVID-19 vaccine over time; these analyses identified temporal changes in these relationships that heretofore had not been identified using conventional logistical regression methodologies.Three regression tree models were built using an R package, Recursive Partitioning for Modeling Survey (rpms), to examine propensities over time of receiving a (1) first dose of a two-dose COVID-19 mRNA primary vaccination series or single dose of the Janssen vaccine (vaccine initiation), (2) primary series completion, and (3) monovalent booster dose, using a conditional linear effect model. Persons ≥50 years were more likely to complete a primary series and receive a first booster dose; persons reporting having received non-COVID-19 vaccines recently were more likely to initiate vaccination, complete the primary series, and get a first booster dose; persons reporting having work or school requirements were more likely to complete the primary series. Persons not reporting having received non-COVID-19 vaccines in 2 years but reporting having work or school vaccination requirements were more likely to initiate vaccination than those without work/school requirements. Among persons not reporting having received non-COVID-19 vaccines in 2 years and not reporting having work or school vaccination requirements, those aged ≥50 years were more likely to initiate vaccination than were younger adults. Propensity of receiving various doses was correlated with age, having recently received non-COVID 19 vaccines, and having vaccination requirements at work or school.Regression tree methodology enabled modeling of different COVID-19 vaccination dose propensities as a linear effect of time, revealed changes in relationships over time between demographic factors and propensity of receipt of different doses, and identified populations that may benefit from vaccination outreach efforts.

Effects of visit restriction in the COVID-19 pandemic: Experiences and perceptions of intensive care nurses.

The visit restrictions imposed as a result of COVID-19 precluded the entrance of the patient's family into the confines of the intensive care unit. This study evaluated the experiences of intensive care nurses (ICNs) regarding COVID-19 visit restrictions and their opinions on these restrictions. From May 2023 to July 2023, semi-structured interviews with 15 ICNs from intensive care units in a tertiary public hospital in Türkiye were conducted. Data were analysed using qualitative content analysis with an inductive approach. Reporting of the study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. The analysis revealed two main themes, 'widespread negative impacts of visit restrictions' and 'adaptive strategies to the visitation ban', and seven sub-themes supporting the main themes. Nurses perceived that the visit restrictions imposed during the COVID-19 pandemic had a severe negative effect on patients, their relatives, themselves and the care environment. They also did not support visit restriction in future pandemics. The COVID-19 visitation policy weakened the involvement of family members in patient care and created serious challenges in the intensive care setting. The study revealed an urgent need for patient-centred, family-sensitive and consistently applied protocols in future pandemics. In future pandemics, strategies such as the benefit-benefit ratio of the visit, the provision and use of adequate personal protective equipment, and vaccination requirements should be considered in visiting decisions of patients hospitalized because of infection. Participation of nurses responsible for patient care in decisions regarding visitor practices should be supported.

COMPARATIVE ANALYSIS OF METHODS FOR DETERMINING THE CONTENT OF THE TOTAL PROTEIN SARS-COV-2 OF THE COVID-19 VIRUS

One of the main requirements for the new vaccines being created is their safety in use, including the total protein content, which are one of the main indicators of the quality and safety of vaccines. This article presents the results of work on the comparative analysis of methods for determining the total protein in the active pharmaceutical substance (AFS) and also the bulk product of the vaccine "QazCovid-in ® .Determination of the total protein concentration was carried out by comparing the methods of Lowry, Bradford, commercial sets of Clini Test-BL and BSA Gold Protein. As a result of the determination of the total protein in the composition of the AFS by the classical Lowry method and the commercial CliniTest-BL kit, the highest values were obtained on average 616.67 and 589 μl/ml, and in the bulk product 51.11 and 47.38 μl/ml, respectively. The most minimal indicator of the total protein content of 38.39±0.000059 is shown by the method using the commercial BSA Gold Protein kit. The average values of total protein content showed the results obtained by the Bradford method and the determination of total protein by a commercial set of Clini Test-BL. The data obtained allow us to recommend the use of a set of Clini Test-BL for use in quality control, since this set is characterized by the ease and speed of the determination method, which is not inferior to the classical Lowry method. When determining the total protein content in the bulk product used to prepare the QazVac vaccine against COVID-19, the classical Lowry method showed the best result with a high degree of sensitivity.

Performance of the ChatGPT large language model for decision support in community pharmacy.

The aim of this study was to assess the ChatGPT-4 (ChatGPT) large language model (LLM) on tasks relevant to community pharmacy. ChatGPT was assessed with community pharmacy-relevant test cases involving drug information retrieval, identifying labelling errors, prescription interpretation, decision-making under uncertainty and multidisciplinary consults. Drug information on rituximab, warfarin, and St. John's wort was queried. The decision-support scenarios consisted of a subject with swollen eyelids and a maculopapular rash in a subject on lisinopril and ferrous sulfate. The multidisciplinary scenarios required the integration of medication management with recommendations for healthy eating and physical activity/exercise. The responses from ChatGPT for rituximab, warfarin, and St. John's wort were satisfactory and cited drug databases and drug-specific monographs. ChatGPT identified labeling errors related to incorrect medication strength, form, route of administration, unit conversion, and directions. For the patient with inflamed eyelids, the course of action developed by ChatGPT was comparable to the pharmacist's approach. For the patient with the maculopapular rash, both the pharmacist and ChatGPT placed a drug reaction to either lisinopril or ferrous sulfate at the top of the differential. ChatGPT provided customized vaccination requirements for travel to Brazil, guidance on management of drug allergies and recovery from a knee injury. ChatGPT provided satisfactory medication management and wellness information for a diabetic on metformin and semaglutide. LLMs have the potential to become a powerful tool in community pharmacy. However, rigorous validation studies across diverse pharmacist queries, drug classes and populations, and engineering to secure patient privacy will be needed to enhance LLM utility.

Measuring vaccination coverage and concerns of vaccine holdouts from web search logs

To design effective vaccine policies, policymakers need detailed data about who has been vaccinated, who is holding out, and why. However, existing data in the US are insufficient: reported vaccination rates are often delayed or not granular enough, and surveys of vaccine hesitancy are limited by high-level questions and self-report biases. Here we show how search engine logs and machine learning can help to fill these gaps, using anonymized Bing data from February to August 2021. First, we develop a vaccine intent classifier that accurately detects when a user is seeking the COVID-19 vaccine on Bing. Our classifier demonstrates strong agreement with CDC vaccination rates, while preceding CDC reporting by 1–2 weeks, and estimates more granular ZIP-level rates, revealing local heterogeneity in vaccine seeking. To study vaccine hesitancy, we use our classifier to identify two groups, vaccine early adopters and vaccine holdouts. We find that holdouts, compared to early adopters matched on covariates, are 67% likelier to click on untrusted news sites, and are much more concerned about vaccine requirements, development, and vaccine myths. Even within holdouts, clusters emerge with different concerns and openness to the vaccine. Finally, we explore the temporal dynamics of vaccine concerns and vaccine seeking, and find that key indicators predict when individuals convert from holding out to seeking the vaccine.

Effect of Childcare Influenza Vaccine Requirement on Vaccination Rates, New York City, 2012-2020.

In 2014, New York City initiated a childcare influenza vaccine requirement to increase influenza vaccination rates among children aged 6-59 months attending city-regulated childcare, including prekindergarten. We evaluated the requirement's effect on vaccination rates in childcare-aged children in New York City. We examined influenza vaccination rates in children aged 6-59 months and by age groups of 1, 2, 3, and 4 years for 8 influenza seasons (2012-2013 through 2019-2020), representing 2 seasons before the requirement, 2 seasons during the requirement, 2 seasons after its suspension, and 2 seasons after its reinstatement. We also assessed rates in a comparison group of children aged 5-8 years. We performed a difference-in-differences analysis to compare rate differences in age groups when the requirement was and was not in effect. We considered P < .05 as significant based on the Wald χ2 test. Influenza vaccination rates among children aged 6-59 months increased 3.7 percentage points (from 47.7% to 51.4%) by the requirement's second year and declined 6.7 percentage points to 44.7% after suspension. After reinstatement, rates increased 10.7 percentage points to 55.4%. Rate changes were most pronounced among 4-year-olds, increasing 12.7 percentage points (from 45.3% to 58.0%) by the requirement's second year, declining 14.1 percentage points to 43.9% after suspension, and increasing 22.2 percentage points to 66.1% after reinstatement. In the comparison group, rates increased 4.9 percentage points (from 36.5% to 41.4%) after reinstatement. Rates increased significantly among 4-year-olds before versus at the initial requirement and decreased significantly after suspension. After reinstatement, rates increased significantly among all groups except 1-year-olds. The New York City influenza vaccine requirement improved influenza vaccination rates among preschool-aged children, adding to the evidence base showing that vaccine requirements raise vaccination rates.

The impact of regional disparities on the availability of meningococcal vaccines in the US

BackgroundIn the United States (US), three types of vaccines are available to prevent invasive meningococcal disease (IMD), a severe and potentially fatal infection: quadrivalent conjugate vaccines against serogroups A, C, W, Y (MenACWY), and monovalent vaccines against serogroup B (MenB) as well as a newly licensed pentavalent vaccine (MenABCWY) protecting against serogroup A, B, C, W, and Y. The CDC’s Advisory Committee on Immunization Practices (ACIP) routinely recommends MenACWY vaccine for all 11- to 12-year-olds with a booster dose at 16 years. MenB vaccination is recommended based on shared clinical decision-making (SCDM) for 16- to 23-year-olds. Recently, the pentavalent meningococcal vaccine (MenABCWY) was recommended by the ACIP. Meningococcal vaccine uptake is suboptimal across the country, particularly among individuals with lower socioeconomic status (SES), despite these recommendations. The objective of the spatial analyses was to assess the relationship between stocking of MenACWY and MenB vaccines, area-level SES, and state-level policies.MethodsThe number of MenACWY and MenB doses stocked by vaccinators was obtained from IQVIA and the CDC’s Vaccine for Children (VFC) program and compiled into a county-level dataset from 2016 to 2019. SES, as measured using the CDC’s Social Vulnerability Index (SVI), state-level school recommendations, and universal purchasing programs were among the main county-level covariates included to control for factors likely influencing stocking. Data were stratified by public and private market. Bayesian spatial regression models were developed to quantify the variations in rates of stocking and the relative rates of stocking of both vaccines.ResultsAfter accounting for county-level characteristics, lower SES counties tended to have fewer doses of MenB relative to MenACWY on both public and private markets. Lower SES counties tended to have more supply of public vs. private doses. Universal purchasing programs had a strong effect on the markets for both vaccines shifting nearly all doses to the public market. School vaccination strategy was key for improving stocking rates.ConclusionsOverall, the results show that MenACWY has greater stock relative to MenB across the US. This difference is exacerbated in vulnerable areas without school entry requirements for vaccination and results in inequity of vaccine availability. Beyond state-level policy and SES differences, SCDM recommendations may be a contributing factor, although this was not directly assessed by our model.

Influenza Vaccination Requirements for Health Care Personnel in US Hospitals

Influenza Vaccination Requirements for Health Care Personnel in US Hospitals

Structural and social factors affecting COVID-19 vaccine uptake among healthcare workers and older people in Uganda: A qualitative analysis.

The COVID-19 vaccine rollout programme in Uganda was launched in March 2021 for priority groups: Healthcare Workers (HCWs), older persons (≥50 years), and persons with chronic conditions. Misinformation, distrust in healthcare systems, and cultural beliefs, pose significant challenges to vaccine uptake. We describe the social and structural factors affecting the uptake of COVID-19 vaccines among HCWs and older people in Uganda. Between September and October 2021, we conducted 33 in-depth interviews with 25 HCWs aged 21-63 years from three hospitals in central Uganda and eight older people from Wakiso district. Participant selection was purposive, based on sex, occupation, education, cadre of HCWs and vaccination status. We explored participants' knowledge, beliefs, personal experiences, barriers, and facilitators to vaccine uptake as well as suggestions for future COVID-19 vaccine rollout. Interviews were audio-recorded, transcribed and translated into English, coded, and analysed by theme. Twenty-two of the 25 (88%) HCWs and 3 of the 8 (38%) older people had received at least one dose of the COVID-19 vaccine at the time of interview. The structural facilitating factors to vaccine uptake included access to correct information, fear of a risky work environment, and mandatory vaccination requirements especially for frontline HCWs. Age, chronic health conditions, and the fear of death were facilitating factors for older people. Misconceptions about COVID-19 vaccines and fear of side effects were common social barriers for both groups. Long distances to vaccination centres, vaccine stock-outs, and long queues at the vaccination centres were specific barriers for older people. The prerequisite of signing a consent form was a specific structural barrier for HCWs. Future roll out of new vaccines should have a comprehensive information dissemination strategy about the vaccines. Improved access to vaccines through community outreach, reliable vaccine supplies and addressing vaccine misinformation, may enhance COVID-19 vaccine uptake.

Justification for coercion in a public health crisis: not just a matter of individual harm.

The COVID pandemic was an exceptional public health situation - which brought with it unprecedented restrictions across the global populace. But what was it about this pandemic which caused us to implement such drastic restrictions on liberty? Much of the ethical debate on restrictive measures such as lockdowns and vaccine requirements focused on the potential harm that individuals cause to other individuals by the risk of infection. I will suggest that this may come from a reliance on J.S. Mill's harm principle as providing the ultimate justification for coercion - i.e., the well-accepted principle that state coercion is justified in order to prevent the imposition of unacceptable risk of harm to others. Though there have been attempts, in the wider public health ethics literature, to use the harm principle as a basis for restricting contribution to collective harms, I will suggest that these attempts cannot rely on the harm principle alone. I will then turn to the ways in which an individual-based line of reasoning does not capture a distinctive sort of harm posed by the COVID pandemic (and others like it): the potential failure of healthcare systems. I will draw out three ways in which a focus on the harm that an individual poses to another individual fails to capture the full scope of harm wrought by the collapse of healthcare systems. First, it can't adequately capture the cumulative and "looping effects" of the harm caused by strained healthcare systems. Second, it fails to capture the widespread ripple effects the failure of a central societal institution can have on other institutions. And third, the failure of a healthcare system can impose "psychic costs", affecting the moral character of all members of society, reducing trust in institutions, and potentially posing an existential threat to the fabric of society. Finally, I will sketch some implications of the recognition of this distinctive sort of harm for the justification of coercive public health measures.

Comparing social responses to Ebola and Covid-19 in Sierra Leone: an institutional analysis.

This paper compares community responses to Ebola and Covid-19 in two regions of southern and eastern Sierra Leone with reference to the theory of institutional dynamics proposed by the anthropologist Mary Douglas. Institutions, Douglas argued, are conveyed by styles of thought, shaped by the ways human communities, through everyday practices, reinforce systems of classification and denotation. Pandemic advice to 'follow the science' proved problematic, since there is no single institution of science, and institutions never stand alone but are bundled with other institutions, reflecting the manifold and intertwined practices of human social life. The paper explores some of the ways a traumatic epidemic of Ebola Virus Disease in Sierra Leone shaped a distinctive local response to this deadly infectious disease in the absence of an effective vaccine. This local approach emphasised social rules based on ideas about sequestration and testing. Communities then proposed to continue this rules-based approach to the pandemic of Covid-19 and showed little initial enthusiasm for vaccination. With Ebola, the adoption of rules resulted in dramatic drops in infection rates. But Covid-19 spreads in different ways, and good results from the application of social rules were much less apparent. The paper shows how communities began to grapple with this new situation. In some cases, vaccine hesitation was overcome by treating the requirement for vaccination as a new form of social discipline. More generally, it is concluded that epidemiologists need to pay specific attention to institutions and institutional dynamics in order to better understand and anticipate public reactions to new disease threats.