When a coronavirus vaccine becomes available in the United States, the federal government and states will face a crucial choice: Should all or most residents be required to get the novel coronavirus vaccine?
Or should it be required only for school children, with a medical exception allowed, and for groups like front-line health-care workers? Some officials might want few or no requirements at all because they think enough people are likely to get the vaccine voluntarily or have immunity from an infection to halt the spread of the disease.
But in states like Oklahoma, efforts to require and promote the vaccine could run into strong headwinds.
Anti-vaccine activists are vocal and influential in the state, spurred on by a national movement. It’s one reason Oklahoma is one of only 15 states, including Texas and Arkansas, that allow parents to cite personal reasons to exempt their children from immunizations required by schools and day-care centers. They fill out and turn in a form. All states grant exemptions for medical reasons, and 45 states plus Washington, D.C., allow exemptions for religious objections.
Vaccine skeptics have successfully fought off efforts in the Legislature and state government to tighten exemptions. Just this year, a state advisory committee proposed requiring parents who opt out of vaccinations for their children for religious or personal reasons to first attend a vaccine education session at their local health department. It also proposed that exemptions expire after sixth grade unless parents renew them. Both measures failed to advance.
A key reason driving proposals like these is Oklahoma’s rising numbers and rates of exemptions. In 2018-19, the overall exemption rate for all kindergarteners in the state was 2.6%, up from 2.2% in 2017-18 and 1.9% in 2016-17, according to the Oklahoma State Department of Health. The number of approved vaccine exemptions doubled from 2,417 in 2014 to 5,082 in 2019.
Liza Greve, executive director of Oklahomans for Health and Parental Rights Foundation, a nonprofit that promotes what is often called vaccine choice or health freedom, said she believes there’s a good chance Oklahoma will add a COVID-19 vaccine to its vaccination schedule for children, and health-care workers will be required to take it. But her organization will advocate for an individual’s right to choose.
“Whatever shakes out, Oklahomans need to have a choice in vaccination and treatment,” she said, citing concerns that rapid development of a COVID-19 vaccine will heighten risks of adverse reactions.
Dr. Ervin Yen, an Oklahoma City anesthesiologist who advocated for stronger immunization policies during his four years in the Oklahoma Senate, said he thinks the federal government should require the vaccine for all citizens because of how deadly and contagious the disease is. But he believes the decision will be left up to the states.
“I think a significant number of states will mandate it, and I think Oklahoma will have to consider it,” Yen said.
‘The public is demanding it’
Oklahoma requires children entering school to be vaccinated for nine diseases, including measles, chickenpox and polio. Parents can apply for exemptions on medical, religious or personal grounds. Medical exemptions represent the smallest share of school exemptions in the state.
House Majority Floor Leader Jon Echols, R-Oklahoma City, anticipates the state health department would update the vaccination schedule for children to include COVID-19 once a safe and effective vaccine is available and the Legislature would approve it as long as parents could apply for the same exemptions.
“I think it would be widely used,” Echols said. “I would take it.”
But a general requirement to be vaccinated would not fly, Echols said. “There’s no chance of the Oklahoma Legislature passing a People’s Republic of China mandate,” he said.
Nationwide nearly half the states require young adults be vaccinated against meningococcal disease before heading to college, and 15 states also require the hepatitis B vaccine.
But unlike policies for children, few requirements exist for adult immunizations in the U.S. and little public health infrastructure supports mass vaccination of adults, according to the National Conference of State Legislatures.
Doctors and scientists say every vaccine has an adverse reaction rate. For the measles vaccine, it is one per 1 million people vaccinated, according to the World Health Organization.. “But you save 40 to 50 people (per million) from dying,” Yen said.
The benefits of the eventual COVID-19 vaccine will “hugely outweigh the risks,” he said. “Coronavirus is way deadlier than measles.” Even if the death rate turns out to be only 1%, a vaccine given to 1 million people would save 10,000 lives, Yen said.
Scientists across the globe are fast-tracking development of a COVID-19 vaccine, with 118 candidate vaccines in the works, the World Health Organization reports. Of those, eight are in clinical or human trials and 100 are not yet being tested on humans.
It’s not clear when a safe and effective vaccine would be developed and available for distribution. Predictions have ranged from 12 or 18 months to at least a few years out, and residents in developed countries, or ones that originate a successful vaccine, could gain vaccine immunity first, while more impoverished countries wait.
The U.S. Food and Drug Administration is streamlining its processes for coronavirus vaccines and therapeutic treatments.
“The FDA is going to rush it through,” said William Hildebrand, a research professor at the University of Oklahoma College of Medicine who is among the many scientists worldwide working to create a vaccine. “The public is demanding it.”
Hildebrand’s team is looking at using the body’s protective T-cells to find and kill virus-infected cells, rather than developing a vaccine that helps the body produce antibodies. It’s a long shot, he said.
“Everybody’s odds are a little long (individually), but collectively our odds are pretty good,” Hildebrand said. “The odds are pretty good the scientific community is going to come up with something that will stop this virus.”
For a vaccine to stop the spread of an infectious disease, a sufficiently high number of people must be immune to the disease. That provides indirect protection, or herd immunity, to those who aren’t vaccinated or who have compromised immune systems and are at greater risk of catching an infection, including babies, older adults or people with certain medical conditions.
Herd immunity for each disease is based on how many additional cases each infected person will cause during their infectious period. One person with measles, for example, will infect 12 to 18 others, so, based on a complex calculation, 90% of the population needs to be vaccinated to ensure the disease does not spread.
In the case of COVID-19, the science shows an infected person will pass it along to about three others, meaning about 70% of the population will need to be vaccinated to reach herd immunity, said Gary Raskob, dean of the OU College of Public Health.
An analysis by the Journal of Infection in mid-March estimateds that the percentage of a population that must be immune via vaccination or natural immunity to halt the spread of COVID-19 varies by country. In Kuwait, it’s less than 6%; in Japan, 33%, and in Spain, 81%. The percentages are based on R-naught values, the epidemiological number for the reproduction rate of the virus.
“The vaccine will be crucial,” Raskob said. “We have to get the public to understand the importance of vaccination.”
Public acceptance likely will be better than for the measles vaccine, he said. “Since measles was eradicated, many people have never seen a case of measles, even most physicians practicing today,” Raskob said.
Not so with COVID-19. People are reminded daily of the severe and fatal effects of the disease and many people have personal experience with it. People are likely to be waiting in line as production scales up once the FDA approves a vaccine, he said.
If there’s not enough vaccine to meet the initial demand, it would likely go first to health-care workers and then the most vulnerable population, Raskob said. Hospitals and long-term care facilities will have the ability to require that employees be vaccinated over any personal objections, he said.
Oklahoma law currently requires hospital employees to provide documentation of immunity to measles, mumps, rubella and varicella. In addition, several hospitals have adopted the Oklahoma Hospital Association policy that supports mandatory employee influenza vaccinations as a condition of employment in hospitals.
‘We have to proceed with caution’
Amid the quest for a coronavirus vaccine, suspicion gathers among networks and groups that object to many proven vaccines and vaccination requirements.
A study published this week in the science journal Nature found nearly 100 million people expressing views on vaccination on Facebook and concluded the explosive growth in anti-vaccination views could increase opposition to a future COVID-19 vaccine and “amplify outbreaks, as happened for measles in 2019.”
The Oklahomans for Health and Parental Rights political action committee, which contributes to legislative campaigns, says vaccines have been linked to chronic childhood conditions, including autism, asthma, diabetes and obesity. Claims like these are made by other anti-vaccination groups nationwide despite scientific research to the contrary showing vaccines are generally safe.
Greve, who leads the PAC as well as the nonprofit advocacy group, said supporters are following the COVID-19 vaccine news and keeping an eye on safety and efficacy studies.
“Sometimes in an emergency situation, corners are cut when they shouldn’t be,” Greve said. “The evolving science is moving very quickly. When it comes to a vaccine, we have to proceed with caution.”
One concern is the risk of immune enhancement, in which a vaccine actually weakens a person’s response to the virus so the person becomes sicker, Greve said.
An example occurred when an investigational vaccine against respiratory syncytial virus (RSV) backfired in the 1960s. In one study, the hospitalization rate of infants who were vaccinated approached 80% compared to 5% for those not vaccinated, and two toddlers died, according to the National Institutes of Health’s National Library of Medicine.
Greve’s advocacy group supported a dozen vaccine-related bills filed this legislative session, including efforts to protect personal exemptions and establish a stronger tracking system for reporting any injuries or deaths from vaccinations.
Hildebrand, of the OU College of Medicine, said multiple studies are underway to provide the answers scientists need to develop an effective COVID-19 vaccine in record time. He said the rush to discover a coronavirus vaccine means the result could carry a greater risk of serious reaction than normal.
“This one might be more relaxed or liberal in its acceptable adverse reaction rate,” he said.
When the vaccine is available, he said, people will have to ask themselves what’s riskier, the odds of an adverse reaction or the danger of getting the disease.