Can vaccine adherence against Sars-CoV-2 become a criterion for access to medical care?

Globally, as of 1 March 2022, more than 10.8 billion of vaccine doses against Covid-19 have been administered. ¹

Full accessibility to vaccinations in developed countries now makes it possible to critically analyse these statistics. Behind the percentage of unvaccinated subjects are hidden both those who cannot access the vaccine for clinical contraindications, and those who do not access it by free choice.

Among those who choose not to vaccinate are those who are totally opposed to vaccination, “anti-vaxxers”, and those who have legitimate doubts about vaccination in terms of safety on their health (vaccine hesitancy).^2,3

As useful as it is to understand the differences in this category of citizens and identify the reasons behind the decision not to vaccinate, we think it is necessary to pay considerable attention in trying to avoid the stigmatization of non-vaccinated subjects. In fact, this could favour a paradoxical effect that could generate an expansion and a further radicalization of antivax ideologies. ⁴

To date vaccination against Covid-19 is mandatory only in eight European countries and only for certain categories of people (Table 1). ⁵ In the remaining countries vaccination is only recommended and the possibility of not getting vaccinated against Sars-CoV-2 remains in theory a possible option for all citizens. In fact, since there is no obligation to vaccinate by law, in these countries the autonomous management of the fundamental right to health remains constitutionally protected.

OPEN IN VIEWER

Table 1.

Mandatory COVID-19 vaccination in European countries.

MANDATORY VACCINATION	EU Countries
Yes, for certain categories of people.	France, for health and care workers, firefighters, and transport workers.
	Greece, for people over 60, and health workers.
	Hungary, for health workers, schoolteachers, and people working in state institutions.
	Italy, for people over 50, healthcare workers, school workers, and law enforcement.
	Latvia, for health workers, schoolteachers, and social care homes workers.
	Poland, for health workers.
	Lithuania, for health, and social workers.
	Austria, for citizens over 18.
No.	Belgium, Bulgaria, Croatia, Czechia, Cyprus, Denmark, Estonia, Finland, Iceland, Ireland, Germany, Liechtenstein, Luxembourg, Malta, the Netherlands, Norway, Portugal, Romania, Slovenia, Slovakia, Spain, Sweden.

Lately, all European countries have been spreading strategies of conviction to induce vaccination, especially through the introduction of vaccination certificates that exclude, drastically, subjects not vaccinated from work and recreational activities as well as from access to public places and services. This is the case, for example, of France, which since the end of January 2022 has mandated the possession of the “vaccine pass” for access to public places for all adults; this certificate is only obtainable by citizens who have completed the vaccination cycle and/or who have recovered of Sars-CoV-2 infection for less than six months and/or who have documented medical contraindications that prevent vaccination.

In Italy, a similar certification – “super green pass” – is mandatory from February 2022 for workers over the age of 50, as well as for certain categories of professionals, regardless of age (healthcare workers, school workers and law enforcement). However, all citizens must present this certification to have access to many public places (restaurants, gyms, theatre, cinema), recreational activities (team sports, events, conferences, exhibitions), and public transport.

These certifications, which are essential to enable citizens to participate in social life, risk, however, encouraging the ghettoization of a category of persons on the basis of a free health choice. Moreover, these restrictions end up influencing a health choice that, although it is not mandatory by law, should instead be the conscious product of a correct scientific information.

What is necessary, to increase the adherence of these subjects to the vaccination plan, is to encourage unambiguous and not confusing information on the positive effects of the vaccine for the individual and for the community. One of the objectives of awareness campaigns should be to try to convey the privilege of being protagonists of scientific progress and to be partisans of collective health.

The reasons behind the decision not to vaccinate are varied and include distrust of science, misinformation and conspiracy theories. ² However, anti-vax also includes people with diagnosed or undiagnosed mental disorders that make them particularly vulnerable to vaccine fear. ⁶ These subjects, different from those who consciously choose not to be vaccinated, are however difficult to identify and distinguish from other anti-vax subjects because mental disorders are often not diagnosed and are also triggered by stress situations (such as the pandemic Covid-19) and the spread of anti-vax theories.

The pandemic highlights the precariousness of countries' health resources worldwide, exacerbating the concept of health as an elitist asset in countries where health care is private. ⁷ However, especially in countries with a public health system, the scarcity of resources emerged in terms of delayed access to first aid services, reduced and sometimes absent availability of medicines and essential devices, overcrowding and unavailability of beds in intensive and semi-intensive care units. The serious imbalance between the supply and demand of care can also force the doctor to choose which patients to give priority access to treatment. For example, in Italy, to meet this need, the National Institute of Health has published the Guidelines formulated by the Italian Society of Anaesthesiologists, Intensivists, and Pain Therapists (SIAARTI) and the Italian Society of Legal Medicine and Insurance (SIMLA) entitled: “Decisions for intensive care in the event of a disproportion between care needs and resources available during the COVID-19 pandemic”. ⁸

This document legitimises the use of triage to select patients to be prioritized during the emergency phase. This allows, based on some parameters (comorbidity, previous functional status, severity of the clinical picture, presumable impact of intensive treatments also in consideration of the patient’s age, the patient’s will about intensive care), to create a medical identikit of the patient bidding for access to intensive care.

In non-emergency conditions, the prevailing criterion for evaluating the possibility of hospitalization in Intensive Care is linked to the clinical situation of the individual patient; in emergency situations such as the one we are experiencing, the health of the community also becomes a central concern in the evaluation (individual-centred care versus community-centred care).

The need to offer adequate care to patients with a higher probability of survival imposes a selectivity of access to intensive treatments among all patients – sick or not sick of Covid-19 – avoiding the risk of consolidation of the illogical criterion, “first come, first served”.

Even in more limited emergency conditions, such as those we have been experiencing in Europe in recent months, there is still a dangerous stalemate in health systems, especially for routine check-ups and screening visits. Access to these services is still restricted. In addition, healthcare facilities are still disposing of elective surgeries and medical visits that have been repeatedly delayed during the worst stages of the pandemic.^9,10 In many European countries the inadequacy of health systems in coping with the pandemic is linked to unsuitable policies that have not sufficiently strengthened public health over the years.

The vaccination history, verifiable also through technological instruments, ¹¹ cannot be considered in this phase a priority criterion for patients' access to medical care for pathologies that have nothing related to Covid-19.

If it is true that anti-vax has contributed and contribute to the economic collapse of the health system, this cannot and must not affect their full accessibility to medical care. They are expected to be as equal as other patients such as, for example, drug addicts and/or smokers and/or alcoholics. These patients, like anti-vax subjects, choose to lead an existence contrary to the good of the community (also, committing a crime in many countries in the case of drug addicts), burdening the health system and depriving more virtuous patients of resources. However, by exaggerating this concept, even some obese individuals (who in the absence of other pathologies decide to lead an unhealthy lifestyle) could erroneously be considered a burden for the National Health Systems.

If, by virtue of the principle of equity and indiscriminate access to care, such patients are guaranteed full access to healthcare resources, the same approach towards anti-vax patients is expected.

Therefore, even in an emergency where there is a need to select access to essential care, it is unthinkable to violate the principle of equity and the right to health of all patients on the basis of their personal choices. These principles must always be considered deontologically essential to avoid the risk of free selection of patients based on vaccination status or other personal choices.

In addition, delayed access of anti-vax, and not only, to care services would likely encourage diagnostic and therapeutic delays. These events could favour medico-legal disputes for healthcare facilities with a further considerable expenditure for the National Health Systems with a worsening in the quality of care.

In our opinion, it is necessary to focus energies and attention on the attempt to “convert” anti-vax subjects into pro-vax. To achieve this goal, it is crucial to implement clear, simple and not contradictory awareness campaigns to explain and illustrate the benefits of the vaccine for the individual and for the community.

When science prospers ignorance succumbs, when science fades away the ignorance spreads.