key: cord-0887982-psutvwf4 authors: Saban, Mor; Myers, Vicki; Shani Ben-Shetrit, L. L.; Wilf-Miron, Rachel title: Issues surrounding incentives and penalties for COVID-19 vaccination: The Israeli experience date: 2021-08-02 journal: Prev Med DOI: 10.1016/j.ypmed.2021.106763 sha: d4d39abdd24eaf08abbf46451ade17bd584fd719 doc_id: 887982 cord_uid: psutvwf4 The purpose of this study was to examine patterns of COVID-19 vaccination in Israel and how these relate to different proposals made about benefits for those vaccinated, and to present the legal and ethical dilemmas surrounding these issues. A retrospective study of COVID-19 vaccination rates in Israel was conducted, with data obtained from the Ministry of Health (MOH). Information on benefits proposed or offered for vaccination and restrictions for non-vaccination were obtained from the MOH and presented in a timeline. By March 1st, 51% of the total population, and 91% of those aged 60 and over, had received their first COVID-19 vaccine. Exemption from quarantine was granted to vaccinated or recovered people from 17th January 2021. The ‘green pass’ incentive scheme, granting access to social, cultural and sporting events for those fully vaccinated or immune, was proposed in December 2020, and came into effect on February 21st 2021. Incentive schemes which impose limitations on those who choose not to vaccinate may motivate some people to take action. Policymakers should use a measured approach to protect public health, with minimum infringement on citizens' rights. Providing transparent and culturally appropriate information on immunization and ensuring maximal and equitable access to COVID-19 vaccines may help build trust. Governments aim to achieve as high a proportion of their population vaccinated against COVID-19 in the shortest time possible, in order to reduce morbidity and mortality, reduce burden on hospitals, and remove restrictions, having witnessed the devastating health, economic and social effects of the pandemic. 7 Incentives have been used previously in an attempt to encourage people to vaccinate against other diseases. Most previous research on incentives for vaccination have concerned childhood vaccines. Some countries have implemented reward schemes, while others applied penalties for non-vaccination. Since 1998 the Australian government, in a bid to improve vaccination rates, made certain childcare payments and benefits dependent on children being vaccinated according to schedule ("no jab no pay" policy). In 2015, the exemption for conscientious objection was revoked. This has contributed to high vaccination rates. 8 A review conducted in Australia which looked at both financial and non-financial incentives found both to be effective in raising child immunization rates. 9 However a more recent study showed while it encouraged some parents to vaccinate on time, the policy did not change the position of those opposed to immunization. 10 The U.S. Department of Health and Human Services' Healthy People 2020 programme, which provides evidence-based resources for health promotion, recommended client or family incentive rewards for vaccination, including financial or other incentives, such as food vouchers or baby products. This was based on recommendation from the Community Preventive Services Task Force which found sufficient evidence of effectiveness in raising vaccination rates, based on 7 studies. 11, 12 In Singapore a study offered monetary incentives to encourage adult vaccination against influenza and found this could boost vaccination rates, though in a limited sample. 13 A review of methods to increase flu vaccination among health workers included 46 studies and found mandatory vaccination to be most effective, while incentives did not make a significant difference in vaccination rates. 14 The case of COVID-19 vaccination differs from other established vaccines: First, during the study period, COVID-19 vaccines were recommended only in adults aged 16 plus so cannot benefit from the lessons accumulated in childhood immunization schemes. Second, and no less important, COVID-19 vaccines have been developed in a rapid international effort, with less than one year from start to conditional market J o u r n a l P r e -p r o o f Journal Pre-proof authorization, raising concerns about this fast-tracked development process in comparison to other vaccines which traditionally take years to come to market. 15 Furthermore, the COVID-19 vaccine makes use of novel messenger RNA (m-RNA) technology, the first of its kind to be approved. 15 These two unique characteristics fuel concerns that are superimposed on long standing vaccine resistance movements. Social media is another factor that facilitates the rapid spread of anti-establishment and conspiracy theories. Indeed, organized antivaccination groups that often have a strong presence on social media have contributed to the drop in vaccination compliance and anxieties concerning vaccination. 16 Though incentives may increase vaccination rates somewhat, they may not be sufficient to overcome health concerns or doubts regarding efficiency in this novel vaccine, especially in light of strong social media presence of anti-vaccine movements. The debate over COVID-19 vaccination has wakened many ethical and legal issues that come into play with regard to possible incentives and restrictions linked to nonvaccination. Israel, with the highest coverage of its total population in the first two months of the vaccination drive 17 , could be an "early adaptor laboratory" to examines these issues. Vaccination in Israel began on the 20 th December 2020 with the Pfizer BioNTech COVID-19 vaccine, given in two doses with a three-week interval. Since Israel was among the first nations to start a widely implemented operation, aimed at gradually reaching all citizens aged 16 years and over, the follow-up of the evolution of incentives and penalties around vaccination are relatively more well-defined. They center around free access to social, sports and cultural activities and events, a novel strategy not used before in vaccine drives. The aims of the study were 1) to examine patterns of COVID vaccination in Israel and how these relate to different proposals and statements made about benefits for those vaccinated and 2) to present the legal and ethical dilemmas around these issues. Vaccination was rolled out in Israel in stages according to age groups. The first priority group from 20 th December included medical staff, age 60 and over, and risk groups (lung disease, diabetes, immunodeficiency). At the beginning of the vaccination drive, the Prime Minster, President, Minister of Health and other senior officials publicly received their vaccinations. This was followed by eligibility for age 50+ from the 13 th January, pregnant women and age 40+ from 19 th January, age 35+ from 20 th January, and age 16-18 from the 22 nd January. On 4 th February, vaccination was opened up to all eligible (16+) age groups. Figure Table 1 presents, in a timely order, various statements that were made by the government on benefits and incentives that would be given for vaccination within the "Green pass" program, and restrictions that would limit entrance to certain social, sports and cultural activities for non-vaccinated people as well as proposed legislation. It also presents when the relevant regulations and legislation came into effect. The most prominent dates were the 17 th January when exemption from quarantine for vaccinated persons who were in contact with an infected person or returned from travel abroad was officially declared; and the 21st of February when the 'Green pass' was officially implemented. After the 17 th January there was a peak in second dose vaccinations, rising to over 200,000 per day. High vaccination rates continued following the highest daily number of new confirmed cases since the pandemic began (10,117 cases or 1,088 cases per million population on 18 th January) and highest fatality rate was reported on 24 th January. 21 Israel has been a leader in COVID-19 vaccination achieving a very high rate per population in a short period of time, due to both a sufficient supply of vaccines, and to efficient rollout through the four Health Maintenance Organizations, as well as hospitals and the Israeli Red Cross. Ahead of most other countries, Israel achieved vaccination of 50% of the population, and 90% of those aged over 60, within the first two months. The Israeli government decided to use incentives and restrictions with the aim of increasing vaccination rates, especially in younger age groups, allowing reduced health burden, re-opening of the economy, and reaching herd immunity. While we cannot surmise a causal relationship, patterns of vaccination seem to be somewhat influenced by announcements on exemption from quarantine (a "pure" incentive") and on the 'Green pass' (both an incentive for those who hold the pass and a penalty for those who are not eligible to hold it). It is reasonable to assume that some people were motivated to vaccinate based on the promise of benefits and access to social and cultural events as well as sports and entertainment venues. These incentives are likely to have more of an impact on the younger population, who may need more reasons to get vaccinated, since they are at lower risk. Changes in infection and fatality rates likely also had an impact on vaccination uptake and we cannot isolate the impact of either of these influences. Survey data shows that not all people will be persuaded by incentives to get vaccinated, for example a survey conducted in Israel found that among 500 respondents, 21% reported not intending to vaccinate, and of these 31% said the offer of green pass would possibly or definitely convince them, while 46% said it would not. 22 Further surveys may be used to assess people"s reasons for vaccinating and whether the incentive scheme had the desired effect. Penalties are less commonly used to boost vaccination rates, though punitive measures were used to halt measles outbreaks in Europe. A 2019 paper examining vaccine policies including those that require vaccination for the provision of social goods, argued that, "It is reasonable to restrict access to public institutions (e.g. schools) with appropriate recourse for medical, philosophical and religious exemptions in contexts where vaccination coverage is low and outbreaks likely," 23 but that these must go hand in hand with strategies to improve trust. Trust in the vaccine is influenced by many factors, including social norms and acceptance of the vaccine among peers, trust in governmental policymakers, and in the medical/pharmaceutical industries. 24 A US study found demographic differences, with men having higher trust in the vaccine, while minority groups demonstrated lower trust. 24 Furthermore individuals who had greater trust in the information received about COVID-19 from the health department and government institutions were more likely to have higher trust in the vaccine. A high rate of distrust has been found in regard to the new COVID-19 vaccines, and it has been suggested that rolemodelling by public officials and targeted public education could help build trust. 25 J o u r n a l P r e -p r o o f Indeed in Israel, the public vaccination of senior government officials was intended to convey a message and set an example to the public. Certain communities may already have lower trust in government institutions, including minority groups, which may translate into lower uptake of vaccines. Indeed, data have shown lower uptake among the Arab minority population and in the ultra- communities. COVID-19 mortality rate was highest amongst Arabs. Conversely, vaccine uptake was lower amongst Arab and ultra-Orthodox Jewish populations and low SES communities. 26 The authors emphasize that "these inequalities were evident even in settings with universal health insurance and high accessibility to healthcare, including COVID-19 diagnostics, treatment and immunization, like Israel". 26 The WHO recently published guidelines for developing a proactive COVID vaccination strategy, which includes behavior change planning, audience targeting, analysis of barriers, mobilization, building vaccine demand, community engagement, access to vaccines, marketing strategy, media outreach and digital media strategy, which when combined are likely to lead to a more effective vaccination campaign. 27 It is important to identify which groups are reticent to vaccinate, and examine their reasons. Fournet et al 28 For other groups we need to listen to and address people"s concerns. Beyond individuals" motivation to vaccinate lie factors of access to the vaccine and practical/logistic issues. In Israel, access has been broader and quicker than in many other countries, indeed many countries do not yet have access to the vaccine. There has been much criticism of the policy of excluding non-vaccinated people from certain venues and events -an appeal was already submitted to the supreme court on this issue in Israel. Several legal and ethical issues are raised by this strategy. The green pass system provides external motivation (as opposed to internal motivation for vaccination) which rewards a desired behavior, and penalizes undesirable behavior (non-vaccination). While intrinsic motivation is considered a stronger motivator of behavior, particularly when it requires long-term maintenance such as smoking cessation or weight loss, 29 external incentives can boost motivation and may be effective for one-off behaviors like vaccination. 30 The incentive system is intended to speed up the vaccination process and thus facilitate a quicker recovery of the economy and improve population health. While vaccinated individuals will enjoy unlimited access to entertainment venues, as well as certain holiday destinations (termed "green islands"), the non-vaccinated will face restrictions. Those with a green pass will also benefit from exemption from 14-day quarantine following contact with a confirmed COVID-19 case. The use of incentives to encourage desirable behavior is legitimate, and some would say essential in order to protect public health in the case of the COVID-19 vaccine against a highly infectious disease. Some would consider it the state"s duty to do all it can to encourage vaccination in order to protect the health and lives of its citizens. 31 While laws and regulations devised during the pandemic (including but not limited to the green pass) were made to protect the health of all citizens, their implementation may sometimes infringe upon human rights, for example freedom of movement, freedom to gather, and with regard to vaccination -the right to autonomy over one"s body. In Israel the sanctity of life is one of the founding principles anchored in the law of human dignity and liberty. 32 This includes the right to autonomy over one"s body and to make autonomous decisions. This principle is protected by constitutional law, and J o u r n a l P r e -p r o o f includes the right to choose whether to vaccinate (for COVID or any other disease) without coercion or manipulation. Since the "green pass" regulation involves a penalty (negative) versus a benefit (positive), the tendency is to see this as a violation of the individual's autonomy. A purely positive incentive would not be considered an infringement on autonomy, but once sanctions are imposed on one group (the nonvaccinated) involving removing some of their rights (eg. Free movement, freedom to work), this could lead someone to feel they have no option but to take the vaccinethis would be an attack on rights. However, rights do not exist in a vacuum and must be considered in light of conflicting interests. According to the Israeli fundamental law "Human Dignity and Liberty", 33 clause 8, four conditions must be met to prevent the unconstitutionality of a law that is alleged to be a violation: 1) The violation was committed by law or by virtue of an explicit authorization; 2) the law is in line with the principles of the state; 3) the law is for a worthy purpose; 4) proportional harm (and no more than absolutely necessary). 34 A law whose purpose is to protect the public interest (in this case its health) could be considered a worthy purpose, in addition to getting the pandemic under control, preventing further lockdowns etc. If so, it would still need to meet the other 3 conditions including proportionality. While the non-eligible population are physically restricted from some places, they have access to alternatives, such as online shopping, or they have the option of presenting a negative COVID test to gain access. Israel has already achieved relatively high COVID-19 vaccination rates in a short period of time. However, vaccination rates are slowing and in order to reach herd immunity, new strategies may be required. If the state decides to use drastic means, which may be justified in order to protect public health and for the common good, it must do so with the minimum of infringement on citizens" rights, while balancing conflicting interests and maintaining proportionality. Furthermore, research has shown that the use of rewards and penalties may displace other motivations for desirable behavior, such as altruism or civic duty. Policymakers may consider whether reinforcing mutual social responsibility may raise intrinsic motivation to vaccinate, alongside external incentives. 35 J o u r n a l P r e -p r o o f Individuals must be allowed to voice their concerns, and clear culturally appropriate information should be readily available, regarding immunization, and the relative risks of adverse vaccine effects and of COVID-19, to help people make an informed decision. Full and equitable access to vaccination must also be ensured to underpin the incentives scheme. Governments implementing incentive schemes have to deliver on the promise of benefits to those vaccinated, which may further encourage an increase in vaccination rates of those who have yet to take the plunge. If the benefits do not materialize, already low public trust in governmental bodies during handling of the pandemic may be further eroded. including incentives, could be a useful short-term measure, a means to an end, which ultimately benefits the whole population. Data access and integrity-The authors declares that they had full access to all of the data in this study and the authors takes complete responsibility for the integrity of the data and the accuracy of the data analysis. ☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. *Hadassah hospital was the first to inform employees that those eligible but refusing to vaccinate would be put on unpaid leave **Highest fatality rate in Israel since start of pandemic. ***Identifying information and contact details will serve local authorities to target efforts to increase vaccination; information on educational staff will be passed to the Ministry of Education to encourage staff to receive the vaccine doses. 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