Vaccination is an essential tool to fight against the spread of the Covid-19 virus and the emergence of variants. What are the conditions for decreeing a vaccination obligation? Advantages ? For which people? Interview with Prof. Dominique Salmon, infectious disease specialist.
Vaccination constitutes an essential tool to fight against the spread of SARS-CoV-2 (virus responsible for the Covid-19 epidemic) and prevent the emergence of new variants. Corn the conditions for decreeing a vaccination obligation are they together? Against which diseases vaccines have been made compulsory? What are the advantages of an obligatory vaccination? The inconvenients ? For what types of people? Interview with Prof. Dominique Salmon, infectious disease specialist at Hôtel Dieu hospital, and president of the HAS working group on prolonged symptoms of Covid-19.
Pr Dominique Salmon : Vaccines were made compulsory for diseases that were considered plagues on Humanity and for which we had an extremely effective vaccine. The vaccine against diphtheria was imposed in 1938, the one against tetanus in 1940 and the one against polio in 1964. At that time, the diseases were very serious, very frequent and very contagious, so it was necessary to take this decision of compulsory vaccination. When the decision to make the polio vaccine mandatory was taken, it was a disease that left many people paralyzed for life and led some to require assisted breathing. It was during this period that intensive care units opened in France. The famous steel lungs were developed for these increasing cases of ascending paralysis, people could no longer breathe spontaneously and spent several months or even years assisted by these machines. There were two vaccines against the polio virus: a vaccine containing inactivated virus (IPV) and an oral vaccine (OPV). In developing countries, oral vaccination has long been favored, as it is administered in the form of drops on a piece of sugar in the mouth of children, from village to village. Despite its many advantages, OPV carries a risk of polysaccharide associated with vaccination, particularly in infants, and cases of vaccine virus reversion paralysis have been reported. But the advantage was major, since vaccination has prevented the virus from circulating and reduced the incidence of the disease. Because of these risks, and now that the incidence of the disease has been greatly reduced, OPV will be phased out in these countries to keep only IPV.
Pr Dominique Salmon : The compulsory vaccination has had incredible effects. The curves for tetanus, diphtheria and polio have dropped from several thousand to less than 10 cases per year for tetanus, for example. In France, no case of acquired polio has been reported since 1989. Vaccination has eradicated certain diseases such as smallpox.
“A vaccine can only be made compulsory if it is accessible to the entire population”
Pr Dominique Salmon : The vaccination obligation is quite rare, it is determined by a legal text and to decree it, it is first necessary to analyze the situation very finely according to several criteria:
“With regard to the criteria required to make vaccination compulsory, not all are met for Covid-19.”
► The severity of the disease: the disease must be really severe for the majority of people, and potentially fatal.
► The effectiveness of the vaccine: the vaccine must be very effective, regardless of the strains responsible for the disease. There should only be one virus or bacteria causing the disease (as in tetanus) or a few viruses (as in polio), but the vaccine should work on all of these strains.
► A very positive benefit-risk balance: this means that, even if the vaccination presents risks, because there are always risks, however small with any medical or vaccination act, these must be very minor compared to the benefits it entails. At the end of clinical trials, we have a good idea of the tolerance of the vaccines, but he waits until millions of people are vaccinated to accurately assess the very minimal risks that affect less than 1 in 1 million.
► Availability of the vaccine: a vaccine can only be made compulsory if it is accessible to the entire population, including in my opinion for people who are not covered by health insurance. Because not vaccinating people who do not have access to healthcare in France would mean allowing individuals to circulate who could continue to contract and transmit the disease.
With regard to the criteria required to make vaccination compulsory, not all are met with regard to Covid-19. All the criteria must be analyzed very precisely to justify the fact that vaccination becomes compulsory. However, to date, many indicators are met but not all are green. However, Covid disease is sometimes very serious, especially for people at risk (elderly, overweight, hypertensive, renal failure, etc.). It is considered less serious in young people and children, but we have recently seen more and more serious forms in young people, but many only think of the acute phase, underestimating the Long Covid which affects 10% of infected people and disabilities with prolonged fatigue and brain fog that persists for months.
Pr Dominique Salmon : Yes, when the vaccines were developed for the strains that were circulating at the time of the first wave, the effectiveness was over 90% against COVID, so very effective. With the emergence of variants, vaccine efficacy remains very high against the risk of severe forms (85%) and 90% against resuscitation, but has dropped to 40% regarding the risk of contracting COVID. At first glance, the risks are very low and on the tens of thousands of patients included in the clinical trials, everything went well. There are still signs that exceptional side effects exist. However, all vaccines carry risks, even if they are extremely low. Several unknowns remain: it is not clear how the vaccine works in those who have already had Covid, in the immunocompromised, in newborns. If the mRNA vaccines were developed according to very strict specifications, they were tested on a smaller cohort than usual, and long-term effects are not known. In the short term, other than a few cases of myocarditis and prolonged fever, there is nothing dramatic. As for the Astrazeneca vaccine, cases of thrombosis have been reported in people under 55 years of age, which is why vaccination with this vaccine is not recommended in this age group.
“The health pass constitutes a hijacked vaccination obligation”
Pr Dominique Salmon : This question raises ethical and societal issues. Can vaccination be made compulsory in elderly and at-risk subjects as has been done for infant vaccinations? “At risk” is a very broad concept which can relate to age (but from when can we consider that we are old, 60, 70 years old?), limmunocompromised subjects but there are many causes of immunosuppression (leukemia, cancer, taking corticosteroids, kidney failure, etc.). that’s why it is not easy to identify categories of people at risk and that the fact that it is compulsory for a certain category and not for another is not necessarily well accepted in a society. Categorizing people is not necessarily well received, it is probably for this reason that the government did not take the decision of a compulsory vaccination, even if the health pass constitutes a backdoor vaccination obligation. As for the vaccination obligation for caregivers, it is justified by their posture: they cannot potentially be transmitters of the virus when their role is to save people’s lives.
Pr Dominique Salmon : Yes, vaccination will undoubtedly make it possible to avoid the majority of serious forms and admissions to intensive care. Currently, if 63% of the population were not vaccinated, resuscitations would be saturated. Admittedly, there are still many cases of contamination, but there are 7 times fewer patients in intensive care than during the first wave (7,000 against 1,000 today for the whole of France). The vaccination made it possible to limit the breakage in a major way. It is quite legitimate and understandable that the lack of perspective on vaccines is worrying, but it is the only solution to stop this epidemic and protect our people at risk. If we had hesitated over smallpox or polio, we would never have come to the end of it.
Thank you to Prof. Dominique Salmon, infectious disease specialist at the Hôtel Dieu hospital, and President of the working group on prolonged symptoms of Covid-19 of the Haute Autorité de Santé (HAS).
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