key: cord-0922066-8bhchln4
authors: Druml, Christiane; Czech, Herwig
title: A pandemic is no private matter: the COVID-19 vaccine mandate in Austria
date: 2022-02-17
journal: Lancet Respir Med
DOI: 10.1016/s2213-2600(22)00063-7
sha: 6b42db67a30e897519e0d2a76b49c3f3b0862ea4
doc_id: 922066
cord_uid: 8bhchln4

nan

After months of being excluded as a possibility by politicians and with no requirement even for people working in health care, the COVID-19 vaccine mandate was announced on Nov 19, 2021. On Feb 3, 2022, the Federal Council, the upper house of the Austrian Parliament, approved a national COVID-19 vaccine mandate for residents older than 18 years by an overwhelming majority. [1] [2] [3] The law was the first of its kind in Europe 4 and went into effect 2 days later. Why did the Austrian Government have this sudden U-turn?

Historically, Austria has been reluctant to introduce mandatory vaccinations. Austria's first and only vaccine mandate was introduced against smallpox 5 in 1938/39, after the German 1874 Reich Vaccination Act was extended to recently annexed Austria. Mandatory smallpox vaccination was then renewed in 1948 and remained until 1980, in keeping with the WHO campaign to eradicate smallpox. Since then, high immunisation rates have been achieved without vaccine mandates for infectious diseases such as polio.

In 2014, rates of vaccination against measles in children and young adults dramatically declined and cases concomitantly increased. The Minister of Health asked the Austrian Bioethics Commission to assess the ethical implications of mandatory vaccination against infectious diseases. At that time, such debates were not common globally and questions around mandatory vaccination were not a priority for ethical concern, something that has changed in the years since. In 2015, the Bioethics Commission published specific recommendations including, most importantly, a legal vaccine mandate for health-care workers based on the principle of non-maleficence and their ethical duty to protect those entrusted to them. The guiding principle of the Commission's reasoning was proportionality: "the more harmless the intervention is for the individual, the 'more dangerous' the disease is for the health of the population and the greater the benefit of vaccination is overall, the more justified the intervention in the physical integrity of the individual is". 6 In 2019, with measles cases continuing to soar and neighbouring countries instituting measles vaccine mandates, the Commission recommended to consider an extended vaccine mandate, covering the general population, not just children and young adults. Furthermore, it called on the Austrian Government to continuously examine the option of extending vaccine mandates to other infectious diseases. 7 However, the government at the time insisted that vaccination would always be on a strictly voluntary basis.

Regarding COVID-19, the Bioethics Commission has issued several statements. In a recommendation 8 on Nov 25, 2020, it referred to a "vaccination requirement" for individual groups, such as health workers, educational staff, key staff at essential infrastructures, and others. The Commission was still hesitant about a general COVID-19 vaccine mandate, since there were no approved vaccines at that point. However, the Commission stated that regarding the decision to get vaccinated, from an ethical point of view, individual freedom goes hand-in-hand with responsibility for oneself and for one's fellow human beings-a view that has in the meantime been vindicated by other voices in the debate. 9 In May, 2021, the Commission renewed its recommendation for a COVID-19 vaccine mandate for health-care workers. 10 Again, nothing happened; the government continued to stress that vaccination against COVID-19 would be strictly voluntary for all groups.

Similarly to other countries, the early months of 2021 were characterised by a scarcity of vaccines, a debate about who should be prioritised to receive vaccines, and an increase in organised protests, with diverse segments of the population protesting against vaccination and against pandemic restrictions more generally. A culmination of these factors led to a growing sense of polarisation, intensified by the visible presence of right-wing political forces and frequent references to the Nazi period. Vaccine hesitancy in Austria is also present within the Austrian Green Partyan additional complication given that the party is part of the governing coalition. At the end of the summer, 2021, only 64% of the population had received a first COVID vaccine dose and uptake was stalling, despite the fact that access was made easy. Vaccination centres are present in many locations, including aeroplanes, Fanatic Studio/Gary Waters/Science Photo Library clubs, the presidential palace, and Vienna's St Stephen's Cathedral.

The political decision to introduce a general vaccination mandate came relatively suddenly, with a volte-face by relevant political actors. As a condition for their consent to a new lockdown, some powerful provincial governors demanded the vaccine mandate be enacted while there was a surge of cases due to the delta variant.

The law itself was changed several times amid a record number of interventions by civil society organisations and private citizens. Exemptions apply to patients with pre-existing conditions rendering vaccination dangerous or ineffective, to people who have tested positive for COVID-19 within 180 days, and to pregnant women. Although the mandate was decided amid a sense of emergency, with the delta variant putting tremendous strain on the health-care system, the underlying justification is strategic, ensuring sufficient immunity within the population to avoid further waves of infection in the future.

It remains to be seen whether the political will to fully implement the law-including fines of up to €3600 every 3 months for people who are not vaccinatedwill survive the next months, with continuing disruptive public protests, a challenge of the law in Austria's Constitutional Court, and critics pointing to the diminished protection that current vaccines offer against the omicron variant. It is yet unclear whether the law's strategic orientation beyond the current wave of infections will have enough weight for political stakeholders to hold course in the face of strong opposition. Also, surprising discrepancies have become apparent, such as the fact that in the workplace, even for health-care employees, vaccination remains optional. The Austrian Government might have hoped that the threat of mandatory vaccination would suffice to increase vaccination rates; however, there is no indication that rates have increased thus far.

Collections and History of Medicine

Bundesgesetzblatt für die Republik Österreich, Teil I, ausgegeben am 4

Pflege und Konsumentenschutz über die Pflicht zur Impfung gegen COVID-19 (COVID-19-Impfpflichtverordnung -COVID-19-IV)

Austria's sweeping Covid vaccine mandate is becoming law

COVID-19 vaccine mandates in Europe

Geschichte der Pocken-Bekämpfung in Österreich

Stellungnahme der Bioethikkommission zum Impfen

Ethical questions about vaccination against COVID-19

Mandatory COVID-19 vaccination and human rights

Vaccination against COVID-19 as a professional requirement for the group of nursing and health professions

We thank Oonagh Hayes for help with editing the language of the article. We declare no competing interests.Christiane Druml, *Herwig Czech herwig.czech@meduniwien.ac.at