California U-Turn on Vaccine Mandates

The California legislature appears to have caved to pressure from opponents of a COVID vaccine mandate for schoolkids. I’d prefer to think of it as a wise and strategic retreat from a battle that mandate advocates could not win.

Mandate advocates in California are a savvy bunch. Led by State Senator Richard Pan, a pediatrician, they eliminated the personal belief exemption from California’s mandate for routine pre-COVID childhood immunizations. After that one, it seemed that a COVID vaccine mandate would be easy. After all, we were in the middle of a pandemic. Kids were dying or getting strange inflammatory illnesses, missing school and forced to wear masks. The vaccine studies in adults showed that vaccines were astoundingly safe and effective. Everyone was just impatiently waiting for similarly upbeat results from pediatric studies. Governor Gavin Newson announced in the fall that, as soon as the FDA approved vaccines for children, they would be mandate. California was on track to proudly be first in the nation to implement such a mandate. In January, 2022, Pan introduced a bill to add COVID-19 vaccine to the panel of vaccines mandated for school entry.

Opposition to the proposed COVID-vaccine mandate was immediate and fierce. Many California school districts took official stands against vaccine mandates and publicly stated that they would not comply.

The stage seemed set for a showdown.

But the plot was too tidy. Kids, it turns out, are not just small adults. It wasn’t enough to just give them a lower dose of vaccine in order to get the same results. Furthermore, the virus itself wasn’t static. Vaccines were less effective against the new Omicron variant than against prior strains.

During Omicron, the Pfizer/BioNTeach vaccine was only 12% effective in preventing COVID infections among 5-11-year-olds. It was only 48% effective in preventing hospitalizations in this age group. The Moderna vaccine wasn’t much better. Furthermore, vaccine-induced immunity seems to wane quickly in children. Two weeks after immunization, the vaccine was 76% effective in preventing cases. By four weeks, it was only 56% effective. If these vaccines are mandated, they will not be one-and-done. They will likely require frequent boosters to be effective. The efficacy of each booster may change as new variants emerge. And nobody knows how often boosters will be needed.

Given these muddy data, nearly 40% of parents say that they would not want their children immunized. Another 40% wanted to wait and see more data before deciding. Parents’ choices reflect these attitudes.

Pan’s colleague, State Senator Connie Leyva, who chairs the Senate Education Committee and also serves on the Senate Health Committee with Dr. Pan, came out against the COVID-vaccine mandate for schoolchildren. She said, “We’re too divided as a community. This bill is just too divisive.”

Senator Pan could see the handwriting on the wall. In April, 2022, withdrew his proposed bill. He tried to put the best spin on it, shifting the focus to improving the rates of voluntary immunization. “People have questions,” he noted, “and want to get them answered.”

The reasons for the U-Turn suggest a way of measuring the likelihood that a mandate will be politically feasible? It seems that mandates are only possible when the public is convinced that the benefits outweigh the risks. But there is an irony. When that is the case, most people will voluntarily seek vaccine. There is no mandate for adults to receive COVID vaccine but more than 80% of adults have been immunized. Fewer than 40% of children have. When the public is skeptical and resistant, mandates may actually hinder efforts to achieve high immunization rates by angering vaccine-hesitant parents and those who support parental choice. To counter such a backlash, our mandates have always been soft and pourous.

California’s U-turn is politically wise and ethically appropriate. Existing vaccines can give some protection to children. But we’ve gotten spoiled by the efficacy rates in adults. 50% protection is no longer good enough. Further, we don’t yet know the best dose or schedule for optimum protection, lowest levels of risk, and most cost-effectiveness. We do now know that studies in adults cannot simply be extrapolated to children. We need to do the studies in kids. Even then, uncertainty will remain. Given the uncertainty, a voluntary program is preferable to a mandate. As parents evaluate the evidence and make decisions, more data will accumulate.

Mandates are ethically and politically controversial. Thus, we have never had strong mandates.

Most states allow religious exemptions. Many others allow exemptions based on personal beliefs. Such policies say, in essence, that you only need to be immunized if you are not willing to fight against it. Even in the landmark Supreme Court case in which the Justices upheld the rights of states to mandate immunization, the penalty for refusing smallpox vaccine was a $5 fine. Our vaccine policies have always been more like a strong suggestion than a true mandate. That is where California ended up, and that is the right place to be.

The skeptical public is right on this one. Until vaccines are more effective, the decision about whether to immunize children should remain with parents.

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