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1 Evaluation of Vaccination as a COVID-19 Mitigation Strategy Brittany Johnson, Krysten Knapp, Marcella Lash, Alicia Namrow and Adel Ponder Ohio University NRSE 7826 Epidemiology for Advanced Nursing Practice Dr. Monique Malmer and Dr. Ilana Chertok October 8, 2023

2 Introduction In late December 2019, an outbreak of mysterious pneumonia in Wuhan, China, spread across provinces and to surrounding countries before the pathogen responsible was identified as a novel coronavirus. The virus spread rapidly worldwide, leading to the worst public health crisis of our century (Rothan & Byrareddy, 2020). During this time, COVID-19 mitigation strategies such as social isolation, travel restrictions, masks, and stay-at-home mandates were implemented in response to the health crisis to reduce the transmission of the COVID-19 virus while scientists developed a vaccination (Moghadas et al., 2021). When COVID-19 vaccinations first became available in December 2020, there was significant controversy regarding the benefits and risks. As a group, we reviewed the literature to identify the advantages, disadvantages, and ethical considerations of COVID-19 vaccinations. We use evidence-based research to discuss health policy and our recommendations for implementation based on Ohio’s population from February through June 2020 compared to today. Search Strategy A literature search of COVID-19 vaccination mitigation and effectiveness was conducted using the PubMed database. The initial search utilized broad keywords and phrases, including “vaccinations in mitigation of COVID-19,” then combined key terms to focus on mitigation, policy, and local enforcement within Ohio. Inclusion criteria included humans, the English language, adults 19 or older, free peer-reviewed journals, and publications from 2020 to 2023. The exclusion criteria included all articles in languages other than English, articles published before 2019, and subjects 18 years of age or younger. The initial search resulted in 2400 articles before using the Boolean operator AND with the terms “Ohio,” “COVID 19 mitigation," and “COVID 19 vaccination." After applying the inclusion and exclusion criteria, the review was

3 further delineated using additional search terms such as “recommendations,” “Ohio," and “United States,” which resulted in 48 different articles. The abstracts were reviewed to determine their relevancy to the topic, and eleven articles were selected (see Table 1). Evaluation of the Evidence The primary advantage of the COVID-19 vaccine is its vaccine effectiveness (VE), defined as the percentage reduction of disease in a vaccinated group compared to an unvaccinated group of people (Zheng et al., 2022). Studies showed that the vaccine provided 89% VE for infection prevention for fully vaccinated persons and 68% VE for those with partial vaccination for the alpha and delta strains (Zheng et al., 2022). In addition, vaccination led to less morbidity and mortality amongst vaccinated persons who happened to contract the virus. Even partial vaccination was associated with 67% VE for preventing hospitalization and intensive care unit (ICU) admission and 58% VE for preventing COVID-19-related deaths (Zheng et al., 2022). Despite their effectiveness, vaccines can have waning immunity, requiring boosters to remain protected (Lauring et al., 2022). Another disadvantage is that the viral mutation can lead to strains that are less susceptible than the existing vaccine, thereby requiring the creation of new vaccines (Lauring et al., 2022). The complex and sensitive nature of storing and transporting the COVID-19 vaccine to prevent direct sun exposure and the strict temperature control created another disadvantage of the vaccines (Khan et al., 2021). Ethical issues surrounding mandated vaccinations during the COVID-19 pandemic included the debate over the duty to protect (beneficence versus non-maleficence) and the personal right to autonomy (Olick et al., 2021). Maximizing immunization while minimizing infringement on personal autonomy was frequently cited (Olick et al., 2021). This concept of least infringement assisted public health officials in providing balanced decisions when

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4 viewing ethical issues during pandemics. For example, when exercising mandated vaccinations in high-risk populations such as health care workers, nursing homes, and schools. Health Policy The COVID-19 vaccination strategy in the U.S. is a complex mixture of federal, state, and local health policies. Public health policies regarding mass vaccinations must consider certain societal factors such as race, socioeconomic class, access to vaccinations, and health disparities, making certain groups more vulnerable to complications during a pandemic (Wang et al., 2020). The Centers for Disease Control and Prevention (CDC), as well as the Food and Drug Administration (FDA), played a vital role in sourcing the vaccines and issued guidance related to vaccine storage and handling, eligibility criteria for vaccination, prioritization of high-risk groups, and safety monitoring protocols (CDC, 2023). These directives aimed to ensure a coordinated and effective vaccination campaign across the country and maintain the safety and efficacy of COVID-19 vaccines throughout the distribution process (CDC, 2023). Ohio tailored its vaccination strategy to suit the unique needs of its population. Access to vaccines for those within less privileged communities, various outreach programs, and community collaborations played a vital role in Ohio's vaccination strategy (Awad et al., 2021). Ohio established designated mass vaccination facilities within local communities to provide access for all individuals (Awad et al., 2021). Ohio implemented vaccination mandates to reduce the spread of disease within healthcare settings to safeguard both care providers and patients. These workers needed to receive vaccinations, not only to protect their patients' health but also to uphold the integrity of our healthcare system during emergencies such as COVID-19 outbreaks (Awad et al., 2021). As vaccinations began being mandated, certain courts ruled against these

5 requirements due to concerns regarding infringement on individual rights and health-related exemptions (Abbasi et al., 2022). Recommendation The development and dissemination of vaccines were essential components in mitigating the spread and transmission of the COVID-19 virus. According to data collected by the Ohio Department of Health (ODH) Bureau of Vital Statistics, during the period between February 2020 and June 2020, the total number of new COVID-19 cases within the state of Ohio was 58,885, with deaths related to COVID-19 totaling 2,601 (ODH, 2023). Despite non- pharmacologic measures such as social distancing and universal masking, new cases continued to rise (Moghadas et al., 2021). The vaccinations added a layer of mitigation and community protection. Ohio's recent statewide incidence of new COVID-19 cases reported by the ODH Bureau of Vital Statistics as of 9/28/23 was 7,210 (ODH, 2023). As genetic assortment of the COVID-19 virus occurs and new strains of the virus develop, Ohio must continue to stay vigilant amidst the recovery phase of the pandemic to prevent a resurgence of the virus. It is essential to continue adherence to non-pharmacological interventions and vaccinations, especially within our high-risk populations, including the elderly, immunocompromised, and those individuals who live and work in congregate settings, to mitigate and contain COVID-19 in Ohio.

6 References Abbasi, J., Rubin, R., & Suran, M. (2022). How the Supreme Court’s COVID-19 vaccine mandate rulings could shape the pandemic’s next phase. JAMA,327(8),706.https://doi.org/10.1001/jama.2022.0791. Awad, S. F., Musuka, G., Mukandavire, Z., Froass, D., MacKinnon, N. J., & Cuadros, D. F. (2021). Implementation of a vaccination program based on epidemic geospatial attributes: COVID-19 pandemic in Ohio as a case study and proof of concept. Vaccines , 9 (11), 1242. https://doi.org/10.3390/vaccines9111242 Centers for Disease Control and Prevention. (2023). How vaccines are developed and approved for use . Centers for Disease Control and Prevention. https://www.cdc.gov/vaccines/basics/test-approve.html Douglas, D. ; Li, C; Josiah W., Robina PhD; Baltrus, P., Caplan, L., Immergluck, L., McKiney, T., Hopkins, J., Mack, D., & Gaglioti, A. (2021). Population-level disparities in exposure to COVID-19 mitigation policies. Journal of Public Health Management and Practice 29 (6):p 874-881, doi: 10.1097/PHH.0000000000001777 Khan, W. H., Hashmi, Z., Goel, A., Ahmad, R., Gupta, K., Khan, N., Alam, I., Ahmed, F., & Ansari, M. A. (2021). COVID-19 pandemic and vaccines update on challenges and resolutions. Frontiers In Cellular and Infection Microbiology , p. 11 , 690621. https://doi- org.proxy.library.ohio.edu/10.3389/fcimb.2021.690621 . Lauring, A. S., Tenforde, M. W., Chappell, J. D., Gaglani, M., Ginde, A. A., McNeal, T., Ghamande, S., Douin, D., Talbot, H., Casey, J., Mohr, N., Zepeski, A., Shapiro, N., Gibbs, K., Files, D., Hager, D., Shehu, A., Prekker, M., Erickson, H., ...Self, W. (2022).

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7 Clinical severity of, and effectiveness of mRNA vaccines against, covid-19 from omicron, delta, and alpha SARS-CoV-2 variants in the United States: Prospective observational study. BMJ (Clinical research ed.) , 376 , e069761. https://doi.org/10.1136/bmj-2021-069761 Moghadas, S. M., Vilches, T. N., Zhang, K., Wells, C. R., Shoukat, A., Singer, B. H., Meyers, L. A., Neuzil, K. M., Langley, J. M., Fitzpatrick, M. C., & Galvani, A. P. (2021). The impact of vaccination on coronavirus disease 2019 (COVID-19) outbreaks in the United States. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America , 73 (12), 2257– 2264. https://doi-org.proxy.library.ohio.edu/10.1093/cid/ciab079 . Ohio Department of Health. (2023). COVID-19 reporting. Retrieved 9/28/2023, from https://data.ohio.gov/wps/myportal/gov/data/view/covid-19-reporting Olick, R. S., Shaw, J., & Yang, Y. T. (2021). Ethical issues in mandating COVID-19 vaccination for health care personnel. Mayo Clinic Proceedings , 96 (12), 2958–2962. https://doi- org.proxy.library.ohio.edu/10.1016/j.mayocp.2021.10.020 . Rydland, H. T., Friedman, J., Stringhini, S., Link, B. G., & Eikemo, T. A. (2022). The radically unequal distribution of COVID-19 vaccinations: A predictable yet avoidable symptom of the fundamental causes of inequality. Humanities and Social Sciences Communications , 9 (1). https://doi.org/10.1057/s41599-022-01073-z Wang, M. L., Behrman, P., Dulin, A., Baskin, M. L., Buscemi, J., Alcaraz, K. I., Goldstein, C. M., Carson, T. L., Shen, M., & Fitzgibbon, M. (2020). Addressing inequities in COVID- 19 morbidity and mortality: Research and policy recommendations. Translational Behavioral Medicine , 10 (3), 516–519. https://doi.org/10.1093/tbm/ibaa055

8 Zheng, C., Shao, W., Chen, X., Zhang, B., Wang, G., & Zhang, W. (2022). Real-world effectiveness of COVID-19 vaccines: A literature review and meta-analysis. International Journal of Infectious Diseases: IJID: Official Publication of the International Society for Infectious Diseases , 114 , 252–260. https://doi.org/10.1016/j.ijid.2021.11.009 .

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