Context

The World Health Organization recently included vaccine hesitancy in the Top 10 of global health threats. In high income as well as low-income countries, people increasingly question the need for, and safety of, vaccinations and therefore decide to forego immunization of their children.In the past, it was often religious convictions that led people to refuse vaccination. Nowadays the main ground for refusal or hesitance is fear of side-effects and doubts about the importance of protecting one’s children against diseases like measles or pertussis. Often these beliefs are triggered or sustained by ‘viral misinformation’, undermining trust in vaccines and vaccinations.

Background

• Second, only to the development of clean water and sewage systems, vaccines have been a major force in reducing the occurrence of infectious diseases worldwide.
• Universal vaccination programs have eliminated smallpox and reduced serious diseases including measles, mumps, rotavirus, and polio.
• However, many ethical issues surround the development and use of vaccines. These issues include:

1. 1. Requiring vaccination by law;
   2. the development and testing of vaccines;
   3. informed consent about the benefits and risks of vaccination; and
   4. the equitable distribution of vaccines.

• Vaccination has raised controversies ever since Edward Jenner conducted his experiments with cowpox.
• For public health authorities and professionals, vaccine hesitancy and refusal create ethical dilemmas.
• It is always argued that to what extent it can be justified to coerce parents to accept vaccination for their children.
• Moreover, many experts also question whether citizens have to be responsible to accept vaccination and contribute to population-level immunity that benefits everyone.

Ethics of immunization and vaccines

The economic and human benefits of vaccination are clear for many vaccines. But, economic and political realities, along with philosophical questions, raise certain ethical issues concerning the use and distribution of vaccines.

• Mandatory vaccination: -
• Vaccines have become victims of their own success.
• As diseases disappear from the general population after successful vaccination campaigns, the real risk of an individual contracting the disease decreases, and the perception of the seriousness of the disease, even if contracted, is reduced.
• Concomitantly, concerns about the real or imagined adverse effects of the vaccines increase.
• As a result, individuals might disagree with government mandates for population-wide vaccination.
• More recently, heightened fears of the perceived adverse effects of other vaccines (such as measles and hepatitis B), even if unproven, have had an impact on immunization rates and the incidence of disease.
• Greater awareness of the consequences of failure to vaccinate, through better education, might be the best tool to combat this problem.

Poverty and priorities: -

• In wealthier countries, the ethical issues that surround vaccination tend to focus on the rights of individuals versus government or society.
• In poorer countries, the fundamental issue is the lack of access to necessities for health, such as adequate nutrition, clean water, medicines, or vaccines.
• Although poverty is the main cause of these deficiencies, other factors contribute, such as the low priority given to health and preventive measures, the disenfranchisement and lack of political and economic power of the people most affected (children and women), corruption, and regional warfare.
• At present, only about 1% of contributions to overseas development are directed towards immunizations.
• The hurdle is not simply the purchase price or availability of vaccines, but for many poor countries, there is a lack of infrastructure for health care in general, and vaccine delivery specifically.
• The trade-off of protecting children now from disease versus an emphasis on the development of new vaccines to protect children in the future is not a debate that can be resolved even by Solomonic wisdom.
• Neither trade-off is ethically defensible, nor the world should, instead, work constructively to increase the resources devoted to health, nutrition, prevention, and specifically immunization, to make vaccines available to all people as required.

‘Trickle-down' or simultaneous introduction:-

• A marked effort is required to introduce vaccines into all necessary areas of the globe in a more timely fashion.
• The average time lag between licensing of a new vaccine for industrialized countries and its use in less developed countries is 10–20 years.
• There are many reasons for this, including the lack of manufacturing capability for vaccines that require new technology in their production, return on investment, and the cost of manufacturing newer technology-based vaccines.
• For example, when the recombinant hepatitis B virus vaccine was first introduced, there was not sufficient capacity worldwide for its production.
• Moreover, the cost of manufacturing such a high-tech vaccine put it beyond the reach of the existing purchasing programs at the time.
• Although the technology that supports recombinant protein vaccines is now available worldwide, it took time and effort to develop that capacity, even in developed countries.

Steps to be taken to address ethical dilemmas:

• The developed countries should treat all of the world's children as their own, rather than denouncing particular groups as causing these inequities.
• Further support must be given rapidly to those whose efforts will result in vaccines that are better tailored for developing countries, both in terms of the disease focus and the development of technologies that will facilitate vaccine access and sustainability.
• New paradigms like public-private partnerships and alliances that are designed to engage local governments and manufacturers at the early stages of research and development are required.
• In this way, each group can contribute what they do best to the common goals of improving access to existing vaccines, developing new vaccines and technologies for existing diseases, and ensuring that increases in immunization rates are sustainable.
• Perhaps most difficult of all will be to change the mindset of people all over the globe.
• We need to place a higher priority on health and disease prevention, and above all to value the lives of all people, no matter where they live even if they are impoverished and powerless.

Conclusion:

Vaccination poses many such ethical dilemmas from the time of formulation of research hypothesis to the final implementation of the vaccination and its conduct till completion including post-vaccination issues that have to be clearly understood by all the stakeholders in vaccination to carry out their responsibilities in protecting the rights of the citizens. However, in the absence of a well-structured vaccination policy in the country, there is a pressing need for continuous capacity building exercises at all levels.  Awareness about national and international guidelines and regulations and putting in place appropriate laws in the country will go a long way in ensuring public confidence about the safety and well being of the people taking the vaccination.