Essays academic service


The ethical issues surrounding vaccinations and its role in global public health

Correspondence to Keymanthri Moodley e-mail: Bulletin of the World Health Organization 2013;91: In the initial emergency response, interventions to reduce communicable disease transmission, such as vaccination, should be deployed along with food, water and shelter, since communicable diseases, including some that are vaccine-preventable, can spread faster and be unusually severe in the crowded, unhygienic conditions that prevail during crises.

Vaccination may be the only practical way to protect people against certain diseases, such as meningococcal meningitis and measles. Individuals who undergo medical or surgical treatment often need ongoing care; those who get vaccinated do not, yet they receive long-lasting benefits. However, the feasibility of a mass vaccination effort depends largely on available resources.

In a recent study on ethics in humanitarian health care, respondents pointed out the need for ethical guidance on issues such as vaccination during emergency situations.

Ethical issues in global health

They then explore the feasibility of a mass vaccination campaign in light of the properties of the necessary vaccine Fig. Algorithm for making decisions surrounding vaccine deployment during acute humanitarian emergencies The conflict between individual good and the common good is at the core of the ethical issues explored in this paper — issues pertaining to the allocation of a limited vaccine supply, the balance between benefits and harms, obtaining informed consent and research conduct.

The key ethical principles that should prevail during public health emergencies are rooted in the more general ethical principles governing clinical medicine and public health. Acute humanitarian emergencies differ widely in nature, in the threats they pose, in the background conditions in which they occur, and in the type of agencies that must respond.

  • When it comes to vaccination, utility is fortunately often greatest when the most socially disadvantaged groups are targeted;
  • Some oppose vaccination and other measures that are not routinely offered in non-crisis settings;
  • Vaccination is highly cost-effective and, in emergencies, it can mitigate the risk of serious infectious disease;
  • Conclusion Ethical considerations are vital to decision-making about the deployment of vaccines in acute humanitarian emergencies;
  • Children are at particularly high risk of contracting communicable diseases during humanitarian crises.

Hence, this paper does not seek to provide specific, prescriptive guidance, but merely highlights the ethical issues that policy-makers need to consider when deciding to conduct mass vaccination during any emergency response.

Beneficence and human rights The international community and national governments have a collective duty of care to ensure that effective, affordable measures for preventing unnecessary illness and death are available to those most in need. During humanitarian emergencies, the risk of communicable disease transmission is higher than usual. According to the duty of care based on the principle of beneficence, governments must make vaccines available against the most contagious diseases. Some oppose vaccination and other measures that are not routinely offered in non-crisis settings.

The underlying concern, based on the doctrines of developmental relief and sustainability, is that introducing such measures will result in aid dependency. However, the argument becomes invalid if vaccination during an acute humanitarian crisis can provide immediate protection against serious illness or death.

It is ethically reasonable for the standard of preventive care to revert to pre-existing levels after the heightened threat has subsided. After an acute emergency, some medical interventions call for ongoing care or rehabilitation.

You are here:

Vaccination does not, yet it provides long-lasting benefits. Humanitarian assistance has traditionally been seen as charity, in keeping with the principle of beneficence, but owing to the growing human rights focus, it has come to be viewed as an obligation. Those who are able to help are obligated to ensure that the rights of affected individuals and populations are respected and promoted. Article 25 of the Universal Declaration of Human Rights states that: Only vaccines that have proved effective and safe in routine use are likely to be considered for mass administration during the acute phase of a humanitarian crisis.

Such vaccines not only protect people against specific diseases; when administered on a large scale, they confer additional benefit through herd immunity, which reduces disease transmission above specific vaccination coverage thresholds.

  • Efforts to maximize utility can conflict with the egalitarian goal of helping the neediest;
  • When limited supplies are allocated to the most vulnerable, overall health utility is sometimes suboptimal e;
  • The amount of information provided to the public needs to be weighed against the risk of delaying action;
  • Guidelines are especially valuable in certain situations:

Vaccines are generally administered before people are exposed to the pathogen causing the targeted disease. Unnecessary vaccination entails opportunity costs and puts people at risk of side-effects. The risk of contagion must justify vaccination. Four variables determine risk magnitude: For example, following the earthquake in Sichuan Province in China in 2008, mass measles vaccination would have been inappropriate because a province-wide measles vaccination campaign with high coverage had just been completed.

Side-effects are an example of individual harm. These range from mild, common reactions, such as inflammation and pain at the injection site, to more severe but extremely rare events. Established vaccines, which are normally used during humanitarian emergencies, have well-known side-effect profiles, but much less is known about adverse events that can occur in ill or malnourished people during a humanitarian emergency.

On the other hand, vaccination is sometimes contraindicated or inappropriate. A child, for instance, can be too young to receive a certain vaccine. With herd immunity compromised, devastating disease outbreaks can occur.

Ethical considerations for vaccination programmes in acute humanitarian emergencies

In these settings, individuals are morally obligated to accept vaccination to prevent harm to others. Failure to provide a vaccine that is indicated in a specific humanitarian emergency violates the principle of non-maleficence because it places vulnerable populations and individuals at risk of contracting a vaccine-preventable disease.

Distributive justice Distributive justice requires the fair allocation of scarce basic resources, such as shelter, food, potable water and vaccines in short supply. A small supply of vaccine could be equitably distributed through a lottery, but prioritizing particularly susceptible groups and individuals, or those most likely to spread the disease, would not be possible. Different rules govern decision-making and priority-setting during acute crises.

Vaccination is highly cost-effective and, in emergencies, it can mitigate the risk of serious infectious disease. Furthermore, large numbers of people can be vaccinated quickly. Other factors to consider are how urgent and intense is the need for vaccination; how much faster can vaccination be delivered than other interventions; and how groups at high risk or with high transmission rates can be targeted in situations where other interventions, such as safe water and sanitation, cannot be rapidly deployed.

All countries, regardless of their socioeconomic status or experience with humanitarian emergencies, need to decide how to allocate resources. All societies have a shared vulnerability to emergencies, although poor societies are more severely devastated because poverty undermines resilience.

When allocating resources, a balance must be sought between utility — maximizing the common good and ensuring smooth economic and social functioning — and equality and fairness. In keeping with egalitarian considerations, resource allocation should not be discriminatory; everyone should have a fair chance of being vaccinated. Utility can conflict with equality or fairness. You can, for example, save the most lives or avert the most DALYs disability affected life years by allocating vaccines to urban rather than rural areas because urban areas have greater population density, 21 but doing so systematically would be inequitable.

In conflict zones, threats to the physical safety of health workers often determine which populations they can and cannot vaccinate. Efforts to maximize utility can conflict with the egalitarian goal of helping the neediest. When limited supplies are allocated to the most vulnerable, overall health utility is sometimes suboptimal e. From the perspective of value pluralism, the ethical issues surrounding vaccinations and its role in global public health utility and equality should be the goal, rather than prioritizing one or the other.

When it comes to vaccination, utility is fortunately often greatest when the most socially disadvantaged groups are targeted. The fair distribution of limited vaccine supplies was an important issue during preparations for the 2009 pandemic influenza. People in certain categories were prioritized: From an inclusive perspective, there is efficiency in covering two communities with all the resources available.

Fair and equitable approaches result in less hostility and rivalry between the host and the displaced communities. However, some communities may place greater value on the social roles of the elderly and of pregnant women and may prioritize their access to health care during emergencies.

From a utilitarian perspective, protecting frontline health workers against disease will indirectly benefit the health of the community. Under the principle of reciprocity, it is fair to prioritize the vaccination of health-care workers, who are often more exposed than others to the risk of contagion, since they are committed to caring for society.

In addition, because health-care workers come into contact with susceptible individuals, they have a moral obligation to get vaccinated to avoid placing patients at risk of infection.

Guidelines are especially valuable in certain situations: Although guidelines do not have mandatory status, if they are evidence-based and contextually appropriate they should be considered normative practice and a benchmark for judging the actions of health officials and practitioners. National legal systems should guide the implementation of vaccination programmes in individual nation states, but they seldom accommodate humanitarian emergencies. When national legislative frameworks are absent or dysfunctional, international human rights law dictates a duty of care to protect people needing assistance, and in such cases implementation should follow international health guidelines.

WHO Member States can legitimately follow WHO vaccination guidelines, which were developed on the strength of the evidence and which take many factors into account, including the epidemiologic and clinical features of the target disease, vaccine characteristics, costs, health system infrastructure, social impact, legal and ethical considerations, and the local context.

Observing appropriate rules of conduct during humanitarian crises is often difficult. Affected populations are often disenfranchised and unable to defend their own interests. All factors considered before the introduction of a vaccination programme should be well documented and publicly available to donors, community leaders, local staff and governments.

Channels should also be established for affected communities to express their concerns directly to responding agencies. Consent Obtaining valid consent from individuals before a medical intervention is an obligation under the principle of respect for the autonomy of persons.

In non-emergency circumstances, the consent process needs to be thorough and takes time.

Bulletin of the World Health Organization

During emergencies, it has to be modified. If time permits, information on the risks and benefits of vaccination should be communicated to target populations in sufficient depth to allow individuals to make informed decisions, while bearing in mind that many will lack a basic understanding of germ theory and immunology. During emergencies, vaccination often takes place while people are too desperate for food and other basic necessities to recognize its importance.

Furthermore, in some developing countries people defer to decision-makers at the expense of individual autonomy. The amount of information provided to the public needs to be weighed against the risk of delaying action.

However, any questions raised by the community should be thoroughly addressed. For example, vaccinators should be prepared to answer common questions about the diseases targeted, the benefits of vaccination, potential side-effects, follow-up and alternative options. They should also know where to refer undecided individuals who have other questions, although this may not always be feasible.

Visual aids and other media can be used to convey important information to the public in a time-efficient manner. Where the threat of widespread, serious infectious disease is imminent, individual liberties may be justifiably curtailed.

Those whose liberty is violated should, when appropriate, be compensated, particularly if they experience vaccine-associated side-effects. Children are at particularly high risk of contracting communicable diseases during humanitarian crises. Research Opportunities for health and health service research abound during humanitarian crises. In countries without functioning research governance structures, researchers must rely on international ethics review boards.

  • Furthermore, large numbers of people can be vaccinated quickly;
  • Individuals who undergo medical or surgical treatment often need ongoing care; those who get vaccinated do not, yet they receive long-lasting benefits;
  • Failure to provide a vaccine that is indicated in a specific humanitarian emergency violates the principle of non-maleficence because it places vulnerable populations and individuals at risk of contracting a vaccine-preventable disease;
  • Empirical research in developing countries has shown that obtaining informed consent from study participants is not easy, even under non-emergency circumstances;
  • However, any questions raised by the community should be thoroughly addressed;
  • Those who are able to help are obligated to ensure that the rights of affected individuals and populations are respected and promoted.

Research must be distinguished from disease and programme surveillance. Since surveillance activities have an opportunity cost, the data collected must be analysed and used to direct public health action. Research protocols should be relevant, methodologically sound and explicit about the benefits and potential harms to study participants.

They should also clearly explain how the findings will be delivered to study participants if they are relocated after the humanitarian crisis.

Page not available

Although most non-medical research conducted during disasters is observational, it is subject to ethics review to ensure that individual and social benefits outweigh any risks. The level of review should be proportional to the risk associated with a specific intervention. An expedited review is admissible if the risk to participants is low, whereas a full committee review is warranted when the research involves a higher risk.

If the research is urgent and very important, it can proceed without ethics committee approval, but retrospective review should be sought as soon as possible. Whenever the nature of the research to be conducted during a humanitarian emergency can be anticipated, a full review of the generic protocols should be planned and discussed in advance with local research ethics committees.

Provision should be made for counselling or debriefing should participants find the research interviews traumatic or distressing.