Compulsory vaccination and conscientious or philosophical exemptions: past, present, and future

Justifications for Non-Consensual Medical Intervention: From Infectious Disease Control to Criminal Rehabilitation

A central tenet of medical ethics holds that it is permissible to perform a medical intervention on a competent individual only if that individual has given informed consent to the intervention. Yet it occasionally seems morally permissible to carry out non-consensual medical interventions on competent individuals for the purpose of infectious disease control (IDC). We describe two different moral frameworks that have been invoked in support of non-consensual IDC interventions and identify five desiderata that might be used to guide assessments of the moral permissibility of such interventions on either kind of fundamental justification. We then consider what these desiderata imply for the justifiability of carrying out non-consensual medical interventions that are designed to facilitate rehabilitation amongst serious criminal offenders. We argue that these desiderata suggest that a plausible case can be made in favor of such interventions.

Increasing Immunization Compliance by Reducing Provisional Admittance

Students in Vermont with incomplete or undocumented immunization status are provisionally admitted to schools and historically had a calendar year to resolve their immunization status. The process of resolving these students’ immunization status was challenging for school nurses. We conducted a school-based quality improvement effort to increase student compliance with Vermont immunization regulations using a collaborative learning approach with public health school liaisons and school nurses from public schools to reduce provisional admittance in 2011–2012. Strategies included using a tracking system, accessing the immunization registry, promoting immunization importance, tracking immunization plans, and working with medical homes to update records. Participating school nurses observed decreases in the number of provisionally admitted students, although this reduction was not significantly different than matched comparison schools. We also found the number of provisionally admitted students fluctuated throughout the year and resolving the immunization status of New Americans and exchange students required special attention. Our approach supports the coordinated school health model and demonstrates the critical role school nurses play in improving population health outcomes.

Vaccine hesitancy: More than a movement

Vaccines are some of if not the most successful public health endeavors ever put into practice. Countless lives have been saved and the occurrences of vaccine preventable diseases are at a fraction of the rate experienced before vaccines. Vaccines and the realization of their compulsory scheduling are highly studied, safe, and purposeful. Despite these realities, there are an alarming number of parents who do not permit the vaccination of their children as scheduled. This is known in the health community as vaccine hesitancy and commonly portrayed in popular media as anti-vaccination sediment. This analysis opens with the topic as it was addressed during a September 2015 debate for the Republic Party's 2016 presidential nomination. Some key historical aspects of vaccine hesitancy are presented. This history leads to a description of the 2014-2015 measles outbreak in California. The factors that aide in the recruitment of under vaccination are then explored. Finally, select strategies to control, combat, and potentially attenuate vaccine hesitancy are presented.

Acceptability of financial incentives or quasi-mandatory schemes to increase uptake of immunisations in preschool children in the United Kingdom: Qualitative study with parents and service delivery staff

INTRODUCTION

Since the 1990 s strenuous attempts have been made to rebuild trust in childhood immunisations. This study aimed to understand if financial incentives (FI) or quasi-mandatory schemes (QMS), e.g. mandating immunisations for entry to universal services such as day care or school, might be acceptable interventions to increase immunisations uptake for preschool children.

MATERIAL AND METHODS

Parents and carers of preschool children (n=91); health and other professionals (n=18); and those responsible for developing and commissioning immunisation services (n=6) took part in the study. Qualitative methods were employed to explore the acceptability of FI/QMS with stakeholders. Framework analysis was used to develop a coding framework that was applied to the whole dataset. Interpretations of the emergent themes were verified between researchers and presented to the project's Parent Reference Group to ensure coherence and relevance.

RESULTS

(1) FI: parents and professionals felt introducing FI was inappropriate. It was acknowledged FI may encourage families living in disadvantage to prioritise immunisation, but unintended consequences could outweigh any advantage. FI essentially changes behaviour into a cash transaction which many equated to bribery that could inadvertently create inequalities. (2) QMS: parents and professionals highlighted the positives of introducing QMS, stating it felt natural, fair and less likely to create inequality. Despite QMS' potential to positively impact on uptake there were concerns about the implementation and workability of such schemes.

DISCUSSION AND CONCLUSION

FI for preschool immunisation may not be acceptable, within a UK context. Introducing FI could have detrimental effects on uptake if it were associated with bribery and coercion. Quasi-mandatory schemes, mandating immunisation for universal service entry, was the most acceptable option and could contribute to the normalising of immunisation. Future work would be needed to assess how this could be successfully implemented and if it did indeed increase uptake.

Controversies and challenges of vaccination: an interview with Elizabeth Miller

Although strong evidence exists that the benefits of vaccination by far outweigh potential adverse events, controversy still exists. This has led opponents of vaccination to question its safety, efficacy and necessity. In an interview with Professor Elizabeth Miller, we discuss the continuum of beliefs held by vaccine refusers and hesitators, the resulting health consequences, and ways in which health professionals and industry regulators can help promote transparency to better convey the substantial health benefits of vaccination.

Do Maternal Living Arrangements Influence the Vaccination Status of Children Age 12-23 Months? A Data Analysis of Demographic Health Surveys 2010-11 from Zimbabwe

Introduction

Although vaccination is an effective intervention to reduce childhood mortality and morbidity, reasons for incomplete vaccination, including maternal living arrangements, have been marginally explored. This study aims at assessing whether maternal living arrangements are associated with vaccination status of children aged 12–23 months in Zimbabwe. It also explores other variables that may be associated with having children not fully vaccinated.

Materials and Methods

A cross-sectional analysis was performed on the DHS-VI done in Zimbabwe in 2010–2011 (response rate 93%). Incomplete vaccination of children (outcome), was defined as not having received one dose of BCG and measles, 3 doses of polio and DPT/Pentavalent. Maternal living arrangements (main exposure), and other exposure variables were analysed. Survey logistic regression was used to calculate crude and adjusted OR for exposures against the outcome.

Results

The dataset included 1,031 children aged 12–23 months. 65.8% of children were fully vaccinated. 65.7% of the mothers were married and cohabitating with a partner, 20.3% were married/partnered but living separately and 14% were not married. Maternal living arrangements were not associated with the vaccination status of children both in crude and adjusted analysis. Factors associated with poorer vaccination status of the children included: no tetanus vaccination for mothers during pregnancy (adjusted OR = 2.1, 95%CI 1.5;3.0), child living away from mother (adjusted OR = 1.5, 95%CI 1.2;1.8), mother’s education (adjusted OR = 0.6, 95%CI 0.4;0.9), high number of children living in the household (adjusted OR = 1.5, 95%CI 1.1;2.2), child age (adjusted OR = 0.7, 95%CI 0.5;0.9).

Discussion

Maternal living arrangements were not associated with vaccination status of Zimbabwean children. Other factors, such as the mother’s health-seeking behaviour and education were major factors associated with the children’s vaccination status. Given the results of this study, it is strongly recommended that the vaccination coverage is increased by improving access to antenatal care and education for the parents.

Ethical Challenges in School-Based Immunization Programs for Adolescents: A Qualitative Study

OBJECTIVES

We investigated ethical issues in school-based immunization programs for adolescents and how they are addressed.

METHODS

We used qualitative methods and an ethnographic approach to observe 9 secondary schools on immunization days in South Australia in 2011; concurrently, we conducted 9 focus groups with female secondary school students, 6 semistructured interviews with parents, and 10 interviews with nurses and teachers. We explored ethical challenges from the perspective of these groups.

RESULTS

We identified ethical challenges for the delivery of adolescent immunization in a school-based setting in 3 main areas: informed consent, restrictions on privacy, and harm to students in the form of fear and anxiety.

CONCLUSIONS

We found areas in which the design and delivery of school-based immunization programs can be improved. Information about immunization should be provided in ways that are appropriate to young people and their parents, and privacy protections should be enhanced when possible. Involving young people in the design and delivery of programs would assist with making these improvements.

Voluntary or Mandatory? The Valence Framing Effect of Attitudes Regarding HPV Vaccination

This study addresses the issue of valence framing effect in the context of immunization, a preventive behavior often addressed by the equation of benefit versus risk. The authors examined how framing (support vs. oppose) the issue of HPV vaccination in Israel's immunization routine affects attitudes regarding vaccine regulations. The study also examined issue involvement as a moderator of valence framing effect. The results demonstrate that participants in the positive framing condition tended to express greater support for voluntary immunization than participants in the negative framing condition (77.5% and 48.5%, respectively). Among those who supported the mandatory HPV immunization policy, the negative framing condition was more prominent than the positive condition (51.5% and 22.5%, respectively). The analysis of interaction between valence framing and issue involvement showed that the latter tends to moderate the direct effect of framing on attitudes towards vaccination. Findings indicate that even attitudes towards such consequential preventive behaviors as vaccination could be affected by different framing of the issue, especially for those who are less involved. Implications of predilection for freedom of choice regarding vaccination are also discussed.

The prevention and eradication of smallpox: a commentary on Sloane (1755) 'An account of inoculation'

Sir Hans Sloane's account of inoculation as a means to protect against smallpox followed several earlier articles published in Philosophical Transactions on this procedure. Inoculation (also called 'variolation') involved the introduction of small amounts of infectious material from smallpox vesicles into the skin of healthy subjects, with the goal of inducing mild symptoms that would result in protection against the more severe naturally acquired disease. It began to be practised in England in 1721 thanks to the efforts of Lady Mary Wortley Montagu who influenced Sloane to promote its use, including the inoculation of the royal family's children. When Edward Jenner's inoculation with the cow pox ('vaccination') followed 75 years later as a safer yet equally effective procedure, the scene was set for the eventual control of smallpox epidemics culminating in the worldwide eradication of smallpox in 1977, officially proclaimed by WHO in 1980. Here, we discuss the significance of variolation and vaccination with respect to scientific, public health and ethical controversies concerning these 'weapons of mass protection'. This commentary was written to celebrate the 350th anniversary of the journal Philosophical Transactions of the Royal Society.

Identifying and addressing vaccine hesitancy

In the 20th century, the introduction of multiple vaccines significantly reduced childhood morbidity, mortality, and disease outbreaks. Despite, and perhaps because of, their public health impact, an increasing number of parents and patients are choosing to delay or refuse vaccines. These individuals are described as "vaccine hesitant." This phenomenon has developed due to the confluence of multiple social, cultural, political, and personal factors. As immunization programs continue to expand, understanding and addressing vaccine hesitancy will be crucial to their successful implementation. This review explores the history of vaccine hesitancy, its causes, and suggested approaches for reducing hesitancy and strengthening vaccine acceptance.

Immunity Against Infectious Diseases Predictive Value of Self-Reported History of Vaccination and Disease

Objective.

To determine whether self-reported history of disease and/or vaccination is predictive of immunity against hepatitis B, varicella, rubella, mumps, and measles.

Design.

The seroprevalence of viral antibodies and the predictive value of a self-report questionnaire were determined for 616 paramedical students who matriculated into Padua Medical School (Padua, Italy) during 2003-2005.

Results.

The majority of subjects (86.9%) remembered being vaccinated against hepatitis B but had no recollection of disease. Among vaccinees, 1.5% showed markers of previous infection, 6.7% tested negative for anti-hepatitis B virus surface antigen (anti-HBsAg) antibodies, and 91.8% tested positive for anti-HBsAg. Self-reported vaccination history had a positive predictive value of 93.2% for test results positive for immunity against hepatitis B. Immunity against varicella (93.7% of subjects) and rubella (95.5%) was high, compared with immunity against mumps (79.9%) and measles (83.1%). In addition, results of tests for detection of immunity against mumps and measles were equivocal for more than 7% of subjects, probably because their vaccination regimen was not completed. Self-reported histories of varicella disease and rubella disease and vaccination had high positive predictive values (greater than 98% each) for testing positive for antiviral antibodies, compared with self-reported histories of mumps disease and vaccination and measles disease and vaccination; however, high positive predictive values were observed for self-reported histories of mumps only (92.0%) and measles only (94.7%).

Conclusions.

The self-report questionnaire used in this study did not accurately predict immunity against 5 transmittable but vaccine-preventable diseases. A complete serological evaluation of healthcare workers, followed by vaccination of those with negative or equivocal results of serological tests, is an appropriate measure to decrease the risk of infection in this population.

Proteção individual versus proteção coletiva: análise bioética do programa nacional de vacinação infantil em massa

A vacinação é considerada como uma das políticas de saúde pública mais efetivas e de menor custo-benefício, utilizada no controle e na prevenção de doenças. Mas é também considerada uma das técnicas biomédicas mais polêmicas e controversas, o que torna difícil evitar uma abordagem ética, principalmente quando a vacinação é utilizada de forma compulsória em toda a população. Com efeito, visto que as vacinas não são totalmente seguras e eficazes, há um conflito ético entre o interesse individual e o coletivo, pois as crianças carregam de fato o ônus da vacinação em benefício da saúde pública quando são acometidas com reações adversas graves e que ficam alheias aos cuidados que deveriam ser oferecidos pelo Poder Público. O objetivo deste artigo foi demonstrar que as ferramentas da bioética são relevantes nesta discussão para analisar e compreender criticamente estes conflitos, fornecendo argumentos cogentes para orientar a elaboração de biopolíticas que considerem não apenas, com rigor, a prevenção, mas, também, a responsabilidade solidária de todos como fundamento para uma proteção que seja tanto individual como coletiva.

Power and persuasion in the vaccine debates: an analysis of political efforts and outcomes in the United States, 1998-2012

CONTEXT

This article examines trends in state-level childhood vaccine policies in the United States from 1998 to 2012 and explains the trajectories for both vaccine-critical and proimmunization legislative efforts. Successful mobilization by vaccine critics during the height of the autism and thimerosal scares (roughly 1998 to 2003) yielded a few state-level expansions for the most permissive type of exemption from vaccine mandates for public school attendance, those based on personal beliefs. Vaccine-critical positions, however, have largely become discredited. How has vaccine critics' ability to advance preferred policies and prevent the passage of unfavorable legislation changed over time?

METHODS

We created a unique data set of childhood vaccine bills (n = 636), introduced from 1998 to 2012 across the 50 state legislatures, and coded them by type of effort (exemption, mandate, mercury ban, and information policies) and outcome. We then mapped out the trends in vaccine policies over time. In order to contextualize the trends we identified, we also reviewed numerous primary sources and conducted interviews with stakeholders.

FINDINGS

In general, we found that vaccine critics' legislative success has begun to wane. In only 20 bills in our data set were vaccine critics able to change policy in their preferred direction via the legislative process. Only 5 of those wins were significant (such as obtaining a new philosophical exemption to vaccine mandates), and the last of these was in 2007. Critics were more successful at preventing passage of proimmunization legislation, such as mandates for the human papillomavirus (HPV) vaccine.

CONCLUSIONS

Recent legislation in California, Oregon, and Washington that tightened philosophical exemptions by means of informational requirements suggests that vaccine politics may be entering another phase, one in which immunization supporters may be able to counter increasing opt-out rates, particularly in states with recent outbreaks and politicians favoring science-based policies.

Should the influenza vaccine be mandatory for frontline staff?

Professor Alan Glasper from the University of Southampton discusses the latest flu plan initiative by the Department of Health, NHS England and Public Health England for the winter of 2014-15 designed to increase flu vaccine uptake among frontline health professionals.

Are we ready to abrogate compulsory vaccinations for children?

In Italy, vaccination against diphtheria, tetanus, polio and hepatitis B is compulsory for infants countrywide, except in Veneto region where since 2007 Health Authorities have experimented the suspension of mandatory vaccination. In light of the recent discussion on the potential abrogation in other regions, we explored the opinion of family pediatricians who play a crucial role in promoting immunization programmes in Italy. In November 2009, we interviewed by phone the family pediatricians working in Puglia region using a standardised, ad hoc and piloted questionnaire. Of the 596 contacted, 502 (84.2%) completed the questionnaire (54% female, median age = 52 y). Among the respondents, 72 (14.3%) would agree on the hypothesis of abrogation. This judgment was associated with having a good opinion on the level of awareness of the importance of vaccinations in the general public (OR = 6.6; 95% CI: 3.6-12.1) and having the perception of adequate organization of Vaccination Services in supporting the abrogation (OR = 3.6; 95% CI: 1.7-5.9). Family pediatricians appeared really sceptical about the abrogation of compulsory vaccination that could be hypothesized only increasing public awareness, communication skills and capability of Vaccination Services personnel in offering vaccinations.

Nonmedical exemptions from school immunization requirements: a systematic review

We summarized studies describing the prevalence of, trends in, and correlates of nonmedical exemptions from school vaccination mandates and the association of these policies with the incidence of vaccine-preventable disease. We searched 4 electronic databases for empirical studies published from 1997 to 2013 to capture exemption dynamics and qualitatively abstracted and synthesized the results. Findings from 42 studies suggest that exemption rates are increasing and occur in clusters; most exemptors questioned vaccine safety, although some exempted out of convenience. Easier state-level exemption procedures increase exemption rates and both individual and community disease risk. State laws influence exemption rates, but policy implementation, exemptors' vaccination status, and underlying mechanisms of geographical clustering need to be examined further to tailor specific interventions.

MODELING THE IMPACT OF AWARENESS CREATED BY MEDIA CAMPAIGNS ON VACCINATION COVERAGE IN A VARIABLE POPULATION

Vaccines are a core component of any preventive strategy designed to ensure the global public health. A major factor influencing the successful implementation of any immunization program is awareness and public acceptance of the vaccine. The present study focuses on potential impacts of awareness created by media campaigns on vaccination coverage of hepatitis B. In this paper, a SIR model with vital dynamics in a population of varying size is investigated, which couples hepatitis B vaccination and awareness created by media within a single framework. It is assumed that media campaigns propagate awareness about measures requisite for escaping the chances of contracting hepatitis B. The awareness created by media motivates people to get vaccinated and attain full immunization against hepatitis B virus. For analyzing the model, stability theory of differential equations is employed. First, equilibria of the system comprising fractions of the population are obtained and their stability behavior is discussed. Then the asymptotic behavior of total population is discussed in detail. Three threshold parameters R0, R1and R2governing the dynamics of infection and total population are also affirmed. The findings of numerical simulations are also in line with analytically obtained results.

Human papillomavirus (HPV), HPV-associated oropharyngeal cancer, and HPV vaccine in the United States--do we need a broader vaccine policy?

BACKGROUND

Human papillomavirus (HPV) is a sexually transmitted infection (STI) of global importance; it is the most prevalent STI in the United States, with strains causally linked to oropharyngeal and other cancers. Efforts to prevent HPV have been made to varying degrees by policies implemented by different state governments; however, HPV and associated oropharyngeal cancer continue to show increasing incidence rates in the US.

DESIGN

A narrative review based on search on SciVerse, PubMed/Medline, Google Scholar, and EMBASE databases, as well as literature/documents from the World Health Organization, Centers for Disease Control and Prevention, American Cancer Society, National Conference of State legislatures, and the U.S. Department of Health and Human Services relevant to HPV and HPV vaccine policy in the US.

RESULTS

Vaccination has proved to be a successful policy in the US, and an extant recommendation aimed at preventing HPV and associated cervical and other anogenital cancers is the routine use of HPV vaccines for males and females. However, HPV vaccines are presently not recommended for preventing oropharyngeal cancer, although they have been shown to be highly effective against the HPV strains that are most commonly found in the oropharynx. And while there is a history of successful vaccine mandate in the US with resulting decrease in occurrence of infectious diseases, implementing HPV vaccine mandate has proved to be very unpopular.

CONCLUSIONS

With emerging evidence of the efficacy of the use of the HPV vaccine in preventing oral-HPV, more focus should be put on extending HPV vaccine to present oral HPV infection and oropharyngeal cancer. Also, implementing a broader HPV vaccine policy that include mandating HPV vaccines as a school-entry requirement for both sexes may increase vaccine use in the US for the greater good of the public.

Vaccination Perceptions and Barriers of School Employees

Schools are where vaccine-preventable diseases can spread. Vaccination of school children has been studied; however, data are lacking on the vaccination status, perceptions, and barriers to vaccination for school employees. We surveyed school employees’ vaccination perceptions, awareness of current vaccination status, and potential barriers to vaccinations. Adult vaccination knowledge is lacking in the school employee population. School employees were unaware of their vaccination status for diseases such as measles and pertussis. Most subjects believed vaccinations were safe and effective, although they believed vaccinations were more important for children than adults. Many believed vaccine mandates should exist for school employees. Knowledge gaps regarding adult vaccines can be positively influenced by school nurses. Gaps may be especially important to bridge regarding adults working in the school setting, an environment ideal for the spreading of communicable diseases.

Behavioral Epidemiology of Infectious Diseases: An Overview

The focus of the growing discipline of behavioral epidemiology (BE) of infectious diseases is on individual behavior as a key determinant of infection trajectories. This overview departs from the central, but static, role of human behavior in traditional mathematical models of infection to motivate the importance of including behavior into epidemiological models. Our aim is threefold. First, we attempt to motivate the historical and cultural background underpinning the BE revolution, focusing on the issue of rational opposition to vaccines as a natural endpoint of the changed relation between man and disease in modern industrialized countries. Second, we review those contributions, from both mathematical epidemiology and economics, that forerun the current “epidemic” of studies on BE. Last, we offer a more detailed overview of the current epidemic phase of BE studies and, still motivated by the issue of immunization choices, introduce some baseline ideas and models.

The interplay of public intervention and private choices in determining the outcome of vaccination programmes

After a long period of stagnation, traditionally explained by the voluntary nature of the programme, a considerable increase in routine measles vaccine uptake has been recently observed in Italy after a set of public interventions aiming to promote MMR immunization, whilst retaining its voluntary aspect. To account for this take-off in coverage we propose a simple SIR transmission model with vaccination choice, where, unlike similar works, vaccinating behaviour spreads not only through the diffusion of "private" information spontaneously circulating among parents of children to be vaccinated, which we call imitation, but also through public information communicated by the public health authorities. We show that public intervention has a stabilising role which is able to reduce the strength of imitation-induced oscillations, to allow disease elimination, and to even make the disease-free equilibrium where everyone is vaccinated globally attractive. The available Italian data are used to evaluate the main behavioural parameters, showing that the proposed model seems to provide a much more plausible behavioural explanation of the observed take-off of uptake of vaccine against measles than models based on pure imitation alone.

Common perceptions of parents requesting personal exemption from vaccination

School nurses, as vaccination advocates, need to be aware of parents' common concerns regarding vaccines, so the nurse can develop strategies to communicate with parents. The purpose of this cross-sectional, descriptive study was to identify common reasons parents in Utah seek exempting rather than vaccinating their children. Data were collected from a convenience sample of 801 parents responding to a 16-item questionnaire about why they exempted their children from receiving vaccinations. The most commonly reported reason for seeking a personal exemption included vaccines conflicting with philosophical beliefs. Parents exempting from one vaccine most commonly exempted the hepatitis series. Most parents communicated their vaccine concerns with their health care provider prior to seeking exemption. The majority of exempting parents did not use the Internet when researching vaccines even though they had Internet access. Considering the common vaccine-related perceptions of parents may be helpful when developing strategies to overcome these barriers to vaccination.

Finding the proper balance between freedom and justice: why we should not eliminate personal belief exemptions to vaccine mandates

Lantos and colleagues (this issue) propose to eliminate personal belief exemptions from school vaccine mandates, particularly for those vaccines that target deadly contagious childhood disease. They argue that not doing so would be unjust. In this counterpoint, we argue that, for reasons grounded in both health policy and morality, a just vaccine policy need not prohibit parents from claiming personal belief exemptions.

The legitimacy of vaccine critics: what is left after the autism hypothesis?

The last dozen years have seen a massive transnational mobilization of the legal, political, and research communities in response to the worrisome hypothesis that vaccines could have a link to childhood autism and other developmental conditions. Vaccine critics, some already organized and some composed of newly galvanized parents, developed an alternate world of internally legitimating studies, blogs, conferences, publications, and spokespeople to affirm a connection. When the consensus turned against the autism hypothesis, these structures and a committed membership base unified all the organizations in resistance. This article examines the relationship between mobilization based on science and the trajectory of legitimacy vaccine criticism has taken. I argue that vaccine critics have run up against the limits of legitimate scientific argument and are now in the curious position of both doubling down on credibility-depleting stances and innovating new and possibly resonant formulations.

Seasonal influenza: what every nurse needs to know

Professor Alan Glasper discusses this year's seasonal influenza advice from the Department of Health in preparation for winter, and the increasing importance of influenza vaccination by nurses, for nurses.

Consent and public engagement in an era of expanded childhood immunisation

Childhood immunisation programmes have seen well-heralded successes in disease control. An increasing number of scheduled vaccines, narrowing risk-benefit ratios and public attention to vaccine safety raise new questions about consent. We first explore the challenges that this highly dynamic environment poses for valid consent. Then, we broaden this discussion to wider public engagement by suggesting how the public - the bearers of vaccine risk and benefit - can be better involved in immunisation policy.

Publics and vaccinomics: beyond public understanding of science

Vaccines have been among the most effective tools for addressing global public health challenges. With the advent of genomics, novel approaches for vaccine discovery are opening up new opportunities for vaccine development and applications, particularly with the expectation of personalized vaccines and the possibility of addressing a broader range of infectious diseases. In this context, it is useful to reflect on the social contexts of vaccine development as these have been influenced by social, ethical, political challenges. This article discusses the historical context of vaccine controversies and factors that help explain public acceptance and resistance, illustrating that these challenges go well beyond simple public misunderstandings. The broader vaccine challenges evident along the innovation trajectory, from development to commercialization and implementation include problems in research and development, organizational issues, and legal and regulatory challenges that may collectively contribute to public resistance or confidence. The recent history of genomics provides further lessons that the developing field of vaccinomics can learn from.

Incidental findings in data-intensive postgenomics science and legal liability of clinician-researchers: ready for vaccinomics?

Vaccinomics encompasses a host of multiomics approaches to characterize variability in host-environment (including pathogens) interactions, with a view to a more directed or personalized use of vaccine-based health interventions. Although vaccinomics has the potential to reduce adverse effects and increase efficacy of vaccines, the use of high-throughput, data-intensive technologies may also lead to unanticipated discoveries beyond the initial aims of a vaccinomics study--discoveries that could be highly significant to the health of the research participants. How do clinician-researchers faced with such information have to act? What are the attendant legal duties in such circumstances and how do they differ from the duties of non-clinician researchers? Together with a critical analysis of the international laws and policies framing researchers' duties with regard to incidental findings, this article also draws from Quebec's civil law--with its rich jurisprudence on clinician and researcher liability--as a case study to evaluate the potential legal implications associated with vaccinomics investigations. Given previous lessons learned from other data-intensive sciences, the education of clinician-researchers with regard to their roles, limitations, and legal obligations remains an important strategy to prevent potential legal complications and civil liability in vaccinomics research in the postgenomics era.

Occupational therapists views and beliefs regarding the risks and benefits of childhood vaccinations

ABSTRACT This study presents findings from an exploratory study of occupational therapists' views and beliefs regarding childhood vaccination safety and vaccination requirements for day care and school attendance. One-on-one, semi-structured telephone interviews were conducted over a six-week period with 25 pediatric occupational therapists across the United States. Participants expressed ideas similar to those found in surveys of parent vaccination attitudes and beliefs, as well as the need to extend the vaccination schedule to prevent overloading a child's immune system. Differences among participants were most clearly seen when comparing those with post-entry-level training to those with only an entry-level degree. The results appear to support the idea that lack of clear communication of public health concepts extends to healthcare professionals as well as consumers.

The impact of vaccine side effects on the natural history of immunization programmes: an imitation-game approach

When the incidence and prevalence of most common vaccine preventable childhood infectious diseases are constantly low, as is the case in many industrialized countries, the incidence of vaccine-associated side effects might become a key determinant in vaccine demand. We study an SIR transmission model with dynamic vaccine demand based on an imitation mechanism where the perceived risk of vaccination is modelled as a function of the incidence of vaccine side effects. The model shows some important differences compared to previous game dynamic models of vaccination, and allows noteworthy inferences as regards both the past and future lifetime of vaccination programmes. In particular it is suggested that a huge disproportion between the perceived risk of disease and vaccination is necessary in order to achieve high coverages. This disproportion is further increased in highly industrialised countries. Such considerations represent serious challenges for future vaccination programmes.

Association between Medicaid reimbursement and child influenza vaccination rates

OBJECTIVE

We examined associations between influenza vaccination rates and Medicaid reimbursement rates for vaccine administration among poor children who were eligible for Medicaid (<100% of the federal poverty level in all states).

METHODS

We analyzed 3 consecutive National Immunization Surveys (NISs) to assess influenza vaccination rates among nationally representative children 6 to 23 months of age during the 2005-2006 (unweighted N = 12 885), 2006-2007 (unweighted N = 9238), and 2007-2008 (unweighted N = 11 785) influenza seasons (weighted N = 3.3-4.0 million per season). We categorized children into 3 income levels (poor, near-poor, or nonpoor). We performed analyses with full influenza vaccination as the dependent variable and state Medicaid reimbursement rates (continuous covariate ranging from $2 to $17.86 per vaccination) and terms with income levels as key covariates.

RESULTS

In total, 21.0%, 21.3%, and 28.9% of all US children and 11.7%, 11.6%, and 18.8% of poor children were fully vaccinated in the 2006, 2007, and 2008 NISs, respectively. Multivariate analyses of all 3 seasons found positive significant (all P < .05) associations between state-level Medicaid reimbursement and influenza vaccination rates among poor children. A $10 increase, from $8 per influenza vaccination (the US average) to $18 (the highest state reimbursement), in the Medicaid reimbursement rate was associated with 6.0-, 9.2-, and 6.4-percentage point increases in full vaccination rates among poor children in the 2006, 2007, and 2008 NIS analyses, respectively.

CONCLUSION

Medicaid reimbursement rates are strongly associated with influenza vaccination rates.

Are there different spheres of conscience?

Interest in understanding the meaning of conscience and conscientious objection in medicine has recently emerged in the academic literature. We would like to contribute to this debate in four ways: (1) to underscore and challenge the existing hierarchy of conscientious objection in health care; (2) to highlight the importance of considering the lay public when discussing the role of conscientious objection in medicine; (3) to critique the numerous proposals put forth in favour of implementing review boards to assess whether appeals to conscience are justifiable, reasonable and sincere; and (4) to introduce the Universal Declaration of Human Rights and the Siracusa Principles into the dialogue around conscience and suggest that perhaps conscientious objection is a human right.

Controversies in vaccine mandates

Policies that mandate immunization have always been controversial. The controversies take different forms in different contexts. For routine childhood immunizations, many parents have fears about both short- and long-term side effects. Parental worries change as the rate of vaccination in the community changes. When most children are vaccinated, parents worry more about side effects than they do about disease. Because of these worries, immunization rates go down. As immunization rates go down, disease rates go up, and parents worry less about side effects of vaccination and more about the complications of the diseases. Immunization rates then go up. For teenagers, controversies arise about the criteria that should guide policies that mandate, rather than merely recommend and encourage, certain immunizations. In particular, policy makers have questioned whether immunizations for human papillomavirus, or other diseases that are not contagious, should be required. For healthcare workers, debates have focused on the strength of institutional mandates. For years, experts have recommended that all healthcare workers be immunized against influenza. Immunizations for other infections including pertussis, measles, mumps, and hepatitis are encouraged but few hospitals have mandated such immunizations-instead, they rely on incentives and education. Pandemics present a different set of problems as people demand vaccines that are in short supply. These issues erupt into controversy on a regular basis. Physicians and policy makers must respond both in their individual practices and as advisory experts to national and state agencies. The articles in this volume will discuss the evolution of national immunization programs in these various settings. We will critically examine the role of vaccine mandates. We will discuss ways that practitioners and public health officials should deal with vaccine refusal. We will contrast responses of the population as a whole, within the healthcare setting, and in the setting of pandemic influenza.