What are the moral obligations of the traveller in relation to vaccination?

Qualitative assessment of caregiver experiences when navigating childhood immunisation in urban communities in Sierra Leone

OBJECTIVE

To gain in-depth understanding of the caregiver experience when navigating urban immunisation services for their children.

DESIGN

An exploratory qualitative assessment comprising 16 in-depth interviews using an interpretative phenomenology approach.

SETTING

Caregivers were purposively recruited from slums (n=8) and other urban communities (n=8) in the capital city of Sierra Leone.

PARTICIPANTS

Caregivers of children ages 6-36 months old who were fully vaccinated (n=8) or undervaccinated (n=8).

RESULTS

Emotional enablers of vaccination were evident in caregivers' sense of parental obligation to their children while also anticipating reciprocal benefits in children's ability to take care of their parents later in life. Practical enablers were found in the diversity of immunisation reminders, information access, information trust, getting fathers more involved, positive experiences with health workers and postvaccination information sharing in the community. Underlying barriers to childhood vaccination were due to practical constraints such as overcrowding and long waiting times at the clinic, feeling disrespected by health workers, expecting to give money to health workers for free services and fear of serious vaccine side effects. To improve vaccination outcomes, caregivers desired more convenient and positive clinic experiences and deeper community engagement.

CONCLUSIONS

Health system interventions, community engagement and vaccination outreach need to be tailored for urban settings. Vaccine communication efforts may resonate more strongly with caregivers when vaccination is framed both around parental responsibilities to do the right thing for the child and the future benefits to the parent.

Antimalarial mass drug administration: ethical considerations

Falciparum malaria is a major cause of death and illness in tropical countries, particularly in childhood. In endemic countries, a significant proportion of the community is infected with malaria asymptomatically. One promising way to eliminate malaria is to give the entire population malaria treatment. This is called mass drug administration (MDA) and it raises a number of ethical issues, as possible long-term benefits are uncertain. The effectiveness of MDA is critically dependent on level of participation, so the promised benefits to the community can be annulled by non-participation of a small number of individuals. These potential benefits range a wide spectrum, from the permanent elimination of malaria (success) to a transient reduction in the prevalence of infection and the incidence of illness (failure). The drawbacks of MDA are: inconvenience, potential toxicity, loss of confidence in the elimination campaign, possible drug resistance (though highly unlikely), and the potential for a rebound of malaria illness (if immunity is lost and malaria is reintroduced later). Other ethical issues are related to balancing individual and public health interests, and potentially limiting individual autonomy by making MDA compulsory.

The sexual ethics of HPV vaccination for boys

Human papillomavirus (HPV) is one of the most common sexually transmitted infections. It is a leading cause of cervical cancer in women but the virus is increasingly being linked to several other cancers in men and women alike. Since the introduction of safe and effective but also expensive vaccines, many developed countries have implemented selective vaccination programs for girls. Some however argue that these programs should be expanded to include boys, since (1) HPV constitutes non-negligible health risks for boys as well and (2) protected boys will indirectly also protect girls. In this paper we approach this discussion from an ethical perspective. First, on which moral grounds can one justify not reimbursing vaccination for the male sex? We develop an ethical framework to evaluate selective vaccination programs and conclude that, in the case of HPV, efficiency needs to be balanced against non-stigmatization, non-discrimination and justice. Second, if vaccination programs were to be expanded to boys as well, do the latter then also have a moral duty to become immunized? Two arguments in favor of such a moral duty are well known in vaccination ethics: the duty not to harm others and to contribute to the public good of public health. However, we argue that these are not particularly convincing in the context of HPV. In contrast, we believe a third, more powerful but also more controversial argument is possible. In our view, the sexual mode of transmission of HPV constitutes an additional reason to believe that boys in fact may have a moral obligation to accept vaccination.

Mutual Moral Obligations in the Prevention of Infectious Diseases

Not so long ago health policy was about little more than the provision of medical care. The availability of treatment is important for those in need of cure, but by now it is a well-shown fact that health is generally determined to a much greater extent by other factors. Genetic constitution, lifestyle choices and socio-economic environment largely explain why some of us become ill or die earlier than others who remain healthy (Mackenbach 1996; McKeown 1976; Wilkinson and Marmot 2003). While some of these factors fall under the control of an individual, the majority does not. Research increasingly indicates how remarkably sensitive our health seems to be to what has become known as the ‘social determinants of health’. These factors generally fall beyond the control of an individual, but can nonetheless be influenced on a population level. This causes a shift in the focus of health policy from the classic provision of health care to policies specifically designed to influence the causal factors of ill-health in different non-medical fields. The flipside of that evolution is a significant increase of the state’s influence in the sphere of individual lives. A pertinent question remains the one that asks for the legitimate role of governments in modifying, discouraging or prohibiting behaviors that lead to ill-health. To what extent can and should we hold public policy responsible for us leading a healthy life? Most scholars will argue that governments indeed have a role to play, but that the limits will be reached when public health measures would imply large sacrifices of individual liberty.

Herd immunity: recent uses in vaccine assessment

Human communities defend themselves against specific infectious agents in a way that extends beyond the simple sum of the immune status of its individuals. By analogy with individual immunity to specific agents, the community level of immunity may vary from complete susceptibility to full protection. Herd immunity has been used to name this community property, which is the result of evolution through natural selection, leading to relationships between two species, typical of prey-predator systems. Varying uses of the term herd immunity led to the use of other expressions, such as herd protection, herd effect and community immunity. Knowledge derived from observational studies and models on herd immunity has supported decisions on the choice of vaccines and vaccination strategies for the benefit of populations. This knowledge is most likely to be extended in the future, with far-reaching effects.