Inducing immunity for the sake of others: altruist and indirect vaccinations

The introduction of vaccination against infectious diseases has been one of the most important contributions to public health of the last century. For this reason, governments actively promote collective immunization in various ways –notably through general programs as the Dutch Rijksvaccinatieprogramma. A characteristic feature of most vaccinations is that they not only directly immunize the individual involved but also indirectly protect people who are not or cannot be immunized themselves. Still, most vaccination programs are primarily justified in terms of the interests of the person involved.

The success of these direct vaccination programs is beyond dispute, but further health benefits can be gained if governmental agencies would promote indirect vaccination strategies that primarily aim at achieving external benefits. Examples thereof are maternal immunization to protect newborns (pertussis; influenza, and in the future possibly RSV, zika), the vaccination of professionals, notably health care workers to protect vulnerable patients against, for example influenza or pertussis; or public health programs that aim to vaccinate persons who run a relatively small risk themselves but might spread infections to vulnerable others (e.g. influenza of children to protect elderly or HPV vaccination of boys).

Even though such indirect vaccination strategies are increasingly endorsed and recommended by for example the WHO and the Health Council of the Netherlands, a systematic ethical justification of such programs is up to now lacking. This proposal seeks to fill that gap by gathering and critically analyzing relevant normative arguments for and against indirect vaccination strategies that primarily aim at achieving external benefits. Indirect vaccination strategies are defined as vaccination programs that target individuals who do not belong to the group or subgroup for whom the most important health benefits are expected and aimed for. These indirect strategies may raise ethical issues and public controversy, especially if benefits for vaccinees themselves are very small, and this problem becomes only more urgent given emerging vaccine hesitancy and slowly declining vaccination rates for regular childhood immunization. On the other hand, indirect immunization does appeal to such ethical notions as non-maleficence (not harming others), benevolence and solidarity.

In this project we explore the possibilities of developing an ethical justification for indirect vaccination, as offered or supported in a programmatic and pro-active way by government, aiming at high vaccination uptake among relevant target groups. We focus on three contexts, namely maternal immunization, professional immunization, and indirect vaccination for public health.
(1) Under what conditions are vaccination policies aiming at external effects ethically justified? (2) When are health authorities justified in implementing such vaccinations in a routine, persuasive or otherwise pro-active manner? (3) What communicative approach to promote such programs would be appropriate and trustworthy? We analyze these questions in the context of current and future vaccination options and against the background of increasing vaccine hesitancy.
The research project is a study in practical ethics, focusing on normative and conceptual analysis, yet informed by focus group studies with target groups, expert/stakeholders discussions, and, above all interaction with advisory and policy practice. The project results in ethical recommendations for vaccination policy and practice including guidance for targeted communication strategies.

This PhD project is carried out by Steven Kraaijeveld, under supervision from Roland Pierik and Marcel Verweij. We collaborate with the Strategic Communication chair group of Wageningen University and with RIVM.