transgenerational justice vaccination and its relevance to A classification of the of aims Lea Atzinger www.jogh.org JoGH ©2020ISGH © 2020TheAuthor(s) 1 2 InstituteofHumanGenetics,SaarlandUniversity, Homburg/Saar, Germany GermanEthicsCouncil(DeutscherEthikrat),Berlin,Germany ity forothers. which entailsaninherentresponsibil tified bytheirfreelychosenprofession and educationalstaff)isethicallyjus tious diseases (eg, health care workers spreading vaccine-preventableinfec at increasedriskofcontractingand certain occupationalgroupswhoare A mandatoryvaccinationpolicyfor • doi:10.7189/jogh.10.010341 exclusively human-to-human transmissible pathogens is not only capable of eliminating a particular dis- Beyond the responsibility of each vaccinable person, the systematic and coordinated use of vaccines against 2019,moreFebruary thantwice thenumberofpeoplekilledbyEbolathere [4 lic of Congo has been heavily affected by a measles epidemic with 5110 people being declared dead since ing their second dose falling from 77% in 2017 to 28% in 2018. (ibid.) Similarly, the Democratic Repub- Samoa was stirred up by a breakdown in vaccine coverage last year, with the proportion of infants receiv- [3 died have whom of 42 least at children, young mainly reported, been have cases 3149 of total a far so where Samoa, in epidemic measles recent the in seen be arguably can This more vulnerablepopulationsglobally. protect to fails locally,also immunity herdbut compromise only not does available, easily are vaccines measles efficient and safe where countries in reasons non-medical for vaccinated be to refusal or glect malnutrition and pre-existing chronic health conditions such as tuberculosis and HIV. Consequently,prevalent to ne- due outcome disease worse often an by exacerbated is situation This repercussions. rious diseases). Thus, low-income countries are disproportionately affected and are far more likely to suffer se- infectious for options treatment limited and coverage vaccine in problems to due instance (for breaks out- with deal to equipped less countries to trade and tourism, migration, global via infrastructure ical ventable communicable diseases may be exported from financially prosperous countries with good med- vaccine-pre- as relevant, ethically particularly is imbalance global This health. public to threats serious very as recognized rightly still are flare-ups measles countries, low-income in that, to contrast sharp In top tenthreats toglobalhealthin2019. the among hesitancy vaccine list to WHO the led has This diminish. to programstends vaccination to 1 , Wolfram Henn 1,2 - - - V of contracting such a disease are often underestimated, and adherence consequences the anymore, diseases infectious vaccine-preventable of manifestations devastating the witness not does typically public disease virtually unknown to the protected group [2 gionally successful vaccination programs have rendered the respective vaccines are about to become a victim of their own success where re- though as seems it countries, industrialized in However,especially [1 worldwide mortality childhood of causes leading the among still are measles Nevertheless, 2017. and 2000 between globally vaccination programs alone have prevented over 21.1 million deaths World HealthOrganization (WHO)estimatesthatmeasles The health. public of instruments proactive cost-efficient accines are well-establishedtobeoneofthemosteffective and 1 June 2020 •Vol. 10 No. 1•010341 ]. The current situation in in situation current The ]. ]. ]. As the general ]. ].

VIEWPOINTS VIEWPOINTS June 2020 •Vol. 10 No. 1•010341 ational justice. duty todoso,thuscontributingtransgener potentially lethalillness,theyhaveanethical future generationsfromcontracting a serious, opportunity toprotectthemselves,othersand If anindividual,orasocietyaswhole,hasthe tion (reduction tozero oftheworldwideincidenceinfection)[5 within that area for a defined period of time, whereas “eradication” refers to the permanent global extinc- infection of cases endemic new no with area geographical defined a in disease particular a of extinction rent population, but also indefinitely shelter indefinitely also but population, rent eases cannot only achieve contemporary global eradication of the given disease, hence protecting the cur dis- infectious transmissible human-to-human exclusively concerning programs vaccination Successful lated recognition byauthoritieswhichcanleadtorapidly spreading epidemics. immunity,population of lack a to due mainly sufficientof be- care sometimes infrastructure, health and disease, of outcomes and courses severe more to lead can regions such into imported Infections demic. Global prevention tion ofpathogenswithinacommunity. circulasustained a - thereforeinhibit is to objective The population. general immunized successfully the als who cannot be vaccinated due to age restrictions or medical contraindications, are protected through viduals, but also creating However, vaccines against communicable diseases serve the double function of not only protecting indi- encephalitis). pose ofvaccination(eg,tetanus,tick-borne transmitted from human to human, but through other vectors, individual protection is the principal pur tial side-effects, as ascertained for the measles vaccine. In the case of some infectious diseases that are not poten- outweigh benefits whose vaccines Prerequisitessafe gen. and readilyherebyavailable, arecheap, possible adverse short- and long-term consequences resulting from an infection with a particular patho- Vaccines as instruments of tion programmes, andfrom thepotentialside-effects ofsuchinterventions. associated with contracting that illness, but also from the financial and logistic burden to design preven- dangers the from spared only not are generations coming eradicated, successfully is disease ventable

Figure 1. aims at averting the export of pathogens to regions where they are not en- not are they where regions to pathogens of export the averting at aims (Level 3) herd immunity individual prevention Classification ofvaccinationobjectives. - (Level 2). Hereby, vaccine non-responders, as well as individu- 2 “elimination” and “eradication”. “Elimination” refers to the the refersto “Elimination” “eradication”. and “elimination” terms the between distinguish to important Hereby,is it tice (seeFigure 1). vaccination, with their implication for transgenerational jus- graded classification of the individual and collective aims of eradication. This disease context can be global illustrated by the following permanent through harm of source ic portunity to spare future generations forever from a specif- today,locally ease op- the generation current the gives but future generations ( (Level 1) serve the purpose of protecting a person from ]. from harm. If a vaccine-pre- a If harm. from Level 4) www.jogh.org • doi:10.7189/jogh.10.010341 - - www.jogh.org Nepal. PhotobyJim HolmesforAusAID(13/2529). routine vaccinations atDistrictPublicHealthOffice,ImmunisationClinic,Pokhara, Photo: Motherbringsherchildtobe vaccinated forMeasles,MumpsandRubelladuring • doi:10.7189/jogh.10.010341 fore considering penalties for non-vaccination. Whether to apply sanctions to “non-vaxxers” (due to to (due “non-vaxxers” to sanctions apply to Whether non-vaccination. for penalties considering fore vaccine access must be removed through investment in medical infrastructure and health education, be- Primarily, challenges. epidemiological given the to sub-group customized specific, individual to barriers population and country region, be must incompliance vaccine to reaction in measures regulatory The wealthy countriesmakingproportionately higherfinancialandlogisticcontributions. transgenerational justice, should follow an equity-based framework of international burden sharing, with of demands the fulfilling eradication, disease global permanent of aim the with policies vaccination of able from their own resources, with access to supranational support. In this context, the implementation ciding to get vaccinated. All health care authorities are obliged to provide the means to do so, and if un- health care system can make a small but indispensable individual contribution to herd immunity by de- al institutions as well as regulatory bodies. Simultaneously, every person with access to a well-functioning tion can only be made through cooperation of local health care providers and nation- with international It is important to note that significant progress in vaccine compliance and consequential disease eradica- as wehavethetoolstodoso. fromprotectsoon beings to as futurehuman best currentlydisease distant fellow our a existing even do recentin seen as managed, rather but Anyway,COVID-19). MERS, Ebola, Zika, (eg, epidemics must we prevented, entirely nor predicted be neither can pathogens new of spread Evidently,and evolution the ecosystem” [6 tice, ie,caringforhumanslivingtodayandthosetomorrow, whilepreserving theintegrityofplanetary tection ofstable,functioning,life-sustainingecologicalsystems.(...)Itisinitsessenceabouttransgenerationaljus- as thedevelopmentofglobalhumansocietytoward astateofbalance(...)betweenhumanneedsandthepro - sible harm from future generations through responsible action in the present. ”Sustainability is understood pos- of deflection demanding medicine, into sustainability of concept political discussed widely the fers trans- concept This justice. transgenerational creating thus so, do to duty ethical an also but pragmatic, a only not have they illness, lethal potentially serious, a contracting from generations future and others Consequently,costs. protect to themselves, opportunity the has whole, a as society a or individual, an if unbearable or effects side relevant of probability unacceptable an ie, burden, or risk disproportionate to exposed not are individuals that implies which vaccine, each for assessment risk-benefit individual An evaluation of the responsibility and feasibility to mimic the smallpox example must certainly entail an with astrategyadaptedtothegivenepidemiologicalchallenges. reproducedsafety, be and pathogen’sshould logistics, the processproperties, of this biological terms in to contribution lasting a as also but health, global for cess eradication of smallpox, declared by the WHO in 1980, cannot only be perceived as a historic grand suc- international the context, this In levels. regional and national the to responsibilities assigning strategies, health public international coordinated designing with tasked is WHO the process, this Toaccelerate ]. 3 . Wherever feasible Whereverfeasible transgenerational justice. fessional. freely their by justified ethically pro chosen - staff,education childcare,and careworkers, health affect primarily should policy strict This title. or permit work their of drawal with- the with sanctioned be could sionals profes- such of Incompliance sense. makes cine-preventable infectious diseases certainly vac- contracting of risk increased at groups occupational certain for policy vaccination of the given situation. However, a mandatory circumstances ethical and cultural, legal, al be reached taking into account the individu- only can which decision a is Germany) and Italy,in France, done (as institutions public from children, particularly persons, cinated tax benefits) or whether to exclude non-vac- financially (as practiced in Australia through countries), or whether to reward vaccination to vaccinate, (like Europeanin some eastern refuse who doctors reasons)or non-medical June 2020 •Vol. 10 No. 1•010341

VIEWPOINTS VIEWPOINTS June 2020 •Vol. 10 No. 1•010341 REFERENCES 5 4 6 3 2 1       Dowdle bmj.l6750 Mahase doi:10.1136/bmj.l6767 WTO law. Leiden:MartinusNijhoff Publishers;2009. Voigt Medline:10063669 Dyer English versiontobepublishedin2020.Available: www.ethikrat.org. Accessed.3April2019. Deutscher Ethikrat/German Ethics Council. Stellungnahme: Impfen als Pflicht? [Opinion: Vaccination as a duty?]. 2019; s11908-015-0506-5 Medline:26446612 2015;17:51. Rep. Dis Infect Curr measles. of reemergence The N. Safdar CL, Abad O C upon request from thecorresponding author)anddeclare noconflictsofinterest. Competing interests: The authors completed the ICMJE Unified Competing Interest form (available Authorship contributions:LAandWHjointlyconceivedwrote themanuscript. Funding: Nonedeclared. Ethics Council,forcontinuoussupportandhelpfuldiscussions. ResearchGalert, Thorsten Dr thank to wish authors The Acknowledgments: Officer German the at . . Sustainable development as a principle of international law: resolving conflicts between climate measures and and measures climate between conflicts resolving law: international of principle a as development Sustainable . E Measles: Samoa declares emergency as cases continue to spike worldwide. WR. . Attacks on Ebola sites in DRC leave four workers dead. The principles of disease elimination and eradication. and elimination disease of principles The

4 p51. BMJ. [email protected] Germany D-66421 Homburg-Saar Bau 68 Institut fürHumangenetikUniversitätsklinikum Prof. Dr. Wolfram Henn Correspondence to: Bull World Health OrganWorld. Health Bull 2019; 367:

BMJ. l6750. 2019; www.jogh.org Medline:31780450 367:

• doi:10.7189/jogh.10.010341 i6767. 1998; Medline:31784495 76 Suppl 2: Suppl doi:10.1007/ doi:10.1136/ 22-

5 .