The success of any vaccine program is plagued by public perception and scientific unknowns. An
excellent example was the recent H1N1 Pandemic Influenza outbreak (pH1N1), where immunization success
was poor, estimated at around 30-40% of the population. Recent scientific data suggests that immunization with
the seasonal flu vaccine prior to immunization with Pandemic Influenza (pH1N1) actually resulted in an
increased susceptibility to pH1N1 (Skowronski et al., 2010. Association between the 2008–09 Seasonal
Influenza Vaccine and Pandemic H1N1 Illness during Spring–Summer 2009: Four Observational Studies from
Canada. PLoS Medicine, 7(4):e1000258), raising scientific questions about vaccine interactions. Other studies
refute the findings. Concomitantly, there is a growing concern among the general public regarding the safety of
vaccines and possible side-effects associated with immunization (i.e., autism). Although the validity of these
claims is questionable and has largely been refuted (vaccine and autism), a significant number of people are
choosing not to vaccinate themselves or their children against many vaccine preventable diseases. As public
concern regarding vaccine safety grows, and complacency sets in, the evolutionary balance shifts in favour of
pathogen evolution and increased virulence and pathogenicity for these vaccine preventable diseases (as
outlined by Dr. Read). Health promotion strategies aimed at changing public perceptions about immunization
are critical for vaccine success.
Alberta Health and Wellness (AHW) published a pamphlet regarding Hepatitis B immunizations in
Alberta (see eCLASS). The target age group for this vaccine strategy is Grade 5 students. It is important to note
that the primary route of transmission of Hepatitis B is sexual intercourse. The underlying rationale for
immunization of Grade 5 students is to induce immunity before students become sexually active as young
adults. Interestingly, there is evidence to suggest that the success rate of vaccine programs related to sexually
transmitted disease (such as Hepatitis B and Human Papilloma Virus [HPV]) is poor when children are the
target age group, due to the parent’s perceptions regarding their child’s sexuality. Yet, the greatest public health
impact for disease control and pathogen emergence (i.e., virulent strains) is intervention during childhood with
widespread vaccination. When does the need to protect the public override personal choice?
Recently, there has been a flurry of media coverage as a result of the measles outbreak (associated with
Disneyland  [ https://blogs.cdc.gov/publichealthmatters/2015/12/year-in-review-measles-linked-todisneyland/], Europe [2017; https://ecdc.europa.eu/en/publications-data/measles-notification-rate-june-2016-
may-2017 ]), igniting a parallel debate on mandatory vaccinations and leading to comments made by the former
President of the United States, Barrack Obama (his comment: “I understand that there are families that, in some
cases, are concerned about the effect of vaccinations. The science is, you know, pretty indisputable.”) and
former US Secretary of State, Hillary Clinton (her now famous tweet: “The science is clear: The earth is round,
the sky is blue, and #vaccineswork. Let’s protect all our kids. #GrandmothersKnowBest) about vaccines.
Several schools now considering mandatory vaccination as part of acceptance into these publically-funded
However, is there a point where health promotion strategies and policies regarding vaccine programs
push the boundaries of ethics? For example, do you feel that Alberta Health pamphlet adequately informs
parents of the transmission risks associated with Hepatitis B (i.e., needle-stick injuries in childhood playgrounds
vs. sexual intercourse)? Based on the known routes of transmission, is the information presented in such a way
that parents can make informed choices regarding immunization for their children? Alternatively, do you feel
the information in the pamphlet misdirects public perception about the true risks of disease transmission (i.e.,
what is the Hep B prevalence of playground-associated needle stick injuries in children)? If so, how could you
improve the messaging. Would you make this a mandatory vaccination program? How does this decision fit
within your public health philosophy as a normativist (i.e., how would you respect the value-based decisions of
parents choosing not to vaccinate) or a naturalist (i.e., over-ride personal choices to meet immunization targets)?
Are personal values more important in our society than protecting public health [normativist vs naturalist])?
Rationalize this in terms of understanding that if vaccine programs aren’t successful, these may represent
evolutionary public health disasters waiting to happen (as mentioned by Dr. Andrew Read)?