Table of Con­tents | Arti­cle doi: 10.17742/IMAGE.IN.11.2.9 | PDF

Overview of Key Legal, Political, and Social Challenges Facing Global Vaccination Efforts

Nico­la Sahar, Olivia Lee, 
Steven J. Hoff­man, Lath­i­ka Sritharan

Despite the proven safe­ty and effec­tive­ness of vac­cines, they are not uti­lized as wide­ly as they should be. This arti­cle pro­vides a high-lev­el overview of five key chal­lenges affect­ing the glob­al vac­cine uptake. First, avail­abil­i­ty is affect­ed by the research costs and coun­ter­feit vac­cines. Sec­ond, acces­si­bil­i­ty is affect­ed by dis­tri­b­u­tion not being pro­por­tion­ate to need, and by poor infra­struc­ture. Third, afford­abil­i­ty is affect­ed by intel­lec­tu­al prop­er­ty pro­tec­tions and costs of man­u­fac­tur­ing and dis­tri­b­u­tion. Fourth, appro­pri­ate­ness is affect­ed by the way vac­cine effec­tive­ness varies and presents risks for immuno­com­pro­mised pop­u­la­tions. Fifth, accept­abil­i­ty is affect­ed by con­tro­ver­sies regard­ing risks and cul­tur­al objections.

Mal­gré l’innocuité et l’efficacité prou­vées des vac­cins, ils ne sont pas util­isés aus­si large­ment qu’ils le devraient. Cet arti­cle four­nit un aperçu de haut niveau de cinq défis clés affec­tant l’adoption mon­di­ale de vac­cins. Pre­mière­ment, la disponi­bil­ité est affec­tée par les coûts de recherche et les vac­cins con­tre­faits. Deux­ième­ment, l’accessibilité est affec­tée par une dis­tri­b­u­tion non pro­por­tion­née aux besoins et par une infra­struc­ture médiocre. Troisième­ment, l’abordabilité est affec­tée par les pro­tec­tions de la pro­priété intel­lectuelle et les coûts de fab­ri­ca­tion et de dis­tri­b­u­tion. Qua­trième­ment, la per­ti­nence est affec­tée par la façon dont l’efficacité du vac­cin varie et présente des risques pour les pop­u­la­tions immun­odéprimées. Cinquième­ment, l’acceptabilité est affec­tée par les con­tro­ver­s­es con­cer­nant les risques et les objec­tions culturelles.


Hailed as one of the great­est pub­lic health achieve­ments of the 20th cen­tu­ry (Cen­ters for Dis­ease Con­trol and Pre­ven­tion, Ten Great Pub­lic Health Achieve­ments), child­hood vac­ci­na­tions have pre­vent­ed more than 100 mil­lion cas­es of seri­ous dis­ease from 1924 to 2012 (Gostin). Despite the proven safe­ty and effec­tive­ness of vac­cines, they are not uti­lized as wide­ly as they should be. Most recent­ly, uptake con­cerns have gar­nered renewed media inter­est in response to the 2019 measles out­breaks in the Unit­ed States—764 indi­vid­ual cas­es report­ed in 23 states from Jan­u­ary 1 to May 3, 2019 (Cen­ters for Dis­ease Con­trol and Pre­ven­tion, Measles Cas­es and Out­breaks). This is the great­est num­ber of measles cas­es report­ed in the US since the elim­i­na­tion of the virus in 2000 (Cen­ters for Dis­ease Con­trol and Pre­ven­tion, Measles Cas­es and Out­breaks).

There are numer­ous legal, polit­i­cal, and social fac­tors that con­tribute to the lim­it­ed uptake of vac­ci­na­tions world­wide. This arti­cle pro­vides a high-lev­el overview of key chal­lenges fac­ing glob­al vac­ci­na­tion uptake, uti­liz­ing the “5A Frame­work” of (1) Avail­abil­i­ty, (2) Acces­si­bil­i­ty, (3) Afford­abil­i­ty, (4) Appro­pri­ate­ness, and (5) Accept­abil­i­ty to sys­tem­at­i­cal­ly orga­nize the issues (Jack­son). Avail­abil­i­ty is affect­ed by the cost­li­ness of research and coun­ter­feit vac­cines. Acces­si­bil­i­ty is affect­ed by dis­tri­b­u­tion not being pro­por­tion­ate to need and poor infra­struc­ture in many areas of the world. Afford­abil­i­ty is affect­ed by inter­na­tion­al intel­lec­tu­al prop­er­ty pro­tec­tions and costs of man­u­fac­tur­ing and dis­tri­b­u­tion. Appro­pri­ate­ness is affect­ed by the way vac­cine effec­tive­ness varies and presents risks for immuno­com­pro­mised pop­u­la­tions. Final­ly, accept­abil­i­ty is affect­ed by con­tro­ver­sies regard­ing risks and ben­e­fits and cul­tur­al objections.


Avail­abil­i­ty ques­tions the exis­tence of vac­cines in an acces­si­ble loca­tion and inad­e­quate sup­ply (Jack­son). Vac­cine avail­abil­i­ty is influ­enced by vac­cine devel­op­ment (i.e., fund­ing for cer­tain dis­eases and clin­i­cal chal­lenges in research) and by vac­cine dis­tri­b­u­tion (i.e., man­age­ment of health sys­tems, mon­i­tor­ing, and super­vi­sion). Both vac­cine devel­op­ment and pro­duc­tion have sig­nif­i­cant­ly increased since the ear­ly 2000s. Major chal­lenges to vac­cine avail­abil­i­ty include bar­ri­ers to devel­op­ing cost-effec­tive vac­cines, such as immuno­log­i­cal com­pli­ca­tions, mar­ket fac­tors, and high research costs.

Vac­cines rep­re­sent one of the fastest grow­ing sec­tors of indus­try, hav­ing almost tripled since 2000, and were val­ued at over US$24 bil­lion in glob­al rev­enue in 2013 (Kad­dar). This trend will most like­ly con­tin­ue, as the glob­al mar­ket for vac­cines is pro­ject­ed to reach US$100 bil­lion by 2025 (Kad­dar). Most of this expan­sion is due to the devel­op­ment of new­er, more cost­ly vac­cines, account­ing for more than half of the total val­ue of vac­cine sales world­wide (Mau­rice and Dav­ey). Fur­ther­more, demand for exist­ing vac­cines has grown in response to well-fund­ed glob­al ini­tia­tives push­ing to erad­i­cate polio and reduce the bur­den of measles and tetanus (Mau­rice and Dav­ey). Final­ly, the avail­abil­i­ty of vac­cines can dif­fer between high- and low- or mid­dle-income coun­tries both in terms of the com­bi­na­tion of vac­cines licensed and vac­cine types (Smith et al.).

Despite growth in the glob­al vac­cine mar­ket, many chal­lenges to pro­duc­ing cost-effec­tive vac­cines remain. For exam­ple, a vari­ety of immuno­log­i­cal com­pli­ca­tions have caused con­sid­er­able bar­ri­ers to the vac­cine devel­op­ment process. Among them are a defi­cien­cy in the avail­abil­i­ty of the anti­bod­ies that con­fer pro­tec­tion against spe­cif­ic infec­tions, sig­nif­i­cant immuno­log­i­cal dif­fer­ences between ani­mal test mod­els and humans, and the pos­si­bil­i­ty of less respon­sive immune sys­tems in the real world (Oys­ton and Robin­son). Vac­cines against virus­es with high muta­tion rates and mul­ti­ple vari­ants, such as the human immun­od­e­fi­cien­cy virus (HIV), may not be effec­tive in destroy­ing the microbe as resis­tant viral vari­ants rapid­ly evolve (Zhou et al.). These immuno­log­i­cal com­pli­ca­tions can dis­cour­age research and devel­op­ment endeavours.

Vac­cine research and devel­op­ment has also proven to be extreme­ly cost­ly, esti­mat­ed at about US$1-2 bil­lion per vac­cine (Wat­son and de Goër). This high cost is most­ly due to the high fail­ure rate, as only 1 in 5,000-10,000 vac­cine for­mu­la­tions will receive approval from gov­ern­ment reg­u­la­to­ry agen­cies like the US Food and Drug Admin­is­tra­tion and Health Cana­da (Oys­ton and Robin­son; Light et al.). While the high fail­ure rate itself acts as a bar­ri­er to research and devel­op­ment, addi­tion­al mar­ket fac­tors deep­en costs. Phar­ma­ceu­ti­cal com­pa­nies, for instance, have lit­tle eco­nom­ic incen­tive to devel­op vac­cines for com­mon infec­tions faced by poor­er pop­u­la­tions in devel­op­ing coun­tries, espe­cial­ly for trop­i­cal dis­eases such as hook­worm infec­tions and Cha­gas dis­ease (Oys­ton and Robin­son). This is because most med­ical research and devel­op­ment is incen­tivized by patents, which typ­i­cal­ly give the patent-hold­er a 20-year gov­ern­ment-enforced monop­oly on the sale of result­ing prod­ucts that allows them to charge high prices, recoup their research invest­ments, and earn prof­it before oth­er vac­cine pro­duc­ers enter that mar­ket. Even costs asso­ci­at­ed with the pro­duc­tion of gener­ic vac­cines are marked­ly dif­fer­ent from those of the com­pa­ra­ble mar­ket of gener­ic med­i­cines, as clin­i­cal test­ing must be repeat­ed before the pro­duc­tion of gener­ic vac­cines, but not med­i­cines (Rid­ley et al.). The impact of cost on vac­cine avail­abil­i­ty can be demon­strat­ed by a 2016 study from the Unit­ed States, which found that low­er vac­cine prices were asso­ci­at­ed with high­er prob­a­bil­i­ties of vac­cine short­ages (Rid­ley et al.). Avail­abil­i­ty and afford­abil­i­ty are both chal­lenged by the fact that there has been an over­all decrease in the num­ber of vac­cine com­pa­nies invest­ing in research and devel­op­ment, from 14 in the 1990s to 4 in 2016 (Wat­son and de Goër).

If a vac­cine man­u­fac­tur­er is will­ing to under­take the costs asso­ci­at­ed with vac­cine pro­duc­tion, there remain oth­er avail­abil­i­ty con­cerns, such as the time between dis­cov­ery and dis­tri­b­u­tion, and the need for region-spe­cif­ic research. Pfiz­er, one of the largest bio­phar­ma­ceu­ti­cal com­pa­nies, report­ed that each new vac­cine gen­er­al­ly requires its own exclu­sive man­u­fac­tur­ing site, which can take rough­ly 5 years to build, with an added 2 years before dis­tri­b­u­tion (Rid­ley et al.). Research tar­get­ed to devel­op­ing coun­tries is need­ed, not just for vac­cines that are only required in devel­op­ing coun­tries, but also for vac­cines already researched and imple­ment­ed in devel­oped coun­tries, as clin­i­cal effi­ca­cy data from devel­oped coun­tries is like­ly not rep­re­sen­ta­tive of results in devel­op­ing coun­tries. Research has shown that the triva­lent polio vac­cine has a per-dose effi­ca­cy of over 50% in Europe and North Amer­i­ca, but only 21% in India (Ser­azin et al.). These needs in devel­op­ing coun­tries are fur­ther chal­lenged by lim­it­ed med­ical research and reg­u­la­to­ry capac­i­ty, which make it dif­fi­cult to con­duct rig­or­ous and eth­i­cal clin­i­cal tri­als (Oys­ton and Robinson).

Those who are per­haps seek­ing to take advan­tage of these avail­abil­i­ty con­cerns have cre­at­ed a grow­ing prob­lem: the pro­lif­er­a­tion of coun­ter­feit vac­cines, par­tic­u­lar­ly in devel­op­ing coun­tries. This includes instances where unau­tho­rized ver­sions of a vac­cine are sold ille­gal­ly by non-patent-hold­ers (there­by under­cut­ting legit­i­mate com­pa­nies’ incen­tives for devel­op­ing vac­cines) and, more impor­tant­ly, where fake or sub­stan­dard prod­ucts are passed-off as gen­uine, there­by deny­ing immuno­log­i­cal pro­tec­tion, poten­tial­ly caus­ing harm, and in turn decreas­ing the accept­abil­i­ty of vac­cines over­all. Coun­ter­feit vac­cines can cre­ate dan­ger­ous glob­al health crises ; a prime instance was the 1995 Niger­ian menin­gi­tis epi­dem­ic, where 50,000 peo­ple were admin­is­tered fake vac­cines, result­ing in 2,500 deaths (World Health Orga­ni­za­tion, Gen­er­al Infor­ma­tion on Coun­ter­feit Med­i­cines).


While vac­cine avail­abil­i­ty is about the exis­tence of a vac­cine for a pop­u­la­tion, acces­si­bil­i­ty refers to the ease and con­ve­nience of obtain­ing and using it (Jack­son). Vac­cine dis­tri­b­u­tion sys­tems vary from coun­try to coun­try, espe­cial­ly between devel­oped and devel­op­ing coun­tries. Dis­par­i­ties in acces­si­bil­i­ty are also wide­spread between coun­tries, both with respect to the types of vac­cines used as well as with how and by whom they are deliv­ered. Addi­tion­al impor­tant chal­lenges include pho­bias of con­ven­tion­al injec­tions, as well as the chal­lenge of cold-stor­ing vac­cines in remote areas of many devel­op­ing coun­tries (also known as the cold chain).1 Vac­cines are also not always effec­tive­ly dis­trib­uted to those who are in most need. The World Health Orga­ni­za­tion (WHO) has pro­ject­ed improv­ing glob­al vac­cine dis­tri­b­u­tion could save an addi­tion­al 1.5 mil­lion lives each year (World Health Orga­ni­za­tion, World Immu­niza­tion Week 2016).

Gov­ern­ment involve­ment with vac­cine dis­tri­b­u­tion is dif­fer­ent in each coun­try. In most devel­oped coun­tries, dis­tri­b­u­tion of a spe­cif­ic vac­cine for­mu­la­tion depends on licen­sure of the vac­cine, which can either occur direct­ly in the coun­try of use giv­en suf­fi­cient­ly devel­oped reg­u­la­to­ry author­i­ties, or in the man­u­fac­tur­ing coun­try, in which case the coun­try of use will review and approve it (Smith et al.). For devel­op­ing coun­tries that may not have ade­quate licensing/regulatory author­i­ties, vac­cines are often obtained by Unit­ed Nations agen­cies and their part­ners, such as Gavi, the Vac­cine Alliance (Gavi), who ensure that the vac­cine meets WHO pre-qual­i­fi­ca­tion stan­dards (Smith et al.). How­ev­er, there remains inad­e­quate access to essen­tial vac­cines (Oys­ton and Robin­son). The WHO esti­mates that near­ly 1 in every 5 chil­dren world­wide lacks a rou­tine immu­niza­tion that could pre­vent dis­eases such as diph­the­ria, per­tus­sis, and tetanus. Fur­ther­more, while 160 vac­cine intro­duc­tions have been made in 99 coun­tries between 2010 and 2015, glob­al vac­ci­na­tion cov­er­age has only increased by a mere 1% (Strate­gic Advi­so­ry Group of Experts on Immu­niza­tion). Man­u­fac­tur­ing capac­i­ties insuf­fi­cient to sat­is­fy glob­al vac­cine demand and the absence of spe­cif­ic pur­chas­ing and sup­ply agree­ments for new vac­cines leave nov­el prod­ucts inac­ces­si­ble to many peo­ple in devel­op­ing coun­tries for at least anoth­er 20 to 30 years (Smith et al.).

Bar­ri­ers to vac­cine acces­si­bil­i­ty in devel­op­ing coun­tries include rel­a­tive­ly weak­er health sys­tems, over­loaded infra­struc­ture, lim­it­ed logis­ti­cal sup­port sys­tems, and insuf­fi­cient under­stand­ing about the impor­tance of vac­cines (Mau­rice and Dav­ey). In devel­oped coun­tries, vac­cines are usu­al­ly acces­si­ble via pri­ma­ry-care physi­cians, phar­ma­cists, or com­mu­ni­ty health clin­ics who either order them direct­ly from a dis­trib­u­tor or are sup­plied by a local pub­lic health agency (Smith et al.; Hat­tingh et al.). Devel­oped coun­tries are usu­al­ly bet­ter able to pro­vide vac­cine access to at-risk groups through social insur­ance and/or sub­si­diza­tion, result­ing in more com­pre­hen­sive vac­ci­na­tion cov­er­age. Fre­quent­ly, there are rou­tine vac­cine pro­grams for both chil­dren and ado­les­cents (Cen­ters for Dis­ease Con­trol and Pre­ven­tion, Nation­al Cen­ter for Health Sta­tis­tics). Unlike most med­i­cines, it is par­tic­u­lar­ly impor­tant to achieve high vac­cine uptake rates for the pur­pose of herd immu­ni­ty, the phe­nom­e­non by which non-immune per­sons are award­ed some form of pro­tec­tion from a dis­ease as a result of a large pro­por­tion of the pop­u­la­tion being vac­ci­nat­ed against that dis­ease (Fine et al.). This effect indi­rect­ly con­trols and mit­i­gates dis­ease out­breaks, as vac­ci­nat­ed indi­vid­u­als will act as bar­ri­ers to the spread of dis­ease, result­ing in the grad­ual elim­i­na­tion of the dis­ease from a pop­u­la­tion after a high uptake thresh­old is achieved (Mer­rill; Somerville et al.). Achiev­ing herd immu­ni­ty is of par­tic­u­lar impor­tance for the many peo­ple who can­not get vac­ci­nat­ed them­selves, includ­ing those who are preg­nant, immun­od­e­fi­cient, or aller­gic to vac­cines, and for those who lack access to vac­cines for rea­sons such as pover­ty (Cen­ters for Dis­ease Con­trol and Pre­ven­tion, Who Should Not Get Vac­ci­nat­ed).

While there are chal­lenges to vac­cine acces­si­bil­i­ty at the sys­tems lev­el, there are also deliv­ery chal­lenges at the indi­vid­ual lev­el. The pain and anx­i­ety com­mon­ly asso­ci­at­ed with nee­dle injec­tions act as sig­nif­i­cant uptake bar­ri­ers, as they are often a source of dis­tress for chil­dren, their par­ents, and even those admin­is­ter­ing the injec­tions (Tad­dio et al.). If not addressed ear­ly on, stud­ies have shown that this pain can lead to much pre-pro­ce­dur­al anx­i­ety (Tad­dio et al.). In fact, up to 25% of adults report a fear of needles—most of which devel­op in childhood—and 10% of the pop­u­la­tion avoids nee­dles and nee­dle-relat­ed pro­ce­dures as a result (Tad­dio et al.). Nov­el vac­cine deliv­ery sys­tems are being devel­oped in the hopes of bol­ster­ing vac­cine dis­tri­b­u­tion and uptake. Poten­tial deliv­ery sub­sti­tutes that can address these issues include aerosol for­mu­la­tions that are sprayed through the nose (such as those already avail­able for the influen­za vac­cine), as well as adhe­sive patch­es, drops under the tongue, and oral pills, all of which are being inves­ti­gat­ed (Mau­rice and Dav­ey). These alter­na­tives show addi­tion­al promise as they are like­ly to not require spe­cial­ized cold-chain stor­age, in turn increas­ing their cost effec­tive­ness (Birk­hoff et al.).

Para­dox­i­cal­ly, a sig­nif­i­cant prob­lem fac­ing vac­cine dis­tri­b­u­tion in devel­oped coun­tries is over­stock in sup­ply. Over­stock­ing of vac­cines increas­es cold-stor­age costs and gen­er­ates waste, both of which are fur­ther exac­er­bat­ed when vol­ume flow increas­es, as it has since 2000 (World Health Orga­ni­za­tion, “Vac­ci­na­tion”). The cold chain is a method of stor­ing and trans­port­ing vac­cines where­by vac­cines are kept between 2° and 8°C, which is cost­ly and logis­ti­cal­ly chal­leng­ing to main­tain, par­tic­u­lar­ly in dif­fi­cult to access areas (World Health Orga­ni­za­tion, “Con­trolled Tem­per­a­ture Chain”). While new vac­cines are often in sin­gle- or two-dose pack­ages, they also cost more per dosage and require up to five times more cold-chain space per dose when com­pared with the tra­di­tion­al Expand­ed Pro­gram on Immu­niza­tion (EPI) vac­cines that come in 10 and 20-dose vials (World Health Orga­ni­za­tion, “Vac­ci­na­tion”). Some coun­tries are forced to post­pone the intro­duc­tion of cer­tain vac­cines because they do not have the capac­i­ty to store them (World Health Orga­ni­za­tion, “Vac­ci­na­tion”). Alter­na­tives to cold-chain stor­age are being inves­ti­gat­ed to address these con­cerns, such as the con­trolled tem­per­a­ture chain method, which allows spec­i­fied vac­cines to be trans­port­ed at tem­per­a­tures up to 40°C for a num­ber of days (World Health Orga­ni­za­tion, “Con­trolled Tem­per­a­ture Chain”). Research study­ing the imple­men­ta­tion of this tech­nique for the menin­gi­tis A vac­cine has shown low vac­cine waste as well as high sat­is­fac­tion and desire for increased imple­men­ta­tion among vac­ci­na­tors (Zipursky et al.). While promis­ing, the con­trolled tem­per­a­ture chain remains in the ear­ly stages of imple­men­ta­tion, and research is required to deter­mine its via­bil­i­ty and ben­e­fits for dif­fer­ent vaccines.

Giv­en the large dis­par­i­ties in access between devel­oped and devel­op­ing coun­tries, as well as the lack of mar­ket incen­tives for com­pa­nies to devel­op vac­cines against dis­eases that pri­mar­i­ly affect mar­gin­al­ized pop­u­la­tions, it is impor­tant to con­sid­er whether glob­al soci­ety is effec­tive­ly dis­trib­ut­ing lim­it­ed vac­cine resources to those most in need. Var­i­ous the­o­ret­i­cal, eth­i­cal, and math­e­mat­i­cal mod­els have been cre­at­ed with the goal of eth­i­cal­ly dis­trib­ut­ing vac­cines for spe­cif­ic dis­eases under the egal­i­tar­i­an prin­ci­ple of equi­ty, which pri­or­i­tizes vac­ci­na­tion of the most vul­ner­a­ble sec­tors of the pop­u­la­tion (e.g., chil­dren, home­less, low socioe­co­nom­ic sta­tus) (Buccieri and Gaetz; Mood­ley et al.). How­ev­er, these equi­table mod­els often con­flict with more util­i­tar­i­an approach­es, where­in the goal is to max­i­mize the total ben­e­fit to soci­ety, such as vac­ci­nat­ing easy-to-reach pop­u­la­tions and front­line health care work­ers (Mood­ley et al.). These ques­tions are par­tic­u­lar­ly impor­tant for nov­el vac­cine dis­tri­b­u­tion dur­ing pan­demics when lim­it­ed sup­ply and high need force dif­fi­cult choices.


Afford­abil­i­ty in the con­text of vac­cines pri­mar­i­ly involves ques­tions of cost—both to investors and fund­ing agen­cies, who decide which dis­eases war­rant the most research, as well as to con­sumers, who decide how much they are will­ing to pay for pro­tec­tion against dis­eases and who often depend on third-par­ty cov­er­age to pay for the life-sav­ing tech­nol­o­gy. Yet the word “afford­able” has dif­fer­ent mean­ings in dif­fer­ent set­tings and has often been used as a con­ve­nient defence for inac­tion when it comes to fund­ing the dis­tri­b­u­tion of vac­cines in devel­op­ing coun­tries (Hey­mann). While some mid­dle-income coun­tries have accept­ed the chal­lenge of pro­vid­ing med­i­cines from their own nation­al gov­ern­ment bud­gets, others—some of which have the resources to pur­chase these medications—have point­ed to vac­cine unaf­ford­abil­i­ty as a defence and jus­ti­fi­ca­tion to wait for finan­cial assis­tance from inter­na­tion­al devel­op­ment agen­cies (Hey­mann). As such, defin­ing “afford­abil­i­ty” in the con­text of vac­cine dis­tri­b­u­tion is chal­leng­ing, as no sim­ple solu­tion can be found in dif­fer­ent pric­ing for dif­fer­ent mar­kets in response to a flex­i­ble appli­ca­tion of intel­lec­tu­al prop­er­ty and trade agree­ments (Hey­mann). As with most vac­cine-relat­ed chal­lenges, the issue is both nuanced and com­plex, and has many nor­ma­tive and eth­i­cal con­sid­er­a­tions, such as deter­min­ing who should be pay­ing for vac­cines. Regard­less, prof­its unfor­tu­nate­ly depend on con­sumers’ abil­i­ty to pay high prices, which is not pos­si­ble for dis­eases that pri­mar­i­ly affect the world’s poor­est people.

At ground lev­el, the cost of vac­ci­na­tion per ful­ly immu­nized child varies accord­ing to the deliv­ery strat­e­gy, the cost of key inputs such as per­son­nel and trans­porta­tion, and the scale of the pro­gram (Levin et al.). In addi­tion, cost vari­a­tion reflects sev­er­al con­tex­tu­al fac­tors, such as nation­al income, pub­lic health infra­struc­ture, health sys­tem poli­cies, and the resources avail­able (Levin et al.). For devel­op­ing coun­tries that qual­i­fy for sup­port from Gavi, the Vac­cine Alliance, bulk pur­chas­ing of vac­cines allows for long-term agree­ments that ensures a smooth and con­stant flow of high-qual­i­ty vac­cines and nec­es­sary sup­plies at afford­able prices (Smith et al.). Anoth­er notable orga­ni­za­tion is UNICEF, which pro­vid­ed 2.7 bil­lion vac­cine dos­es in 2014 for US$1.5 bil­lion, cor­re­spond­ing to a 97% aver­age price reduc­tion (Hill et al.).

The human papil­lo­mavirus (HPV) vac­cine serves as a good exam­ple for how costs and asso­ci­at­ed chal­lenges vary across coun­tries and income economies. This vac­cine, impor­tant for pre­vent­ing cer­vi­cal can­cer and rec­om­mend­ed by WHO, costs more than US$100 per dose in the Unit­ed States, or US$300 for the three-dose series (Levin et al.). In devel­op­ing coun­tries, Gavi has been able to obtain sig­nif­i­cant dis­counts from major man­u­fac­tures, with one dis­trib­u­tor even offer­ing the quadri­va­lent HPV vac­cine at US$5 per dose for use in eli­gi­ble coun­tries (Levin et al.; But­ler). Fur­ther­more, Gavi’s pledg­ing con­fer­ence in Jan­u­ary 2015 raised over US$4.3 bil­lion, which, when accom­pa­nied with the low­er pric­ing, promis­es progress in achiev­ing more afford­able vac­cines to peo­ple in devel­op­ing coun­tries (Nguyen et al.). Nonethe­less, coun­tries that apply for vac­cine sup­port through Gavi have to com­mit to a co-financ­ing pol­i­cy, where­by each country’s income deter­mines the pro­por­tion of co-financ­ing the coun­try must com­mit (Gavi, the Vac­cine Alliance). While this stip­u­la­tion may be chal­leng­ing for some coun­tries to sat­is­fy, the pol­i­cy remains ben­e­fi­cial, as it requires the coun­try to play an active role in financ­ing its vac­ci­na­tion pro­grams, thus improv­ing sus­tain­abil­i­ty as coun­tries’ economies grow and gov­ern­ments tran­si­tion out of Gavi fund­ing (Gavi, the Vac­cine Alliance). Despite being inel­i­gi­ble for Gavi’s dis­count­ed prices, low- and mid­dle-income coun­tries in Latin Amer­i­ca can still pur­chase the HPV vac­cine for only US$10 to $15 per dose through the Revolv­ing Fund of the Pan Amer­i­can Health Orga­ni­za­tion (Levin et al.). For such vac­cines, there has been sig­nif­i­cant progress towards achiev­ing afford­abil­i­ty in devel­op­ing coun­tries; how­ev­er, there is much work to be done to ensure that this is the case for all peo­ple and for all need­ed vaccines.

In rela­tion to afford­abil­i­ty, there have been sev­er­al inter­na­tion­al intel­lec­tu­al prop­er­ty (IP) pol­i­cy chal­lenges asso­ci­at­ed with devel­op­ing and man­u­fac­tur­ing vac­cines and their impact on pub­lic health. The Indone­sian government’s stance on the avian flu well illus­trates the intri­ca­cies and chal­lenges involved in cre­at­ing IP that has the poten­tial for glob­al, and not mere­ly state, ben­e­fit. In the mid-2000s, Indone­sia was most affect­ed by the evolv­ing avian influen­za virus and was asked by the inter­na­tion­al com­mu­ni­ty to sup­ply sam­ples of the avian influen­za virus for free to uni­ver­si­ty researchers and phar­ma­ceu­ti­cal com­pa­nies as per WHO’s rec­om­men­da­tion. The Indone­sian gov­ern­ment, how­ev­er, was reluc­tant to freely sup­ply these sam­ples in fear that they would be used to devel­op patent­ed vac­cines tar­get­ed for use in devel­oped coun­tries, and in the process, become unaf­ford­able to devel­op­ing coun­tries such as itself (Ger­hard­sen).

Afford­abil­i­ty is far less of a con­cern in devel­oped coun­tries, where gov­ern­ments often sub­si­dize or com­plete­ly pay for cer­tain vac­ci­na­tions, espe­cial­ly those aimed at chil­dren. The Unit­ed States, for exam­ple, has passed the Vac­ci­na­tion Assis­tance Act, which aims to sup­port child­hood vac­ci­na­tion, and intro­duced the Vac­cines for Chil­dren Pro­gram, which pro­vides addi­tion­al sup­port (Hin­man et al.). How­ev­er, most adult vac­cines are obtained through the pri­vate sec­tor. More com­pre­hen­sive­ly, the provin­cial gov­ern­ments of Cana­da each offer pub­licly fund­ed immu­niza­tion sched­ules for chil­dren, as well as vac­ci­na­tions against spe­cif­ic dis­eases for adults, although the sched­ules and qual­i­fy­ing dis­eases vary across provinces (Pub­lic Health Agency of Cana­da, “Immu­niza­tion Schedules”).


The ques­tion of appro­pri­ate­ness con­cerns the cor­rect­ness of the ser­vice pro­vid­ed for the pre­ven­tion of a dis­ease (Jack­son). In terms of vac­cines, screen­ing and assess­ment tools can be uti­lized to ensure that the tar­get pop­u­la­tion for a par­tic­u­lar vac­cine will result in the most effec­tive pro­tec­tion and the most cost-effi­cient use of resources. Deter­min­ing the appro­pri­ate­ness of vac­cines as a pre­ven­tive mea­sure involves an analy­sis of ben­e­fits, costs, and poten­tial harms. Addi­tion­al chal­lenges also arise when con­sid­er­ing vac­ci­nat­ing chil­dren ver­sus vac­ci­nat­ing adolescents.

To deter­mine the appro­pri­ate­ness of vac­cines, we observe that vac­cines con­sti­tute the inter­ven­tion per­formed, and that the intend­ed out­come is of pre­vent­ing a spe­cif­ic dis­ease. In these terms, it seems that vac­cines are indeed effec­tive at pre­vent­ing their tar­get dis­eases: esti­mates sug­gest that child­hood vac­ci­na­tions pre­vent­ed more than 100 mil­lion cas­es of seri­ous dis­ease between 1924 and 2012 (Gostin). On an indi­vid­ual lev­el, vir­tu­al­ly all per­sons who receive a vac­cine will react to the for­mu­la­tion and devel­op anti­bod­ies, result­ing in long-term, and most like­ly life­long, vac­cine-induced immu­ni­ty to the tar­get dis­ease (Atkin­son et al.). On a pop­u­la­tion lev­el, immu­niza­tion sched­ules are cru­cial for con­tain­ing and con­trol­ling poten­tial infec­tious dis­eases, pre­vent­ing them from esca­lat­ing into seri­ous pub­lic health risks. In this capac­i­ty, they are high­ly cost-effec­tive, as the dis­eases they pre­vent pose sig­nif­i­cant costs to indi­vid­u­als, health sys­tems, and soci­ety in the form of increased health care bur­dens (e.g., vis­its to health care providers, hos­pi­tal­iza­tion), pre­ma­ture deaths, and over­all loss of pro­duc­tiv­i­ty due to sick­ness (Pub­lic Health Agency of Cana­da, Ben­e­fits of Immu­niza­tion). It is thus much more ben­e­fi­cial, both to the indi­vid­ual and for soci­ety as a whole, to imple­ment an immu­niza­tion sched­ule than to treat cas­es of the dis­ease that may have arisen with­out such a pro­gram (Pub­lic Health Agency of Cana­da, Ben­e­fits of Immu­niza­tion). How­ev­er, it is impor­tant to note that not all research shows equal­ly strong sup­port. A sys­tem­at­ic review ana­lyz­ing the effi­ca­cy of influen­za vac­cines found them to be only mod­er­ate­ly effec­tive, with the high­est rel­a­tive effi­ca­cy not­ed in chil­dren (Oster­holm et al.).

Vac­cines are gen­er­al­ly regard­ed as high­ly appro­pri­ate with respect to safe­ty, but they may result in minor side effects, which can include reac­tions at the injec­tion site, mild fevers, headaches, and mus­cle and joint pain (Cen­ters for Dis­ease Con­trol and Pre­ven­tion, Vac­cines). Vac­ci­na­tions may also pose addi­tion­al risks to cer­tain vul­ner­a­ble pop­u­la­tions, such as the immune-com­pro­mised, who may not be able to mount a suf­fi­cient immune response to the vac­ci­na­tion (Cen­ters for Dis­ease Con­trol and Pre­ven­tion, Who Should Not Get Vac­ci­nat­ed; Shep­herd and Graben­stein). In the immune-com­pro­mised, a live vac­cine (i.e., one that includes a live atten­u­at­ed virus) could cause com­pli­ca­tions, includ­ing infec­tions. This can be avoid­ed, for the most part, by admin­is­ter­ing inac­tive DNA or com­po­nent vac­cines to these select pop­u­la­tions, although the effec­tive­ness of these alter­na­tives varies (Shep­herd and Graben­stein; World Health Orga­ni­za­tion, “WHO | DNA Vac­cines”; Cen­ters for Dis­ease Con­trol and Pre­ven­tion, Who Should Not Get Vac­ci­nat­ed). For the major­i­ty of the pop­u­la­tion, it is clear that the ben­e­fits of vac­cines far out­weigh the risk.

Safe­ty, effec­tive­ness, and age at immu­niza­tion are all con­sid­ered when devel­op­ing vac­cine sched­ules and guide­lines for appro­pri­ate­ness (Smith). While most vac­cines are offered dur­ing ear­ly child­hood, rates of vac­cine deliv­ery to ado­les­cents have recent­ly been mea­sured as sub­stan­tial­ly low­er than for young people—below the Healthy Peo­ple 2010 goals (Ford et al.). Vac­cines that tar­get young peo­ple between 9 and 25 years of age are met with unique con­sid­er­a­tions, includ­ing vari­a­tion in par­ent-child rela­tion­ships, cog­ni­tive devel­op­ment, auton­o­my, time spent in school, legal sta­tus, and the like­li­hood of hav­ing insur­ance (Ford et al.). As a result, tra­di­tion­al strate­gies to increase vac­ci­na­tion rates among young chil­dren may not effec­tive­ly reach all ado­les­cent groups (Ford et al.). These con­sid­er­a­tions are impor­tant to keep in mind when deter­min­ing the appro­pri­ate­ness of immu­niza­tion sched­ules to spe­cif­ic tar­get groups, be it young chil­dren or young adults.

Per­cep­tions of appro­pri­ate­ness have a large role in inform­ing accept­abil­i­ty. Some have spec­u­lat­ed that one of the bar­ri­ers to the sup­port of vac­cines is that they are admin­is­tered to healthy indi­vid­u­als and pro­vide dis­ease pro­tec­tion in the long term with no imme­di­ate or tan­gi­ble ben­e­fit to recip­i­ents. Addi­tion­al­ly, thanks to the effec­tive­ness of vac­cines, cit­i­zens have the priv­i­lege of for­get­ting the phys­i­o­log­i­cal, eco­nom­ic, and social impacts of the dis­eases that vac­cines pre­vent (Tay­lor, Miller, Far­ring­ton, et al.). Low­er rates of vac­cine-pre­ventable dis­ease in devel­oped coun­tries may offer a false sense that vac­cines are not an appro­pri­ate or nec­es­sary mea­sure. The nature of vac­cines as a pre­ven­ta­tive mea­sure that works in healthy indi­vid­u­als is an inher­ent ben­e­fit; unfor­tu­nate­ly, mis­per­cep­tions of this qual­i­ty set vac­cines up for mis­trust and decreased support.


Accept­abil­i­ty is the degree to which vac­cines are con­gru­ent with cul­tur­al beliefs, val­ues, and world­view, from the per­spec­tive of the recip­i­ent (Jack­son). This can also be applied to rel­e­vant stake­hold­ers includ­ing the pub­lic, the gov­ern­ment, and asso­ci­at­ed orga­ni­za­tions. For the most part, gov­ern­ments of both devel­op­ing and devel­oped coun­tries have rec­og­nized the impor­tance and val­ue of vac­ci­na­tions, and have sought to devel­op and sus­tain nation­al immu­niza­tion pro­grams. Asso­ci­at­ed orga­ni­za­tions, includ­ing the WHO and Gavi, have sim­i­lar­ly sup­port­ed vac­ci­na­tions and have sought to advo­cate and sup­ply them to devel­op­ing coun­tries. The pub­lic, how­ev­er, has been divid­ed. In devel­oped coun­tries, vac­cines have been a hot­ly debat­ed top­ic in the pub­lic sphere, with both pro- and anti-vac­ci­na­tion advo­cates express­ing polar­ized views on the ben­e­fits and risks of vac­ci­na­tions.2 In addi­tion to con­cerns about health risks, vac­cine accept­abil­i­ty con­cerns can arise from reli­gious, philo­soph­i­cal, or per­son­al beliefs, as well as from mis­in­for­ma­tion about risks and dis­eases, mis­trust of health­care pro­fes­sion­als and gov­ern­ment, and fear of the phar­ma­ceu­ti­cal indus­try (Offit and Moser; Sid­diqui et al.).

Vac­cine use and relat­ed accept­abil­i­ty con­cerns are shaped by social, eco­nom­ic, polit­i­cal, and reli­gious con­texts, which dif­fer between devel­op­ing and devel­oped coun­tries. To under­stand accept­abil­i­ty, it is impor­tant to con­sid­er how vac­cines play dif­fer­ent roles in dif­fer­ent coun­tries. In many devel­oped coun­tries, vac­cines are one part of a com­pre­hen­sive pre­ven­ta­tive strat­e­gy to com­bat dis­ease, serv­ing to com­ple­ment reg­u­lar check-ups, screen­ing for at-risk pop­u­la­tions, and med­ical care when dis­ease occurs. This presents the pos­si­bil­i­ty of alter­na­tive vac­cine sched­ules and con­tributes to low­er per­ceived risks of vac­cine-pre­ventable dis­eases. Devel­oped coun­tries can take advan­tage of exist­ing infra­struc­ture, such as the inter­net and oth­er media, to orga­nize and pub­li­cize oppo­si­tion to vac­cines. So, while the exis­tence of accept­abil­i­ty con­cerns is com­mon to devel­op­ing and devel­oped coun­tries, the anti-vac­cine move­ment is pri­mar­i­ly asso­ci­at­ed with devel­oped coun­tries. In con­trast, devel­op­ing coun­tries often have rel­a­tive­ly weak­er health sys­tems in which vac­cines rep­re­sent an impor­tant mea­sure against infec­tious dis­ease, and some­times the only avail­able mea­sure. Reduced health care acces­si­bil­i­ty and infra­struc­ture make the accept­abil­i­ty con­cerns of devel­oped coun­tries less preva­lent. Instead, pre­vail­ing cul­tur­al and soci­etal issues raise unique accept­abil­i­ty chal­lenges in devel­op­ing coun­tries. Briefly, these addi­tion­al obsta­cles can stem from pover­ty, illit­er­a­cy, reli­gious influ­ence, taboos, and super­sti­tion (Pang). These con­tex­tu­al fac­tors can cause health illit­er­a­cy and mis­in­for­ma­tion, leav­ing peo­ple both unaware of the impor­tance of vac­cines and afraid of their use. Pre­vail­ing false per­cep­tions include the belief that vac­cines are cura­tive, not pre­ven­ta­tive, which leads to the con­clu­sion that healthy chil­dren do not need to be vac­ci­nat­ed (Pang). Reli­gious influ­ence and tra­di­tion can also pro­pel fears, as some may believe that dis­ease is delib­er­ate­ly cre­at­ed by the super­nat­ur­al, lead­ing to the idea that immu­niza­tion against dis­ease will anger these enti­ties. Oth­ers fear that vac­ci­nat­ing chil­dren will lead them to become too depen­dent on West­ern med­i­cine and reduce their fer­til­i­ty as they grow old­er (Pang). Sim­i­lar to the anti-vac­cine move­ment in devel­oped coun­tries, many par­ents in devel­op­ing coun­tries remain insuf­fi­cient­ly edu­cat­ed about vac­cines and hold var­i­ous con­cerns about their safe­ty, both of which can unfor­tu­nate­ly affect their deci­sion to vac­ci­nate (Wake­field et al.). His­tor­i­cal­ly, as with the exam­ple of the British col­o­niza­tion of India, some opposed vac­cine pro­grams as an intru­sion of the colo­nial state (Streefland). Par­ents in both devel­op­ing and devel­oped coun­tries, either out of mis­trust of the gov­ern­ment offi­cials, health work­ers, or phar­ma­ceu­ti­cal coun­tries, may also per­ceive mass vac­ci­na­tions as unsafe under the belief that they have been delib­er­ate­ly con­t­a­m­i­nat­ed. These issues per­tain­ing to trust­ing the sup­pli­er or provider can affect uptake, as it has been found that Amer­i­can anti-vac­ci­na­tion advo­cates often do not trust their gov­ern­ment (Grab­meier).

In light of a series of vac­cine con­tro­ver­sies in the main­stream media, it may be the case that the anti-vac­cine move­ment is gain­ing pop­u­lar­i­ty. The move­ment was large­ly fuelled by the retract­ed Lancet study that report­ed a cor­re­la­tion between the measles, mumps, rubel­la (MMR) vac­cine and autism, based on fraud­u­lent data (Wake­field et al.). Despite the large ensu­ing body of evi­dence fail­ing to find any such cor­re­la­tion, claims of cau­sa­tion per­sist­ed where none were war­rant­ed, and anti-vac­cine hys­te­ria spread rapid­ly in part due to media sen­sa­tion­al­iza­tion of the orig­i­nal Lancet study (Tay­lor, Miller, Far­ring­ton, et al.; Tay­lor, Miller, Lingam, et al.; Hon­da et al.; Insti­tute of Med­i­cine (US) Immu­niza­tion Safe­ty Review Com­mit­tee; Mad­sen et al.). Sev­er­al oth­er sim­i­lar hypothe­ses have since been per­pet­u­at­ed by “anti-vaxxers,” with one of the more noto­ri­ous assert­ing a cor­re­la­tion between the mer­cury-based thimeros­al com­po­nent of vac­cines and autism (Kennedy). The move­ment has also gar­nered wide­spread atten­tion, sup­port, and advo­ca­cy from celebri­ties and pub­lic fig­ures with the abil­i­ty to sig­nif­i­cant­ly influ­ence pub­lic atti­tudes and opin­ions against vac­cines (Kennedy). Cur­rent­ly, the anti-vac­ci­na­tion move­ment is pre­dom­i­nant­ly inter­net-based, with web­sites that pro­mote a gen­er­al dis­trust of sci­ence and that rely on strong emo­tion­al appeals for their argu­ments (Ernst and Jacobs). These sites even include “how-to” guides for obtain­ing vac­ci­na­tion exemp­tions eas­i­ly, con­tribut­ing to the increase of philo­soph­i­cal and per­son­al belief exemp­tion uti­liza­tion in the Unit­ed States (Ernst and Jacobs). These web­sites seem to have tan­gi­ble effects on the deci­sion-mak­ing of par­ents who choose not to vac­ci­nate their chil­dren. For exam­ple, it was found that par­ents of chil­dren who received exemp­tions for school vac­ci­na­tions were more like­ly than par­ents of vac­ci­nat­ed chil­dren to obtain infor­ma­tion from the inter­net and have providers who offer com­ple­men­tary or alter­na­tive health care (Omer et al.).

Of course, the anti-vac­cine movement’s activ­i­ties pose sig­nif­i­cant pub­lic health risks. Vac­cines work best through herd immu­ni­ty,3 which occurs when the vast major­i­ty of the pop­u­la­tion is vac­ci­nat­ed against a cer­tain dis­ease (Nation­al Insti­tute of Aller­gy and Infec­tious Dis­eases). Inter­est­ing­ly, some anti-vac­cine pro­mot­ers acknowl­edge the valid­i­ty of herd immu­ni­ty as pro­tect­ing com­mu­ni­ties from vac­cine-pre­ventable dis­eases, but instead of strength­en­ing and sup­port­ing this phe­nom­e­non by vac­ci­nat­ing, they sug­gest tak­ing advan­tage of herd immunity’s ben­e­fits while simul­ta­ne­ous­ly under­min­ing its effec­tive­ness (Offit and Moser). That is, some anti-vac­cine pro­mot­ers say that you don’t need to risk vac­cine-relat­ed adverse events when you can prof­it from herd immu­ni­ty to pro­tect you from dis­ease instead (Offit and Moser). This and oth­er men­tal­i­ties in the anti-vac­cine move­ment are flawed because when vac­ci­na­tion rates decrease—as we have seen occur­ring with the rise of the anti-vac­ci­na­tion movement—the like­li­hood of an out­break increas­es, and this can have dev­as­tat­ing effects for entire communities.

The unsub­stan­ti­at­ed per­cep­tions and beliefs held by the anti-vac­cine move­ment about the dan­gers of vac­ci­na­tions have con­tributed to vac­cine hesitancy—the reluc­tance or refusal to vac­ci­nate when vac­ci­na­tions are avail­able (World Health Orga­ni­za­tion, Ten Threats to Glob­al Health). Those who are vac­cine hes­i­tant may not refuse vac­cines entire­ly; indi­vid­u­als in this group may accept the role of vac­cines but expe­ri­ence a reluc­tance to embrace the estab­lished approach to vac­ci­na­tion. They may agree to receive some vac­cines, while refus­ing oth­ers; delay the rec­om­mend­ed vac­ci­na­tion sched­ule; or feel unsure about vac­ci­nat­ing them­selves and their chil­dren (Lar­son et al.). Aside from the influ­ence of the anti-vac­ci­na­tion move­ment, there are many addi­tion­al fac­tors that may con­tribute to vac­cine hes­i­tan­cy, which include unfa­mil­iar­i­ty with vac­cine-pre­ventable dis­eases, the lack of trust in pub­lic health agen­cies and cor­po­ra­tions, fear of adverse health out­comes, and the com­pul­so­ry nature of vac­cines (Salmon et al.).

Instead of refus­ing vac­cines, some vac­cine-hes­i­tant par­ents choose to delay vac­ci­na­tion of their chil­dren or fol­low a nov­el vac­cine sched­ule pro­posed by indi­vid­ual physi­cians, as opposed to those devel­oped by expert com­mit­tees (Omer et al.). Most nov­el sched­ules involve admin­is­ter­ing vac­cines over a longer peri­od than that rec­om­mend­ed by the Advi­so­ry Com­mit­tee on Immu­niza­tion Prac­tices, the Amer­i­can Acad­e­my of Pedi­atrics, the Cen­ters for Dis­ease Con­trol and Pre­ven­tion, the Amer­i­can Acad­e­my of Fam­i­ly Physi­cians, and sim­i­lar orga­ni­za­tions in oth­er coun­tries (Omer et al.; Offit and Moser). Some alter­na­tive sched­ules rec­om­mend delay­ing some vac­cines and avoid­ing oth­ers alto­geth­er (Dempsey et al.). Although the indi­vid­ual con­se­quences of delayed vac­ci­na­tion sched­ules have not been stud­ied in detail, it is well known that under-immu­niza­tion presents seri­ous risks of vac­cine-pre­ventable dis­eases (Dempsey et al.). Vac­cine delays are of par­tic­u­lar con­cern as the risk of vac­cine-pre­ventable dis­eases are not con­stant through­out child­hood, with younger chil­dren at an increased risk for ill­ness and death relat­ed to infec­tious dis­ease (Song). Nov­el vac­cine sched­ules that rec­om­mend admin­is­ter­ing vac­ci­na­tions over a longer peri­od of time may also exac­er­bate health inequal­i­ties, as par­ents of high­er socioe­co­nom­ic sta­tus may be more capa­ble of mak­ing the extra med­ical vis­its required by the alter­na­tive sched­ule (Omer et al.). Fur­ther­more, the dis­taste that is some­times seen among anti-vac­cine advo­cates against sci­ence gen­er­ates skep­ti­cism and dis­ap­proval of health care pro­fes­sion­als and the sci­en­tif­ic process in gen­er­al, which itself can be harmful.

Beyond the anti-vac­cine move­ment and those who are vac­cine-hes­i­tant, there are more sub­stan­tive objec­tions to vac­cines; these include objec­tions on reli­gious, cul­tur­al, eth­i­cal, and moral grounds. Although all 50 Amer­i­can states rec­om­mend that chil­dren be vac­ci­nat­ed before attend­ing school, var­i­ous exemp­tions are also allowed (Song). Reli­gious exemp­tions are per­mit­ted in all states except for Mis­sis­sip­pi and West Vir­ginia, and rough­ly 20 states also grant exemp­tions for philo­soph­i­cal rea­sons (Song). Refusal can also be based on eth­i­cal objec­tions to state laws that man­date vac­ci­na­tions, on the grounds that they vio­late per­son­al auton­o­my (Sadaf et al.).

The eth­i­cal dilem­ma for indi­vid­u­als who choose not to vac­ci­nate them­selves or their chil­dren is whether an individual’s right to per­son­al auton­o­my over­rides the unre­al­ized health ben­e­fits to the entire vul­ner­a­ble pop­u­la­tion (Amin et al.). While this eth­i­cal dilem­ma is dif­fi­cult to resolve, one can begin by ana­lyz­ing the sce­nario through the util­i­tar­i­an prin­ci­ple of “pro­duc­ing the max­i­mal bal­ance of ben­e­fits over harm or oth­er costs” (Amin et al.). Giv­en that we can view unvac­ci­nat­ed per­sons as a “harm” to the com­mu­ni­ty at large (Dieke­ma and Mar­cuse), any indi­vid­u­als fail­ing to vac­ci­nate them­selves and/or their chil­dren put every­one else at risk. In oth­er words, the total harm that an indi­vid­ual fail­ing to vac­ci­nate will create—whether via ini­ti­at­ing or prop­a­gat­ing an out­break or increas­ing bur­dens on the health care system—will like­ly be greater than the ben­e­fit that the indi­vid­ual will receive by retain­ing auton­o­my. This line of rea­son­ing presents strong eth­i­cal grounds for enact­ing and enforc­ing manda­to­ry vac­ci­na­tion laws. Of course, the same eth­i­cal dilem­ma could be con­sid­ered under oth­er principles—like lib­er­tar­i­an ones—leading to pos­si­bly dif­fer­ent conclusions.

As a result of the var­i­ous objec­tions pre­vi­ous­ly men­tioned, non-med­ical exemp­tions (NME), such as reli­gious and philo­soph­i­cal beliefs, have recent­ly been on the rise in many Amer­i­can states (Olive et al.). The most com­mon rea­son giv­en by par­ents seek­ing exemp­tions from school vac­ci­na­tion require­ments is a con­cern that the vac­cine will cause their chil­dren harm (Dieke­ma). Stud­ies have shown that geo­graph­i­cal NME clus­ters are asso­ci­at­ed with high socioe­co­nom­ic sta­tus, low­er pop­u­la­tion den­si­ty, low­er aver­age fam­i­ly size, low­er per­cent­age of racial or eth­nic minori­ties, and high­er medi­an house­hold income (Atwell et al.). The process for acquir­ing an NME varies in rigour by state, with some requir­ing as lit­tle as a sig­na­ture on a pre-print­ed form (Gostin). State exemp­tion process­es sig­nif­i­cant­ly influ­ence vac­ci­na­tion rates and inci­dences of vac­cine-pre­ventable ill­ness. In fact, in 2012, researchers report­ed NME rates 2.3 times high­er in states with easy admin­is­tra­tive poli­cies as com­pared to those with more dif­fi­cult poli­cies (Gostin).

Ulti­mate­ly, many fac­tors fil­ter into and rein­force soci­etal and cul­tur­al atti­tudes towards vac­ci­na­tions, there­by affect­ing accept­abil­i­ty. It seems that a lack of effec­tive com­mu­ni­ca­tion between health care providers and par­ents regard­ing the types of vac­cines admin­is­tered, the impor­tance of vac­cines, and the pos­si­ble adverse effects are facil­i­tat­ing many of these mis­con­cep­tions (Asi­imwe et al.).


This overview has out­lined some of the key legal, polit­i­cal, and social issues relat­ed to vac­ci­na­tion efforts world­wide. Although vac­ci­na­tion uptake has increased sub­stan­tial­ly over the last hun­dred years, it is clear that there is still more work to be done. Glob­al vac­ci­na­tion uptake not only requires the sup­port of many stake­hold­ers, it needs fund­ing, research and devel­op­ment, stor­age facil­i­ties, part­ner­ships, prop­er deliv­ery sys­tems, and pub­lic sup­port. Har­ness­ing the promise of vac­cines depends on their avail­abil­i­ty, acces­si­bil­i­ty, afford­abil­i­ty, appro­pri­ate­ness, and accept­abil­i­ty. With­out these require­ments, the goal of uni­ver­sal vac­ci­na­tion will be dif­fi­cult to achieve.

Works Cited

Amin, Alvin Nel­son El, et al. “Eth­i­cal Issues Con­cern­ing Vac­ci­na­tion Require­ments.” Pub­lic Health Reviews, vol. 34, no. 1, June 2012. doi:10.1007/BF03391666.

Asi­imwe, D., et al. “Vac­cine Safe­ty Per­cep­tions among Par­ents in Devel­op­ing Coun­tries and Influ­ence of Adverse Events Fol­low­ing Immu­niza­tion (AEFI) on Their Deci­sions to Vac­ci­nate Chil­dren.” World Health Orga­ni­za­tion, 2006.

Atkin­son, William, et al. Epi­demi­ol­o­gy and Pre­ven­tion of Vac­cine-Pre­ventable Dis­eases. Pub­lic Health Foun­da­tion, 2011.

Atwell, Jes­si­ca E., et al. “Non­med­ical Vac­cine Exemp­tions and Per­tus­sis in Cal­i­for­nia, 2010.” Pedi­atrics, vol. 132, no. 4, 2013, pp. 624–30.

Birk­hoff, M., et al. “Advan­tages of Intranasal Vac­ci­na­tion and Con­sid­er­a­tions on Device Selec­tion.” Indi­an Jour­nal of Phar­ma­ceu­ti­cal Sci­ences, vol. 71, no. 6, 2009, pp. 729–31.

Buccieri, K., and S. Gaetz. “Eth­i­cal Vac­cine Dis­tri­b­u­tion Plan­ning for Pan­dem­ic Influen­za: Pri­or­i­tiz­ing Home­less and Hard-to-Reach Pop­u­la­tions.” Pub­lic Health Ethics, vol. 6, no. 2, July 2013, pp. 185–96. doi:10.1093/phe/pht005.

But­ler, Declan. “Vac­cine Cam­paign to Tar­get Dead­ly Child­hood Diar­rhoea.” Nature News, vol. 477, no. 7366, Sept. 2011, pp. 519–519. www​.nature​.com, doi:10.1038/477519a.

Cen­ters for Dis­ease Con­trol and Pre­ven­tion. Measles Cas­es and Out­breaks. 29 May 2019, www​.cdc​.gov/​m​e​a​s​l​e​s​/​c​a​s​e​s​-​o​u​t​b​r​e​a​k​s​.​h​tml.

—. Nation­al Cen­ter for Health Sta­tis­tics: Immu­niza­tion. 17 Mar. 2017, www​.cdc​.gov/​n​c​h​s​/​f​a​s​t​a​t​s​/​i​m​m​u​n​i​z​e​.​htm.

—. Ten Great Pub­lic Health Achievements—United States, 1900-1999, vol. 48, no. 12, 2 Apr. 1999, pp. 241–43, www​.cdc​.gov/​m​m​w​r​/​p​r​e​v​i​e​w​/​m​m​w​r​h​t​m​l​/​0​0​0​5​6​7​9​6​.​htm.

—. Vac­cines & Immu­niza­tions. 12 July 2017, www​.cdc​.gov/​v​a​c​c​i​n​e​s​/​v​a​c​-​g​e​n​/​s​i​d​e​-​e​f​f​e​c​t​s​.​htm.

—. Who Should Not Get Vac­ci­nat­ed | CDC. 10 Apr. 2019, www​.cdc​.gov/​v​a​c​c​i​n​e​s​/​v​p​d​/​s​h​o​u​l​d​-​n​o​t​-​v​a​c​c​.​h​tml.

Dempsey, A.F., et al. “Alter­na­tive Vac­ci­na­tion Sched­ule Pref­er­ences among Par­ents of Young Chil­dren.” PEDIATRICS, vol. 128, no. 5, Nov. 2011, pp. 848–56. doi:10.1542/peds.2011-0400.

Dieke­ma, Dou­glas S. “Per­son­al Belief Exemp­tions from School Vac­ci­na­tion Require­ments.” Annu­al Review of Pub­lic Health, vol. 35, no. 1, 2014, pp. 275–92. Annu­al Reviews, doi:10.1146/annurev-publhealth-032013-182452.

Dieke­ma, Dou­glas, and E. Mar­cuse. “Eth­i­cal Issues in the Vac­ci­na­tion of Chil­dren.” Pub­lic Health Ethics: The­o­ry, Pol­i­cy, and Prac­tice, edit­ed by Ronald Bay­er et al., Oxford Uni­ver­si­ty Press, USA, 2007, pp. 279–88.

Ernst, Kacey, and Eliz­a­beth T. Jacobs. “Impli­ca­tions of Philo­soph­i­cal and Per­son­al Belief Exemp­tions on Re-Emer­gence of Vac­cine-Pre­ventable Dis­ease: The Role of Spa­tial Clus­ter­ing in Under-Vac­ci­na­tion.” Human Vac­cines & Immunother­a­peu­tics, vol. 8, no. 6, June 2012, pp. 838–41. doi:10.4161/hv.19743.

Fine, Paul, et al. “‘Herd Immu­ni­ty’: A Rough Guide.” Clin­i­cal Infec­tious Dis­eases, vol. 52, no. 7, Apr. 2011, pp. 911–16. cid​.oxford​jour​nals​.org, doi:10.1093/cid/cir007.

Ford, Car­ol A., et al. “Increas­ing Ado­les­cent Vac­ci­na­tion: Bar­ri­ers and Strate­gies in the Con­text of Pol­i­cy, Legal, and Finan­cial Issues.” Jour­nal of Ado­les­cent Health, vol. 44, no. 6, 2009, pp. 568–74.

Gavi, the Vac­cine Alliance. Gavi Strat­e­gy. 2019, www​.gavi​.org/​a​b​o​u​t​/​s​t​r​a​t​e​gy/.

Ger­hard­sen, T. “Indone­sian Avian Flu Stance Reveals Poten­tial Weak­ness in Glob­al Sys­tem.” Intel­lec­tu­al Prop­er­ty Watch, 8 Mar. 2007, www​.ip​-watch​.org/​2​0​0​7​/​0​3​/​0​8​/​i​n​d​o​n​e​s​i​a​n​-​a​v​i​a​n​-​f​l​u​-​s​t​a​n​c​e​-​r​e​v​e​a​l​s​-​p​o​t​e​n​t​i​a​l​-​w​e​a​k​n​e​s​s​-​i​n​-​g​l​o​b​a​l​-​s​y​s​t​em/.

Gostin, L. “Law, Ethics, and Pub­lic Health in the Vac­ci­na­tion Debates: Pol­i­tics of the Measles Out­break.” JAMA, vol. 313, no. 11, Mar. 2015, pp. 1099–100. Sil­ver­chair, doi:10.1001/jama.2015.1518.

Grab­meier, J. “Con­fi­dence in Gov­ern­ment Linked to Will­ing­ness to Vac­ci­nate.” Con­fi­dence in Gov­ern­ment Linked to Will­ing­ness to Vac­ci­nate, 2 Feb. 2015, https://​news​.osu​.edu/​c​o​n​f​i​d​e​n​c​e​-​i​n​-​g​o​v​e​r​n​m​e​n​t​-​l​i​n​k​e​d​-​t​o​-​w​i​l​l​i​n​g​n​e​s​s​-​t​o​-​v​a​c​c​i​n​a​te/.

Hat­tingh, H. Laeti­tia, et al. “Eval­u­a­tion of the First Phar­ma­cist-Admin­is­tered Vac­ci­na­tions in West­ern Aus­tralia: A Mixed-Meth­ods Study.” BMJ Open, vol. 6, no. 9, Sept. 2016, p. e011948. doi:10.1136/bmjopen-2016-011948.

Hey­mann, D. L. “A Con­ve­nient Defense—Defining Afford­abil­i­ty.” To Save Human­i­ty: What Mat­ters Most for a Healthy Future, edit­ed by Julio Frenk and Steven Hoff­man, Oxford Uni­ver­si­ty Press, 2015, pp. 169–71.

Hill, Andrew B., et al. “Improv­ing Glob­al Vac­cine Acces­si­bil­i­ty.” Cur­rent Opin­ion in Biotech­nol­o­gy, vol. 42, Dec. 2016, pp. 67–73. doi:10.1016/j.copbio.2016.03.002.

Hin­man, Alan R., et al. “Financ­ing Immu­niza­tions in the Unit­ed States.” Clin­i­cal Infec­tious Dis­eases, vol. 38, no. 10, 2004, pp. 1440–46.

Hon­da, Hideo, et al. “No Effect of MMR With­draw­al on the Inci­dence of Autism: A Total Pop­u­la­tion Study.” Jour­nal of Child Psy­chol­o­gy and Psy­chi­a­try, vol. 46, no. 6, 2005, pp. 572–79.

Insti­tute of Med­i­cine (US) Immu­niza­tion Safe­ty Review Com­mit­tee. Immu­niza­tion Safe­ty Review: Measles-Mumps-Rubel­la Vac­cine and Autism. Edit­ed by Kath­leen Strat­ton et al., Nation­al Acad­e­mies Press (US), 2001. PubMed, www​.ncbi​.nlm​.nih​.gov/​b​o​o​k​s​/​N​B​K​2​2​3​3​76/.

Jack­son, V. “A Look at Dis­par­i­ties by Avail­abil­i­ty, Acces­si­bil­i­ty, Afford­abil­i­ty, Appro­pri­ate­ness, Accept­abil­i­ty.” Sci­ence Super­course, 18 Mar. 2010, http://​ssc​.bibalex​.org/​v​i​e​w​e​r​/​d​e​t​a​i​l​.​j​s​f​?​l​i​d​=​B​8​7​3​6​5​8​7​C​0​8​8​B​E​5​9​1​0​A​D​9​7​9​1​5​6​B​5​1​ADC.

Kad­dar, Miloud. Glob­al Vac­cine Mar­ket Fea­tures and Trends. WHO Meet­ing, Gene­va. http://​who​.int/​i​n​f​l​u​e​n​z​a​_​v​a​c​c​i​n​e​s​_​p​l​a​n​/​r​e​s​o​u​r​c​e​s​/​s​e​s​s​i​o​n​_​1​0​_​k​a​d​d​a​r​.​pdf.

Kennedy, Robert. “Attack on Moth­ers.” The Huff­in­g­ton Post, 19 June 2007, www​.huff​post​.com/​e​n​t​r​y​/​a​t​t​a​c​k​-​o​n​-​m​o​t​h​e​r​s​_​b​_​5​2​894.

Lar­son, Hei­di J., et al. “Under­stand­ing Vac­cine Hes­i­tan­cy around Vac­cines and Vac­ci­na­tion from a Glob­al Per­spec­tive: A Sys­tem­at­ic Review of Pub­lished Lit­er­a­ture, 2007–2012.” Vac­cine, vol. 32, no. 19, Apr. 2014, pp. 2150–59. Sci­enceDi­rect, doi:10.1016/j.vaccine.2014.01.081.

Levin, Car­ol E., et al. “Deliv­ery Cost of Human Papil­lo­mavirus Vac­ci­na­tion of Young Ado­les­cent Girls in Peru, Ugan­da and Viet Nam.” Bul­letin of the World Health Orga­ni­za­tion, vol. 91, no. 8, Aug. 2013, pp. 585–92. Cross­ref, doi:10.2471/BLT.12.113837.

Light, Don­ald W., et al. “Esti­mat­ed Research and Devel­op­ment Costs of Rotavirus Vac­cines.” Vac­cine, vol. 27, no. 47, Nov. 2009, pp. 6627–33. Sci­enceDi­rect, doi:10.1016/j.vaccine.2009.07.077.

Mad­sen, Kreesten Meldgaard, et al. “A Pop­u­la­tion-Based Study of Measles, Mumps, and Rubel­la Vac­ci­na­tion and Autism.” New Eng­land Jour­nal of Med­i­cine, vol. 347, no. 19, Nov. 2002, pp. 1477–82. doi:10.1056/NEJMoa021134.

Mau­rice, J. M., and Sheila Dav­ey. State of the World’s Vac­cines and Immu­niza­tion. 3rd ed., World Health Orga­ni­za­tion, 2009.

Mer­rill, Ray M. Intro­duc­tion to Epi­demi­ol­o­gy. Jones & Bartlett Pub­lish­ers, 2013.

Mood­ley, Key­man­thri, et al. “Eth­i­cal Con­sid­er­a­tions for Vac­ci­na­tion Pro­grammes in Acute Human­i­tar­i­an Emer­gen­cies.” Bul­letin of the World Health Orga­ni­za­tion, vol. 91, no. 4, Apr. 2013, pp. 290–97. doi:10.2471/BLT.12.113480.

Nation­al Insti­tute of Aller­gy and Infec­tious Dis­eases (NIAID). Com­mu­ni­ty Immu­ni­ty (“Herd Immu­ni­ty”) | Vac​cines​.Gov. 2015, www​.vac​cines​.gov/​b​a​s​i​c​s​/​p​r​o​t​e​c​t​i​on/.

Nguyen, A., et al. Work­ing towards Afford­able Pric­ing for HPV Vac­cines for Devel­op­ing Coun­tries: The Role of GAVI. 3, Har­vard Glob­al Equi­ty Ini­tia­tive, 2011.

Offit, P.A., and C.A. Moser. “The Prob­lem with Dr Bob’s Alter­na­tive Vac­cine Sched­ule.” PEDIATRICS, vol. 123, no. 1, Jan. 2009, pp. 164–69. doi:10.1542/peds.2008-2189.

Omer, Saad B., et al. “Vac­cine Refusal, Manda­to­ry Immu­niza­tion, and the Risks of Vac­cine-Pre­ventable Dis­eases.” New Eng­land Jour­nal of Med­i­cine, vol. 360, no. 19, 2009, pp. 1981–88.

Oster­holm, Michael T., et al. “Effi­ca­cy and Effec­tive­ness of Influen­za Vac­cines: A Sys­tem­at­ic Review and Meta-Analy­sis.” The Lancet Infec­tious Dis­eases, vol. 12, no. 1, 2012, pp. 36–44.

Oys­ton, Petra, and Karen Robin­son. “The Cur­rent Chal­lenges for Vac­cine Devel­op­ment.” Jour­nal of Med­ical Micro­bi­ol­o­gy, vol. 61, no. 7, July 2012, pp. 889–94. doi:10.1099/jmm.0.039180-0.

Pang, T. “Vac­ci­na­tion in Devel­op­ing Coun­tries: Prob­lems, Chal­lenges and Oppor­tu­ni­ties.” Glob­al Per­spec­tives in Health, vol. 2.

Pub­lic Health Agency of Cana­da. Ben­e­fits of Immunization—Part 1—General Guidelines—Canadian Immu­niza­tion Guide. 2015, www​.phac​-aspc​.gc​.ca/​p​u​b​l​i​c​a​t​/​c​i​g​-​g​c​i​/​p​0​1​-​0​2​-​e​n​g​.​php.

—. “Immu­niza­tion Schedules—Public Health Agency of Cana­da.” Pub­lic Health Agency of Cana­da, 2014, www​.phac​-aspc​.gc​.ca/​i​m​/​i​s​-​c​v​/​i​n​d​e​x​-​e​n​g​.​php.

Rid­ley, David B., et al. “No Shot: US Vac­cine Prices And Short­ages.” Health Affairs, vol. 35, no. 2, Feb. 2016, pp. 235–41. doi:10.1377/hlthaff.2015.0420.

Sadaf, Ali­na, et al. “A Sys­tem­at­ic Review of Inter­ven­tions for Reduc­ing Parental Vac­cine Refusal and Vac­cine Hes­i­tan­cy.” Vac­cine, vol. 31, no. 40, 2013, pp. 4293–304.

Salmon, Daniel A., et al. “Vac­cine Hes­i­tan­cy: Caus­es, Con­se­quences, and a Call to Action.” Vac­cine, vol. 33, Nov. 2015, pp. D66–71. doi:10.1016/j.vaccine.2015.09.035.

Ser­azin, Andrew C., et al. “Improv­ing the Per­for­mance of Enteric Vac­cines in the Devel­op­ing World.” Nature Immunol­o­gy, vol. 11, no. 9, Sept. 2010, pp. 769–73. doi:10.1038/ni0910-769.

Shep­herd, Janet E., and John D. Graben­stein. “Immu­niza­tions for High-Risk Pop­u­la­tions.” Jour­nal of the Amer­i­can Phar­ma­ceu­ti­cal Asso­ci­a­tion (1996), vol. 41, no. 6, Nov. 2001, pp. 839–49. doi:10.1016/S1086-5802(16)31332-8.

Sid­diqui, Mari­am, et al. “Epi­demi­ol­o­gy of Vac­cine Hes­i­tan­cy in the Unit­ed States.” Human Vac­cines & Immunother­a­peu­tics, vol. 9, no. 12, Dec. 2013, pp. 2643–48. doi:10.4161/hv.27243.

Smith, Jean Clare. “The Struc­ture, Role, and Pro­ce­dures of the U.S. Advi­so­ry Com­mit­tee on Immu­niza­tion Prac­tices (ACIP).” Vac­cine, vol. 28, Apr. 2010, pp. A68–75. doi:10.1016/j.vaccine.2010.02.037.

Smith, Jon, et al. “Vac­cine Pro­duc­tion, Dis­tri­b­u­tion, Access, and Uptake.” The Lancet, vol. 378, no. 9789, July 2011, pp. 428–38. doi:10.1016/S0140-6736(11)60478-9.

Somerville, Mar­garet, et al. Pub­lic Health and Epi­demi­ol­o­gy at a Glance: With Self-Test. Wiley-Black­well, 2012.

Song, Geo­boo. “Under­stand­ing Pub­lic Per­cep­tions of Ben­e­fits and Risks of Child­hood Vac­ci­na­tions in the Unit­ed States: Ben­e­fit-Risk Per­cep­tions of Child­hood Vac­ci­na­tions.” Risk Analy­sis, vol. 34, no. 3, Mar. 2014, pp. 541–55. doi:10.1111/risa.12114.

Strate­gic Advi­so­ry Group of Experts on Immu­niza­tion. 2016 Midterm Review of the Glob­al Vac­cine Action Plan. 2016, www​.who​.int/​i​m​m​u​n​i​z​a​t​i​o​n​/​s​a​g​e​/​m​e​e​t​i​n​g​s​/​2​0​1​6​/​o​c​t​o​b​e​r​/​1​_​D​r​a​f​t​_​G​V​A​P​_​A​s​s​e​s​s​m​e​n​t​_​r​e​p​o​r​t​_​2​0​1​6​_​f​o​r​_​Y​e​l​l​o​w​_​B​o​o​k​_​2​8​_​S​e​p​_​2​0​1​6​.​pdf.

Streefland, Pieter H. “Pub­lic Doubts about Vac­ci­na­tion Safe­ty and Resis­tance against Vac­ci­na­tion.” Health Pol­i­cy, vol. 55, no. 3, Mar. 2001, pp. 159–72. doi:10.1016/S0168-8510(00)00132-9.

Tad­dio, Anna, et al. “Reduc­ing the Pain of Child­hood Vac­ci­na­tion: An Evi­dence-Based Clin­i­cal Prac­tice Guide­line (Sum­ma­ry).” Cana­di­an Med­ical Asso­ci­a­tion Jour­nal, vol. 182, no. 18, Dec. 2010, pp. 1989–95. www​.cmaj​.ca, doi:10.1503/cmaj.092048.

Tay­lor, Brent, Eliz­a­beth Miller, CPad­dy Far­ring­ton, et al. “Autism and Measles, Mumps, and Rubel­la Vac­cine: No Epi­demi­o­log­i­cal Evi­dence for a Causal Asso­ci­a­tion.” The Lancet, vol. 353, no. 9169, 1999, pp. 2026–29.

Tay­lor, Brent, Eliz­a­beth Miller, Raghu Lingam, et al. “Measles, Mumps, and Rubel­la Vac­ci­na­tion and Bow­el Prob­lems or Devel­op­men­tal Regres­sion in Chil­dren with Autism: Pop­u­la­tion Study.” Bmj, vol. 324, no. 7334, 2002, pp. 393–96.

Wake­field, Aj, et al. “RETRACTED: Ileal-Lym­phoid-Nodu­lar Hyper­pla­sia, Non-Spe­cif­ic Col­i­tis, and Per­va­sive Devel­op­men­tal Dis­or­der in Chil­dren.” The Lancet, vol. 351, no. 9103, Feb. 1998, pp. 637–41. doi:10.1016/S0140-6736(97)11096-0.

Wat­son, Michael, and Eliot Faron de Goër. “Are Good Inten­tions Putting the Vac­ci­na­tion Ecosys­tem at Risk?” Human Vac­cines & Immunother­a­peu­tics, vol. 12, no. 9, Sept. 2016, pp. 2469–74. doi:10.1080/21645515.2016.1172162.

World Health Orga­ni­za­tion. “Con­trolled Tem­per­a­ture Chain (CTC).” WHO, 2018, www​.who​.int/​i​m​m​u​n​i​z​a​t​i​o​n​/​p​r​o​g​r​a​m​m​e​s​_​s​y​s​t​e​m​s​/​s​u​p​p​l​y​_​c​h​a​i​n​/​c​t​c​/​en/.

—. Gen­er­al Infor­ma­tion on Coun­ter­feit Med­i­cines. www​.who​.int/​m​e​d​i​c​i​n​e​s​/​s​e​r​v​i​c​e​s​/​c​o​u​n​t​e​r​f​e​i​t​/​o​v​e​r​v​i​e​w​/en. Accessed 5 Aug. 2015.

—. Ten Threats to Glob­al Health in 2019. 2019, www​.who​.int/​e​m​e​r​g​e​n​c​i​e​s​/​t​e​n​-​t​h​r​e​a​t​s​-​t​o​-​g​l​o​b​a​l​-​h​e​a​l​t​h​-​i​n​-​2​019.

—. “Vac­ci­na­tion: Rat­tling the Sup­ply Chain.” Bul­letin of the World Health Orga­ni­za­tion, vol. 89, no. 5, May 2011, pp. 324–25. doi:10.2471/BLT.11.030511.

—. “WHO | DNA Vac­cines.” DNA Vac­cines, www​.who​.int/​b​i​o​l​o​g​i​c​a​l​s​/​a​r​e​a​s​/​v​a​c​c​i​n​e​s​/​d​n​a​/​en/. Accessed 30 May 2019.

—. World Immu­niza­tion Week 2016: Immu­niza­tion Game-Chang­ers Should Be the Norm World­wide. 21 Apr. 2016, www​.who​.int/​n​e​w​s​-​r​o​o​m​/​d​e​t​a​i​l​/​2​1​-​0​4​-​2​0​1​6​-​w​o​r​l​d​-​i​m​m​u​n​i​z​a​t​i​o​n​-​w​e​e​k​-​2​0​1​6​-​i​m​m​u​n​i​z​a​t​i​o​n​-​g​a​m​e​-​c​h​a​n​g​e​r​s​-​s​h​o​u​l​d​-​b​e​-​t​h​e​-​n​o​r​m​-​w​o​r​l​d​w​ide.

Zhou, Tongqing, et al. “Struc­tur­al Def­i­n­i­tion of a Con­served Neu­tral­iza­tion Epi­tope on HIV-1 Gp120.” Nature, vol. 445, no. 7129, Feb. 2007, pp. 732–37. doi:10.1038/nature05580.

Zipursky, Simona, et al. “Ben­e­fits of Using Vac­cines out of the Cold Chain: Deliv­er­ing Menin­gi­tis A Vac­cine in a Con­trolled Tem­per­a­ture Chain dur­ing the Mass Immu­niza­tion Cam­paign in Benin.” Vac­cine, vol. 32, no. 13, Mar. 2014, pp. 1431–35. doi:10.1016/j.vaccine.2014.01.038.


  1. Editor’s note: Jes­per Alvaer’s work for the <Immune Nations> exhi­bi­tion address­es the chal­lenge of cold-stor­ing vac­cines in remote areas of devel­op­ing coun­tries. See Alvaer, “Upstream­ing the Cold Chain,” this vol­ume. Hou and Mahon also men­tion the cold chain in their dia­logue, “Reflect­ing on the Gen­e­sis and Real­iza­tion of Design for a Dis­se­mu­niza­tion Sta­tion,” in this vol­ume.

  2. Editor’s note: On this, see Kaisu Kos­ki and Johan Holst’s con­tri­bu­tion to this vol­ume. See also Kos­ki, K., and J. Holst, “Inter­dis­ci­pli­nary Dia­logue on Vac­cine Hes­i­tan­cy: Devel­op­ing Trust and Shift­ing Stereo­types,” Jour­nal of Clin­i­cal Research & Bioethics, vol. 9, no. 1, 2018, doi: 10.4172/2155-9627.1000320; and Kos­ki, K., and J. Holst, “Explor­ing Vac­cine Hes­i­tan­cy through an Artist-Sci­en­tist Col­lab­o­ra­tion: Visu­al­iz­ing Vac­cine-Crit­i­cal Par­ents’ Health Beliefs,” Jour­nal of Bioeth­i­cal Inquiry, vol. 14, no. 3, 2017, pp. 411–26, http://​rdcu​.be/​u​213.

  3. Editor’s note: Herd immu­ni­ty is addressed by Shad­ow­pox, one of the works in <Immune Nations> and dis­cussed by col­lab­o­ra­tors Ali­son Humphrey, Caitlin Fish­er, and Steven Hoff­man in “Shad­ow­pox: The Anti­body Politic – Thoughts and Reflec­tions,” in the Reports and Dia­logues sec­tion of this vol­ume.