4.9.2 Case Description You are the chief public health officer in a province of Spain.

4.9.2 Case Description You are the chief public health officer in a province of Spain. One day, a pediatrician tells you about a 13-year-old who is suspected to have measles. The child and his family attended a wedding the week before. Within 10 days, six more people who also attended the wedding were diagnosed with measles and nine secondary cases are confirmed. Of the secondary cases, seven were thought to have been exposed at school and two were in the hospital emergency ward. All cases occurred in a historic quarter of the city with a large degree of cultural, economic, religious, ethnic, and social diversity. This multicultural identity diverges from the relative homogeneity of the rest of the city. The public primary school of the historic quarter is now the focal point of the outbreak. There are 216 students enrolled in the school. You order two initial public health measures outlined in the regional health ministry’s Alert Protocol for Measles: (1) that a letter be sent to parents asking them to bring their child’s vaccination booklet to the school, and (2) that a meeting be held with the parents to have health professionals inform them about the disease and the immunization process. As a result of the letter, the parents of 137 children take the vaccine booklet to the school, which shows a low degree of measles vaccine coverage (60 %). Those children not immunized are then vaccinated with their parents’ consent. However, the parents of 79 children fail to bring the vaccine booklet to the school. In the parent meeting, some of the parents express their support for the antivaccination movement. They express sentiments such as “the disease is a natural process, so we prefer to organize measles parties;” “risk of measles is very low, but vaccines are toxic poisons;” “a lot of hidden complications of vaccines exist, for example, autism;” and “Big Pharma and politicians are looking out for profits, not for the welfare of our kids.” They also allege, “vaccination is not obligatory in Spain, and we have a right to educate our children in accordance with our values.” These remarks generated a heated dispute between parents for and against vaccination. The majority of parents seem misinformed about the risks and benefits of vaccination and do not even know the immunization status of their own children. The next day, the measles outbreak at the school comes to the attention of the local and national media. Alarmist messages and negative stories about anti-vaccination groups grab headlines. There are stories that seem to blame the outbreak on the cultural diversity of the historic quarter. You worry that the negative media reports may stigmatize the people living in this quarter or, even more worrisome; blame specific religious or ethnic groups. Therefore, you consider adopting additional public health measures such as maximizing surveillance in the city, controlling emergency rooms to decrease (or eliminate) transmission, and vaccinating health professionals and children under 6 months. You also consider having unvaccinated children stay home, but health authorities reject the idea, alleging it would violate the right to education. Little by little, a number of parents consent to having their children vaccinated, or the children are stricken and become immune. Nevertheless, new cases linked to the school continue to occur. In the regional health ministry, attention is turned to the possibility of requiring vaccination via a court order, citing a fundamental law that enables such exceptional actions in public health emergencies. Finally, a request is put to the judge to authorize the enforced vaccination of 35 children. He does and you inform the parents. Two nurses, accompanied by a police officer, visit the houses one by one. The majority of the parents give consent to the vaccination. Ten days later, only nine children remain unvaccinated as a result of the refusal of their parents. You inform the judge that the number is so low that the situation of special risk generated has now been overcome. You suspend compulsory vaccinations. Since the first case was diagnosed, 10 months have elapsed. A total of 308 cases have been confirmed, 96 in minors younger than 1 year old. And 71 patients required hospitalization (23 %), including five adults.

4.9.3 Discussion

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Questions 1.What are the values, ethical principles, and rights that come into conflict in this case? If it is not possible to respect all of them, how should they be prioritized?

2.Is the decision to allow unvaccinated children to attend the school justified?

3.Think of a solution that adequately balances the freedom of choice of parents who are against vaccination with the protection of the health of a community where vaccination is not compulsory.

4.Was there sufficient epidemiological risk to justify the court order? Were there other possible solutions? Once the judicial measure had been adopted, why was it not pursued to its conclusion? Does the argument to suspend administering vaccines provide sufficient grounds for this decision?

5.Once the outbreak has subsided, what measures should be introduced to avoid further outbreaks? If the vaccination rate in the country later falls and new out- breaks occur, should the government consider mandatory vaccination?