Vaccines are by far one of the most controversial issues worldwide. The more evolved we become, the more protection we require from our environment. Nurses need to become educated on both the risk and benefits that they possess so that they can provide their patient with the best care. Nurses who are educated on the social, economical, political, ethical, and cultural aspect will be in a position to offer guidance and support to their patients. SOCIAL ASPECT GOES RIGHT HERE BRYANHealthcare is extremely expensive. According to the WHO, the World Health Organization, the total global expenditure on healthcare is 6.5 trillion dollars. Vaccines are considered to be the most cost effective intervention in the healthcare economic system. The purpose of vaccines is to avert and manage infectious diseases that cost the healthcare system billions of dollars (Mirelman, 2014).The expenditure of vaccines in certain countries is an international focus especially regarding childhood vaccinations. With support from the World Health Organization, the Global Alliance for Vaccines and Immunization (GAVI Alliance) was created. The purpose of this organization is to provide low cost vaccinations to certain developing countries known as BRICS (Brazil, Russia, India, China and South Africa). The GAVI has estimated that India, if children are vaccinated with the rotavirus vaccine, they will save 21 million US dollars. The pneumococcal and H. influenzae type b pneumonia vaccination will save an estimated 1.5 billion US dollars between 2011 to 2020, (Mirelman, 2014). Vaccines also contribute to a country’s economic status because it increases the health and productivity to the individuals within that community. The people instead of being sick and costing the country millions of dollars in medical costs, can work and increase their contributions in productivity. The WHO states that the value of a life-year saved in a low or middle-income country is estimated at 1.5 times a country’s GDP per capita.14 The GDP, the gross domestic product, is the most effective way to estimate a country’s economic value. (Mirelman, 2014.) The WHO used India and China as examples of how vaccines affect society. If all child deaths caused by the H. influenzae type b were prevented by the pneumococcal conjugate vaccine and rotavirus vaccines it’s estimated that it will save 157,000 lives. The WHO then estimated the annual economic and social gains by these lives saved being 14.9 US billion dollars, (Mirelman, 2014). Based on studies provided by the World Health Organization billions of dollars can be saved by the use of vaccinations especially in the emerging countries known as BRICS. Not only do the vaccines prevent high medical costs treating people infected with these diseases it also prevents deaths related to the diseases and allows the community to increase in productivity which improves their economic status.In 1855, Massachusetts passed the first US state law-mandating vaccinations for schoolchildren followed by New York in 1862, Connecticut in 1872, Indiana in 1881, and Arkansas in 1882. Then, on November 13, 1922, the constitutionality of mandatory vaccination of school children was challenged and upheld in the Zucht vs. King; the US Supreme Court declined to hear the case, stating that it was “within the police power of a state to decide on compulsory vaccination.” Currently, all fifty states require vaccinations for children entering public schools even though no mandatory federal vaccination laws exist. All fifty states issue medical exemptions, 48 states (excluding Mississippi and West Virginia) permit religious exemptions, and 19 states allow an exemption for philosophical reasons (Rabinowitz, 2016). Being a part of particular political party may or may not affect one’s stance about vaccinations. The research done and the evidence found are quite ambiguous. It has been suggested that the anti-vaccination movement in the U.S. is largely a liberal development. The assumption, therefore, is that liberals would be especially likely to perceive vaccines as harmful or unnecessary. Robert F. Kennedy, a former democratic senator of New York, stated that, “From PBS to the broadcast networks, the message of all-natural food and holistic, homeopathic medicine has been broadcast for decades, while traditional scientific medicine has been brought under suspicion as something being put over on us by the government and corporations.” Generally, but not precisely, the states that have granted the most exemptions from vaccinating kindergarteners are more likely to be liberal-leaning states, such as Oregon, Illinois, Vermont, Michigan, and Maine (Rabinowitz, 2016). However, a public opinion poll of 1,000 U.S. adults administered by YouGov and the Huffington Post, revealed that despite bickering among politicians, there are no clear stereotypes linking one political group to skepticism about vaccination. A 2009 Pew Survey suggested that 71% of Democrats and 71% of Republicans felt that childhood vaccinations should be required. Few, if any, studies of public opinion have delved more deeply into the specific contents of beliefs about vaccination and whether there are legitimate political differences. Additionally, despite disputes amongst national political leaders, many of them are in support of mandatory vaccinations whether or not they are democrats or republicans. Hillary Clinton, a democrat, declared her support of vaccines in February of this year. “The science is clear: The earth is round, the sky is blue, and vaccines work. Let’s protect all our kids,” she said.  The republican representative of Texas, Sarah Davis states, “Texas mandates childhood vaccines for enrollment in our schools because all children should have the opportunity to be educated in a safe and healthy environment. A twisted concept of parental personal liberty should not risk the health and safety of millions of schoolchildren…” Former democratic president Barack Obama stated, “science is pretty indisputable,” he said last year. “There is every reason to get vaccinated, there aren’t reasons to not (Rabinowitz, 2016).”In today’s society preventing an outbreak is always seen as the right thing to do. However, in order to slow, stop or even prevent outbreaks; society is faced with a number of ethical challenges. Three concerns related to preventative vaccinations include: the impact of vaccine research on public health, guaranteed access to safe and effective vaccine, and autonomy over mandates. According to the FDA, the standards for vaccine research is set highest over other products due to the fact that they are administered to healthy individuals. In regards to vaccine research, ethical dilemmas arise from the risk vs. benefit consideration. Currently, the world health organization has been conducting trials on HIV preventative vaccines, such trials however present ethical challenges that may place individuals at greater risk of acquiring HIV because they may believe the vaccine will be successful in preventing the infection, thus resulting in their tendency to fail to protect themselves by engaging in risky behaviors. Another ethical principle that has been neglected, especially when clinical trials of all sorts are conducted in developing countries, is the distribution of justice, according to research done by Macklin and Greenwood. According, to their research, the benefits should be distributed equality regardless of race, geographic, or socioeconomically background.  Ethical requirements states for there to be a distribution of justice, research must be conducted with fairness to all population of people. A convention has been established that vaccines that have been developed for use in developing countries, such as malaria vaccine, should be tested first on volunteers in the industrial country of the sponsor before being administered to volunteers in the population for which the vaccine is intended (Macklin, 2002). For health professional the approach to resolve ethical issues must resolve around the motto “first do no harm”. Benefiting others, preventing and removing harms and producing maximum benefits are critical to public health. Respect for autonomy and privacy may limit public health activities. The health education profession is grounded in fundamental ethics principles: respect for autonomy, promotion of social justice, active promotion of good, and avoidance of arm. Health educators have a responsibility to the public; they must support the rights of individuals to make informed decisions, as long as the decisions as no threat to the health of others. They must encourage social policies that support the best balance and benefits over harm. And they must act on issues that can adversely affect the health of individuals, families and communities.Should vaccines be mandated? Mandated are important tools for achieving high vaccination levels. However and ethical dilemma exist in the balancing of personal choice verses protecting the entire population. Ethical issues arise because some individuals disagree with mandates or have religious or philosophical beliefs that conflict with vaccination. Some people may have deep seated beliefs in deferring their individual freedoms for the benefits of society. Others may believe in the sanctity of individual freedom and personal choice. Some people have come to believe that vaccines can save children’s lives, that adverse reactions are rare, and that preventable diseases have not disappeared. Therefore vaccinations are still necessary to protect communities and future generations. Those who oppose vaccines believe that vaccines can cause serious and sometimes fatal side effects. That they contain harmful ingredients and they are immoral. They believe that the disease that these vaccines target have essentially disappeared and natural immunity is more effective. How do we as health educators balance the right of individuals verses the benefits to society with regard to vaccination mandates? The code of ethics for health educators defines the ultimate responsibly to the public for improving and maintaining health for individuals, families, and communities. Those who chose not to vaccinate should understand the risk to themselves and to the general public and how to minimize those risk. Health educators can also increase public awareness of vaccine preventable diseases, promoting a better understanding of herd immunity and advocating for vaccine availability for disadvantaged socioeconomic groups. Nurses who are culturally competent have the opportunity to provide their patients with care that is culturally appropriate. Culture can be defined as a system of beliefs and behaviors that are shared among a group of individuals (Black, 2014). Culture has a significant influence on medical treatments such as vaccinations. For many years, vaccines have been known to prevent infectious diseases. Two disease preventing vaccines are the HPV and TB vaccines. As nurses, it is our duty to educate our patients about both the risk and benefits and listen to their concerns and inquiries about vaccines.Cervical cancer is a life threatening disease and has become the second leading cause of death in women worldwide. Fortunately, it is a disease that can be prevented with the use of the human papillomavirus vaccine. A research study was conducted in Johannesburg, South African on women’s “knowledge, attitudes, beliefs, vaccine awareness, and acceptance,” on cervical cancer and what it actually entails. The study was conducted on a group of 86 women whom all had to meet various requirements of the study. They were divided into three groups and were given a survey of questions to answer. The research results found that attitudes towards the HPV vaccine was directly related to patient not wanting to “experience pain”, questions about potential “harmful ingredients,” and  the chances of “long term side effects”. However, once the participants were reassured by having their questions and concerns answered they agreed to screenings and vacations of themselves and their children. One of the participant reported that young girls will benefit from receiving the vaccine since they live in unsafe areas were rape is common. The study also noted that within this particular group, the women were the deciding factors on healthcare decisions (Francis, 2011). Tuberculosis is an infectious disease that affects the lungs and respiratory system. It is a disease that is prevalent globally. As nurses when we perform our assessments on our patients, we must be aware of certain scars such as a raisin like scar located on the lateral side of the upper arm of our patients. Patients who have migrated from countries outside of the U.S may or may not have a scar that can be the result of a TB vaccine called the BCG vaccine, Bacillus Calmette Guerin. Patients who generally have this scar usually have a false positive reaction to the TB skin test. “I was born and raised in Spanish, Town Jamaica. Growing up in the United States, I can remember being self conscious of the scar on my arm and it was referred to as the foreigner scar.  In 2001 I was given a TB skin Test at school by a school nurse. My result read “positive.” I endured nine rigorous months of medication treatment. To this day I can remember the bitterness of the medication and my mother having to crush it in apple sauce. Once I completed my treatment, I was given a certificate stating that I was to never receive a TB skin test. When I began my educational studies, I had to get chest x-rays to show that my “TB” was inactive and further down the road, the Quantiferon blood test was invented and my results were negative (Michelin).”After years of research, the results of TB skin test and scaring from BCG vaccine where compared. According to a research study conducted on 762 children from several different countries, the BCG vaccine directly affects the result of TB skin test. So therefore, individuals were over diagnosed and put on unnecessary medical treatments. Although the TB skin Test is still a best practice to detect TB, QFT, Quantiferon blood test can determine the present of latent TB and does not interact with previous BCG vaccine (Gudjondfottir 2016). Nurses have the ability to get to know their patients and their background. Nurses can advocate for patients and reduce the need for unnecessary test and over medication of their patients.

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