1. Nili Karako Eyal, School of Law, College of Management, Israel
Infectious Diseases, Vaccination Policy and Healthcare Disparities: Why Improving Accessibility to Health Technologies is not Enough?
Nili Karako Eyal, School of Law, College of Management, Israel

2. Health Disparities in Vaccination Coverage
Immunization is among the safest and most effective public health interventions.
Many children are still unvaccinated or under-vaccinated
Immunization coverage is closely related to economic status, mother’s education level and place of residence
There is a strong correlation between socio-economic inequality, inequality in immunization coverage and inequality in morbidity and death rates due to infectious diseases.
The discourse regarding inequality in the context of immunization usually addresses the issue of inequity in vaccination coverage and strategies to reduce it.

3. Thesis
Inequality in the context of immunization might be manifested in other ways, sometimes more sophisticated or subtle.
Policymakers should be aware that issues of inequality may extend the classic boundaries of inequality in vaccination coverage

4. The Measles Outbreak.
From April 2018 to June 2019 approximately 4000 cases of infection with measles were reported to the IMH.
Israeli Law does not require children to be vaccinated against certain infectious diseases to attend school.
In the absence of a legal duty a private initiative- called the vaccinated kindergarten- emerged.
Only private kindergartens can join this voluntary enterprise. Public kindergartens are compiled by law, which doesn't require children to be vaccinated to attend school

5. The Measles Outbreak.
In the absence of a legal duty to vaccinate a child, non-vaccinated children will be routed to public kindergartens.
As the number of non-vaccinated children in public kindergartens will rise, clusters of non-vaccinated children will be created, and herd immunity will be lost.
The vaccinated kindergarten enterprise places children of poor families in a higher risk to be infected with infectious diseases
The vaccinated kindergartens enterprise is expected to impose on poor children the burden or costs created by unvaccinated children.

6. The Polio Case
During a wild-type Poliovirus 1 (WPV1) was detected in Israel.
On July 2013 a decisions was made that children who were born after 1/1/2004 and who received at least one dose of inactivated Poliovirus vaccine (IPV) will be vaccinated with bivalent oral Polio vaccine (bOPV).
The benefit of bOPV to IPV-vaccinated children was marginal. The main purpose of the bOPV was to protect groups at special risk from being infected with WPV1 .
Out of fear that parents will not vaccinate their Childe if fully aware to the OPV “social” nature, the IMH suppressed its real nature.

7. The Polio Case
65.81% of the overall target population was vaccinated. Two districts- Tel Aviv and Jerusalem, fell below this percentage, reaching only to 55%. Other districts reached 68% and 78%.
The low vaccination rates in Tel Aviv was connected to the high socio- economic status of parents living there.
Highly educated parents were the most likely to learn that OPV had no real benefit for the vaccinated child, and that its real purpose was to protect others. At the same time, they were also the most likely to learn about the risks involved in OPV.
Eventually the north district and the southern districts carried a bigger portion of the burden involved in vaccination then Tel Aviv.

8. Conclusions
The policy adopted by the IMH regarding school vaccination requirements in the measles case and the communication policy it adopted during the polio crisis created another layer of inequality in the context of vaccination, one that extend the classic discourse of disparities in the provision of health technologies.
Policymakers should be sensitive to all the possible distributive effects of the vaccination policy they adopt.