Featured Journal Content
Nov 24, 2018 Volume 392 Number 10161 p2237-2324
The state of vaccine confidence
Heidi J Larson
On Oct 17, 2018, WHO reported 52,958 measles cases in the European region since the beginning of 2018, which is more than double the 23 757 cases reported for Africa in the same period.1 The USA reported about 80 000 influenza deaths and a record high of over 950 000 influenza-related hospital admissions during the winter of 2017–18. 2 Overall, seasonal influenza vaccination coverage in the USA in adults was only 37·1%, 6·2% lower than the 2016–17 season.3
In Europe, 29,464 of the measles cases were in Ukraine,4 where a combination of anxieties about vaccine safety, historic distrust in government, and a health system needing reform5n converged to create fertile ground for the outbreak. In England, too, by the end of October, 2018, there were 913 measles cases,6 largely among teenagers and young adults who missed their childhood measles, mumps, and rubella vaccination because of parental anxieties over a decade ago. The 2018 European measles outbreak should not be a surprise. In 2016, a global study on vaccine confidence found that vaccine scepticism was highest in Europe. 7 There were more than 37 measles-related deaths reported in countries across Europe in the first half of 2018, with the highest number of deaths in Serbia at 14. 8
Complex determinants of vaccination, such as alternative health beliefs, politics, histories, trust, relationships, and emotions, contribute to the overall stagnation of childhood and adult vaccine uptake globally. Vaccine anxieties are not new, but the viral spread of concerns, reinforced by a quagmire of online misinformation, is increasingly connected and global.
Although the USA reported only 143 measles cases by early October, 2018,9 there are growing anti-vaccine networks and vaccine refusals and increasing numbers of non-medical vaccine exemptions.10 In 2015, after an outbreak in California, measles spread across multiple US states, causing 188 cases largely among those who were unvaccinated.9 This outbreak became a tipping point for pro-vaccine parents who organised a movement to overturn the personal-belief exemption in California. The emotional appeal of a young boy named Rhett with leukaemia, dependent on others to be vaccinated, lent a powerful voice to the movement and the State Assembly passed the senate bill. Vaccine critics share emotional stories and personal testimonies using YouTube and Facebook as platforms. In this case, the story of Rhett was a powerful way to change minds in support of vaccination. In Italy, concerned teachers similarly mobilised to urge the government to keep compulsory vaccination intact because they did not want unvaccinated children in the classroom. 11 Initiatives like these need to be championed as examples to motivate others.
What else can be done? The international public health community and national immunisation programmes have increasingly acknowledged the seriousness of growing vaccine hesitancy. In November 2011, the WHO Strategic Advisory Group of Experts (SAGE) on Immunization expressed concerns about growing vaccine reluctance and the Working Group on Vaccine Hesitancy was set up in March, 2012. 12 In February2013, the US National Vaccine Advisory Committee established the Vaccine Confidence Working Group. 13 These groups have produced analyses on the drivers of vaccine hesitancy and strategies to shift the tide of reluctance. In Europe, the European Commission is supporting a joint action involving 23 countries to strengthen vaccination efforts, with a key focus on vaccine hesitancy,14 and the European Centre for Disease Prevention and Control produced a Catalogue of Interventions Addressing Vaccine Hesitancy, 15 among other reports investigating the issue.
These initiatives have changed the policy landscape and created an openness for political and programmatic changes. But investments and other actions are needed to move analyses into action.
First, investment is needed at local levels to monitor public sentiments and fund the resources to respond. Although there are some common vaccine concerns and anxieties globally, specific local issues will differ. Resources are needed for immunisation programmes to undertake local research to better understand specific issues and to identify the key influencers and the emerging issues before they become crises.
Second, investment is needed for piloting and implementing strategies to find out what works best. There is a wealth of new research and proposed solutions to address vaccine hesitancy and build confidence. Many of these suggested interventions, such as motivational interviewing, innovative uses of social media, mapping and engaging trust networks, need to be trialled in different contexts to understand what works and then tailored to be taken to scale.
Third, dialogue, including through social media, is important. Public health officials too often shy away from social media, but they and other relevant stakeholders need to go where the discussions are happening and where influence is being leveraged. Social media engagement can help.16
Fourth, more opportunities need to be created—eg, in clinics and schools—for parents and other stakeholders to discuss their questions and concerns. The power of listening and dialogue should never be underestimated.17 Having someone available to answer questions in clinic waiting rooms or in community settings can help mitigate anxiety and allow hesitant parents to feel that their concerns are being listened to.
Finally, more support is needed for those on the front line of questioning. If there are good listening mechanisms—whether face-to-face discussions in clinics or other settings or through media monitoring— anticipating questions and preparing answers in advance can support health-care workers and officials who are confronted with difficult questions.18
Although there are some positive initiatives to address vaccine hesitancy, the spread of misinformation is moving quickly and boldly, appealing to emotions and heightening anxieties. Building vaccine confidence goes beyond changing an individual’s mind. The dissenting voices have become highly connected networks, undermining one of the most effective disease prevention tools. We need globally and locally connected positive voices and interventions that are vigilant, listening, and have the resources and capacity to respond.
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