This week is World Immunisation Week, a public awareness event celebrated each year in the last week of April. The event aims to raise awareness and encourage people around the world to protect themselves and their families against vaccine-preventable diseases. However, for many people, immunisation programmes remain a highly contentious issue. In this article, I explore the rise of the anti-vaccination movement to understand what it has meant for global health, and outline some of the initiatives that are aiming to combat the dangers it presents.
Saving lives since 1796
Vaccines are widely seen as one of the greatest innovations in medical history. In the two hundred plus years since the discovery of vaccination by Edward Jenner in 1796, huge advances have been made in research and development, introducing new vaccines and expanding the reach of immunisation programmes.
Today, over 25 infectious diseases are now preventable through vaccination and the World Health Organisation (WHO) reports that immunisation programmes prevent an estimated 2.5 million deaths each year.
Jenner’s early experiments paved the way for the complete eradication of smallpox in 1977, the first and only human disease to be fully eradicated. Another major vaccines accomplishment is polio. The global push to end the disease is now in its final stages, with just three remaining countries - Afghanistan, Nigeria, and Pakistan - working to eradicate polio within the next decade.
However, despite these successes, new setbacks are slowing the rate of progress. More than three million people still die from vaccine-preventable diseases each year - approximately half of whom are children under five years old. While uptake of new and underused vaccines may be increasing, The United Nations Children's Fund (UNICEF) reports that 71 countries have yet to achieve the Global Vaccine Action Plan (GVAP) target of 90% coverage for the Diphtheria, Tetanus and Pertussis vaccine (DTP), which is often used as a key indicator of how well countries are providing routine immunisation services. Global vaccination coverage for DTP has remained at 85% for the past few years.
Two steps forward, one step back
Global health organisations have also started to report increasing numbers of measles outbreaks due to gaps in vaccination coverage. In 2017, measles cases spiked in multiple countries all over the world, resulting in an estimated 110,000 measles-related deaths. The United States, which in 2000 had declared the complete elimination of measles, recently reported 626 new cases. Just four months in to 2019, the Centers for Disease Control and Prevention estimates the number of cases is about to surpass the total number reported in 2014 (667 cases). The picture does not look great for Europe either. The WHO reports that more than 80,000 people in 47 European countries contracted measles in 2018 – the highest in a decade and three times the total reported in 2017 (23,927 cases). Early successes in controlling measles had made this highly contagious disease another potential target for global eradication. So what went wrong?
Birth of a movement
The late twentieth century witnessed a catastrophic wave of anti-vaccination propaganda. In February 1998, the now discredited British gastroenterologist, Andrew Wakefield, authored a research paper that would later be published in leading medical journal, The Lancet. It falsely claimed a link between the Measles, Mumps and Rubella (MMR) vaccine, autism and crohn’s disease. Wakefield’s findings were quickly debunked, the paper was eventually retracted and his medical license revoked by the British General Medical Council. However, the damage had already been done. With the growing adoption of the internet, Wakefield’s misinformation spread and immunisation rates began to fall – first in the UK and then eventually around the world. Over twenty years later, his beliefs have never been so popular.
New wave of propaganda
While anti-vaccination sentiment has been around since the early 1800s, albeit bubbling away under the surface, Wakefield’s pseudoscience bought this into the mainstream and, arguably, birthed the modern ‘anti-vaxxer movement’. Today we are experiencing a new and unprecedented wave of vaccination refusal, one that is fuelled by conspiracy theories and the spread of misleading information online. In an age in which we are more connected than ever before, these dangerous mistruths and fake news are wide reaching and have resulted in huge numbers people becoming vaccine hesitant, causing immunisation rates to drop all around the world.
Why is this happening?
Many factors have contributed to the rapid rise of the new anti-vaxxer movement, but social media is undoubtedly one of the strongest influences. What initially began as posts by grassroots activists in online forums and Facebook groups very quickly evolved and made social media a breeding ground for anti-vaccination material. Over time, organised groups have built up strong online presences and adopt a range of tactics to spread conspiracy-style fake news and popularise anti-vaccination sentiment. A 2017 study published in Social Science & Medicine looked into anti-vaccine beliefs on Twitter between 2009 and 2015 and found that vaccine misconceptions were widespread on the social media network. This is all compounded by the ‘echo-chamber effect’ - where users of social media are only presented with information that echoes their own beliefs. Another 2017 study analysed the interaction of over two million Facebook users over 7 years and found that the consumption of vaccine-related content is dominated by the echo chamber effect, and polarisation of views on vaccination increased over the length of the study.
News and entertainment outlets have also contributed to the fear and distrust of vaccinations by giving credence to campaigns. Often, in an effort to provide balance, media coverage tends to over-represent anti-vaccine voices and frames the debate as though expert opinion is evenly divided. Furthermore, a recent study by public health researchers in the US found that around one in three vaccine-related stories published between 1995 and 2005 reported vaccines in a negative light, often suggesting they are unsafe.
In addition, celebrities are using their fame as a platform to question the safety of vaccines. In 2007, American actress Jenny McCarthy appeared on The Oprah Winfrey Show, to tell the audience that her Google research and mother’s intuition had led her to believe the MMR vaccine had caused her son’s autism and that she was able to ‘cure’ him through a specialist diet. Days after her appearance, McCarthy appeared on several other American daytime talk shows to repeat her claims, reaching an estimated 20 million viewers. Hollywood actor, Robert De Niro, who has a son with autism, has also questioned the safety of vaccines. In 2016, he expressed his support for a controversial anti-vaccination documentary directed by Andrew Wakefield called ‘Vaxxed: From Cover-Up to Catastrophe’. In a series of interviews, he said he wanted people to know "the truth" about vaccines.
Religious and philosophical beliefs are two of the most common reasons for vaccine exemption. Many ‘anti-vaxxers’ claim enforced immunisation programmes violate their religious freedoms and often seek exemptions based on these grounds. Some studies show that the number of religious exemptions is on the rise, leading to increased outbreaks of vaccine-preventable diseases. For example, in 2013 The Netherlands experienced a huge outbreak of measles, mainly affecting a single religious community. The vast majority of the 2,700 reported cases were in unvaccinated members of Orthodox Protestant Reformed churches.
According to Dr. John Lantos, Director of paediatric bioethics, complacency may also explain the rise of vaccine hesitancy. In a recent interview he said, “There’s a trend that’s been noticed that when immunisation rates are higher, there aren’t as many diseases…and people get complacent,” He continued, “When the polio vaccine came out in the fifties, everyone knew someone who had polio and were terrified, so there wasn’t a lot of refusal. In general, if people see the disease, they want the vaccine. If they don’t see it, they think it’s not necessary”. The WHO agrees that complacency is a contributing factor. In its Vaccine Hesitancy Working Group report, it states “Immunisation program success may, paradoxically, result in complacency and ultimately, hesitancy, as individuals weigh risks of vaccines against risks of diseases that are no longer common.”
Herd immunity is an indirect protection that is created when a high percentage of a population is immunised, making it difficult for infectious diseases to spread. If a small proportion of the population are not vaccinated, such as immune-compromised individuals who are contra-indicated to vaccines and legitimately cannot be vaccinated, they can be protected due to ‘herd immunity’ from the remainder of the population. However with the rise of the anti-vaccination movement, if the proportion of vaccinated individuals within a population drops below the herd immunity threshold (90-95%), then the risk to unvaccinated individuals increases, which is what we are seeing in the case of these recent measles outbreaks. Therefore, by not vaccinating eligible patients, the lives of those with weakened immune systems are put at risk.
What is being done?
The rise of the modern anti-vaxxer movement has not gone unnoticed. The WHO has listed vaccine hesitancy as one of its ten threats to global health in 2019, alongside climate change, anti-microbial resistance, and high-threat pathogens such as Ebola. Many Governments have also recognised the growing anti-vaccination movement as a threat to public health and have begun taking steps to increase immunisation coverage through legislation.
In Europe, France has introduced a new policy requiring all children born after 1st January 2018 to receive 11 mandatory vaccinations. If parents refuse the mandatory vaccines, their child will not be accepted into many schools. Similarly in Germany, legislation has been introduced which requires all nurseries to notify local health authorities if parents are unable to provide proof of vaccination for their children. Many other European countries such as Italy are following suit. Finland (which has a voluntary immunisation programme supported by regulations that require children to attend regular checkups), introduced the Infectious Diseases Act in 2017 which requires health and social care providers to ensure staff are immunised against specific diseases to be able to work with patients.
In America, all 50 states have legislation that requires students to be vaccinated to attend school. However, every state controls their only immunisation policies all allow varying levels exemption. Almost all states grant religious exemptions for people who have religious beliefs against vaccination. Currently, 17 states allow philosophical exemptions for those who object because of personal, moral or other beliefs.
Social media companies such as Facebook, YouTube and Pinterest are also taking responsibility for their part in amplifying anti-vaccine sentiment and recently launched initiatives to reduce vaccine misinformation on their platforms. Earlier this year Facebook announced it would aim to reduce the search ranking of groups and pages that spread misinformation about vaccinations, as well as reject advertisements from anti-vaccination groups. In a blog post outlining the measures Facebook would be taking, Monika Bickert, Head of Global Policy, said the company is "fully committed to combating vaccine misinformation”, She continued, “If these vaccine hoaxes appear on Facebook, we will take action against them”.
Global health organisations such as the WHO, UNICEF and in particular GAVI, The Vaccine Alliance are working to strengthen and provide support for immunisaion programmes. Launched in January 2000 at the World Economic Forum, GAVI is an independent public-private partnership of scientists, healthcare experts, government and business leaders, and philanthropic organisations whose aim is to improve access to sustainable immunisation services in low and middle-income countries. So far, the alliance has saved over 9 million lives and remains on target to immunise 300 million children by 2020. In addition to financing the purchase of vaccines, their work includes community outreach and advocacy for immunisation. Less-educated mothers are less likely to be aware of the benefits of vaccination or feel confident in interacting with medical staff, and are therefore less likely to vaccinate their children. Dr. Seth Berkley, CEO of GAVI said last year “Combined, efforts to increase access to vaccination and education can have an even greater positive impact on both. As global health agencies come together with governments to discuss ways to increase access to vaccination and protect children from disease, we are simultaneously helping to close the gender gap in education.”
Rebuilding public confidence
Are all of these measures enough to address the rise of the anti-vaxxer movement? Attempts to address this global phenomenon are complex and must be part of a wider effort involving multiple stakeholders, including public health bodies, the pharmaceutical industry, and citizens. If the efforts of national governments to reduce the movement are perceived to be violating civil liberties and the actions of tech companies seen as censorship, they may only harden anti-vaccination views.
A more holistic approach needs to be taken in order to improve public confidence in vaccines. This will require an in-depth understanding of people’s attitudes to vaccination and vaccine risks, and a dissection of the contributing factors leading to those attitudes, as well as an identification of what would be needed to shift those beliefs within different segments of the population. Understanding the healthcare consumer journey through exploratory market research, underpinned with an analytical framework of behavioural science, can help to uncover some of the drivers and barriers to vaccination, and help to identify the belief shifts needed to overcome vaccine hesitancy.