Improving Vaccination Uptake

Vaccine Hesitancy and Misinformation

Over the past few decades, vaccine hesitancy has become increasingly prevalent globally. The World Health Organization (WHO) declared vaccine hesitancy one of its top 10 global health threats in 2019. Generally, reasons for vaccine hesitancy fall into three main categories:

• a lack of confidence in the effectiveness and safety of vaccines, or a lack of trust in the healthcare system and policymakers;
• complacency (i.e., a perceived low risk of contracting vaccine-preventable diseases), and
• a lack of convenience (issues related to the availability, accessibility and appeal of immunization services, including factors such as time, location, language and cultural context).

In addition to the general risk factors for vaccine hesitancy, measles vaccine uptake was negatively impacted by the publication in 1998 of a paper by the gastroenterologist Andrew Wakefield that made the claim that the measles, mumps, and rubella (MMR) vaccine potentially causes inflammatory bowel disease, and, secondarily, autism. No evidence for a link between the MMR vaccine and autism was uncovered by numerous studies. To take just one example, a retrospective cohort study of all 537,000 children born in Denmark between 1991 and 1998 (of whom 440,000 received the MMR vaccine) found no link between autism and MMR vaccination. The 1998 paper was thus found to be incorrect in its conclusions, and further investigation revealed it to be fraudulent, containing falsified patient records. Although Wakefield’s paper was retracted in 2010, fear of autism remains the most common reason for MMR vaccine hesitancy.

An American Academy of Pediatrics (AAP) clinical report on strategies for improving vaccine uptake suggested a categorization of parents into five classes on the basis of vaccine hesitancy, including:

• Immunization supporters (who actively seek out immunization for their children)
• Go along to get along parents (who do not question vaccination)
• Cautious acceptors (who have some reservations but generally vaccinate their children)
• Fence-sitters (who have significant concerns about vaccination)
• Refusers (who are strongly against vaccination).

An effective strategy to overcome vaccine hesitancy must contain elements that target “fence-sitters” and “refusers”. An incentive-based approach, spreading of awareness and education and technology-based health literacy are strategies to be implemented (Figure 6-1). A variety of resources may be employed in patient education, including lectures, videos, podcasts, online modules, role-play simulations and others.

The AAP suggests the following strategies to help overcome vaccine hesitancy:

• Strong recommendations: Clinicians should provide a strong, confident recommendation for vaccines using a presumptive format (i.e., assume that the parent will vaccinate)
• Early conversations: Vaccine discussions should be initiated during the prenatal period
• Motivational interviewing: A patient-centered interviewing technique that uses open-ended questions, affirmation of parent engagement in the decision-making process, reflection on reasons for hesitancy, and other strategies to alleviate defensiveness.

Other organizations have suggested similar approaches. The FrameWorks Institute proposed the following five strategies to improve childhood vaccination:

• Presenting the benefits of vaccination as a common good
• Talking about improving vaccination access as a preventive public health measure
• Focusing the benefits vaccines have on the long-term health and wellbeing of children and adolescents
• Use the metaphor of software updates to explain vaccination as a form of immune system update
• Use the metaphor of literacy to explain that the immune system learns to respond to pathogens via vaccination.

Additionally, community health training can address specific concerns and misinformation about vaccines. Engaging with communities to understand their specific concerns and working collaboratively can build trust and acceptance. For this, training healthcare providers to communicate effectively about vaccines is crucial. Educators may have to “compete” with family members, friends, religious and political leaders and celebrity “antivaxxers” who may present an opposing message that seems all the more concerning because of fear generated by misinformation. Additionally, improving the accessibility and convenience of vaccination services can further reduce vaccination hesitancy. Lastly, implementing policies that encourage vaccination, such as school-entry requirements, can increase vaccination rates. Policies should also support efforts to reduce misinformation and promote vaccine benefits.

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The Role of Public Health Initiatives in Measles Eradication Efforts

Public health initiatives play a crucial role in addressing vaccine hesitancy through various strategic approaches. The WHO has led multiple initiatives, including the development of a Global Vaccine Action Plan aimed at strengthening immunization systems and promoting vaccine confidence worldwide. This plan includes measures to improve communication strategies, enhance vaccine delivery and ensure everyone has equal access to vaccines. Additionally, the WHO has worked on improving monitoring systems to better understand the reasons behind vaccine hesitancy and to tailor interventions accordingly. Besides prevention, public health initiatives are responsible for adequate response to disease outbreaks. Strategies used to limit measles spread in elimination settings include assembly of an outbreak control committee, isolation of measles cases while infectious, exclusion and quarantining of individuals without evidence of immunity, vaccination of susceptible individuals, use of immunoglobulin to prevent measles in exposed susceptible high-risk persons, and maintaining laboratory proficiency for confirmation of measles; see Assessment and Treatment and Prevention and Control for more information.