Vaccine Hesitancy

The term “Vaccine Hesitancy (VH)” is defined by the WHO as delay in “acceptance of vaccine despite the availability of vaccine services.”[1] A publication in the New England Journal of Medicine (2022) states that this is a state of indecision and uncertainty about vaccination before a decision is made to act (or not act).[2] Recently, VH has been reported from more than 90% of the countries of the world, and thus, this has become a growing challenge to immunization program.[3] VH and refusal are not recent phenomenon. Their roots can be traced back to 1998 when Andrew J. Wakesfield fraudulently proposed a causative link between the MMR vaccine and the insurgence of autism. The WHO in 2019 declared VH as one of the top 10 threats to global health, following five-fold increase of measles cases even in developed countries, which could have been prevented by vaccination.[4] In fact, VH has become a key challenge to public health in terms of containing infectious diseases and preventing pandemics. Specially, VH has come to surface widely during the recent pandemic of COVID-19, whereas many developed countries became the worst victims partly due to the issue of hesitancy and refusal of the available vaccines. According to the WHO, globally, vaccination alone can reduce 2–3 million deaths annually.[4] In spite, at present, around 21% of the world’s population does not think that vaccines are safe and 10% choose not to vaccinate their children. As far as COVID-19 vaccination is concerned, a survey of vaccine acceptance across 23 countries in 2022 depicts recorded VH as follows – US (19.8%), UK (19.6%), Italy (15.4%), Russia (39.2%), Spain (10.1%), South Africa (52.1%), Nigeria (28.17%), Germany (21.9%), Brazil (12.8%), Canada (13%), and China (3.4%), but India performed well with 1.7% only.[5] Determinant of Vaccine Hesitancy This is complex, context-specific, and varying across time, place, and vaccine type. Evidence suggests this has become more pronounced globally due to the advancement of information and communication technologies.[6] VH of varying degrees is prevalent in rural and urban communities, low and high literacy groups, low-, middle-, and high-income groups. Determinants can be referred to as factors, reasons, and causes. The WHO strategic advisory group of VH Report 2014 states that there are myriads of factors, influencing the vaccine decision process. However, the 3C model designed by the group is simple to comprehend. This consists of three main determinants, namely, confidence, convenience, and complacency.[7] Confidence This covers issues of trust in the safety and effectiveness of vaccines as well as the competence of the health-care system and personnel who delivers and administers them.[8] Convenience It involves the case or otherwise at which the vaccines and related services are accessed, their affordability and the willingness of the individuals to pay. Complacency This occurs when the need to vaccinate is low because the perceived risk of vaccine-preventable diseases is deemed to be low. Besides the aforementioned issues, few other factors of VH are worth mentioning. They are: Health-care and socioeconomic inequalities Lack of effective public health message Unethical research bias Low level of education accessing high-quality information Growing spread of misinformation, conspiracy, and rumors through online platforms Barriers to access ability including vaccine delivery time, place, and cost related to socioeconomic inequalities. Impact of Vaccine Hesitancy VH directly affects the uptake and level of coverage needed to contain outbreaks and spread of vaccine preventable diseases. Thus, it impedes the success and effectiveness of immunization program. As a result, the required degree of herd immunity and herd protection is not achieved, posing danger to the individuals their dependents and the society at large. By this, the young and comorbid children become the worse victims. Hence, the objective of control/elimination/eradication of infectious diseases is jeopardized. Few examples in this context are VH to Polio vaccine, which resulted in five-fold increase of Polio cases in Nigeria between 2002 and 2006, the recent insurgence of cases of measles in 27 countries, especially developed countries such as US and UK, COVID-19 VH precipitating the havoc all over the globe. Solution to Vaccine Hesitancy Since the WHO, in 2019, declared VH as one of the top ten global health threats, there is strong recommendation that it or its proxies should be constantly monitored and development of tools are essential to detect and measure VH. Identification and measurement of barriers to vaccine acceptance are critical to formulating cost-effective strategies to address VH. There are well-validated tools such as “measurements of parental attitudes about childhood vaccines,” and the “vaccine confidence scale.”[7] These have been developed to asses five psychosocial antecedents of vaccination (confidence, complacency, constraints, calculation, and collective responsibility), capturing an individual’s attitudinal and behavioral tendencies. The WHO working group on the behavioral and social drivers of vaccination is developing standardized quantitative and qualitative tools of the measurement of vaccine accessibility and acceptances. Communication and Community Engagement Vaccine-hesitant parents who are on the fence far outnumber vaccine refusers. Thus, proper communication and counseling could be the game changer.[9] Since VH is a complex psychosocial problem, a multiprong approach such as participatory communication, group discussion, and individual persuasions are expected to yield good results.[10] Involvement in multimedia information system, including local and social media is helpful. Removal of Misinformation and Disinformation Misinformation is “inaccurate or false information gathered while disinformation is false information deliberately designed to deceive people.” Both of these pose complex challenges in the community. Very often, the antivaccine activists spread disinformation. All efforts should be made by public health personnel and social activists to debunk the false ideas. Mass awareness on the benefits of vaccination is vital. Positive Reinforcement and Incentives VH is a social menace effecting all groups of in society, whether vaccine refusers or hesitants. The public health providers should utilize all methods of reinforcement, incentives, workplace rewards to achieve the goal by any means.[11] At government level, measures such as mandatory updated vaccine cards at school entry and other legal methods as appropriate may be undertaken. Primary care providers and family physicians have a key role in one-to-one communication and removing the myths at the family and societal levels. Conclusion Even though vaccines are one of the best discoveries of the millennium, saving millions of children, VH is still prevailing all over the world and rather increasing. It is a complex phenomenon and encompasses more than just a knowledge deficit. A holistic approach with all types of communication processes is the call of the day, starting from grassroot level of health care to the topmost medical institutions to avoid this preventable menace to save the humanity.

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