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immunization rates to 90.6%4. In theUnited States, Britain and Australia, up toone-third of parents report concerns aboutthe number of vaccines that babies are nowreceiving and are more distrustful of newervaccines, a phenomenon that may increaseas more are introduced. A survey in 200809 found that up to about onefifth of par-

ents from five European countries reporteddoubts about having their child vaccinated5.Communities of parents particularly

those who espouse the alternative life-styles, anthroposophical or religious beliefsthat oppose vaccination continue tocontribute to outbreaks of diseases suchas pertussis, measles and Haemophilusinfluenzae type b (Hib).

But the greatest causes for concern areunfounded scares around particular vac-cines leading to anything from smalldownturns in immunization rates to thecessation of entire programmes. Japan

had one such scare in the 1970s, when thedeaths of two children within 24 hours ofreceiving the DTP vaccine led to the sus-pension of that programme and then itsresumption two months later with a pri-mary dose beginning at two years of agerather than at three months. A pertus-sis epidemic followed in 1979 with morethan 13,000 cases leading to 41 deaths6.Britains recent MMR experience palesin comparison with its own DTP scareof the late 1970s when the vaccine waslinked to encephalopathy. Immunizationrates fell from 80% to 30%; there followed

70 deaths among more than 300,000 casesof pertussis7.

As a social scientist specializing in immu-nization take-up,it is clear to me that wecan and must work harder to head off suchscares by better engaging fence-sitting par-ents and wavering health professionals. Justas vaccine programmes must be informed by

sound research, so too must communicationstrategies.

SCARE STORIES

What makes a vaccine scare take hold? It isa complex interplay of factors embedded ina countrys historical, social and politicalcontext.

Sporadic media reports do not imme-diately affect vaccine uptake. The mediatends to sideline groups that criticize vac-cines until a prominent figure championsa theory against a backdrop of mistrust ingovernment. The MMRautism and DTP

encephalopathy links were advanced bydoctors committed to their hypotheses;both were charismatic individuals fromrespected institutions laying their theoriesGalileo-like at the door of the scientificchurch.

The British doctor Andrew Wakefield,who linked the MMR vaccine with autism, juxtaposed stereotypes of hard-pressedparents and kindly clinicians against thoseof unyielding health authorities. His viewsfed a hunger for autisms cause. A similarhunger drove the now equally discreditedattempt to link the DTP vaccine with sudden

infant death syndrome (SIDS), which lostits currency by the late 1990s with betterunderstanding of the precursors of SIDS.

Such figures can give a scare enoughtraction or politicization to become main-stream. At this point, media editors oftenmarginalize medical reporters who areknowledgeable enough to discern quality of

evidence in favour of general newshounds.Reports may then begin to give weight orfalse equivalence to theories with scantscientific support.

Health professionals are key in tipping ascare towards widespread vaccine rejection.They too are affected by persistent publicmessages. In 1976, at the height of Brit-ains DTP scare, up to one-third of generalpractitioners (GPs) were advising againstpertussis immunization8. In 1998, just fourmonths after the publication that triggeredthe MMR scare, 13% of GPs and 27% ofpractice nurses in north Wales thought it

very likely or possible that the vaccine wasassociated with autism9. Committed, confi-dent and knowledgeable health professionalsare the cornerstone of successful immuni-zation programmes. Parents repeatedly ratethem as their most trusted source of advice.So if doctors and nurses lose confidence, itcan have a profound effect.

Many commentators assume that afailure to vaccinate is caused by parentspoor understanding of immunization.Under this logic, parents who are givenscientific facts will abandon their errone-ous beliefs and proceed to vaccinate. How-ever, the work of Nobel laureate DanielKahneman and Amos Tversky and otherson heuristics and biases demolished theseassumptions. Decisions about whether toimmunize are not usually made rationallynor at one moment in time. And knowledgerarely predicts vaccine uptake indeed,refusers are more likely to have universityeducation than those who accept vaccina-tion. Hence scientific arguments alone willnot sway them, and may even increase theirresolve to not immunize.

THREE STEPSThere are three ways in which governments

can maintain or retain high uptake of safe,effective childhood vaccines. First, they mustminimize the structural barriers. For everyconcerned parent or carer like Emily, there isanother who finds it difficult to get her childimmunized on time because of practicalbarriers such as a lack of transport, moneyor help to mind other children.

Countries with high child-immunizationrates have well-oiled systems: free and acces-sible vaccines, national record keeping andreminders. Financial incentives for par-ents and providers and sanctions such asexclusion of unvaccinated children from

childcare during outbreaks or compulsoryUK doctor Andrew Wakefield retained support when he was struck off the medical register in May 2010.

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immunization also have an effect. But nointervention works in isolation and pro-grammes must be comprehensive to suc-ceed.

Second, communication strategies needto be tailored to groups for whom realgains can be made. Between 3% and 7% ofall children are under-vaccinated becausetheir parents refuse some or all vaccines;these parents tend to have intractable views.Hesitant parents such as Emily are a largerand more attentive group who usuallyvaccinate but might delay or decline a stig-matized vaccine.

Communication with this group shouldbe the priority and needs to be informed bybetter evidence. Governments and healthorganizations must move beyond deficitmodels of communication that assume thepublic to be passively awaiting their infor-mation fill. Rather, they must recognize thatpeople interact with information accordingto their experiences and social settings10.

Tools can include: motivational inter-viewing where health professionalsguide hesitant parents to engage with theissue and elicit motivation for changewhile respecting their autonomy; decisionaids (such as that of Australias National

Centre for Immunisation Research andSurveillance; go.nature.com/hp6l56) thathelp parents to consider the pros and consof their options; peer-led and expert-resourced parent discussion groups;and social-media strategies that addressrumours and promote vaccination.

Third, health professionals must be kepton board. This involves initiatives to sus-tain their confidence in safe vaccines andraise their competence to address parentalconcerns. More time should be spent onimmunization in medical and nursingcurricula; continuing education should be

provided; and timely updates issued when

scares arise. More pragmatically, systemsshould be put in place to prompt doctors ornurses when a vaccine is due or overdue, toevaluate their performance as vaccinationproviders, and to enable suitably qualifiedhealth professionals to give a vaccine withouta doctors involvement each time.

Better government engagement of healthprofessionals and the public will alsoenhance systems for reporting and acting

on adverse eventsfollowing immuniza-tion. An atmospherethat censors anypublic concerns canunwittingly hinderefforts to hear andrespond to real prob-lems and can alienatehesitant parents, themost important audi-ence to keep on side.

In sum, anti-vaccine sentiment is inevita-ble, so the professionals involved should beprepared. It is too late once a scare arrives.Countries need to monitor and engage withtheir public and professionals and developcommunication plans pro-actively. In thatcommunication they also need to assure

the public that a truly robust programme ofproactive research continues to explore thesafety of existing and emerging vaccines. TheUnited States has led the way, for example,in holding workshops with the public thatinformed the governments vaccine safetyresearch agenda.

THE FUTURE

Many questions remain about the precur-sors to large declines in vaccine acceptance.The UK and US governments have ongoingsurveys to measure attitudinal trends. Othergovernments should commit to similar

evaluations both of coverage and of public

attitudes, and surveys should be harmonizedfor comparison across countries and overtime5. Furthermore, researchers shouldground their studies in theories of healthbehaviour and use validated measures. Suchmeasurement needs to be complementedby qualitative enquiry, asking the why andhow questions. For example, interviews

with new parents could explore how theynegotiate anti-vaccination information fromtheir social-media networks.

The MOTIV (Motors of Trust in Vac-cination) Think Tank initiated by SanofiPasteur and the London School of Hygieneand Tropical Medicine was established inDecember last year to better understand thediverse factors that drive immunization rates.This multidisciplinary group has proposed aresearch agenda centred on three broad areas:decision-making, social norms and commu-nication. Questions include: what cognitiveprocesses underpin vaccine decision-making

and what are their relative weights in differ-ent contexts? How do social networks shapedisease and vaccine perceptions? How doespublic engagement influence levels of trust invaccines and vaccination-promoting groupsor organizations? The group is launching aninternational Centre for Decision-Making onImmunisation to take forward multidiscipli-nary research to address these questions.

The safest and most effective vaccinesare of little use if too few people take them.Public support for immunization remainshigh in most industrialized countries, butvaccine scares will continue. Our strategiesmust be tailored to our times they mustbe consultative and grounded in sociology,psychology and communication science.

Julie Leaskis at the National Centre forImmunisation Research and Surveillance,Discipline of Paediatrics and Child Health,School of Public Health, University ofSydney, New South Wales 2006, Australia.e-mail: [email protected]

1. Quarterly Vaccination Coverage Statistics forChildren Aged up to Five Years in the UK (COVERprogramme): July to September 2010 in HealthProtection Report4(38) (Health ProtectionAgency, 2010).

2. Centers for Disease Control and Prevention.Morb. Mortal. Wkly Rep.59, 11711177 (2010).3. Hull, B. P., Mahajan, D., Dey, A., Menzies, R. I. &

McIntyre, P. B. Commun. Dis. Intell.34, 241258(2010).

4. National Committee for Quality Assurance. TheState of Health Care Quality(NCQA, 2010).

5. Stefanoff, P. et al. Vaccine28,57315737(2010).

6. Gangarosa, E. J. et al. Lancet351, 356361(1998).

7. Nicoll, A., Elliman, D. & Ross, E. Br. Med. J.316,715716 (1998).

8. Swansea Research Unit of the Royal College ofGeneral Practitioners. Br. Med. J.282, 2326(1981).

9. Petrovic, M., Roberts, R. & Ramsay, M. S.Br. Med. J.322, 8285 (2001).

10. Leach, M. & Fairhead, J. Vaccine Anxieties: Global

Science, Child Health and Society(Earthscan, 2007).

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THE COST OF A SCAREIn the wake of the now-debunked claims in 1998 of a link between the measles, mumps andrubella vaccine and autism, vaccination dropped and measles cases rose in England and Wales.

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

72

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ConrmedmeaslescasesinEn

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200

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Anatmospherethat censors

any publicconcerns canunwittinglyalienatehesitantparents.

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