vaccine hesitancy: an international perspective -...
TRANSCRIPT
Vaccine Hesitancy: an international
perspective
Noni MacDonald1, Sarah Lane 2, Melanie Marti3
1. Dept Pediatrics, Dalhousie University, Canadian Centre for Vaccinology, Halifax, Canada
2. Faculty of Medicine, Dalhousie University, Halifax Canada
3. Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
Nov 3,2017
Brickset.com
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Faculty/Presenter Disclosure Relationships with commercial interests:
• No financial conflicts to declare • Grants/Research Support: Canadian Institute for Health Research, Canadian Immunization Research Network Nova Scotia Health Research Foundation Public Health Agency of Canada • Consulting Fees: World Health Organization • Other: employee of Dalhousie University
My Biases:
-Consultant to Canadian Pediatric Society Imm/ID Cmt
-Member SAGE WHO
-Consultant to WHO Immunization/Vaccines & Biologicals
-Canadian Centre for Vaccinology:
Health Policy and Translation Group 2
GVAP: Strategic Objective 2 • Individuals and communities
understand the values of vaccines and demand immunization both as a right and a responsibility.
• SAGE WG on Vaccine Hesitancy in 2014 • Definition
• Indicators to track hesitancy
• Incorporated into WHO/UNICEF Joint Reporting Form Questions
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http://www.who.int/immunization/sage/meetings/2014/october/SAGE_working_group_revised_report_vaccine_hesitancy.pdf
Vaccine Acceptance and Hesitancy Vaccine Hesitancy
• refers to delay in acceptance or refusal of vaccines despite availability of vaccine services
• complex and context specific varying across time, place
and vaccine
• influenced by such factors as complacency, convenience and confidence
Problem in HIC, MIC ,LIC
MacDonald NE and SAGE Working Group on Vaccine Hesitancy. Vaccine 2015; 33(34):4161-4
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TARGET
Assess the top three reasons for vaccine hesitancy in the country in the past year to monitor determinants of vaccine hesitancy over time. Monitor the trend in the percentage of Member States that have assessed the level of hesitancy towards vaccination at national or subnational level in the previous five years.
DEFINITION OF INDICATOR
Indicator 1: Reasons for vaccine hesitancy
Question 1: what are the top three reasons for not accepting vaccines according
to the national schedule?
Question 2: is this response based on or supported by some type of assessment,
or is it an opinion based on your knowledge and expertise?
Indicator 2: Percentage of countries that have assessed the level of hesitancy towards vaccination at the national or subnational level in the previous five years.
Question 1: has there been some assessment (or measurement) of the level of
hesitancy in vaccination at national or subnational level in the past (<5 years)?
Question 2: if yes, please specify the type and year and provide assessment
title(s) and reference(s) to any publication or report.
DATA SOURCES All 194 countries within the six WHO regions included both indicators in their 2015, 2016 and 2017 JRF to collect country data for 2014, 2015, 2016 (referred to as year JRF data).
Joint Reporting Form: Hesitancy Indicators added in 2014
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Methods for Review JRF Vaccine Hesitancy Data Timing: 2014 -all data reported 2015 - all data reported 2016 -all data available by end June 2017: due to GVAP assessment report deadline
Reported reasons categorized using SAGE WG Matrix contextual influences individual and group influences vaccine /vaccination –specific influences
Standardization • SL reviewed categories; discussed examples with NM, MM. • Outliers discussed and agreed upon • All decisions recorded for back referral to ensure consistency • All 3 years reviewed using same process
http://www.who.int/immunization/sage/meetings/2014/october/SAGE_working_group_revised_report_vaccine_hesitancy.pdf 6
CONTEXTUAL INFLUENCES Influences arising due to historic,
socio-cultural, environmental,
health system/institutional,
economic or political factors
Communication and media environment Influential leaders, immunization program gatekeepers, anti- or pro-vaccination lobbies.
Historical influences Religion/culture/ gender/socio-economic Politics/policies Geographic barriers Perception of the pharmaceutical industry
INDIVIDUAL AND GROUP
INFLUENCES Influences arising from personal
perception of the vaccine or
influences of the social/peer
environment
Personal, family and/or community members’ experience with vaccination, including pain
Beliefs, attitudes about health and prevention Knowledge/awareness Health system and providers-trust and personal experience.
Risk/benefit (perceived, heuristic) Immunisation as a social norm vs. not needed/harmful
VACCINE/ VACCINATION–SPECIFIC ISSUES Directly related to vaccine or
vaccination
Risk/ Benefit (epidemiological and scientific evidence)
Introduction of a new vaccine or new formulation or a new recommendation for an existing vaccine Mode of administration Design of vaccination program/Mode of delivery (e.g. routine program or mass campaign)
Reliability and/or source of supply of vaccine and/or vaccination equipment
Vaccination schedule Costs Strength of recommendation and/or knowledge base and/or attitude of HCPs
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GVAP SO2 Indicators In JRF*: Vaccine Hesitancy
Response:
2014 73% (131/180) 29% assessment
2015 79% (145/183) 36% “
2016 83% (152/184) 33% “
* potential 194 countries
Response rate by Region 2016
Total countries submitted JRF
Any Reason %
Question Not Completed %
AFR 47 94% 6%
AMR 34 88% 12%
EMR 20 70% 30%
EUR 48 83% 17%
SEAR 11 100% 0%
WPR 24 58% 42% 8
Reported Reasons for Vaccine Hesitancy globally: 2016 JRF data
Most common reasons
1) risk/ benefit (epidemiological and scientific evidence) N=88,
2) religion/culture/socio-economic influences N= 47
3) knowledge/awareness N= 38
4) influential leaders N= 22
5) Beliefs, attitudes N=22
about health and prevention
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ContextualIndividual & Group InfluencesVaccine/VaccinationNo HesitancyOther
28%
26%
36%
4% 7%
10
0 10 20 30 40 50 60 70 80 90
100
1 C
om
mu
nic
atio
n a
nd
me
dia
e
nvi
ron
me
nt
2 In
flu
en
tial
lead
ers
, gat
eke
ep
ers
an
d a
nti
-or
pro
- va
ccin
atio
n …
3 H
isto
rica
l in
flu
en
ces
4 R
elig
ion/c
ult
ure/g
en
de
r/so
cio
-e
con
om
ic
6 G
eo
grap
hic
bar
rie
rs
7 P
har
mac
eu
tica
l in
du
stry
8 E
xpe
rie
nce
wit
h p
ast
vacc
inat
ion
9 B
elie
fs, a
ttit
ud
es
abo
ut
he
alth
an
d p
reve
nti
on
10
Kn
ow
led
ge/a
war
en
ess
11
He
alth
sys
tem
an
d p
rovi
de
rs-
tru
st a
nd
pe
rso
nal
exp
eri
en
ce
12
Ris
k/b
en
efit
(p
erc
ieve
d,
he
uri
stic
)
13
Imm
un
izat
ion
as
a so
cial
no
rm
vs. n
ot
ne
ed
ed/h
arm
ful
14
Ris
k/B
en
efit
(sc
ien
tifi
c e
vid
en
ce)
15
Intr
od
uct
ion
of
a n
ew
vac
cin
e
or
ne
w f
orm
ula
tio
n
17
De
sign
of
vacc
inat
ion
p
rogr
am/M
od
e o
f d
eliv
ery
18
Re
liab
ility
an
d/o
r so
urc
e o
f va
ccin
e s
up
ply
19
Vac
cin
atio
n s
che
du
le
20
Co
sts
21
Ro
le o
f h
eal
thca
re
pro
fess
ion
als
Contextual Influences Individual and Group Influences Vaccine and Vaccination - specific Issues
2016 Global Reasons for Vaccine Hesitancy - Frequencies
By Country Income level: 2016
0
5
10
15
20
25
30
35
Low Income Lower Middle Income
Upper Middle Income High Income
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Focus on WPR
Top 4 reasons 2016 14 countries 1) risk/ benefit (epi & sci evidence) N=15 2) knowledge/awareness N=6 3) belief /attitude N=4 4) health systems N=3
Six Important lessons from WPR Countries’ experiences 1) hesitancy can develop quickly even in population previously high vaccine uptake 2) traditional media / social media stories can have a major impact on hesitancy; 3) suspending a vaccine program has big impact on confidence; increases hesitancy- decision must not be done in haste 4) pre-planning for crisis communication required for a timely and effective response; 5) concerns in one country may spill over to another country and are not uniform within a country ; 6) hesitancy can be assessed using surveys
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2013 media reports infant deaths due to HBV vaccine Uptake plummeted - esp if heard media reports Causality assessment – co-incidental Lessons learned: difficult to convincingly explain coincidental
events suspending a vaccine program immediately
leads to a sharp decrease in vaccine confidence; recovery of confidence can be tricky
monitoring media and parental concerns helpful for programs to understand context for parental decisions
comprehensive communication strategy important to maintain confidence in vaccines. 15
China:
Yu WZ, et al. Loss in confidence in vaccines following media reports of infant deaths after HBV vaccination in China. International Journal of Epidemiology 2016;45(2):441-449
South Korea: HPV introduction- impact –ve stories
Slower uptake than anticipated Attributed to: a) lack of parental recognition b) low perceived risk of cervical
cancer in this population c) safety concerns
Concurrent media HPV concerns a) Death post HPV vaccine in UK b) Sterility post vaccine in US c) Inability to walk post vaccine in
New Zealand All unfounded but damaging 16
Jun July 1-4wk Aug 1-4wk Sep 1-4wk Oct 1-5wk Nov 1-4wk Dec 1-5wk
Minkyung Kim, KCDC
HPV Vaccine Coverage 1st Dose by Birth Cohort In Nordic Countries
Denmark Started 2008
Sweden Norway Finland Iceland
Birth Cohort
Malaysia: Change in Hesitancy Reasons
2014, 2015
• Religious concerns #1 – “ No halal certification of vaccines”
• Concerns NOT supported by Islamic religious leaders nor by the Islamic Organization for Medical Sciences.
• Worked with Imans and other leaders locally to change understanding re halal & acceptability of vaccines
2016
Top 3 reasons
1) Practice of homeopathic medications
2) Unsure of vaccine content
3) Worry about adverse events
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Assessments informed program interventions
Australia: 2014, 2015, 2016 Top 3 Reasons given in JRF
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House of Australia
2014 1. Limited understanding or knowledge 2. Barriers to access 3. Timeliness for completing the course
2015 1. Barriers to access 2. Timeliness for completing the course 3. Concern about the safety of vaccines
2016 1. Safety of vaccines 2. Too many vaccines, too soon 3. Concerns about ingredients in vaccines
All based upon assessments
Summary Main JRF Findings: Vaccine Hesitancy
• ↑ response rate to JRF indicator questions over the 3 years
• Vaccine hesitancy: global problem <7% countries reported no hesitancy
• Reasons varied by: LIC vs LMIC vs UMIC vs HIC
WHO region
Within same country overtime
• Many responses involved risk benefit concerns BUT not only areas
Not just issues of confidence/ trust in vaccines, in program, in gov’t
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2016 GVAP Assessment report: SAGE Recommandation
# 7.
Hesitancy: Each country should develop a vaccine hesitancy management strategy and crisis response plan
• Main responsibility: Countries; other key stakeholders: WHO regional offices, RITAGs, Global NITAG Network and associated technical experts, CSOs
Shift focus from Hesitancy to Resilience
• Focus on demand and uptake
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