WHAT IS VACCINE HESITANCY? Also known as anti-vaccination or anti-vax, vaccine hesitancy is a reluctance (or refusal) to be vaccinated or to have one's children vaccinated against contagious diseases — despite the availability of vaccination services. Healthcare workers encounter patients who have reservations about getting vaccinations for themselves or their children. [Sources: WHO and FDA]
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ANTI-VACCINE CAMPAIGNERS: It's the scourge of modern, instant communication. Disinformation, fear-mongering and misconceptions hyper-shared on social media, and becoming viral. Coupled with confirmation bias (seeking only the information one believes in), and algorithmic promotion, it’s the noisiest bunch that’s often heard loud and clear. There’s a fringe community of people trashing vaccines as a whole, citing non-existent “evidence” – and driving up vaccine hesitancy.
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GROWING OPPOSITION TO VACCINES? The World Health Organisation (WHO) defines vaccine hesitancy as a “delay in acceptance or refusal of vaccines despite availability of vaccination services. Based on studies of social networks, it emerges that opposition to vaccines is small but far-reaching — and growing. Photo shows anti-vaccine activists joining hundreds of protesters at the Capitol in Olympia, Washington, on April 19, 2020 to protest the state's stay-at-home order.
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ACHIEVING HERD IMMUNITY: The Lancet reports that vaccine hesitancy exists in more than 90% of countries in the world. In many areas, immunisation for measles, a vaccine-preventable disease that was largely eliminated following widespread use of the measles-mumps-rubella (MMR) vaccine, has decreased to less than the 95% threshold set by WHO as that required for herd immunity.
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ORAL POLIO VACCINE: A child at a camp in Nigeria gets an oral polio vaccine. The US CDC and the WHO listed six common misconceptions parroted by anti-vaxxers about immunisation. A guide was published by medical practitioners giving vaccinations to children in their practices. Following are the misconceptions, and aswers:
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#1 MISCONCEPTION: "Diseases had already begun to disappear before vaccines were introduced, because of better hygiene and sanitation.” The message behind this claim: that vaccines are not needed.
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[RESPONSE A to #1]: This is a common, but unproven “fact” that the anti-vaccine camp cites. Modern life, with improved socioeconomic conditions, lower birth rates, antibiotics and other treatments, have increased survival rates among the sick. However, the actual incidence of disease leaves little doubt of the significant direct impact vaccines have had, even in modern times. For example, a permanent drop in measles incidence directly correlated with the licensure and wide use of measles vaccine beginning in 1963. The same thing with polio, pertussis, measles, diphtheria and other vaccine-treatable disease. Photo shows a child with smallpox (left). Edward Jenner, an English physician and scientist, invented the smallpox vaccine.
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[RESPONSE B to #1]: When several developed countries (UK, Sweden and Japan), allowed their immunisation levels for pertussis (whooping cough) to drop because of fear about the vaccine, the effect was dramatic and immediate. In the UK, a drop in pertussis vaccination in 1974 was followed by an epidemic of more than 100,000 cases of pertussis and 36 deaths by 1978. In Japan, around the same time, a drop in vaccination rates from 70% to 20%-40% led to a jump in pertussis from 393 cases and no deaths in 1974 to 13,000 cases and 41 deaths in 1979. In Sweden, the annual incidence rate of pertussis per 100,000 children of 0-6 years of age increased from 700 cases in 1981 to 3,200 in 1985. It’s a clear indication that if the world were to stop vaccinating, such diseases would come back. [Data: CDC/WHO]
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[RESPONSE C to #1]: In Russia, major epidemics of diphtheria broke out (in the former Soviet Union) in the 1990s. The main culprits: low primary immunisation rates for children and the lack of booster vaccinations for adults. The result: an increase from 839 cases in 1989 to nearly 50,000 cases and 1,700 deaths in 1994.
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#2 MISCONCEPTION: “The majority of people who get disease have been vaccinated.” The message behind this claim: This proves vaccines don’t work.
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[RESPONSE A to #2]: It is true that in an outbreak, those who have been vaccinated often outnumber those who have not — even with vaccines such as measles, known to be about 98% effective when used as recommended. Two factors explain this apparent paradox. First, no vaccine is 100% effective. To make vaccines safer than the disease, the bacteria or virus is killed or weakened (attenuated). For reasons related to the individual, not all vaccinated persons develop immunity. Most routine childhood vaccines are effective for 85% to 95% of recipients. Second, in certain countries, the people who have been vaccinated vastly outnumber those who have not.
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[RESPONSE B to #2]: Looking at a hypothetical example: In a high school of 1,000 students, none has ever had measles. All but five of the students have had two doses of measles vaccine, and so are fully immunised. The entire student body is exposed to measles, and every susceptible student becomes infected. Naturally, the 5 unvaccinated students will be infected. But of the 995 who have been vaccinated, we would expect several not to respond to the vaccine. The efficacy rate for two doses of measles vaccine can be as high as >99%. In this class, seven students do not respond, and they, too, become infected. Therefore seven of 12 (including the 5 who were unvaccinated) or about 58%, of the cases occur in students who have been fully vaccinated, according to the CDC.
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[RESPONSE C TO #2]: This doesn't prove the vaccine didn't work — only that most of the children in the class had been vaccinated, so those who were vaccinated and did not respond outnumbered those who had not been vaccinated. Looking at it another way, 100% of the children who had not been vaccinated got measles, compared with less than 1% of those who had been vaccinated. Measles vaccine protected most of the class; if nobody in the class had been vaccinated, there would probably have been 1,000 cases of measles. Photo shows a child with measles.
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MISCONCEPTION #3: "There are ‘hot lots’ of vaccine that have been associated with more adverse events and deaths than others. Parents should find the numbers of these lots and not allow their children to receive vaccines from them.” The message behind this claim: the more reports of adverse events a vaccine lot is associated with, the more dangerous the vaccine in that lot; that by consulting a list of the number of reports per lot, a parent can identify vaccine lots to avoid.
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[RESPONSE A TO #3]: This argument gets a lot of media attention. First of all, the concept of a "hot lot" of vaccine as it is used in this context is wrong. This is misleading for two reasons: One, an adverse report following vaccination does not mean that the vaccine caused the event. Statistically, a certain number of serious illnesses, even deaths, can be expected to occur by chance alone among children recently vaccinated. Second, although vaccines are known to cause minor, temporary side effects such as soreness or fever, there is little, if any, evidence linking vaccination with permanent health problems or death. The point is that just because an adverse event has been reported by the surveillance system, it does not mean it was caused by a vaccine.
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[RESPONSE B TO #3]: Vaccine lots are not the same. The sizes of vaccine lots might vary from several hundred thousand doses to several million, and some are in distribution much longer than others. Naturally a larger lot or one that is in distribution for a longer period will be associated with more adverse events, simply by chance.
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[RESPONSE C TO #3]: Also, more coincidental deaths are associated with vaccines given in infancy than later in childhood, as the “background death rates” for children are highest during the first year of life. So knowing that lot A has been associated with X number of adverse events while lot B has been associated with Y number would not necessarily say anything about the relative safety of the two lots, even if the vaccine did cause the events. The Who said that all vaccines purchased through the UNICEF vaccine procurement system meet World Health Organization standards for safety and quality of production.
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MISCONCEPTION #4: “Vaccines cause many harmful side effects, illnesses, even death — and possible long-term effects we don't even know about.”
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[RESPONSE A TO #4]: Vaccines are actually very safe, despite implications to the contrary in many anti-vaccine literature. Most vaccine adverse events are minor and temporary, such as a sore arm or mild fever. These can often be controlled by taking paracetamol after vaccination. More serious adverse events occur rarely (on the order of one per thousands to one per millions of doses), and some are so rare that risk cannot be accurately assessed.
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[RESPONSE B TO #4]: As for vaccines causing death, so few deaths can plausibly be attributed to vaccines that it is hard to assess the risk statistically. Each death reported to ministries of health is generally thoroughly examined to assess whether it is really related to administration of vaccine, and if so, what exactly is the cause. When, after careful investigation, an event is felt to be a genuine vaccine-related event, it is most frequently found to be a programmatic error, not related to vaccine manufacture.
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[RESPONSE C TO #4]: One myth that won't seem to go away is that Diphtheria-tetanus-pertussis (DTP) vaccine causes sudden infant death syndrome (SIDS). This belief came about because a moderate proportion of children who die of SIDS have recently been vaccinated with DTP; on the surface, this seems to point toward a causal connection. However, this logic is faulty — it’s like saying eating bread causes car crashes, as most drivers who crash their cars could probably be shown to have eaten bread within the past 24 hours. CDC pointed out that in several, children who had recently received a DTP shot were less likely to get SIDS. The Institute of Medicine reported that "all controlled studies that have compared immunised versus non-immunized children have found either no association ... or a decreased risk ... of SIDS among immunized children" and concluded that "the evidence does not indicate a causal relation between [DTP] vaccine and SIDS." When a number of well-controlled studies were conducted during the 1980s, the investigators found, nearly unanimously, that the number of SIDS deaths temporally associated with DTP vaccination was within the range expected to occur by chance. In other words, the SIDS deaths would have occurred even if no vaccinations had been given.
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MISCONCEPTION #5: ”Vaccine-preventable diseases have been virtually eliminated from my country, so there is no need for my child to be vaccinated.” [RESPONSE A TO #5]: In many countries, vaccination has enabled us to reduce most vaccine-preventable diseases to very low levels. Take polio for example. There was a time, when thousands of people young and old were affected by polio, including a US president. You don’t hear much about polio-afflicted children today, thanks to polio shots. However, some disease are still quite prevalent — even epidemic — in other parts of the world. Travellers can unknowingly bring these diseases into any country, and if the community were not protected by vaccinations, these diseases could quickly spread throughout the population, causing epidemics there.
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[RESPONSE B TO #5]: The relatively few cases of an infectious disease that a country may currently have could very quickly become tens or hundreds of thousands of cases — without the protection given by vaccines. We should therefore still be vaccinated, for two reasons. The first is to protect ourselves. Even if we think our chances of getting any of these diseases are small, the diseases still exist and can still infect anyone who is not protected. The second is to protect those around us.
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[RESPONSE C TO #5]: There is a small number of people who cannot be vaccinated (because of severe allergies to vaccine components, for example), and a small percentage of people don't respond to vaccines. These people are susceptible to disease, and their only hope of protection is that people around them are immune and cannot pass disease on to them. A successful vaccination program, like a successful society, depends on the cooperation of every individual to ensure the good of all. We would think it irresponsible of a driver to ignore all traffic regulations on the presumption that other drivers will watch out for him or her. In the same way we shouldn't rely on people around us to stop the spread of disease; we, too, must do what we can.
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MISCONCEPTION #6: "Giving a child multiple vaccinations for different diseases at the same time increases the risk of harmful side effects and can overload the immune system". [RESPONSE A TO #6]: Children are exposed to many foreign antigens every day. Eating food introduces new bacteria into the body, and numerous bacteria live in the mouth and nose, exposing the immune system to still more antigens. An upper respiratory viral infection exposes a child to four to ten antigens, and a case of "strep throat" to 25 - 50. According to "Adverse events Associated with childhood vaccines", a 1994 report from the US Institute of Medicine: "In the face of these normal events, it seems unlikely that the number of separate antigens contained in childhood vaccines ... would represent an appreciable added burden on the immune system that would be immuno-suppressive.”
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[RESPONSE A to #6]: Children are exposed to many foreign antigens every day. Eating food introduces new bacteria into the body, and numerous bacteria live in the mouth and nose, exposing the immune system to still more antigens. An upper respiratory viral infection exposes a child to four to ten antigens, and a case of "strep throat" to 25 - 50. According to "Adverse events Associated with childhood vaccines", a 1994 report from the US Institute of Medicine: "In the face of these normal events, it seems unlikely that the number of separate antigens contained in childhood vaccines ... would represent an appreciable added burden on the immune system that would be immuno-suppressive.”
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[RESPONSE B to #6]: Available scientific data show that simultaneous vaccination with multiple vaccines (multivalent) has no adverse effect on the normal childhood immune system. A number of studies and reviews have been conducted to examine the effects of giving various combinations of vaccines simultaneously. These studies have shown that the recommended vaccines are as effective in combination as they are individually —and that such combinations carry no greater risk for adverse side effects. Research is under way to find ways to combine more antigens in a single vaccine injection (for example, measles, mumps, rubella (MMR) and chickenpox). This will provide all the advantages of the individual vaccines, but will require fewer shots.
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[RESPONSE C to #6]: Giving several vaccinations at the same time will mean fewer clinic visits for vaccinations, which saves parents both time and money and may be less traumatic for the child. In countries where there is a likelihood of reduced contact with the health care system, there is an added advantage of ensuring that there are no missed opportunities to complete the recommended vaccinations for a child.
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