From fear to fatwas: the data behind the growing mistrust in vaccines

Aisha Majid
A measles vaccination campaign is underway in Rockland County, New York, after a surge in the number of cases - AP

Startling figures released by the World Health Organization (WHO) on Monday showed the extent to which measles has overrun the globe in the last few months.

The data show that the number of cases of measles worldwide more than trebled in the first three months of 2019, compared to the same period in 2018, increasing from around 28,000 to 112,000 cases.

WHO is clear that stagnating vaccination rates are one of the key reasons behind the disease's resurgence.

At least 95 per cent of people need to be vaccinated against measles to stop it spreading, to achieve what is known as "herd immunity". However, from the end of 2017 just 67 per cent of people globally had received the recommended two doses of the vaccine, with coverage rates pitifully low in many places.

Yet even places with high overall coverage rates are not immune to outbreaks. With highly infectious diseases like measles, it only takes a few pockets of poor coverage within a country or a city for an outbreak to happen.

Reasons for inadequate immunisation rates vary. Some children, particularly in poor or conflict-affected countries miss out on vaccines because they do not have access to good quality healthcare. However, others are not immunised due to their parents’ eschewal of vaccines.  

Such is the concern over the rise in negative attitudes towards vaccination that the WHO earlier this year included vaccine hesitancy – the reluctance or refusal to vaccinate despite the availability of vaccines – among the 10 biggest threats to global health. Vaccines save 2.5 million lives a year but the WHO says that vaccine hesitancy threatens to reverse this progress.

Although often dubbed “the anti-vax movement”, vaccination naysayers are a disparate group including among others Orthodox Jewish mothers in Brooklyn and populist politicians in Italy. 

Yet, although what drives reluctance to vaccinate might vary from one country to the next, what’s clear is the potential vaccine hesitancy has to derail efforts to fight infectious disease.

Below we’ve pulled together six charts which reveal what vaccines have done for us, what’s driving the hesitancy and the consequences of the failure to vaccinate.

Vaccines work

The simple truth is that vaccines work. Since the development of the first vaccine against smallpox in 1796, vaccines have become one of the biggest success stories of modern medicine, slashing rates of once-common childhood diseases.

In 1980, just 17 per cent of one-year olds received the first dose of the measles vaccine. Today 85 per cent of children – four times as many – are covered. The number of children receiving the DTP3 vaccine, which protects against diphtheria, tetanus and whooping cough (or pertussis) has also quadrupled since 1980.

As a result, the number of cases of whooping cough fell more than 90 per cent from 1.97 million cases in 1980 to almost 144,000 cases in 2017. In that same time frame, the number of measles cases also fell 90 per cent from just over 3.85 million cases in 1980 to some 307,000 in 2018.

Once preventable diseases are on the march again

While the long-term picture might be positive, there’s recently been a worrying uptick in outbreaks of vaccine-preventable diseases such as mumps and measles.  

Measles has increased in every region of the world, particularly in Europe where cases more than tripled to over 82,500 cases in 2018, compared to almost 25,900 in 2017.

Immunisation rates are falling

The WHO says that reasons behind surging measles rates are complex – but inadequate immunisation rates are a major factor.

And it’s not just poor countries that are to blame.

While poverty and weak health systems means that it’s generally the poorest countries that have the lowest immunisation rates, Rwanda and Sri Lanka are examples of two lower-income countries doing better than rich countries such as the UK and France when it comes to measles vaccination.

In fact only five European Union countries have immunisation levels above herd immunity.

Since 2010 measles vaccine coverage has fallen in 12 EU states. The sharpest fall has been in Romania which has recorded around half of all measles cases in the EU since 2016. In 2017 (the latest available data) just 75 per cent of Romania’s population was immunised, compared to 93 percent in 2010.

Vaccine hesitancy is driven by many things

Reasons for inadequate vaccination rates vary from country to country.

While poor immunisation rates can be blamed on vaccine shortages and weak health systems in poorer countries, in wealthier countries failure to vaccinate is often the result of a choice not to vaccinate.

Why people choose not to vaccinate also varies from country to country, says Professor Heidi Larson who leads the Vaccine Confidence Project at the London School of Hygiene and Tropical Medicine (LSHTM).

“It’s different people in different countries with different issues,” she says.

According to a survey on views towards vaccines by LSHTM, a quarter of respondents in south-east Asian countries said that vaccines were not compatible with their religious beliefs.

Millions of parents in Indonesia for example, eschewed a measles rubella vaccine after the country’s main Islamic body declared it to be forbidden – haram – as pork is used in its production.

While religious concerns also stop some families vaccinating their children in Europe and the US, fears around the safety of vaccines are more likely to abound with much of the mistrust stemming from the theories of disgraced doctor Andrew Wakefield, who falsely alleged a link between the measles, mumps and rubella vaccine and autism.

Mistrust of experts

According to experts, a lot of vaccine hesitancy stems from general mistrust of authorities.

“A lot of it is because people are anti-government,” says Prof Larson. “People have less choice and that’s part of the resentment to vaccines. It’s less about the vaccine and more about their relationship with government.”

A recent study focused on western Europe in the European Journal of Public Health found that scepticism towards vaccines rises in line with votes for populist parties – countries with populist governments such as Italy and Greece showed the highest levels of skepticism towards vaccines.

“What links concerns about the safety of vaccines and political populism is the increasing anger and suspicion towards elites and experts,” says study author, Dr Jonathan Kennedy of Queen Mary University of London.

Online war

Much of the war against vaccines is being waged in the online space, particularly on social media, where a small group of anti-vax activists drum up fear around the safety of vaccines.  

According to Dr Myron Levine, an expert in immunology at the University of Maryland’s medical school, the truth has little value in such spaces.

“Facts don’t seem to have much impact because the true anti-vaccine fringe who create vaccine hesitancy have perfected the way they appeal to fear,” he says.

Indeed, research by Meghan Moran, an assistant professor at Johns Hopkins Bloomberg School of Public Health, looking into the tactics used by 480 anti-vaccine web pages found that over 65 per cent stoked fears – including making claims of links between vaccines and brain damage and autism.

Many also used personal stories and anecdotes to persuade parents.

“Stories and anecdotes are really really powerful and when people hear an anecdote and then make a decision they may put more weight on the anecdote than actual data,” says Prof Moran.

Prof Moran also found that notions of freedom and choice were often evoked. "People said things like ‘think for yourself, don’t be brainwashed by the government’.

"That’s another thing that’s problematic for public health officials. If someone doesn’t want to vaccinate their kids we think it’s because they don’t understand that vaccines are effective. But when [anti-vaccine sentiment] is linked to values it’s much harder to challenge. We’re asking someone to change their entire perspective and worldview," she says.

Although their beliefs might be rooted in pseudoscience or eschewal of facts, when it comes to fighting vaccine hesitancy, Dr Kennedy believes that dismissing the concerns of people wary of vaccines is ineffective.

“People write off vaccine sceptics as idiots. This is counterproductive,” he says. “We need to understand how they have constituted this view of experts as problematic.”

Prof Larson concurs. While the hardcore anti-vaxxers likely won’t be swayed, she believes there is still an opportunity to maintain confidence in vaccines among some of those that are unsure.

“It’s a mix of some reason and a lot of emotion,” she says. “We need to be much more in touch with our publics and vice versa.”

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