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Vaccine Hesitancy: an international perspective Noni MacDonald 1 , Sarah Lane 2, Melanie Marti 3 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 1

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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

1

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

3

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

4

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

5

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

7

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

9

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

Top 3 Reasons by WHO Regions: 2016

0

5

10

15

20

25

30

35

40

AMR AFR EMR EUR SEAR WPR

11

By Country Income level: 2016

0

5

10

15

20

25

30

35

Low Income Lower Middle Income

Upper Middle Income High Income

12

Global Top 3 Category of Reasons: 2014, 2015, 2016

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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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