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Catching the anti-vax bug

05 June 2019

As concern grows about the spread of measles worldwide and the role of social media in sharing misinformation on immunisation, journalist Juliette Astrup looks at the scale of the problem and what can be done to combat the anti-vax movement.

Vaccine hesitancy, the reluctance or refusal to vaccinate, was among the WHO’s top 10 threats to global health in 2019 (WHO, 2019), and its effects are already being felt.

An estimated 169 million children worldwide missed out on the first dose of the measles vaccine between 2010 and 2017, according to the latest figures (UNICEF, 2019). Among high-income nations, the UK has the third highest number of children potentially at risk, with more than 500,000 missing out on this first dose over the past eight years, behind only the US and France, with more than 2.5 million and 600,000 respectively (UNICEF, 2019).

It is no surprise then that the numbers of measles cases are rising dramatically. In the first three months of 2019, more than 110,000 incidents were reported worldwide – up nearly 300% from the same period last year. An estimated 110,000 people – most of them children – died from measles in 2017, 22% more than the year before (UNICEF, 2019).

UK Coverage and outbreaks

These trends are being reflected here in the UK: while overall vaccination coverage remains high, uptake is falling across all four nations. In some cases it is below the 95% rate needed to achieve ‘herd immunity’ (Information Services Division Scotland, 2019; Public Health Agency, 2019a; NHS Digital, 2018; Public Health Wales, 2018).

In England, where MMR vaccination coverage among children reaching their second birthday is now 91% – with just 87% receiving the second dose by their fifth birthday (NHS Digital, 2018) – there has been a sharp rise in the number of measles cases, increasing from 259 in 2017 to 966 last year (Public Health England (PHE), 2019a).

Wales, too, has seen a couple of outbreaks since 2017, thought to be linked to the outbreaks in Europe (Public Health Wales, 2018), while Scotland saw just two cases in the last year (Health Protection Scotland, 2018) and Northern Ireland had no confirmed cases (Public Health Agency, 2019b).

The bottom line is that vaccines prevent disease and ultimately save lives – the WHO estimates vaccination programmes prevent two million to three million deaths a year (WHO, 2019). It follows then that vaccine hesitancy puts children and wider society at risk. So, what is going on? Is the so-called anti-vax movement to blame?

The spread of anti-vax messages

An advisory group identified complacency, inconvenience and a lack of confidence as the key factors underlying hesitancy

The sharing of misinformation and anti-vaccine sentiments on the internet no doubt has had a significant role to play. A recent UK survey found two in five parents are exposed to negative messages about vaccines on social media, rising to half of parents of under-fives. And across a range of vaccines, including MMR, HPV and flu, fear of side effects was the most common reason for choosing not to vaccinate (Royal Society for Public Health, 2018).

Shirley Cramer, chief executive of the Royal Society for Public Health, points the finger at social media for the spread of such fears. ‘With the rise of social media, we must guard against the spread of “fake news” about vaccinations,’ she says. ‘We have found worrying levels of exposure to negative messages about vaccinations on social media, and the spread of misinformation – if it impacts uptake of vaccines – could severely damage the public’s health.’

NHS England’s chief executive Simon Stevens has been even more vocal in his condemnation. He called vaccine rejection ‘a serious and growing public health timebomb,’ adding: ‘With measles cases almost quadrupling in England in just one year, it is grossly irresponsible for anybody to spread scare stories about vaccines. Social media firms should have a zero-tolerance approach towards this dangerous content.’

In an effort to combat ‘verifiable vaccine hoaxes’ posted on Instagram, Facebook recently announced that it ‘won’t show or recommend content that contains misinformation about vaccinations on Instagram Explore or hashtag pages’ (Facebook, 2019).

The government is now looking closely at how to tackle this issue (Twitter, 2019), but even if the voices of anti-vaxxers could be silenced, would it be the magic bullet to reverse the trend?

The truth is that the reasons people choose not to vaccinate are complex. A vaccines advisory group to WHO identified complacency, inconvenience in accessing vaccines and a lack of confidence as the key factors underlying hesitancy (WHO, 2019). And while ‘anti-vaxxers’ is the label given in the press, the movement is far from a coordinated effort or even a coherent one – so to unite them under one umbrella term is perhaps unhelpful.

Some commentators have even likened the anti-vax movement to the rise of populism and the general mistrust of the establishment, but if – as MP Michael Gove famously put it – we have ‘had enough of experts’ (YouTube, 2016), how can the robust, evidence-based arguments for vaccination be heard above the noise?

Expert advice?

The good news is that the general public do still place a real value on the advice of medical professionals, such as health visitors and school nurses. A poll of 1674 parents by PHE found that 93% had confidence in the information on vaccinations given by healthcare professionals. And, while almost one in 10 parents said they had seen information in the past year that made them question whether to vaccinate their child, the survey found the least trusted sources were the internet, social media and Facebook (PHE, 2019b).

Chief executive of PHE Duncan Selbie believes that frontline healthcare professionals – who he calls ‘vaccine heroes’ – have a key role to play: ‘In a world where misinformation is so easily spread online, we must all speak confidently about the value of vaccines and leave the public in no doubt that they are safe and save lives.’

Indeed, research has found that parents who trust the information given to them by health professionals are most likely to have their children vaccinated at the scheduled age (Campbell et al, 2017). Health visitors are well placed to be those trusted professionals who are ‘speaking confidently’ to reassure parents, as reflected in the guidelines (Public Health Wales, 2016).


What the public health agencies say

Public Health England

Health visitors play an important role in discussing immunisation with parents, for example, during the mandated visits at 10 to 14 days and six to eight weeks

David Green, nurse consultant for immunisations, PHE, says: ‘We carefully look at anything that may have an impact on uptake. Inaccurate claims about safety and effectiveness can lead to doubts about vaccines, putting people at risk of serious illness. It’s vital that all websites and social media platforms ensure accurate coverage of public health issues like vaccination.

‘But we also know that there are other factors that affect vaccine uptake, such as sending out reminders, making immunisation appointments as convenient as possible, and ensuring healthcare workers promote vaccines to parents and encourage their uptake. These things will make the biggest difference in promoting vaccine confidence and reducing the number of children not getting vaccinated.’

He adds: ‘Health visitors play an important role in discussing timely immunisation with parents and answering questions, for example, during the mandated visits at 10 to 14 days and six to eight weeks. School nurses and school immunisation teams are vital to the ongoing success of teenage immunisation programmes against HPV, MenACWY and Td/IPV. Such sessions may also provide an opportunity to assess immunisation and offer catch up doses of missing vaccines, for example, MMR.’

Public Health Wales

Anne McGowan, nurse consultant at Public Health Wales, says: ‘Vaccine hesitancy is nothing new. There has always been a small minority of people who don’t get vaccinated on time. The evidence suggests the reasons people delay vaccination are multifactorial and include social deprivation and access. The number of vaccine refusers is really very small compared to those hard-to-reach people who might take longer to get vaccinations but get there in time.

‘We want to do everything possible to ensure children are protected at the earliest opportunity. We ensure that the public are supported with the facts, and we are increasing signposting and developing the more detailed information that some people want, as well as providing it in the formats that people want.

‘It is vital the public have the information they need to make an informed choice, and the role of health visitors and school nurses is critical in that. We know that healthcare professionals are a trusted source of information. Health visitors and school nurses are having those conversations with parents and with young people, listening to them, responding to their concerns and helping them move toward a decision to get vaccinated.’

Health Protection Scotland

A spokeswoman for Health Protection Scotland says that as well as ensuring ‘all those involved in giving or discussing immunisation are themselves well informed and supported… communicating with patients and parents is an incredibly important part of ensuring high vaccine uptake’. Channels include the WHO-accredited Scottish National Immunisation website, and a Twitter account, ‘which aims to improve the reach of clear and correct information about vaccines, their safety and impact, as we know the role of social media cannot be underestimated.

‘Everyone who works with patients and parents needs to be well-informed about immunisation. We all have a potential role in answering questions from patients and parents, and signposting the public and patients to reliable, up-to-date information on vaccines.’

Public Health Agency in Northern Ireland

Dr Jillian Johnston, consultant in health protection at the Public Health Agency, says: ‘The childhood vaccination programme has been a tremendous success, with Northern Ireland having uptake rates well above the UK average. However, some vaccines have seen a decline in uptake, albeit a small one.

‘Some could argue that the immunisation programme has been a victim of its own success. People may have forgotten or have never had the experience in their lifetime of seeing the devastation that measles, polio or whooping cough can have on a community, and some have perhaps become complacent about getting their kids protected against these illnesses.

‘But it is only when people continue to get their children and themselves vaccinated in large numbers that we can prevent these diseases, and the possible deaths, so it is vitally important that we don’t take our health and that of our children for granted.’


Deconstructing concerns

But can they stem the tide of anti-vax views one person at a time?

Gavin Fergie, lead professional officer for health at Unite, says: ‘I think everyone will have at least one or two families on their caseloads who have such views because they are so widespread now.

‘As practitioners, they are the key point of information and they will be having those conversations about the vaccination schedule during appointments.

‘Parents will have questions, but it isn’t about being dogmatic and saying “I am right and you are wrong”, because that just won’t work. It’s about building up a positive relationship, listening to their legitimate concerns and helping them, trying to find out why they feel that way, then trying to deconstruct those concerns and build up their knowledge base to a more positive place.

‘Unfortunately, sometimes practitioner numbers are so low and the pressure so intense they don’t have the time they need to have those conversations. Fewer people with the right experience and expertise means other parts of the system begin to degrade, and that may well be immunisations. If we don’t have people in post who are able to advocate for immunisation, that’s part of the problem as well.

‘But we don’t have a coercive culture in our society. There are no sanctions for a family if, ultimately, even after those conversations, they decide not to immunise their child. It can be very difficult, but we have to ensure our personal ethics don’t impinge on our ability to practise. It’s a great shame but, ultimately, we have to swallow that.’

A carrot and stick approach?

While, for now at least, the UK has stopped short of sanctions, other countries have crossed that threshold. Italy, for example, has introduced a law that bars children under six from attending school unless their parents can prove they have been immunised, and such is the concern over measles in New York that a public health emergency was declared in April, with residents in certain parts of Brooklyn warned to get vaccinated or face a fine.

But a study by Australian researchers exploring the moral profiles of vaccination attitudes found that coercive measures aimed at forcing parents to allow vaccinations may actually be counterproductive. They could push those ‘on the fence’ further into the refusal camp by undermining their trust and challenging their strong belief in parents’ rights. The authors caution against the use of ‘adversarial approaches… that promote vaccination uptake by restricting parental freedoms, as they may backfire’ (Rossen et al, 2019).

With the obvious ‘carrot’ of protecting a child from disease not proving compelling for all parents, and with no recourse to the ‘stick’ of sanctions, are we at risk of being overrun by the anti-vax message?

It is true that worries and fears about vaccinations appear to be catching, and the spread of them online doesn’t look set to stop any time soon, but there is still hope in the power of health professionals to reach people with evidence-based information. For some parents, these conversations with a trusted practitioner could well be the inoculation they need to protect them against the misinformation and scare stories they’re being exposed to elsewhere.


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References

 

Campbell H, Edwards A, Letley L, Bedford H, Ramsay M, Yarwood J. (2017) Changing attitudes to childhood immunisation in English parents. Vaccine. 19;35(22):2979-2985. See https://www.ncbi.nlm.nih.gov/pubmed/28442229 (accessed 16 May 2019).

Facebook. (2019) Combatting Vaccine Misinformation. See https://newsroom.fb.com/news/2019/03/combatting-vaccine-misinformation/ (accessed 16 May 2019).

Health Protection Scotland. (2018) Measles: Surveillance update for 2018. See https://www.hps.scot.nhs.uk/a-to-z-of-topics/measles/ (accessed 16 May 2019).

Information Services Division. (2019) Childhood Immunisation Statistics Scotland, Quarter and year ending 31 December 2018. See https://www.isdscotland.org/Health-Topics/Child-Health/Publications/2019-03-26/2019-03-26-Childhood-Immunisation-Report.pdf (accessed 16 May 2019).

NHS Digital. (2018) Childhood Vaccination Coverage Statistics – England 2017-18. See https://digital.nhs.uk/data-and-information/publications/statistical/nhs-immunisation-statistics/england-2017-18 (accessed 16 May 2019).

Public Health Agency. (2018) Annual Immunisation Report for Northern Ireland 2017-18. See https://www.publichealth.hscni.net/sites/default/files/2019-01/Annual%20Immunisation%20Report%20for%20NI%202017-18_0.pdf (accessed 16 May 2019).

Public Health Agency. (2019) Annual Vaccine Preventable Diseases Report for Northern Ireland 2019. See https://www.publichealth.hscni.net/sites/default/files/2019-05/Annual%20VPDs%20Report%20for%20NI%202019%20%282018%20data%29.pdf (accessed 16 May 2019).

Public Health England. (2019) Laboratory-confirmed cases of measles, rubella and mumps, England: October to December 2018. See https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/791349/hpr0819_mmr.pdf (accessed 16 May 2019).

Public Health England. (2019) PHE offers support to UK vaccine heroes. See https://www.gov.uk/government/news/phe-offers-support-to-uk-vaccine-heroes (accessed 16 May 2019).

Public Health Wales. (2016) All Wales Health Visitor good practice guidelines for the follow up of preschool children who are outstanding routine immunisations. See http://www2.nphs.wales.nhs.uk:8080/VaccinationsImmunisationProgsDocs.nsf/($All)/76E3103811494AE480257FE7002A200A/$File/All%20Wales%20HV%20good%20practice%20%20for%20the%20follow%20up%20of%20outstanding%20preschool%20i.docx?OpenElement (accessed 16 May 2019).

Public Health Wales. (2018) Vaccine Uptake in Children in Wales COVER Annual Report 2018 Data for the year ending 31st March 2018. See http://www2.nphs.wales.nhs.uk:8080/CommunitySurveillanceDocs.nsf/3dc04669c9e1eaa880257062003b246b/0d6a10b603497f9f8025829c002c9d61/$FILE/COVER20172018_v1b.pdf (accessed 16 May 2019).

Rossen I, Hurlstone MJ, Dunlop PD, Lawrence C. (2019) Accepters, fence sitters, or rejecters: Moral profiles of vaccination attitudes. Social Science and Medicine. Mar;224:23-27. See https://www.sciencedirect.com/science/article/abs/pii/S0277953619300395?via%3Dihub (accessed 16 May 2019).

Royal Society for Public Health. (2019) Moving the Needle: Promoting vaccination uptake across the life course. See https://www.rsph.org.uk/our-work/policy/vaccinations/moving-the-needle-promoting-vaccination-uptake-across-the-life-course.html (accessed 16 May 2019).

Twitter. (2019) Vaccines protect us and our children from awful diseases – Social Media companies must act to stop dangerous anti-vax messages spreading online. See https://twitter.com/matthancock/status/1121395202932060160 (accessed 16 May 2019).

UNICEF. (2019) Over 20 million children worldwide missed out on measles vaccine annually in past 8 years, creating a pathway to current global outbreaks – UNICEF. See https://www.unicef.org/laos/press-releases/over-20-million-children-worldwide-missed-out-measles-vaccine-annually-past-8-years (accessed 16 May 2019).

WHO. (2019) Ten threats to global health in 2019. See https://www.who.int/emergencies/ten-threats-to-global-health-in-2019 (accessed 16 May 2019).

YouTube. (2016) Gove: Britons "Have Had Enough of Experts". See https://www.youtube.com/watch?v=GGgiGtJk7MA (accessed 16 May 2019).

 

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