This is the third instalment of Paula Jardine’s six-part investigation into the planning behind ensuring vaccine acceptance and countering vaccine ‘hesitancy’. You can read Part 1, published on Wednesday, here, and Part 2, published yesterday, here.
IN 2018 the Wellcome Trust reported that vaccine scepticism is highest in high income industrialised countries where over 80 per cent of all global vaccine sales occur. Months before Covid-19 was declared a Public Health Emergency, the World Health Organisation had listed vaccine hesitancy as one of ten threats to global health, threatening to reverse progress made in tackling vaccine-preventable diseases: ‘Given that the majority of parents accept vaccines, pro-vaccine messages may be needed to reinforce and support positive sentiment and help prevent emerging hesitancy from expanding.’
In fact they had been working for years trying to shore up positive sentiments, in 2003 establishing the WHO endorsed global network of websites called the Vaccine Safety Net to provide ‘trustworthy’ information to ‘counterbalance websites that provide unbalanced, misleading and alarming information on vaccine safety’.
A decade later, in 2013, this counterbalancing programme had not proved enough for some. David Ropeik, who taught risk communication at Harvard School of Public Health, chillingly said, ‘What’s dangerous about widely broadcast vaccine debates, in a sense, is the debate itself: by putting out misleading information to people with little fundamental understanding of the performance and value of vaccines, the anti-vaccine movement and its social media echo chambers create doubt when, in fact, there is not a true scientific debate.’
So certain was Ropeik of the absence of a debate that he called for punitive measures, including restricting the ability of the unvaccinated to participate fully in community activities, to be used as a means of achieving full vaccination, long before Covid saw countries introduce such restrictions by way of vaccine passes.
Dr Emily Brunson, an anthropologist who like Dr Heidi Larson, referred to yesterday, studies vaccine confidence issues, was less absolutist than Ropeik. ‘I think we need to avoid the trap of thinking that information or knowledge is enough, because for a lot of the people, and when you look at hesitancy and parental vaccine hesitancy in the US, the group who is most likely to purposefully choose to not vaccinate are highly educated . . . these are people who have read the primary literature themselves, and they’re correctly interpreting it, so it’s not a misunderstanding. They have other concerns that go beyond the traditional public health message of “This is what you should be doing”.’
Communications strategies that are ‘vaccine positive’ and developed with input from the vaccine confidence teams are disseminated around the world today. Larson and Brunson were both members of the expert panel convened by the US National Institute of Health (NIH) to develop communications guidance as the Covid-19 vaccines rollout under emergency use authorisations began. They both contributed to a Vaccine Communications Principles guide published by the Centre for Public Interest Communications which describes its mission as ‘building communications strategies for the common good’.
Larson was also a member of the WHO Scientific Advisory Group of Experts (SAGE) working group on vaccines that developed a model to address hesitancy based on what it calls the three Cs: confidence, complacency and convenience. The key to confidence, they observed, lies with health workers, who are trusted by the public and able to influence vaccination decisions.
Over recent years, seasonal and pandemic influenza vaccine uptake has become the bellwether for vaccine confidence amongst health care workers. One lesson learned from the 2009 swine flu pandemic was that many of these workers began to exhibit less than universal enthusiasm for vaccines. In the United States fewer than half accepted the swine flu vaccine. Of course, if they were not taking the vaccines themselves, they couldn’t be relied upon as recruiting sergeants for the War on Microbes. Some needed more than education, they needed pressganging. So health departments and employers began mandating vaccines as a pre-condition of employment. Others stopped short of mandates, requiring instead that unvaccinated staff wear masks so that they could be more easily identified.
In England, where annual flu vaccine uptake by NHS staff hovers around 64 per cent overall with a wide variation in uptake between trusts, a different ‘inducement’ approach was introduced. In 2016, NHS England began offering financial incentives to the trusts linked to the number of staff inoculated. Behavioural modification tactics courtesy of the behavioural psychologists were deployed including ‘social norming’, that is creating peer pressure to make people think ‘if everyone else is doing it, I should too’. As NHS England explains, ‘Even something as simple as a sticker to show they have had their jab can be worn as a sign of pride and signal to others that they should have the flu vaccination.’
Whether volunteers or conscripts for the War on Microbes, the job of these trusted voices is to sell to the public products that are meant to be a long-term investment in their own health or their children’s health. The 2019 Global Vaccination Summit said more could be done to support them to provide ‘trusted, credible information on vaccines’ by giving more prominence to vaccination and communication skills in medical curricula and by increasing continuing professional training on vaccination issues.
The question is, what exactly are they being taught?