Ivividly remember caring for an infant with whooping cough while a student nurse in 1974. There is perhaps nothing worse in clinical nursing than seeing a child becoming more and more cyanosed and coughing and coughing until, at the point of death itself, taking a large breath and producing the fearsome whooping sound—something I never want to encounter again!
Concerns about the side effects of the pertussis vaccine in the 1970s and 1980s followed the publication of a series of clinical cases in 1974 that suggested an association between the vaccine and neurological complications. This led to a dramatic fall in vaccination uptake, which in turn caused an epidemic of the disease. During that 1974 pertussis outbreak in England and Wales there were 25 deaths among the total 25 135 whooping cough notifications (Pollock et al, 1984). Subsequent studies rejected any link between the vaccine and severe neurological diseases (Gasparini et al, 2015).
Background
It is important to stress that public fear of immunisation is as old as the history of vaccination itself. Since Edward Jenner's groundbreaking work in 1796 using lymph from cowpox blisters to immunise children against smallpox (History.com, 2018), objections to vaccination have periodically surfaced (College of Physicians of Philadelphia, 2018). Prior to Jenner's work, diseases such as smallpox affected all levels of society, irrespective of rank or privilege. In 18th century Europe, 400 000 people died annually from smallpox, and one-third of the survivors went blind. It was not until 8 May 1980 that the World Health Assembly announced that the world was free of smallpox (Riedel, 2005).
Those who watched the recent film Mary Queen of Scots will have seen Elizabeth I develop smallpox early on in the story—the queen did actually develop the disease in October 1562 and became gravely ill but survived (Ridgway, 2015). Prince Albert, the consort of Queen Victoria, died in 1861 from typhoid, a disease that can now be prevented by vaccination. Despite the obvious success of vaccines in immunising people from diseases that can kill, fear of vaccine side effects is as old as Jenner's success in preventing smallpox. Amanna and Slifka (2005) pointed out that public confidence in vaccination may diminish and that this is attributable to real or perceived risks associated with immunisation, and this in turn may lead to lower vaccination coverage and loss of herd immunity. The English town of Leicester was especially associated with public fear of smallpox vaccination and subsequently became the site of many anti-vaccine demonstrations (Charlton, 1983).
Public fear of vaccines is not confined to the past. Boddice (2016) indicated that vaccination remains stubbornly controversial in contemporary society. In recent months newspaper headlines and television news reports have frequently covered the issue. For example, The New York Times recently reported that booklets distributed in some Jewish communities in New York contradict the scientific consensus that vaccines are safe and highly effective and give false warnings that vaccines cause autism and contain cells from aborted human fetuses (Pager, 2019).
In many parts of the world different vaccines appear to engender similar fears ranging from the utterly false link between the measles, mumps and rubella (MMR) vaccine and autism in parts of North America and Europe, through to claims that tetanus vaccines are a vehicle to mask the administration of birth control agents in Kenya and Nigeria. In Afghanistan the Taliban has been strident in opposing the administration of polio vaccine because of fears that this is an attempt by the West to use the vaccine as a method of sterilising Muslim children. Undoubtedly these public fears are exacerbated by the voices of powerful people in public office with, for example, Catholic bishops in Kenya calling for a boycott of a polio vaccination campaign, citing safety concerns with the vaccine (Njeru et al, 2016).
In 1998 a study published in the Lancet by Dr Andrew Wakefield appeared to show a link between the combined MMR vaccine and autism. This publication and the media coverage it engendered further fanned the fires of public fear and led to a dangerous fall in immunisation rates, which threatened herd immunity. Infectious diseases such as measles can kill. Herd immunity protects the population of a society and this occurs when a large percentage of that population become immune to a specific infection primarily through immunisation, thereby protecting individuals who are not. Wakefield's paper led to a fall in MMR immunisation, down to 81% by 2005 (Boseley, 2010).
Wakefield's paper was later retracted by The Lancet, which went some way to alleviating the decrease in vaccination rates. Subsequently, Wakefield was found guilty by the General Medical Council of a range of unprofessional issues and he was struck off the medical register (Boseley, 2010). However Wakefield is still a prominent anti-vaccine campaigner and lives in the USA where he has the support of President Donald Trump (Buncombe, 2018).
Research conducted since Wakefield's publication has overwhelmingly rejected a link between MMR vaccination and autism in young children (Donald and Muthu, 2002). A 2012 systematic Cochrane review of the safety and effectiveness of the MMR vaccine (Demicheli et al, 2012) also rejected any significant association between MMR immunisation and diseases such as autism and should have laid the ghost of vaccine-related diseases to rest, but fears still exist.
Strategies to overcome public fears of vaccination
Successive governments, third sector charities and royal colleges, among others, recognise that members of the public, and especially parents, have fears about vaccines.
In December 2018 the Royal Society for Public Health (RSPH)—an independent health education charity—published a report aimed at promoting immunisation and allaying public fears about vaccines. Entitled Moving the Needle: Promoting vaccination uptake across the life course, this report underscores the value and importance of understanding the public's attitudes to vaccination to help maintain the uptake of vaccines (RSPH, 2018). This report shows that it is the fear of side effects of vaccines that is the primary reason for parents choosing not to vaccinate their children.
Another key player in championing vaccines is the World Health Organization (WHO), which holds its World Immunization Week during the last week of April. Its 2019 campaign encourages the uptake of vaccines among the world's populations to alleviate the burden of disease (https://tinyurl.com/y4dgpanm). WHO recognises that vaccines, which are very cost effective, are responsible for saving millions of lives every year. However, there are currently still nearly 20 million unvaccinated and under-vaccinated children in the world (WHO, 2019). Hence the WHO theme of ‘Protected Together: Vaccines Work!’ will endeavour to celebrate vaccine heroes from around the world—not just scientists and healthcare workers, but also parents and community members who work tirelessly to help their communities stay safe through immunisation.
Discussion
The WHO campaign and the RSPH report recognise that more needs to be done to allay public fears about vaccines and advocate that steps should be taken to tackle negative misconceptions. The RSPH also believes that efforts should be implemented to limit health misinformation online and via social media. It also considers that the press should do better at sharing factual information about vaccines to the public and that education on vaccines in schools should be increased. There have been unprecedented high levels of measles infections across Europe caused by a reduction in the number of MMR vaccinations, with 41 000 cases in the year up to August 2018. Similar outbreaks have occurred in the USA and the RSPH believes that some populist politicians are fuelling anti-vaccination sentiment (RSPH, 2018; Hassan and Oppel, 2019).
Recently the BBC hosted a television debate with parents about the safety of vaccines. The programme revealed that a growing number of parents are confused about whether to vaccinate their children, with many being influenced by anti-vaccine propaganda material hosted on social media. One of the key themes explored was concerns raised by parents about the accuracy and quality of information given to them about vaccines by health professionals. One of the examples cited was parental concerns about the use of aluminium in vaccines. In reality this is a very important part of the vaccine, which helps to disseminate the active ingredients. The concentration of the aluminium in vaccines is very low and only a small percentage of what occurs in the natural environment. Reassuring information such as this is rarely given to parents and it is easy to understand how insignificant aspects of immunisation such as this become magnified in the minds of many parents. The programme also exposed the fact that information leaflets in vaccine packaging are not always offered to parents before the immunisation injections (Gatenby, 2019)
Social media company Facebook has announced that it is working to address vaccine misinformation on its pages by providing readers with authoritative information. The media company will not show or recommend content that contains misinformation about vaccinations on Instagram Explore or hashtag pages (Bickert, 2019).
Recently, health secretary Matt Hancock said he has not ruled out the possibility of banning non-vaccinated children from UK schools (Blanchard and Thompson, 2019). Even Trump has now recommended vaccinations for measles, following outbreaks in many US states (BBC News, 2019).
Combatting vaccine misinformation should be a priority for all health professionals.