Mains Article

Vaccine hesitancy [Mains Article]

Vaccine hesitancy is threatening the historical achievements made in reducing the burden of infectious diseases, which have plagued humanity for centuries. Only a collaborative effort between family doctors, parents, governments and civil society will allow myths around vaccination to be dispelled.
By IT's Mains Articles Team
September 27, 2019


  • Why it was in News?
  • What is Vaccine hesitancy?
  • WHO Ten threats to global health in 2019
  • Measles vaccine hesitancy
  • Factors influencing Vaccine hesitancy
  • Suggestions
  • Conclusion

Vaccine hesitancy

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Why it was in News?


  • With a 30% increase in measles cases worldwide in 2018, the World Health Organization, in January 2019, included ‘vaccine hesitancy’ as one of the 10 threats to global health in 2019.

What is Vaccine hesitancy?

  • Vaccine hesitancy refers to delay in acceptance or refusal of vaccines despite availability of vaccination services.

WHO Ten threats to global health in 2019


Air pollution and climate change

  • In 2019, air pollution is considered by WHO as the greatest environmental risk to health.
  • Around 90% of these deaths are in low- and middle-income countries.
  • In October 2018, WHO held its first ever Global Conference on Air Pollution and Health in Geneva.

Noncommunicable diseases

  • Noncommunicable diseases, such as diabetes, cancer and heart disease, are collectively responsible for over 70% of all deaths worldwide.
  • Over 85% of these premature deaths are in low- and middle-income countries.
  • The rise of these diseases has been driven by five major risk factors: tobacco use, physical inactivity, the harmful use of alcohol, unhealthy diets and air pollution.

Global influenza pandemic

  • Every year, WHO recommends which strains should be included in the flu vaccine to protect people from seasonal flu.

Fragile and vulnerable settings

  • More than 22% of the global population live in places where protracted crises (through a combination of challenges such as drought, conflict, and population displacement) and weak health services leave them without access to basic care.
  • Fragile settings are where half of the key targets in the sustainable development goals, including on child and maternal health, remains unmet.

Antimicrobial resistance

  • Antimicrobial resistance is the ability of bacteria, parasites, viruses and fungi to resist the medicines. The inability to prevent infections could seriously compromise surgery and procedures such as chemotherapy.

Ebola and other high-threat pathogens

  • In 2018, the Congo saw two separate Ebola outbreaks, both of which spread to cities of more than 1 million people.
  • At a conference on Preparedness for Public Health Emergencies held in 2018 December called for designating 2019 as a “Year of action on preparedness for health emergencies”.
  • WHO’s R&D Blueprint identifies diseases that have potential to cause a public health emergency but lack effective treatments. This watch list for priority research includes Ebola, Zika, Nipah, Middle East respiratory syndrome coronavirus (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS) and disease X, which represents the need to prepare for an unknown pathogen that could cause a serious epidemic.

Weak primary health care

  • Primary health care can meet the majority of a person’s health needs of the course of their life. Yet many countries do not have adequate primary health care facilities.
  • This neglect may be a lack of resources in low- or middle-income countries, but possibly also a focus in the past few decades on single disease programmes.
  • In 2018, WHO co-hosted a major global conference in Astana, Kazakhstan at which all countries committed to renew the commitment to primary health care made in the Alma-Ata declaration in 1978.

Vaccine hesitancy

  • The reasons why people choose not to vaccinate are complex. Inconvenience in accessing vaccines and lack of confidence are key reasons underlying hesitancy.


  • Dengue has been a growing threat for decades. A high number of cases occur in the rainy seasons of countries such as Bangladesh and India.
  • Now, its season in these countries is lengthening significantly and the disease is spreading to less tropical and more temperate countries such as Nepal, that have not traditionally seen the disease.
  • An estimated 40% of the world is at risk of dengue fever. WHO’s Dengue control strategy aims to reduce deaths by 50% by 2020.


  • HIV kills nearly a million people every year.
  • A group increasingly affected by HIV are young girls and women (aged 15–24), who are particularly at high risk and account for 1 in 4 HIV infections in sub-Saharan Africa despite being only 10% of the population.

Measles vaccine hesitancy

Measles vaccine hesitancy

  • In many areas, immunisation for measles has been decreased despite the fact that it was largely eliminated following widespread use of the measles-mumps-rubella (MMR) vaccine.
  • The biggest increase in measles, of 900% in the first six months in 2019 compared with the same period last year, has been from the WHO African region, with the Congo, Madagascar and Nigeria accounting for most cases.
  • There were 30% rise in measles cases worldwide, even in countries such as the USA, where measles had been eradicated in the year 2000.
  • India stood fourth among 194 countries in the number of measles cases registered between July 2018 and June 2019.
  • India accounts for an estimated to be over 36 per cent of measles-related deaths in children.
  • There has been a sharp increase in the WHO European region too.

A 2018 report on vaccine confidence among the European Union member shows why vaccine coverage has not been increasing in the European region.

It found that,

  • Younger people (18-34 years) and those with less education are less likely to agree that the measles, mumps, and rubella (MMR) vaccine is safe.
  • Only 52% respondents from 28 EU member countries agree that vaccines are definitely effective in preventing diseases.
  • 48% of the respondents believed that vaccines cause serious side effects and 38% think vaccines actually cause the disease that they are supposed to protect against.

Factors influencing Vaccine hesitancy

Factors influencing Vaccine hesitancy

Contextual Influences

Communication and media environment


  • Media and social media can create a negative or positive vaccine sentiment and can provide a platform for key opinion leaders to influence others.

Influential leaders, gatekeepers and anti/pro vaccination lobbies

  • Community leaders and influencers, including religious leaders in some settings, celebrities in others, can all have a significant influence on vaccine acceptance or hesitancy.

Historical influences

  • Historic influences such as the negative experience of the Trovan trial in Nigeria (against cerebro-spinal meningitis bacteria) can undermine public trust.
  • On the other hand, Historic influences can influence vaccine acceptance, as it did for polio, especially when combined with pressures of influential leaders and media.


  • Some religious leaders prohibit vaccines, Some cultures do not want men vaccinating children, Some cultures value boys over girls and fathers don’t allow children to be vaccinated


  • Vaccine mandates can provoke vaccine hesitancy not necessarily because of safety or other concerns, but due to resistance to the notion of forced vaccination.

Geographic barriers

  • A population can have general confidence in a vaccine and health service but hesitate as the health center is too far away or access is difficult.

Pharmaceutical industry

  • Industry may be distrusted and influence vaccine hesitancy when perceived as driven only by financial motives and not in public health interest

Individual and Group Influences

Experience with past vaccination

  • Past negative or positive experience with a particular vaccination can influence hesitancy or willingness to vaccinate.

Beliefs, attitudes about health and prevention

  • Vaccine hesitancy can result from i) beliefs that vaccine preventable diseases (VPD) are needed to build immunity or 2) beliefs that other behaviors (breastfeeding, traditional/alternative medicine) are more important than vaccination.


  • Vaccine acceptance or hesitancy can be affected by whether an individual or group has accurate knowledge, a lack of awareness due to no information, or misperceptions due to misinformation.

Health system and providers-trust and personal experience

  • Trust or distrust in government or authorities in general, can affect trust in vaccines and vaccination programmes mandated by the government.

Risk/benefit (perceived, heuristic)

  • Perceptions of risk as well as perceptions of lack of risk can affect vaccine acceptance.
  • Vaccine hesitancy sets in when the perception of disease risk is low and little felt need for vaccination.

Immunisation as a social norm vs. not needed/harmful

  • Vaccine acceptance or hesitancy is influenced by peer group and social norms

Vaccine/ Vaccination -Specific Issues

Risk/ Benefit (scientific evidence)

  • Scientific evidence of risk/benefit can prompt individuals to hesitate, even when safety issues have been clarified.

Introduction of a new vaccine or new formulation

  • Individuals may hesitate to accept a new vaccine when they feel it has not been used/tested for long enough or feel that the new vaccine is not needed, or do not see the direct impact of the vaccine.

Mode of administration

  • Mode of administration can influence vaccine hesitancy for different reasons. E.g. oral or nasal administrations are more convenient and may be accepted by those who find injections fearful or they do not have confidence in the health workers skills.

Design of vaccination program/Mode of delivery

  • Delivery mode can affect vaccine hesitancy in multiple ways. Some parents may not have confidence in a vaccinator coming house-to house; or a campaign approach driven by the government.

Source of vaccine supply

  • Individuals may hesitate if they do not have confidence in the source of the supply (e.g. if produced in a specific country/culture the individual is suspicious of)

Vaccination schedule

  • There may be reluctance to comply with the recommended schedule (e.g. multiple vaccines or age of vaccination).
  • Vaccination schedules have some flexibility. While this may alleviate hesitancy issues, accommodating individual demands are not feasible at a population level.


  • An individual may have confidence in a vaccine’s safety, but not be able to afford the vaccine. Alternatively, the value of the vaccine might be diminished if provided for free.

Role of healthcare professionals

  • If Health care professionals (HCP) hesitate for any reason (e.g. due to lack of confidence in a vaccine’s safety or need) it can influence their clients’ willingness to vaccinate.

Indian Perspective

Effort made by Indian Government

  • India first introduced the Expanded Programme of Immunization (EPI) in 1978.
  • In 1985, the programme was renamed Universal Immunization Programme (UIP) and is today recognised as the largest such health programme in the world.
  • The Ministry of Health and Family Welfare provides different vaccines to infants, children, and pregnant women via the UIP, making vaccines available free of cost.
  • Mission Indradhanush, launched in 2014, seeks to drive towards 90% full immunization coverage of India and sustain the same by year
  • To further boost the programme, the ‘Intensified Mission Indradhanush’ (IMI) was launched in 2017. Through IMI, the government aims to reach every child up to two years of age and all pregnant women who have been left uncovered under the routine immunisation programme.

Low Immunization  

  • A 2018 study found low awareness to be the main reason why 45% of children missed different vaccinations in 121 Indian districts that have higher rates of unimmunised children.
  • While 24% did not get vaccinated due to apprehension about adverse effects, 11% were reluctant to get immunised for reasons other than fear of adverse effects.
  • In 2015-16, the average national full immunisation coverage was as low as 62 percent.
  • Influenced by religious suspicions and rumors, there was mass community resistance in Uttar Pradesh and Bihar during polio campaigns before the country eradicated the disease in 2014
  • Major rumors included suggestions that the polio vaccine caused infertility, especially among Muslim boys and that vaccination programmes were part of a government agenda to reduce high birthrates in the Muslim community.
  • India has only recently started phased national rollouts of Rotavirus vaccine (RVV), beginning in 2016, and Measles-Rubella (MR) in 2017. However, the coverage of these campaign remains low even in the states where they have been rolled out.
  • In developing countries such as India, the inadequacy of the public health system, including poverty, disparity in infant mortality rates or life expectancy and shortages of trained providers, can significantly reduce community trust.
  • Despite government efforts, low vaccination coverage rates remain a persistent problem in many pockets throughout India.


  • All child health workers must promote vaccination and must be afforded sufficient time with each family to effectively do so.
  • A clear presentation of the risks that delaying or refusing vaccination might pose to the child is pivotal to help parents understand how critical their decision is.
  • Governments and health policy makers should play an essential role in promoting vaccination, educating the general public, and implementing policies that reduce the public health risks associated with vaccine hesitancy.
  • Paediatricians and family doctors have a key role in helping parents appreciate the benefits of vaccination. In this context, physicians’ advice has been shown to be the most important predictor of vaccine acceptance.
  • France has made vaccination with 11 vaccines mandatory for children and unvaccinated children cannot be enrolled at nurseries or schools. In Australia, parents of children who are not vaccinated are denied the universal Family Allowance welfare payments. Such interventions can be copied in India.
  • Government should incorporate a plan to measure and address vaccine hesitancy into their country’s immunization program as part of good program practices.
  • There is need to create and /or facilitate opportunities for sharing lessons learned about vaccine hesitancy on a regular basis.
  • Facebook announced that groups and pages that share anti-vaccine misinformation would be removed from its recommendation algorithm. Such partnerships are crucial for allowing widespread promotion of evidence-based information explaining the benefits of vaccination.
  • Effective use of counselling on immunisation should be implemented during contact with care seekers under Janani Shishu Suraksha Karyakram or Pradhan Mantri Jan Arogya Yojana or National Health Protection Scheme.
  • Available opportunities must be maximised, including the “home-based newborn care”, where health workers promote breastfeeding as well as programmes to promote the use of vaccines.


  • Vaccine hesitancy is threatening the historical achievements made in reducing the burden of infectious diseases, which have plagued humanity for centuries.
  • Only a collaborative effort between paediatricians, family doctors, parents, public health officials, governments and civil society will allow misinformation around vaccination to be dispelled.
  • As vaccine hesitancy is a complex behavioural phenomenon, and no single best practice intervention to address hesitancy in all its contexts has been found, more nuanced, locally tailored and multicomponent approaches are required.


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