Vaccine Hesitancy: an international perspective

Transcription

1 Vaccine Hesitancy: an international perspective Brickset.com 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 1

2 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

3 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 SAGE_working_group_revised_report_vaccine_hesitancy.pdf Incorporated into WHO/UNICEF Joint Reporting Form Questions 3

4 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):

5 Joint Reporting Form: Hesitancy Indicators added in 2014 TARGET DEFINITION OF INDICATOR DATA SOURCES 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. 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. 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). 5

6 Methods for Review JRF Vaccine Hesitancy Data Timing: all data reported all data reported 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 6

7 CONTEXTUAL INFLUENCES Influences arising due to historic, socio-cultural, environmental, health system/institutional, economic or political factors INDIVIDUAL AND GROUP INFLUENCES Influences arising from personal perception of the vaccine or influences of the social/peer environment VACCINE/ VACCINATION SPECIFIC ISSUES Directly related to vaccine or vaccination 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 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 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

8 GVAP SO2 Indicators In JRF*: Vaccine Hesitancy Response: % (131/180) 29% assessment % (145/183) 36% % (152/184) 33% * potential 194 countries Response rate by Region 2016 Total countries submitted JRF Any Reason % AFR 47 94% 6% AMR 34 88% 12% EMR 20 70% 30% EUR 48 83% 17% SEAR % 0% Question Not Completed % WPR 24 58% 42% 8

9 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 36% 4% 7% 28% 26% Contextual Individual & Group Influences Vaccine/Vaccination No Hesitancy Other 9

10 1 Communication and media environment 2 Influential leaders, gatekeepers and anti-or pro- vaccination 3 Historical influences 4 Religion /culture /gender /socioeconomic 6 Geographic barriers 7 Pharmaceutical industry 8 Experience with past vaccination 9 Beliefs, attitudes about health and prevention 10 Knowledge /awareness 11 Health system and providerstrust and personal experience 12 Risk /benefit (percieved, heuristic) 13 Immunization as a social norm vs. not needed /harmful 14 Risk /Benefit (scientific evidence) 15 Introduction of a new vaccine or new formulation 17 Design of vaccination program /Mode of delivery 18 Reliability and /or source of vaccine supply 19 Vaccination schedule 20 Costs 21 Role of healthcare professionals Global Reasons for Vaccine Hesitancy - Frequencies Contextual Influences Individual and Group Influences Vaccine and Vaccination - specific Issues 10

11 Top 3 Reasons by WHO Regions: AMR AFR EMR EUR SEAR WPR 11

12 By Country Income level: Low Income Upper Middle Income Lower Middle Income High Income 12

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

14 Focus on WPR Top 4 reasons 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 14

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): 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

16 South Korea: HPV introduction- impact ve stories Minkyung Kim, KCDC Jun July 1-4wk Aug 1-4wk Sep 1-4wk Oct 1-5wk Nov 1-4wk Dec 1-5wk 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

17 HPV Vaccine Coverage 1 st Dose by Birth Cohort In Nordic Countries Denmark Started 2008 Birth Cohort Sweden Norway Finland Iceland

18 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 Assessments informed program interventions 18

19 Australia: 2014, 2015, 2016 Top 3 Reasons given in JRF Limited understanding or knowledge 2. Barriers to access 3. Timeliness for completing the course House of Australia Barriers to access 2. Timeliness for completing the course 3. Concern about the safety of vaccines Safety of vaccines 2. Too many vaccines, too soon 3. Concerns about ingredients in vaccines All based upon assessments 19

20 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 20

21 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 21