IssueOct 20

Vaccine Conversation We Should Have: Public perception of vaccines

How Public perception of vaccines threatens vaccination programmes worldwide and what can we do about it

The world is waiting to get back to its axis. After being displaced by the most unprecedented healthcare challenge in decades, the wait for near-normalcy life is getting impatient. The Covid-19 vaccine is the only beacon of hope for many to get back to life without fear of infection. However, with growing concern on Covid and varied political and religious views regarding the pandemic management, there is a lot of conflicting and confusing opinions about Covid vaccines. Public perceptions and the understanding of what people think about vaccine could help vaccine acceptance, and possible and end to the current pandemic.

Understanding Vaccine Confidence


A group of scientists have reviewed the inputs of 250 thousand people across the globe on how they felt about the vaccine. Recently, Prof. Heidi Larson, Director, Vaccine Confidence Project, and colleagues at the London School of Hygiene and Tropical Medicine, UK, have published a paper in The Lancet on the findings from surveys on vaccine confidence conducted over five years. The study found that the public confidence in vaccines varies widely between countries and regions around the world. The authors found signs that public trust may be improving in parts of Europe, but several countries experiencing political instability and religious extremism are seeing growing scepticism that vaccines are safe, and the spread of misinformation online is threatening vaccination programmes worldwide.The new research maps global trends in vaccine confidence across 149 countries for a period of five years between 2015- 2019, is based on data from over 284,000 adults (aged 18 years and older) surveyed about their views on whether vaccines are important, safe, and effective. The study was funded by the European Commission, Wellcome Trust, and EPSRC. It was conducted by researchers at London School of Hygiene & Tropical Medicine, London, UK; Imperial College London, UK; University of Washington, USA; and University of Antwerp, Belgium.

Understanding Public Trust

Understanding vaccine confidence and the reasons why people may not want a vaccine, is critical to ensuring vaccine uptake, and will be especially important if a COVID-19 vaccine becomes available. Although existing data systems are able to measure the number of people vaccinated, they often don’t routinely capture levels of vaccine confidence.Public trust in immunisation is an increasingly important global health issue, with WHO declaring vaccine hesitancy as one of the top ten threats to global health in 2019. Declining confidence can result in vaccine delays or refusals, which is contributing to a rising number of vaccine preventable disease outbreaks including measles, polio, and meningitis worldwide. “It is vital with new and emerging disease threats such as the COVID-19 pandemic, that we regularly monitor public attitudes to quickly identify countries and groups with declining confidence, so we can help guide where we need to build trust to optimise uptake of new life-saving vaccines,” says Professor Heidi Larson, London school of Hygiene & Tropical Medicine, UK, who led the research.

“One of the main threats to the resilience of vaccination programmes globally is the rapid and global spread of misinformation. When there is a large drop in vaccination coverage, it is often because there’s an unproven vaccine safety scare seeding doubt and distrust. Sometimes there is a genuine small risk that gets rapidly spread and amplified to appear to be a much larger risk. There are also cases where vaccine debates have been purposefully polarised, exploiting the doubting public and system weaknesses for political purposes, while waning vaccine confidence in other places may be influenced by a general distrust in government and scientific elites,” she adds.

Vaccine Confidence Project

Although, immunisation coverage is reported across the world, no comparable global estimates and monitoring of vaccine confidence are available. The Vaccine Confidence Project (VCP) was founded a decade ago to help plug the gap, providing a systematic approach to monitoring public attitudes to vaccines and to inform policymakers of the changing trends and determinants of vaccine confidence around the world.

How the Study was Done

Researchers analysed data from 290 nationally representative surveys conducted between September 2015 and December 2019—combining previously published data from nearly 250,000 survey responses with 50,000 additional interviews from 2019. They modelled data to estimate trends in public perceptions about the safety and effectiveness of vaccines, and the importance of vaccinating children. They also studied the relationship between vaccine uptake in each country and demographics like age, sex, religious beliefs, etc., socioeconomic factors like income, education and source of trust (eg, family, friends, health professionals). In fact, estimates of vaccine confidence for some countries shows wide confidence intervals reflecting lower numbers of recent data. “For these countries, the estimates are a weighting of the countries’ overall trend and the trend of the whole continent,” authors said.More recent changes in vaccine safety perceptions were evaluated for the EU, where a higher frequency of surveys has been conducted per country, on average, compared with the rest of the world.

Feedback from Europe

The study found that across the European Union recent significant losses in confidence in vaccine safety were detected in Poland (a dip from 64 per cent strongly agreeing vaccines are safe in Nov 2018 to 53 per cent by Dec 2019), reflecting the growing impact of a highly organised local anti-vaccine movement. However, confidence in vaccine safety is increasing in several countries, including Finland, France, Italy, and Ireland as well as the UK, the study showed. In France, where confidence in vaccines has been persistently low, there has been a marked rise in confidence, from 22 per cent of those surveyed strongly agreeing vaccines are safe in Nov 2018, to 30 per cent in Dec 2019. Interestingly, in the UK, confidence in vaccine safety rose from 47 per cent in May 2018 to around 52 per cent in Nov 2019.

Hesitancy Hotspots

In contrast, six countries (Afghanistan 2 per cent of those surveyed strongly disagreeing vaccines are safe in 2015 rising to 3 per cent in 2019, Azerbaijan 2 per cent-17 per cent , Indonesia 1 per cent-3 per cent, Nigeria 1 per cent-2 per cent, Pakistan 2 per cent-4 per cent, and Serbia 4 per cent-7 per cent) have witnessed substantial increases in people strongly disagreeing vaccines are safe. This means that they are not just being less convinced, but are actively against vaccines. The researchers describe it as a “worrying trend”, with negative attitudes mirroring trends in political instability and religious extremism in these six countries.The analysis also suggests that overall confidence in vaccines—including safety, effectiveness, and importance—fell in Indonesia, the Philippines, Pakistan, and South Korea between November 2015 and December 2019. For example, risks of a dengue vaccine (Dengvaxia) in the Philippines in 2017 led to a dramatic drop in public confidence in vaccine safety and impacted the uptake of routine vaccines. This caused the Philippines to drop out of the top 10 countries. Imagine, they had the highest overall vaccine confidence in 2015 which fell to ranking no higher than 70th in 2019. In South Korea, online mobilisation efforts against childhood immunisation by communities such as ANAKI (Korean abbreviation of ‘raising children without medication’), have been identified as key barrier to vaccination.Indonesia has witnessed one of the largest falls in public trust worldwide between 2015 and 2019. The authors say negative attitudes may have been partly triggered by Muslim leaders questioning the safety of the measles, mumps, and rubella (MMR) vaccine, and issuing a fatwa (religious ruling) claiming that the vaccine was haram (forbidden) and contained ingredients derived from pigs, as well as local healers promoting natural alternatives to vaccines.

Believing in Vaccines

The authors believe that confidence in the importance of vaccines, rather than in their safety or effectiveness, is most strongly linked with vaccine uptake. By December 2019, the majority of European countries were displaying increased levels of confidence in the importance of vaccination than in their safety and effectiveness, the study says.“Our findings suggest that people do not necessarily dismiss the importance of vaccinating their children even if they have doubts about how safe vaccines are,”says co-lead author Clarissa Simas, London School of Hygiene & Tropical Medicine, UK. “The public seem to generally understand the value of vaccines, but the scientific and public health community needs to do much better at building public trust in the safety of vaccination, particularly with the hope of a COVID-19 vaccine,” she adds.Interestingly, the study found that in 2019, Iraq (95 per cent), Liberia (93 per cent), and Senegal (92 per cent) had the highest proportion of respondents who agreed that it is important for children to be vaccinated, while Hong Kong (36 per cent), Russia (34 per cent), and Albania (26per cent) reported the lowest proportion strongly agreeing on the importance of vaccines.The study also found that being male or less educated were linked with a lower chance of vaccine uptake. The study also found that people who trusted health-care workers for medical or health advice, rather than family, friends, and other non-medical sources were more likely to take vaccine. Researchers also found that people from minority religious groups or those refusing to provide their religious belief were less likely to take vaccine.

Balancing the Perspective

These results should be seen in totality and not from a skewed sense as the study had some important limitations. One of the limitations was the lack of consistency between survey responses that meant vaccination beliefs were pooled into extreme categories of “strongly agree” or “strongly disagree”, potentially masking key information.The researchers have also said that the vaccination status was based on parental recall, and that the findings do not reveal whether attitudes were related to specific vaccines. Sharing his views in another article, Dr Daniel Salmon, John Hopkins Bloomberg School of Public Health, USA, says that most vaccine scares are not supported by scientific evidence. “Vaccines have a remarkable safety record, based on rigorous processes of phased randomised controlled trials and on licensure requirements, which have ensured that the benefits of vaccination outweigh the risks. Situations such as Dengvaxia are exceedingly rare,” he says. Dr Salmon was not involved in the study.He further says that global investment in vaccine safety and communication infrastructure is much needed. “Without substantial global investment in active vaccine safety surveillance, continuous monitoring of public perceptions, and development of rapid and flexible communication strategies, there is a risk of SARS-CoV-2 vaccines never reaching their potential due to a continued inability to quickly and effectively respond to public vaccine safety concerns, real or otherwise. With every crisis comes opportunity; it should not be ignored,” he concludes.

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