Vaccine hesitancy –

a worldwide systemic issue

Marie-Paule Kieny
Directeur de recherche

24 October 2019
 Structure of the presentation

 General considerations on vaccine hesitancy

 European case studies on addressing vaccine
hesitancy
 Mandatory vaccination in France : rationale and
first results
 HPV vaccine coverage
 Possible approaches to reduce resistance to
vaccination

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 Global distribution of vaccine hesitancy

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 Demography of vaccine hesitancy

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 Link between trust in government and
in science, and trust in vaccines

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 Vaccination coverage and herd
immunity

Herd immunity 2015 vaccination

Disease threashold coverage in France

Diphteria 80 % 96,7 %

Measles 94 % 79 %

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Measles Cases per Month – Mandatory
Notification in France since 2008
Total cases > 27 500 Hospitalized pneumonia > 1650
Encéphalitis, myélitis: 40
Deaths: 24

10
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Distrust and Vaccine Hesitancy Increase Among the
General Population

2.7 3.3
5.8 7.8 8.2
6.3
19.0
13.0 16.5

19.2
47.6 47.7

54.5 48.8
A(H1N1)
vaccination
campaign
46.2

43.6 42.3

24.3 26.3
15.0

2000 2005 2010 2014 2016

Very unfavorable Somewhat unfavourable Somewhat favourable Very favourable

12
Would Immunize His/Her Child If DTP
Vaccine was NO Longer Mandatory?

Defnitvely Yes Probably Yes Probably No Defnitevly No Ukn

13
Health Barometer 2016: parents of at least one child 1-15 years old
 Vaccine obligation before the 2017 law

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Implementation of the 2017 Law in Compulsory Vaccination

• Law extending vaccination mandates to all routine

immunizations for children < 2 years passed on December 2017

• Applies to all children born since 1st of January 2018

• No exemption other than medical contra-indication retained

• Proof of vaccination required for child registration in any form of

social life as of June 2018

• Extension of mandates to 11 vaccinations “only” enlargement of

rules and habits implemented for the 3 already mandatory ones

16
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Communication about the New Obligations

Post-cards Brochures
Posters

19
More Communication…
Infographics
Experts’
vidéos
Emissions on
frequency M

Epidemiological
bulletin

20
First Data on Coverage and Adhesion after One Year

• First estimations of vaccination coverage through analysis of the

National Health Reimbursement Database covering virtually the
whole French population

• Survey on a representative sample of 1002 parents of children

under two in February 2019 (quota method)

• Data on paediatricians perceptions : on line survey by ambulatory

paediatricians learning society (AFPA) in March 2019 (615
answers)

• Data for GPs perceptions: on line survey done by the College of

General Practitioners (CMG) in February-March 2019 (758
answers)
Proportion of Infants Receiving an Hepatitis B Containing Vaccine
for Primo-vaccination, 2015-2018

100%

95%

90%

85%

Month of delivery

Infants born in Infants born in Différence

January-May January-May 2018
2017
Hexavalent vaccine (% use) 93,1 % 98,6 % + 5,5%

Hépatite B at least 1 dose 92 % 98 %

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Source SNDS-DCIR, traitement Santé publique France

 Impact of Infant Vaccination Obligation on Vaccination Coverage
of Infants Born January - May 2018

Infants born in Infants born in Différence

January-May 2017 January-May 2018
Coverage at 7 mths Coverage at 7 mths

Pneumococcal at least 1 dose 98,0 % 99,4 % + 1,4 %

Méningococcal C 1st dose 39,3 % 75,7 % + 36,4 %

Infants born in Infants born in

January 2017 January 2018
Coverage at 12 mths Coverage at 12 mths

Hexavalent booster 74,7 % 79,7% +5%

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Source SNDS-DCIR, treatment Santé publique France – Data updated on 31/12/2018 (31/01/2019 for the hexavalent booster)
INCIDENCE OF INVASIVE MENINGOCOCCAL
INFECTIONS IN INFANTS IN FRANCE – 2006-2018

Taux de notf caton / 100 000 hab

Mandatory
vaccination
N b de cas

30 3.50

25 3.00

2.50
20
2.00
15
1.50
10
1.00
5 0.50

0 0.00
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
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Perception of Parents of Children under 2 Years about the
New Vaccine Obligation

Are you very, rather, rather not or not at all

favorable to the extension from 3 to 11 mandatory
vaccinations for infants born since 1st January
2018 ?
February
2019

Very favorable 21%

67 %
Rather favorable 46 %

Rathor not favorable 23%

Not favorable at all 10%

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 Practitioners Attitude towards the New Vaccination
Obligation

ADHÉSION A LA VACCINATION ET GPs Paediatricians

Do you consider the decision regarding the extension of vaccination mandates for children born since
1st of January 2018 as…
Good 75% 96%
Bad 8% 2%
No opinion/answer 16% 2%
What consequences has this decision had on your relationship with the parents of eligible infants?

No or little impact 46% 19%

It has simplified it 41% 77%
It has complicated it 10% 3%
No opinion/answer 4% 1%
Following the extension of vaccination obligation, how do you perceive the evolution of resistance
from certain parents to vaccines?
No change 45% 22%
Increase 15% 6%
Decrease 28% 69%
No opinion/answer 11% 3% 26
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 Potential approaches to fight vaccine
hesitancy
 Educate health professionals on vaccine
safety and effectiveness
 Use traditional and social media to reach
the population with positive messages
about vaccination and community health
 Change messaging to target moral
values
 Make vaccination compulsory
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 Key findings from Wellcome Global
Monitor 2018 Report
Doctors and nurses are most trusted for health
advice.
• 73% of people worldwide would trust a doctor or nurse
more than any other source of health advice, including
family, friends, religious leaders or famous people.
• Across the world, people with the lowest household
income have less confidence in hospitals and
healthcare systems.
• Worldwide, 79% of people agree that vaccines are
safe and 84% agree that they are effective.

https://wellcome.ac.uk/reports/wellcome-global-monitor/2018
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 Potential approaches to fight vaccine
hesitancy
 Educate health professionals on vaccine
safety and effectiveness
 Use traditional and social media to reach
the population with positive messages
about vaccination and community health
 Change messaging to target moral
values
 Make vaccination compulsory
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 Case study: Newspaper coverage before and
after the HPV vaccination crisis began in Japan
Okuhara et al. BMC Public Health (2019) 19:770

Contents related to cervical After March 2013, they were

cancer prevention (risk of replaced with anti-vaccination
developing cervical cancer, effects contents (adverse effects, alleged
of vaccination) were frequently victims and related lawsuits).
conveyed until 2012.

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 How can messaging influence vaccine hesitancy?
The effect of falsely
balanced reporting of the
autism–vaccine
controversy on vaccine
safety perceptions and
behavioral intentions
Graham Dixon and Christopher Clarke,
Health Education Research, 28,2, 2013
352–359

Two-sided presentations eliciting a stronger perception

that experts (both scientists and medical experts) are
divided over the autism–vaccine link than ‘link-only’
presentations.
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 The Vaccine-Autism Myth Started 20 Years
Ago. Here's Why It Still Endures Today
Jonathan D. Quick, Heidi Larson, Time Magazine, February 28, 2018

“Print and broadcast media have a special responsibility

to provide clear, evidenced-based reporting.
The decline in MMR immunization following Wakefield’s
article was accelerated by the pro-Wakefield UK media,
despite increasingly strong evidence refuting Wakefield’s
claims.
Conversely, the recovery from Wakefield’s damaging
impact was catalyzed by the 2004 investigative journalism
reports exposing Wakefield’s flawed science and conflicts
of interest.
Truth wins, if we’re committed to telling it.”
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 Potential approaches to fight vaccine
hesitancy
 Educate health professionals on vaccine
safety and effectiveness
 Use traditional and social media to reach
the population with positive messages
about vaccination and community health
 Change messaging to target moral
values
 Make vaccination compulsory
24 October 2019 39
 Association of Moral Foundations with
Vaccine Hesitancy

Avnika B. Amin et al. NATURE HUMAN

BEHAVIOUR | VOL 1 | DECEMBER 2017 | 873–
880 | www.nature.com/nathumbehav

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 Examples of potential Moral Foundations-
based Messaging on Vaccination
 An intervention framed in terms of the purity foundation
might read, ‘Boost your child’s natural defences against
diseases! Keep your child pure of infections – Vaccinate!’ This
message might show a picture of a child with measles.
 An intervention framed in terms of the liberty foundation
might read, ‘Take personal control of your child’s health!
Vaccinations can help your child and others be free to live a
happy and healthy life’, along with pictures of children playing.

Messages could be displayed at public schools, libraries, doctors’

offices and even on the Internet, where parents frequently obtain
information about vaccines and would likely encounter them to have
their children vaccinated. Avnika B. Amin et al. NATURE HUMAN BEHAVIOUR | VOL 1 |
DECEMBER 2017 | 873–880 | www.nature.com/nathumbehav
24 October 2019 41
 Potential approaches to fight vaccine
hesitancy
 Educate health professionals on vaccine
safety and effectiveness
 Use traditional and social media to reach
the population with positive messages
about vaccination and community health
 Change messaging to target moral
values
 Make vaccination compulsory
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 Compulsory vaccination in Europe
Countries without Countries with at Comments
compulsory least one
vaccination compulsory vaccine
Austria Belgium 1 compulsory vaccine
Cyprus Bulgaria > 4 compulsory vaccines
Denmark Croatia > 4 compulsory vaccines
Estonia France 11 compulsory vaccine since 2018
Finland Greece 4 compulsory vaccines
Germany Hungary > 4 compulsory vaccines
Ireland Italy 10 compulsory vaccines since 2017
Island Latvia > 4 compulsory vaccines
Lithuania Malte 4 compulsory vaccines
Luxembourg Poland > 4 compulsory vaccines
Netherlands Romania > 4 compulsory vaccines
Norway Slovakia > 4 compulsory vaccines
Portugal Slovenia 9 compulsory vaccines
Spain
Sweden
United Kingdom

24 October 2019
 Potential approaches to fight vaccine
hesitancy
 Educate health professionals on vaccine safety and
effectiveness
 Use traditional and social media to reach the
population with positive messages about vaccination
and community health
 Change messaging to target moral values
 Make vaccination compulsory
 More research is needed to understand
vaccine hesitancy and to design appropriate
evidence-based strategy to engage health
workers and communities
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 Acknowledgements

Slides from
 Charlie Weller, Wellcome Trust, UK
 HSE - Health System Ireland
 Patrick Brasseur, Direction générale de la
santé, France
 Daniel Levy-Brühl, Santé publique France

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