Some 300 years after inoculation was first introduced to these shores, why are some people still so reluctant to recognise the health benefits that vaccination confers?

In 1717 Lady Mary Wortley Montague arrived with her husband, the British ambassador, at the court of the Ottoman Empire. While in Constantinople she noted that the local practice of deliberately stimulating a mild form of smallpox through inoculation conferred immunity. On her return to England, however, her decision to vaccinate her son was seen as a “dangerous Oriental method”.¹

Matters weren’t made much better when, under the Vaccination Act of 1853, parents faced fines or imprisonment if they didn’t vaccinate their children against smallpox in the first three months of life. Several violent riots ensued.²

We now know that immunisation saves millions of lives. GAVI (gavi.org), which improves access to vaccines in the world’s poorest countries, estimates that they save between 2 and 3 million lives a year globally yet, according to the Health and Social Care Information Centre, one in 10 children in England don’t receive the MMR jab.

Coverage at 24 months and five years was 92.3 and 88.6 per cent respectively during 2014-15, while one in 20 children (coverage of 94.2 per cent) didn’t receive the fivein- one (diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type b) jab at 12 months. A quarter of adults over 65 years don’t receive the flu vaccine, leading to coverage of just 73 per cent.

Discredited

Research has also found that high immunisation rates “do not necessarily imply high confidence in vaccines”.³ What confidence there is can be undermined easily. Take the backlash against the MMR vaccination in 2003-04. MMR coverage at 24 months fell to 79.9 per cent at the height of concerns over the now discredited link with autism.

Vaccine refusal has probably also encouraged outbreaks of invasive H. influenzae type b disease, varicella, pneumococcal disease, measles and pertussis.⁴

Numerous factors contribute to ‘vaccine hesitancy’, which range from uneasiness to strident opposition.⁵ Most fundamentally, perhaps, many people feel that vaccination is counter-intuitive. Miton and Mercier noted recently that our “intuitive sense of disgust” is largely “dose-insensitive”.

This intuition evolved to help us avoid infections from, for instance, rotten food and faeces, but can also leave people “wary” of vaccines that contain minute amounts of contaminants.

In addition, most people “intuitively think it is morally worse to harm someone by doing something than by not doing something”. As a result, people worry more about side-effects than the risk of disease.⁵

One in 10 children in England still don’t receive the MMR jab...

 

Personal experience

Vaccines are victims of their own success. I suffered German measles and mumps as a child. I can still, almost 50 years later, recall how dreadful I felt, especially with mumps. But, as Miton and Mercier note, “the very efficacy of vaccination has rendered the threat from vaccine-preventable diseases much less salient”.⁵

Today’s parents do not appreciate how unpleasant and dangerous measles, mumps or diphtheria are, being more familiar with, for example, autism spectrum diseases.⁴ Many admit to difficulties balancing risks and benefits.³

The internet exacerbates the “palpable tension”³ between the scientific and non-scientific aspects of the decision to vaccinate. You can quickly find anti-vaccine sites ranging from tragic stories of side-effects and genuine concerns over excipients, to those accusing big pharma of profiteering and disease mongering, and governments of eugenics.

In contrast to the emotive, powerful and intuitive antivaccine stories, advocacy sites focus on reasonable argument, balance and science. No wonder parents don’t know which way to turn.

As a recent American study reported: “Parents who sought out vaccine information were often overwhelmed by the quantity and ambiguity … and, consequently, had to rely on their own instinct or judgment.”

For instance, parents knew the link between autism and MMR is discredited scientifically, yet the “media hype … generated doubts and fears in the back of their minds that were difficult to silence”.³

Concerted effort

Addressing all the different doubts and anxieties concerning vaccination requires a concerted effort that reaches from Whitehall to the high street. For example, presenting vaccines as part of a routine may help drive vaccine consent⁴, while offering immunisation in pharmacies would underline the very fact that vaccines are routine. Since many people mistrust pro-vaccine information, which largely derives from governments and pharmaceutical companies, individualised, face-to-face discussions to address a person’s specific concerns could increase support for vaccines.⁶

Pharmacists are trusted sources of information and ideally placed to raise awareness about vaccines and hold the non-confrontational, empathic consultations needed to address each individual’s concerns. In the US, interventions led by community pharmacists increased uptake of the herpes zoster vaccine by more than 200 per cent, albeit from a low baseline6, and several studies show that community pharmacists can – and do – increase uptake of influenza vaccines.

Not enough

A one-off initiative won’t be enough. Pharmacist-driven interventions need ongoing reinforcement – and funding – to be fully effective.⁶ Addressing vaccine concerns takes time and, as we saw recently with flu vaccinations, outdated protectionist barriers in primary care don’t help.

In 2017, it will be 300 years since Lady Montagu inoculated her son against smallpox. It is time to look at new solutions to vaccine hesitancy – and these should include pharmacists as both educators and vaccinators (a role they are taking on with promising results in areas like flu, pneumococcal disease and meningitis B). Because if action is not taken, discussions about vaccination will remain as divisive and heated as ever – and children and adults will continue to suffer and die from preventable diseases.