GIVING VACCINES A HELPING HAND

Ever since Lady Mary Wortley Montagu imported inoculation against smallpox almost 300 years ago - after witnessing variolation in Turkey - vaccination has attracted fierce resistance. Although routine in Constantinople, Montagu encountered opposition to this “dangerous Oriental method” on her return to England [1]. 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. The act provoked several violent riots [2]. 

We now know that immunisation saves millions of lives. GAVI (www.gavi.org), which improves access to vaccines in the world’s poorest countries, estimates that vaccines save between 2 million and 3 million lives a year globally. Yet according to the Health and Social Care Information Centre, 1-in-10 children in England don’t receive the MMR jab. Coverage at 24 months and five years was 92.3% and 88.6% respectively during 2014-15. One-in-20 (coverage of 94.2%) children didn’t receive the 5-in-1 (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 (coverage was 72.7%). 

Furthermore, several studies suggest that high immunisation rates “do not necessarily imply high confidence in vaccines” [3]. So, what confidence there is can be undermined easily. MMR coverage at 24 months fell to 79.9% in 2003-4 at the height of concerns over the now discredited link with autism, for example. Vaccine refusal 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 ranges 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]. 

Indeed, vaccines are victim 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, Miton and Mercier note, “The very efficacy of vaccination has rendered the threat from vaccine-preventable diseases much less salient” [5]. Today’s parents don’t appreciate how unpleasant and dangerous measles, mumps or diphtheria are. They are more familiar with, say, autism spectrum diseases [4]. So, 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 antivaccine sites, including tragic stories of side effects, to 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, and balance and science. 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].   

Against this background, addressing vaccine hesitancy’s numerous complex causes requires a concerted effort from Whitehall to the high street. For example, presenting vaccines as part of routine may help drive vaccine consent [4]. Perhaps offering immunisation in pharmacies would underscore that vaccines are routine. 

In addition, many people mistrust pro-vaccine information, which, after all, largely derives from governments and pharmaceutical companies. Moreover, people place dramatically difference weights on information. So, individualised, face-to-face discussions to address a person’s specific concerns can increase support for vaccines [6]. 

Pharmacists are trusted sources of information and are ideally placed to raise awareness about vaccines and hold the non-confrontational, empathic consultations needed to address each individual’s concerns. In the USA, interventions led by community pharmacists increased uptake of the herpes zoster vaccine by more than 200%, albeit from a low baseline [6] and several studies show that pharmacists can increase uptake of influenza vaccines. A one-off initiative probably won’t be enough: pharmacist-driven interventions may need on-going reinforcement to be fully effective [6]. However, addressing vaccine concerns takes time. So, yet again, an invaluable potential role for pharmacists could remain unrealised due to lack of reimbursement. And, as we saw recently with influenza, outdated, protectionist barriers in primary care certainly don’t help. 

In 2017, it’ll be 300 years since Lady Montagu inoculated her son against smallpox. It’s time look at new solutions to vaccine hesitancy, which should include pharmacists as educators and vaccinators. If we don’t take action, discussions about vaccination will remain as divisive and heated as ever – and children and adults will continue to suffer and die from preventable diseases. 

References

1. Phil Trans R Soc B (2015) dx.doi.org/10.1098/rstb.2014.0378
2. BMJ 2002;325:430–2
3. Vaccine (2015)dx.doi.org/10.1016/j.vaccine.2015.10.090
4. Am J Prev Med (2015) dx.doi.org/10.1016/j.amepre.2015.06.009
5. Trends Cog Sci (2015) dx.doi.org/10.1016/j.tics.2015.08.007
6. Am Pharm Assoc 2013; 53: 46–53