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Heidi J. Larson, PhD, is Director of the Vaccine Confidence Project at the London School of Hygiene & Tropical Medicine, where she is a Professor of Anthropology, Risk and Decision Science. Her particular research interest is the impact of rumours and risk perceptions on health programmes, particularly vaccines and immunisation.

Could you tell us a bit about the Vaccine Confidence Project?

I founded the Vaccine Confidence Project in 2009. I had been working in UNICEF leading their global immunisation strategy and communication particularly around new vaccines, and saw what seemed to be an epidemic of outbreaks of communities, individuals, and governments questioning or refusing different vaccines. The news that made it to mainstream press was about the boycott of the polio vaccine in a state in northern Nigeria but there were also a lot of smaller related incidents that never made it to the news. Because this seemed to be a growing trend, I felt that we needed to do more research into what’s driving it. So I set up this initiative with a group of multidisciplinary researchers to look at what are the locally driven but also transnational networks and movements that are highly influential in the spread of negative and questioning sentiment around vaccines.

Why do we do it? Well it’s not just about anecdotal stories. One of the points of our group is to document the triggers and amplifiers of this anxiety over time. These are not just “crazy” people. These are mainstream, sometimes very educated people that have a different view on immune systems and health or may have a high distrust of the government. We are doing a lot of documentation and working on teaching modules because often in public health you learn about all the good things we have and strategies to deliver them, but we don’t look at what happens when you have all these great, well proven interventions, but people not only don’t come to get them but they actively refuse them.

What is some of the current discourse around vaccines that you’ve come across?

As you said, the issues are very global and that’s one of the reasons we work globally. They used to say when the US sneezes, the world gets a cold. But it’s not just the US, it’s Europe and other places where triggers of discontent can leaders to the rapid spread of vaccine anxieties and concerns globally.

Purity

The number one anxiety is safety and a preference for anything natural. Safety is a big concern even though we’ve got some of the best and most rigorous safety protocols and processes in the history of immunisation. But there are still anxieties. Part of the challenge is that we’ve been successful overall with vaccination, which means that some of the diseases that they’re preventing are no longer so visible, which makes people focus their attention on vaccine risks because they’re not as concerned about the disease risk. We’ve seen this particularly in Europe with some pretty awful measles outbreaks and over 50 deaths in the EU in the past two years. Some of this is a result of misinformation about what’s actually in a vaccine and some of it is due to alternative beliefs, such as naturopathy.

Liberty

The second big thing which goes back to the very first anti-vaccine league in the UK is about freedom of choice. The UK doesn’t have any mandates around vaccines, but a lot of countries require them for going to school. I’m not a big fan of mandates, but I do feel that  if there is a risk of a  highly infectious disease spreading in a group setting, such as a in hospitals orin daycare and school settings, not getting vaccinated puts other people at risk. The big argument though is that people want to have a choice. In an ideal world, people would choose vaccination not only for personal protection but for the health of the community. Unfortunately, that’s not always the case.

Number of vaccines

A final point of contention is the number of vaccines. It was one thing when there were five or six vaccines and the diseases were very apparent. But these days we have more and more vaccines and combinations of vaccines and parents are starting to say, “Enough is enough. I think that’s too much to put in my healthy baby. How can they tolerate it?” Scientific evidence stands by the value of the multiple vaccines without the risks that people have concerns about, but we still need to have the conversation around how many vaccines will be acceptable.

What role do you think vaccines play in outbreak preparedness activities?

It depends on the disease because not all diseases are vaccine preventable. If it is a vaccine preventable diseases like influenza, I think that it can play a tremendous role in outbreak. But, because influenza strains are always evolving, and vaccines take time to develop, including the needed processes to ensure their safety, their effectiveness is never 100%  leading some people to wonder whether they are worth taking.

Sometimes people ask me what keeps me up at night in terms of this issue. I would say how poorly we did in 2009 in response to the H1N1 pandemic as a global community and the responsiveness and acceptance of the H1N1 vaccine. There were a number of reasons for this and we should learn from that experience. Looking back at the 1918 “Spanish” Influenza pandemic, up to 50 million people died of flu-related illness. On the one hand, one could say we didn’t have a vaccine or the tools we have now, but the world is much more mobile now and the population is much larger, so  the spread could be much quicker than it was in 1918. The other factor is that, in 1918, government officials were suppressing the information about the flu because they wanted to keep the public focused on the war. Troops were sent into combat even against some of the public health advice. The reason it’s called the “Spanish” flu is not because it started in Spain, but because that was where they started reporting this rapid and dangerous disease in mainstream media.

In some ways we have more tools now, but we also have bigger and more complex challenges. We need to think hard, particularly about pandemic preparedness. I’m working on the Ebola vaccine trials in Sierra Leone where we have focused on local engagement, trust building, rumour monitoring and management. Paying attention to the way people react and the role of trust in engagement of the communities has been pivotal to the trial’s functioning.

How can vaccine programmes establish trust and engage with communities – what should they do?

We talk about three things at the Vaccine Confidence Project:

1. Trust in the product (the vaccine)
2. Trust in the provider (the health workers or health professionals)
3. Trust in the policy (or the politician)

You can trust the product, but if you don’t have trust in the health professional or if you’ve had a bad experience at the clinic, you may not go and get it. There are a lot of ways to do that before we have a pandemic. We live in a highly polarized world right now and the degree of distrust is at an all-time high. Therefore, it’s important to find ways that we could build trust in the health system, as well as content with their health provider, and knowledge of when and where to go for basic health services.

It is also necessary to make the health systems more welcoming, more open. One of the resistance factors is people feel like they’re not being listened to. Part of that is because of the stress on systems and health providers. Doctors and nurses see a line out the door and they’ve got to get a lot done in a day. But on the citizens’ side, they feel like they’re just a number being counted. They sometimes feel like when they try to ask questions, they get cut off and that contributes to their distrust. The more we can build in opportunities for better dialogue and conversation before we’re in a crisis, the better.

Is there anything else you want to add or any final thoughts? Anything in the pipeline of what the Vaccine Confidence Project is doing?

In the pipeline, we’re working closely with the European Union to rerun our vaccine confidence index in the 28 EU countries. That will be launched in the fall. We’ve also been called into countries like the Philippines that had a scare around the new dengue vaccine after new risks were reported.  The vaccine scare not only created a lot of panic and anxiety around the dengue vaccine, it  became a highly  politicized issue and contributed to a decline in vaccine confidence around vaccines more generally reflected in drops in measles acceptance and measles outbreaks.  In short, concerns around one vaccine can have spillover effect on confidence in other vaccines.