Vaccine Hesitancy in a

Changing World

Kristen A. Feemster, MD MPH MSHP

Medical Director- Immunization Program and Acute
Communicable Disease
Philadelphia Department of Public Health
Research Director, Vaccine Education Center
The Children’s Hospital of Philadelphia
DISCLOSURES

I have no financial disclosures or

conflicts of interest related to this
content to report.
OBJECTIVES
• Describe the epidemiology of vaccine hesitancy and identify
key factors associated with the decision to accept, delay or
refuse vaccines

• Identify potential communication and policy approaches to

address vaccine hesitancy
 VACCINE HESITANCY IS NOT NEW

National Antivaccination League- UK (1871)

• Vaccine safety
Antivaccination League of America (1908)
• Diseases are due to
lack of good hygiene
‘Dissatisfied Parents Together (1982) -->
• ‘Be your own doctor’ National Vaccine Information Center (1991)
• Medicine and public
health overstepping
boundaries

4
Photo: Wellcome collection
2019 VACCINE SCHEDULE: CHILD
 EPIDEMIOLOGY OF VACCINE HESITANCY

• Majority of US adults believe vaccination is extremely or

very important BUT…
• Increasing proportion believe vaccines are more dangerous than
diseases

• Majority of physicians report >1 vaccine refusal / month

• 13% children under-vaccinated due to parental choice
• Growing number of pediatricians always / often accept
requests for delay (13  37%)

Glanz JM JAMA Pediatr. 2013;167(3):274-281; Gowda, etal. Hum Vac Imm, 2013;
Kempe A Pediatrics. 2015
EPIDEMIOLOGY OF VACCINE HESITANCY
Patterns of Vaccine Receipt: 2004-2008 Birth Cohorts

Glanz JM JAMA Pediatr. 2013;167(3):274-281

A CONSEQUENCE OF SUCCESS

• Low perceived risk of

Concerns VPD’s and
about disease underappreciation of
risk
transmission risks
• Underappreciation of
disease severity
• Easy access to
Concerns misinformation 
about persistent vaccine
vaccine
safety
safety concerns
A CONSEQUENCE OF SUCCESS AND
CHANGING TIMES

Distrust and Rapid

scientific dissemination
denialism of information

Changes in
Naturalism Decision-
making
WHY DOES VACCINE HESITANCY MATTER?

• Challenges for providers

• Not enough time to provide counseling and address
concerns
• Documenting alternative schedules could lead to errors
in vaccine administration
• No reimbursement for vaccine counseling
• Feelings of frustration or mistrust in patient-provider
relationship

• Risk of vaccine preventable diseases

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VACCINE HESITANCY AND MEASLES

• Review of 18 published measles studies (1416 cases)

through November 2015
• 56.8% no history of measles vaccination
• 16.3% unknown vaccination status
• 14.1% vaccinated
• Of 574 unvaccinated individuals who were age-
eligible for vaccine, 70.6% unvaccinated due to
NON-MEDICAL exemption
• Children with vaccine exemptions at significantly higher risk
for acquiring measles compared to fully vaccinated children
(35x)

*Phadke VK, etal. JAMA 2016;315(11):1149-58.

DEFINING VACCINE HESITANCY
• Vaccine hesitancy is a behavior influenced by a number
of factors including issues of confidence, complacency,
and convenience.

• Vaccine-hesitant individuals are a heterogeneous

group who hold varying degrees of indecision about
specific vaccines or vaccination in general.

• Vaccine hesitant individuals may accept all vaccines but

remain concerned about vaccines; some may refuse or
delay some vaccines, but accept others; some
individuals may refuse all vaccines.
SAGE MODEL Individual /
Group
Influences
• Health
Contextual beliefs
Influences • Social
• Media Norms
• History • Perceived
• Politics Risk

Vaccine
CONFIDENCE
Specific
Issues
• Cost
• Schedule
• Delivery
Adapted from MacDonald NE, SAGE Working Group on Vaccine Hesitancy;
Vaccine 33 (2015).
THE SPECTRUM OF VACCINE ACCEPTANCE

Go along to Health Immunization

Worried Fence Sitter
get along advocate Advocate
(2.6%) (13%)
(26%) (25%) (33%)

Late /
Cautious Unquestionin
Refuser Selective The hesitant
Acceptor (25- g Acceptor
(<2%) Vaccinator (2- (20-30%)
35%) (30-40%)
27%)

Gust DA, et al. Am J Health Behavior, 2005,29;

Leask J, etal. BMC Pediatrics. 2012, 12.
 ADDRESSING HESITANCY
COMMUNICATION AND POLICY

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 PROVIDER RECOMMENDATION MATTERS
Provider beliefs associated with beliefs of parents of
vaccinated and unvaccinated children
• Be proactive
• Find a common ground
• Use numbers to communicate risk and provide
perspective
• Use personal stories
• Know the vaccine- acknowledge known side effects
but also emphasize evidence supporting safety and
benefit
• Know about additional resources
• Make recommendation strong and consistent
https://www.cdc.gov/vaccines/hcp/conversations/conv-materials.html
Healy CM, etal Pediatrics 2011;127 Suppl 1:S127-33; Offit PA, Coffin SE. Vaccine 2003;22:1-6; Turnbull AE.
Health Commun 2011;26:775-6.; Macdonald NE, etal.. Biologicals 2011.; Daley MF, etal. Sci Am 2011;305:32, 4.
 A STRONG RECOMMENDATION CAN DRIVE
ACCEPTANCE

47% accept if
provider pursues
initial rec.

• Parents in participatory approach group significantly more

likely to resist vaccine recommendation compared to
presumptive approach group (83% vs 26%)
Opel DJ, etal. Pediatrics 2013
 ARE STRONG RECOMMENDATIONS
ALWAYS GIVEN?

• Variation in recommendation strength for human papillomavirus (HPV)

vaccine
• Associated with provider comfort discussing sex, perceived hesitancy
among parents and perceived risk of patient
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 PROVIDER VACCINE HESITANCY

• 2016 review of 185 studies evaluating hesitancy

among healthcare providers

• Likelihood and strength of recommendation

associated with:
• Knowledge about vaccine
• Confidence in addressing questions
• Beliefs about vaccine safety and effectiveness

• Variation in views about vaccination as individual

choice vs public health activity
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 WHAT ARE COMMON
CONCERNS ABOUT VACCINES?
• Parent of a 12 month old is preparing for their
child’s 1 year visit. The child is due for all of her
1 year vaccines. When the pediatrician starts
their recommendation, the parent stops and
asks: ‘do we need to all of these vaccines today- I
am worried that it is too much for my child’s
immune system and too many injections.’
Vaccine Are these vaccines
safety?? necessary?

Vaccines overwhelm or
Vaccine
suppress the immune system?
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ingredients
 THE SCHEDULE HAS CHANGED…

Year Vaccines # shots by 2 # shots at one

years of age time
1900 Smallpox 1 1

1980 DTwP, Polio (OPV) 5 2

MMR

2011 DTaP, Polio (IPV) 26 5

MMR, Varicella
Hib, Pneumococcal conj.
Hepatitis A and B
Influenza, Rotavirus
 HOW DO VACCINES WORK?

https://ufhealth.org/vaccines-immunizations-overview http://www.mlive.com/news/index.ssf/2014/12/how_do_vaccinations_work_the_s.html
AREN’T ALL THESE VACCINES TOO MUCH
FOR AN INFANT’S IMMUNE SYSTEM?
• Fewer immunologic components in vaccines today -
much smaller antigen load than what infants confront
each day
-1900: 200 antigens 
-1980: ~3,000 antigens 
-2012: ~150 antigens
• Within the first week of life, immune system keeps
colonizing bacteria from invading.
• Study showing that two shots are not more likely to
induce cortisol (as a marker for stress) than one shot.
 WHAT ABOUT VACCINE ADDITIVES?

• Phenol, thimerosal
Preservatives • Prevent contamination, important for multidose vials

• Sugars, amino acids, proteins

Stabilizers • Prevent antigens from degrading, especially during
temperature changes

• Ex. Formaldehyde
Inactivating • Inactivate a virus, bacteria or toxoid during production
agents • Removed after production

• Aluminum salts most widely used

• Enhance immune response for vaccines that use only a
Adjuvants few antigens (not needed for attenuated or whole cell
inactivated vaccines)
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 ARE THESE INGREDIENTS SAFE?

• Adjuvants, preservative and inactivating agents

necessary for vaccine safety and effectiveness

• Use of additives strictly regulated by FDA  type and

amount must be listed on label

• Aluminum and mercury in environment and

formaldehyde is a necessary part of human metabolic
pathways

• No evidence that exposure causes toxicity or illness

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HOW CAN YOU BE SURE ALL OF THESE
VACCINES ARE SAFE FOR MY CHILD?

• Safety is a key part of vaccine development: benefits

need to clearly outweigh risks

• There are known potential side effects

• Minor: injection site pain
• Major: low platelets from measles vaccine

• Every vaccine has precautions and contraindications for

administration to optimize safety and effectiveness
 WHAT MODERATE TO SEVERE ADVERSE
EVENTS CAN HAPPEN AFTER VACCINATION?

• Syncope or fainting due to vasovagal response

• Febrile seizures: MMR, concomitant influenza + PCV13
or DTaP, MMRV
• Important to note that 1 in 20 children can have a febrile
seizure after fever of any cause
• Shoulder Injury related to Vaccine Administration
• Transient rash (MMR, VZV)
• Transient low platelets, transient arthritis (MMR)
• Full arm / leg swelling after 4th or 5th dose of DTaP
(self-resolves)
• Anaphylaxis (very rare)
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VACCINE SAFETY INFRASTRUCTURE
• Vaccine Adverse Events Reporting System
• Passive – reported events only, does NOT establish causation
• ~30,000 reported events / year  ~90% mild (10 million vaccine doses
for children / year)

• Vaccine Safety Datalink

• Active surveillance for specific outcomes
• 9 managed care associations, 9 million children and adults

• Clinical Immunization Safety Assessment Network (CISA)

• 7 academic centers
• Identifies who is at risk for serious adverse events

• Post-licensure Rapid Immunization Safety Monitoring (PRISM)

• Links EHRs with immunization registries
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FETAL CELLS AND VACCINES?
• Fetal cells used to support growth of human viruses, sterile
• Used extensively in biomedical research
• Cell lines from 2 different elective abortions in1960s used for
rubella, rabies, chickenpox, hepatitis A vaccines

• July 2005: Vatican’s Pontifical Academy for Life

• Those initially involved “cooperated with evil”
• Current day administration does not indicate any negative
moral value compared to the greater good of preventing life-
threatening infections
• Choosing to not vaccine (and not try to save your own child)
“was a much more proximate cooperative with evil”
 WHAT ABOUT VACCINES AND AUTISM
• 1998 publication in The Lancet by Wakefield, etal linking autism
and MMR
• Study retracted and findings refuted by multiple studies that have
shown no evidence of this link1

• Institute of Medicine 2011 report:

• “The committee has a high degree of confidence in the epidemiologic
evidence based on four studies with validity and precision to assess an
association between MMR vaccine and autism; these studies consistently
report a null association…The evidence favors rejection of a causal
relationship between MMR vaccine and autism.”

• Concern has shifted to thimerosal and mercury

• No link found in multiple studies AND even after thimerosal
removed from vaccines, autism rates have increased
Dales, etal. JAMA 2001; D’Souza etal. Pediatrics 2006; Farrington, etal. Vaccine 2001; Madsen etal, NEJM
2002, Taylor, etal. BMJ 2002; Taylor, etal. Lancet 1999.
HAS EVIDENCE REMOVED CONCERN?
• Power of anecdote- parents report behavior changes around the
time their child has received a vaccine
• But in general population, first signs of autism often noted in early
childhood when most vaccines are received  by chance will have
new cases identified around the time vaccines are received

• Enhanced attention to symptoms after vaccine receipt

• Distrust of scientific evidence

IF I DON’T GET VACCINATED, ISN’T NATURAL
EXPOSURE BETTER?

• Choosing not to vaccine takes a risk

• Some illnesses, risk is small, but not zero
• Other illnesses, either common or highly contagious
• Influenza, pneumococcus, meningococcus, chickenpox, measles, HPV
• Serious sequelae: cancer, hospitalization, death

• Immune response following natural infection is generally

stronger than immunization BUT natural infection has a
high price
• Certain vaccines produce a better response than natural
infection
 HOW TO EFFECTIVELY
COMMUNICATE VACCINE
INFORMATION??

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 COMMUNICATION: IS PROVIDING
INFORMATION EFFECTIVE?
• Different types of information about measles did not change
beliefs about MMR and side effects or vaccines and autism
• Parents who received a narrative about measles disease more
likely to report belief that MMR causes significant side effects
• Parents who saw images of a child with measles were more likely
to report agreement with statement that vaccines cause autism

• Mothers who received discouraging vaccine information during

pregnancy were less likely to vaccinate their infant on time
compared to no information but encouraging information had
no effect

Nyhan B, etal. Pediatrics 2014;

TAILORED MESSAGING

Confidence Convenience Calculation Complacency

Most Remove Use a firm

Address
difficult to barriers to recommend-
concerns
address access ation

Raise
awareness
Focus on Reminder / Reliable
about
trust Recall information
disease
outbreaks

Betsch C, etal , Policy Insights from the Behav Brain Sci. 2015, 2(1).
 WHAT ABOUT THAT STORY I SAW
ON YOU TUBE ABOUT THE
TEENAGER WHO STARTED
HAVING PROBLEMS AFTER
GETTING THE HPV VACCINE?

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VACCINE COMMUNICATION: WEB 2.0

• Internet is a primary source of health information for

majority of people  ~42% of parents consult internet
for vaccine information (CENSIS)

• Majority of U.S. users trust health info on internet but

only sometimes or never evaluate information source

• You-tube immunization videos- 32% anti-vaccine AND

more highly rated than pro-vaccine videos
• Almost half disseminate inaccurate information
GOOGLE SEARCH: ‘VACCINE INFORMATION

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 EVALUATING INFORMATION

• Source, tone and content

• Who is the presenter- expertise, website sponsor
• References
• Scientific studies vs anecdote

• Strength of scientific studies

• Study size
• Comparison group?
• Do methods account for bias?
• Validity

https://www.chop.edu/centers-programs/vaccine-
education-center/vaccine-science/evaluating-scientific-
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information-and-studies
 PUBLIC HEALTH POLICY
AND VACCINE HESITANCY

“Liberty consists of the freedom to do everything which injures

no one else.”
-Declaration of the Rights of Man and of the Citizen
HOW CAN POLICY INFLUENCE VACCINE
DECISION-MAKING
Mandatory
Vaccination Complacency
Calculation Programs

Incentives
Liability or
Penalties
Policy
Approaches

Social Optimize
Restriction Access

Reshape
Convenience
Social
Confidence Norms
 MANDATORY VACCINATION AS STATE
POLICY
• All 50 states in U.S. have school entry requirements for
childhood vaccines but states may allow exemptions
• 46 states allow religious exemptions
• In 2013, CDC identifies ~30,000 children whose parents
chose not to vaccinate for religious reasons
• 16 states allow personal belief / philosophical
exemptions
• Ease of obtaining an exemption significantly differs
 EASE OF REFUSAL CAN INFLUENCE
LIKELIHOOD OF REFUSAL

Several states have tightened exemption laws in response to

recent outbreaks
Omer SB, etal. NEJM 2012; 367; Omer SB JAMAPediatrics 2014;311(6).
 VACCINES ARE A PUBLIC HEALTH
SUCCESS BUT…
• Ongoing vigilance is important
• Vaccine schedule will continue to evolve with changing
epidemiology
• Vaccine hesitancy is a complex challenge that will
require a multifaceted approach

A strong, consistent
message and
dissemination of CONFIDENCE

accurate information
is crucial
 THANK YOU!

“We’re Immunized!” Parents of Kids with Infectious Diseases “I’m Immunized” Campaign