Globally, fewer people are dying from measles than ever before; overall deaths fell by 84% from 2000-2016, saving an estimated 20.4 million lives.
But decades of global effort spent trying to wipe out the virus — which, if severe, can lead to pneumonia, deafness and the swelling of the brain — are now under critical threat from a growing anti-vaxx movement that reaches from affluent neighbourhoods in San Francisco to church groups in Zimbabwe.
In 2016, Europe appeared to be on track to eliminate measles; the continent recorded its lowest ever number of annual cases, just 5,273. But, a year later, those numbers suddenly increased fourfold, with reported infections rising to 21,315 in 2017.
The countries worst hit by this outbreak were Romania and Italy, where the 2018 election saw vaccine scepticism used as a vote-winner after unpopular mandatory vaccinations were introduced. From 2011 to 2015, there was a 5.3% reduction in Italian children receiving the measles vaccine, a pattern repeated in several countries around Europe.
Even small reductions in numbers of vaccines can be incredibly dangerous and risk the disease returning. Many assume that if a significant enough proportion of the population is immune — what’s called “herd immunity” — then a contagious disease will be resisted. The trouble is, herd protection only works if unvaccinated people are evenly dispersed within the population.
“Vaccine refusers cluster in communities,” explained Dr Saad Omer, a professor in global health, epidemiology and paediatrics at Emory University. “Therefore, even if you have high mean rates of vaccination, if you have these pockets of susceptibility then you have a problem.” The World Health Organisation (WHO) therefore recommends that 95% of the population should be immunised to prevent outbreaks. In Italy, only 85.3% of two-year-olds were vaccinated for measles in 2015.
Even more dangerous are the risks posed by the spread of Europe’s anti-vaxx movement to the developing world, where more than 95% of measles deaths occur. Health professionals worry that some of the great strides of recent years could be undermined.
Why are people anti-vaccination?
One problem is that the vaccine has been a victim of its own success. “Overall, the fact that vaccines have been successful results in a decrease in the incidence of disease,” explained Omer: people aren’t as willing to be immunised because they’re unfamiliar with the dangers of measles.
Scares about the impact of immunisation have also made a large impact. A 1998 study published in the Lancet by Dr Andrew Wakefield, a now-disgraced British doctor, connected the MMR vaccine (Measles, Mumps and Rubella) to autism in children. Wakefield’s study was since retracted after being exposed as fraudulent, but the damage was done.
"There’s a potential to backfire if you throw a lot of information at people"
The study is frequently used to back up anti-vaxxer claims. For example, Minnesota has seen a dramatic decrease in the numbers of Somali-American children being vaccinated — rates dropped from 92% vaccinated with MMR in 2004 to just 45% in 2013. As a result, in 2017 the state experienced its worst outbreak since 1990. Many apportion blame to Wakefield, who was invited there by local anti-vaccination proponents and whose work spread through the state.
So, who are the people that have become convinced by Wakefield and others? A study published in February 2018, surveying 5,323 people in 24 countries, examined the roots of these anti-vaccination attitudes. Those who had beliefs in conspiracy theories, low tolerance for impingements on their personal freedoms, disgust towards blood and needles and strong individualistic worldviews were most likely to be anti-vaccine. Interestingly, demographic variables including education accounted for no significant variation.
And, as opposed to evidence driving attitudes, researchers find that people frequently develop these views through intuitions and gut responses which are hard to articulate, and are then motivated to find the evidence to support their attitude. This means that giving anti-vaxxers more information won’t necessarily help; these are people who already seek out facts.
Much of their information is spread on social media, which has become an important platform for anti-vaxxers’ interactions. In Brazil, for example, where coverage indexes of important immunisations have been dropping, the Ministry of Health found five anti-vaccine Facebook groups bringing together more than 13,200 people.
“If anything, there’s a potential to backfire if you throw a lot of information at people who already have these hardened opinions about vaccines,” Omer explained.
The anti-vaxx movement has become part of a larger political identity, making its way onto the platform of populist leaders from President Trump to the Five Star Movement and League parties in Italy's 2018 election. “Sometimes scientists bundle vaccines with climate change, and that may end up making it part of the social and political identity of a huge chunk of people,” Omer said.
How can government win parents' minds?
Cynicism towards government is often at the heart of anti-vaccination views, which means public health organisations must critically invest in systems that convince the population they are taking concerns seriously and basing their vaccine campaigns on scientifically rigorous evidence.
“Government should first of all focus on trust in vaccines,” said Omer, “in terms of having an open and scientifically-robust system where vaccine-adverse events are evaluated on an ongoing basis, and people understand the risks associated with non-vaccination.”
Secondly, government can encourage parents to opt-in by redesigning the decision-making process they go through. “They should not eliminate choice when these laws are enacted but should change the balance of convenience in favour of vaccination,” Omer explained.
This means introducing a strong nudge — making the decision to refuse their child’s vaccinations less convenient for parents. In Washington State, for example, a law introduced in 2011 forced parents who want to exempt their child from immunisation to first get information about the benefits and risks of vaccinations from a licensed healthcare provider. As a result, there was a reduction of 40% in vaccine refusal.
"The single most trustworthy source on vaccination remains the healthcare provider"
“You’re changing the balance of convenience of vaccinating vs not vaccinating by adding these rational requirements,” said Omer. And the evidence backs it up: those US states which make the vaccination exemption process easy and allow parents to exempt children due to personal (not religious) beliefs have lower rates of immunisation.
However, Omer cautioned against going as far as using laws to force people to immunise their children. “So far it seems that stricter mandates have the potential for backfiring,” he explained. “Often, in the long-run, they don’t get implemented: a lot of states of the former Soviet Union have these strict laws on their books, and the fact that they’re so strict means the laws aren’t implemented.”
Aggressive measures are being introduced in a number of countries including Romania, France, Finland and Australia. In New South Wales, Australia, strict "no jab, no play" laws were introduced in January 2018, which prevent unvaccinated kids from preschool and day care and fine directors of childcare centres if they break the rules. However, the jury is still out as to whether they will be effective. An EU-funded study suggested that there was no clear relationship between vaccination coverage and national policies on compulsory vaccinations in Europe.
Finally, policymakers must not underestimate the role of doctors. “Even with a lot of online activity,” Omer said, “the single most trustworthy source on vaccination remains the healthcare provider,” even for those who are anti-vaccines. “If a woman goes to the primary healthcare setting and is not treated appropriately when she tries to get her child vaccinated, she is much less likely to come back.”
Therefore, policies which improve the interactions between a doctor and young families could be vital in turning the tide, such as giving new parents more time with their healthcare providers. One study suggested that a third of initially hesitant parents can be persuaded to vaccinate their children by doctors' motivational interviewing techniques.
If governments don't act quickly against measles and develop the right strategies to combat the anti-vaxx movement, then one of the world's most deadly diseases could regain momentum. In the face of a disease which kills one or two children for every thousand who catch it, complacency is not an option.
(Picture credit: Flickr/Sanofi Pasteur)
Jack Graham
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