Trust and Confidence in Vaccines: Tales of Three Vaccines, Lessons for Others

"Listening is key both to understanding what is driving concerns and to devising effective responses."

Because anxiety regarding vaccines can stem from a range of cultural, political, religious, and social forces, addressing concerns can require more than the provision of scientific information. This chapter looks at a range of different vaccines and different settings where trust issues emerged for a variety of reasons, and it offers examples of how trust issues were successfully addressed and overcome. It highlights the importance of an ongoing process of building and sustaining trust to ensure the success of any immunisation effort.

Each of the three case studies involves a complicated mix of factors that drove vaccine hesitancy and distrust. The cases are:

• The 2014-2015 Disneyland measles outbreak in the United States (US), which prompted the state of California to pass a law that did away with religious and "personal belief" exemptions for vaccines
• The 2003-2004 Nigerian polio boycott, which started with a rumour - that the oral polio vaccine (OPV) was being used as part of a Western conspiracy to sterilise Muslims - and was fueled by Muslim leaders.
• The human papillomavirus (HPV) vaccine in Japan and the US, which involved a mixed reception that led to millions of women being unnecessarily placed at risk for cervical cancer.

The chapter then looks at some of the lessons learned from these experiences. For example, in the Nigerian case, the approach to rebuilding and maintaining public trust involved sustained, directed engagement efforts. The Global Polio Eradication Initiative (GPEI) began by identifying individuals or institutions that did have the trust of the public, such as Ibrahim Gambari, a United Nations senior advisor for African affairs who bridged the country's main political divide simply by virtue of having a northern Muslim father and a southern mother. Gambari then approached Ibrahim Shekarau, the governor of the Kano State and vocal opponent of the polio vaccine, and conveyed the cost that a continued boycott would bring to Shekarau's reputation. The United Nations Children's Fund (UNICEF) drew attention to the fact that the polio vaccine was being procured from an Indonesian producer, allowing Shekarau to save face by reporting that the vaccine was sourced from a Muslim country. Time and energy were also dedicated to building and maintaining relationships with traditional and religious leaders in Northern communities through, for example, the creation of a Northern Traditional Leaders Committee on Primary Health Care. In this way, trusted local leaders became part of the polio programme. Another effort to include local voices led to the organisation of groups of polio survivors, who would talk about the value of vaccination through the lens of personal experience.

Another type of lesson emerges from the HPV case, which demonstrates the need for the public health community to not only anticipate concerns that are likely to arise but also to respond to concerns promptly when they are voiced. A prompt and transparent response can preempt any potential crisis of confidence, and rapid engagement with the media can quell concerns and negative media coverage if an adverse incident should occur.

The chapter's authors review some of the research that has been done in an attempt to generate evidence-based recommendations for the future, exploring some of the challenges associated with devising effective strategies for discussing vaccines, reducing misperceptions about vaccines, and increasing vaccination rates. From their perspective: "Strategies to communicate with vaccine-wary parents cannot be devised through hunches and intuition. The nature of public health, policy, and patient communication around vaccines and immunization needs to move from being didactic to dialogic, from feeling coercive to becoming conversational. The questions and reasons for vaccine hesitancy need to be listened to, not guessed. Public health needs public trust, built through genuine engagement."

In conclusion: "One of the key overall lessons across the case studies presented in this chapter is the importance of recognizing the multiple levels of confidence that effective immunization programs depend on - public confidence, provider confidence, and political confidence in vaccination. Hesitancy around vaccination by members of the public, their health providers or politicians who make key policy and funding decisions, must all be addressed early to preempt potential disruptions to immunization programs and their public health impacts."