The Public Health Crisis of Underimmunisation: A Global Plan of Action

"Crucially, an effective response must be multidisciplinary and multisectoral, spanning governments, international organisations, the private sector, and civil society."

Data show that vaccination rates are falling - in some countries, below levels needed for so-called herd immunity, resulting in outbreaks. Recognising a problem whose impact ranges from hyperlocal to national and worldwide, the World Health Organization (WHO) deemed vaccine hesitancy - reluctance or refusal to vaccinate despite vaccine availability - as one of the top ten global health threats of 2019. In light of the emerging crisis, this article offers an action plan based on scientific evidence, ethics, and human rights.

The viewpoint piece opens with an examination of underlying determinants of low vaccination rates, including vaccine unaffordability and inaccessibility, low public trust, poor governance, and humanitarian crises. For example, the anti-vaccine messaging that targets local communities but is also disseminated widely on internet platforms and social media can contribute to distrust. Even government officials can sometimes discourage immunisations and perpetuate conspiracy theories, as could be seen in April 2018, when Pakistani politicians tweeted false information to discredit polio vaccines.

Some governments enact laws to mandate or encourage vaccinations, depending on cultural and legal traditions. In the United States (US), all but five states permit religious or conscientious exemptions to varying degrees, but lax enforcement of vaccination requirements and permissive rules for so-called opt-outs can result in local clusters of religious or conscientious objectors. At the other extreme, in 2019, Pakistani officials incarcerated individuals who refused polio vaccination. (As the authors argue: "Ethically sound vaccine mandates should be proportionate to actual risks and impose the least restrictive means needed to achieve public health objectives.")

What the researchers offer is a three-pronged strategy focused on:

• Vaccine affordability, accessibility, and availability - e.g., "Global partnerships like the Coalition for Epidemic Preparedness Innovations (CEPI) align public and private actors to fund, develop, and equitably distribute vaccines."
• Evidence-based health communication campaigns at local, national, and global levels - "...Key components of effective communication campaigns include objective messaging in traditional and social media designed to assuage fears and promote accurate health information and immunisation outcomes. Campaigns should recruit well trusted spokespeople such as leaders in sport, entertainment, and religion. Health engagement is often the most effective at the community level through local leaders, teachers, and religious figures. Governments should also adopt transparent, lawful, and measured regulations to correct or remove disinformation from the internet and social media..."
• National or regional law reform that has public acceptance and is fairly implemented - "...Governments should consider repealing or restricting permissive religious and philosophical exceptions. Such reforms are consistent with freedoms of religion and conscience because they do not target particular religious or other communities..."

In conclusion: "Finding the political will and holding governments accountable are essential. Countless lives can be saved if the international community sustainably funds vaccination systems, assures reliable information, and safeguards the common good through meaningful law reform."