We need a global plan to tackle low vaccine uptake and vaccine hesitancy

A cornerstone of disease prevention could crumble if we don’t tackle vaccine hesitancy

As news about infectious disease outbreaks and vaccine hesitancy continue to dominate the headlines, it is clear that we need to step-up our efforts to reverse these trends and prevent the spread of infectious diseases.

A recent report commissioned by the Wellcome Trust assesses the opportunities and challenges for developing bacterial vaccines to fight antimicrobial resistance (AMR). The report has information on 18 pathogens and the state of the pipeline for vaccine development, the ease of trials, the expected policy stance for a vaccine, and the likelihood of support. The report includes a scoring system that incorporates cultural barriers in the final score and makes recommendations on activities that would drive vaccine development and uptake. But, what is the use of vaccine development if there is no uptake?

In many countries across the globe, the cultural, religious, social, and political barriers to vaccine acceptance and uptake are costing lives. In LMICs, vaccine hesitancy is exemplified by repeated outbreaks of polio. Large measles outbreaks with fatalities are ongoing in countries that had previously eliminated or interrupted endemic transmission. In January 2019, Romania, Italy, Poland and France had the highest measles case counts with 261, 165, 133 and 125 cases, respectively. Between 1 February 2018 and 31 January 2019, 30 EU/EEA Member States reported 12 266 cases of measles. Thirty-five measles related deaths have been reported in EU countries in 2018 and vaccination coverage is below 95% in most countries. A look at the reasons for vaccine hesitancy will distinguish between barriers related to acceptance and access.

We have seen HPV vaccine hesitancy in the USA, Japan, Denmark and Ireland driven by social, religious, and cultural barriers and the failure of political leaders and the media to support public health professionals to ensure high rates of vaccination. HPV vaccination completion rates plummeted to just 0·6% in Japan in 2013 after advisory suspension by the government and have stagnated at about 30% since, despite universal recommendation being reinstated. Data from Public Health England highlight how the UK’s national human papillomavirus (HPV)/cervical cancer vaccination programme has reduced the prevalence of HPV in young women. But HPV vaccine uptake in the UK varies substantially by region.

The current vaccine armamentarium includes many other vaccines that are not effectively deployed with complex vaccine hesitancy issues playing a part, for example, flu vaccine in high risk patients (including pregnant women), whooping cough vaccine in pregnancy, pneumococcal vaccines in high-risk patients, and routine childhood vaccinations in children. Even though vaccines are recommended for these groups, uptake is not as high as it should be. Nevertheless, uptake of whooping cough vaccine in pregnancy in the UK has improved and deaths of neonatal whooping cough practically vanished thanks to a coordinated and creative approach to tackle vaccine hesitancy.

The UK is now a world leader in maternal immunization. As a mother and paediatrician, I am often asked at the school gate for advice on which vaccines are safe and which “are not safe”, and therefore by implication best avoided. I’m also asked which are necessary and which “are not necessary”. It is easy to understand why some parents are torn when deciding what to do. They are bombarded by ill-informed media and baseless internet reports which cite the risks of vaccines. Healthcare providers are not good at explaining statistics and risk, even though factual information on vaccine risks is readily available in the public domain and accessible to the public and the media. It is worth highlighting the high uptake in the recently launched meningococcal B vaccine in the UK, with huge interest from parents of children of all age groups surging after a very sad case of fulminant and fatal meningococcal disease in a toddler was widely reported by the media. At the time of the launch of the meningococcal B vaccine, there was full transparency in the patient information literature on the risk of reactogenicity to the vaccine; this did not appear to diminish the interest from the public.

In 1962 Roald Dahl’s daughter Olivia died of measles. There was no effective measles vaccine at the time. Many years later, when measles vaccine was available but uptake was lower than hoped, he wrote that “It really is almost a crime to allow your child to go unimmunised” If we are to use vaccines effectively to prevent infectious diseases, vaccine hesitancy needs to be tackled. We need to think about how we start challenging those that make unfounded assertions against public health interventions more effectively. Should we be making all immunizations mandatory? Or incentivising the public to encourage vaccination uptake?

Simon Stevens, NHS England’s chief executive, highlighted vaccine hesitancy as the cause for falling vaccination uptake at the Nuffield Trust Summit earlier this year. He used a quote from a young parent to bring this public health issue sharply into focus. Concrete action by our leaders is necessary. We need to think more broadly than the normal response. We need to discuss the role of schools in supporting the education of families on the importance of  vaccines. A core approach of our efforts to improve public health should be a focus on the importance of vaccines, and this must be part of every relevant clinical interaction.

Nuria Martinez-Alier is a senior paediatric infectious diseases specialist. She co-established the paediatric infectious diseases and immunology department at Evelina London Children’s Hospital. Her work now includes clinical trials including tuberculosis and norovirus vaccines.

Competing interests:  In my role as an infectious diseases and vaccines medical strategy advisor for IQVIA I contribute to the conduct of clinical trials and the development of vaccines.


Claire Lemer is a consultant general paediatrician at the Evelina London Children’s Hospital. Alongside this work she is the deputy director of CYPHP, an innovative data driven public health focused system level transformation. She combines clinical medicine with medical management, service improvement and policy work. 

Competing interests: CL edits for Archives of Disease in Childhood and receives an honorarium. She used to edit for BMJ Quality and Safety. She is occasionally paid to speak on medical management.