The state of vaccine confidence in 2018

Last week my colleagues from the Vaccine Confidence Project released their State of Vaccine Confidence Report for 2018 ¹. In 2016 the group reported a survey that investigated public perception towards vaccination across 67 countries ². Within that report, seven of the ten countries with the lowest levels of confidence in vaccination were in Europe. This new report for 2018 focused specifically on the 28 EU member states in order to track levels of confidence towards vaccination and see if changes have occurred over the last couple of years. ^{Title image credit: Torange}

Vaccine hesitancy

When talking about vaccine beliefs, the words we choose to use really matter. Often when people turn against vaccination the term that you will see in reference to their beliefs is _“Anti-vaccination”_ (or the individuals being labelled the more derogatory _“Anti-vaxxers”_). This ‘anti’ prefix implies a dichotomy of, those that are for vaccination and those that are against it. While there is certainly a dichotomy in the outcome of a vaccine decision (taking or refusing a particular vaccine) the term vaccine hesitancy takes the for-or-against narrative and places it on a continuum. Vaccine hesitancy (or vaccine confidence, which I use interchangeably thought this post) therefore, allows us to distinguish between those individuals that will not accept vaccination under any circumstances and those that have concerns about vaccination but may be convinced through an effective communication strategy.

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Easy access to safe and effective vaccination is without a doubt the most important influencing factors when it comes to vaccine uptake. When these factors are present and uptake falls, it can often be associated with high levels of vaccine hesitancy. With measles currently appearing across multiple countries within the European health region ⁴, the occurrence of which is highly avoidable through vaccination, vaccine hesitancy has been cited as one of the possible determinants of such outbreaks ⁵.

This is probably a good place to mention again that while I talk a lot about vaccination on this blog, I’m a psychologist, I study risk perception and information seeking in regards to medical decision making. I accept the scientific consensus on vaccination and I outline my reasoning for doing so in a previous post here

Quick and easy measurement of Vaccine Hesitancy

When designing attitudinal surveys there is always a trade off between depth and brevity. Make a survey too long and people drop out half way through, make a survey too brief and you run the risk of overinterpreting your findings. Depth is possible with a smaller sample size (as you can often incentivise for participation), with larger sample size, however, brevity is a must (unless you have extensive funding).

For the purposes of this report the measurement was nearer the brief-but-broad end of the survey spectrum, asking the public 4 core questions (asked in 2018 and in the previous survey conducted in 2015) and 4 additional questions (asked in 2018 only).

This year’s survey involved 28,782 participants across the 28 EU member states, with a nationally representative sample of around 1000 citizens per country.

All questions were on a Likert scale that involved a statement and asked for the participant to responds with one of 5 answers: Strongly agree, tend to agree, do not know (or no response), tend to disagree, or strongly disagree.

The four core questions were as follows:

Side note: Number four is a bigger deal than it at first might seem. For instance the flu vaccine uses traces porcine gelatine (i.e. pig) as a stabiliser which may conflict with the religious views of devout Muslim and Jewish individuals ⁶. Vaccine scientists, if you’re reading this please hurry up and solve this problem!

The four additional questions focused more specifically on the safety and importance of the MMR and seasonal influenza vaccines for pregnant women:

The state of vaccine confidence in 2018

As was found in the previous report, this year saw large variations in the perception towards vaccination across the EU.

Portugal has the highest confidence in vaccination with 95.1% and 96.6% tending to agree or strongly agreeing that vaccines are safe and effective, respectively (congratulations @abigail-dantes seeing as you’re the only person I know living in Portugal I’m crediting you with this success!). Other high achievers are Denmark, Spain, Hungary and us here in the UK (I’m taking full credit for this one! Can’t be any other explanation)

Bulgaria, Latvia and France are the countries that are least likely to agree that vaccines are safe (66.3%, 68.2% and 69.9% tending to agree or strongly agreeing with Q2). Bulgaria (again), Poland and Slovakia are the three countries that are least likely to agree that vaccines are important (78.4%, 75.9% and 85.5% tending to agree or strongly agreeing with Q1).

Change in European Vaccine confidence between 2015 and 2018

In the previous State of Vaccine Confidence Report ² France, Italy, Greece and much of eastern Europe were identified as having some of the most concerning attitudes towards vaccination. France held the highest level of hesitancy with 41% of the countries respondents either tending to disagree or strongly disagreeing with the statement “Overall, I think vaccines are safe”

^{Image source: The state of vaccine confidence report 2016. Open access publication.}

This year there has been some changes. France, Greece, Italy and Slovenia have become more confident in the safety of vaccination, however, over the same time Czech Republic, Finland, Poland, and Sweden have become less confident.

Below I’ve reproduced the change in each of the responses between the two measurements. Each arrow represents a statically significant shift (alpha = 0.05, controlling for multiple hypothesis testing) in attitude. Ordered left to right by the magnitude of the overall attitude change (i.e. Slovenia made the biggest positive shift and Poland made the biggest negative shift).

^{Image made for post}
Mostly good news it would seem. Look at all that green!

Differences across vaccines

With the addition of the new questions it is also now possible to see the comparison across vaccines.

As might be expected the MMR vaccine is seen as more important than the seasonal influenza vaccine for pregnant women.

The influenza vaccine was however seen is less safe than the MMR vaccine, this is likely due to the fact that it’s a new vaccine being given to pregnant women. I’m also currently finding this is a concern for many women that I’ve surveyed in the course of my research, so it’s reassuring that I’m seeing it in these results (support that my sampling is representative).

Side note: If you’re interested in why we have recently started vaccinating pregnant women for influenza and pertussis I’ve written a previous post on this topic here.

^{Image source: The state of vaccine confidence report 2018 Open access publication.}

Across countries it would appear that Sweden has the lowest confidence in the MMR vaccine with only 57.1% of respondents tending to agree or strongly agreeing that the vaccine is important (Q5) and 56.5% of respondents tending to agree or strongly agreeing that the vaccine is safe (Q6). These results are a full 39.3% (important) and 40.1% (safe) lower than that of Portugal!

As for the seasonal influenza vaccine for pregnant women, Sweden and Belgium again have similar safety and efficacy issues with the vaccine. Sweden also is the only country to say that the seasonal influenza vaccine is more important than the MMR vaccine. In short, something weird is going down in Sweden.

Edit: Its a week after I originally published this post. I passed it along to my friend that worked on this project, and this Sweden result may be a data error issue rather than an accurate representation of attitudes. Let this be a lesson to you all, never take a single data point as gospel. Always remember to replicate and triangulate if you want to do good science! I've left the rest of the Sweden references unchanged for transparency (also edits would be a tonne of effort)

General Practitioners (GPs) vaccine confidence

GP’s are people too. As such they make decisions with the same biases and cognitive processes that the rest of us use when making a decision. While most have the benefit of extensive medical knowledge and act according to the recommended evidence-based guidelines, a small minority of GP’s hold vaccine hesitant views of their own. At the extreme end these views may lead to the GP discouraging people from taking a vaccination, but in their milder form they can also lead to them giving a week, or no, recommendation, which can often have the same ultimate outcome (a vaccine non-uptake/refusal).

For the first time, this survey also contacted 100 GPs from 10 of the surveyed countries. They were asked the 8 standard questions and the three GP specific questions

Results indicated that overall, the likelihood of GPs recommending the MMR vaccine is high across most of Europe, there were however two striking exceptions. In Czech Republic only 36.4% of GPs were somewhat likely or highly likely to recommend the MMR vaccine. Slovakia was similar with 46.7% likely to recommend the vaccine.

In every country over 90% of GPs recommended the general sessional influenza vaccine to patients. However when it came to the pregnancy vaccine this dropped dramatically with the Czech Republic, Poland and Slovakia standing out once again.

My take on these findings

Its always good to take findings from surveys like this with a note of caution. For instance France being the most hesitant last survey and being one of the biggest improvers this time may be because of changes in vaccine communication policy, however, it may also simply be regression to the mean. The best way to use findings like this in my experience is as a means of cross validating rumours that we hear through other channels (e.g. reporting, social media etc).

We know that Poland has been having issues with the compulsory vaccination policy for a while now ⁷ and the finding of this report certainly backs up the theory that negative sentiment towards vaccination is driving it. The GP results however suggest that it isn’t likely to be down to GPs attitude to vaccination. Czech Republic, however, may be a whole other issue. With a current measles outbreak and such a small number of GPs recommending the vaccine we can expect a worrying drop in uptake rates in the near future unless they can be reassured otherwise.

I’ll have to give Sweden and Belgium more attention in the future. It would seem from the discussion in the report that this hesitancy is likely to be driven by the UKs chief vaccine rumour export: Andrew Wakefield and his MMR vaccine cause Blank heavily debunked “theory” (sorry about that, our bad).

All in all, these findings help to take the vaccine hesitancy temperature of the region. Diagnosis, however, will takes further study. We’ve had a similar tracker survey running in the UK for a number of years and it certainly helped to inform the communication stratagem of Public Health England, to the point where we’ve now all but recovered from our Wakefield mess. Hopefully this survey will continue and do similar for Europe in the future. As I’ve mentioned before, this kind of maintenance isn’t sexy but it’s necessary once we’ve been successful and the fear of disease is all but gone from living memory.

If you’d like the information for your own country (if in Europe) you can access the report here or feel free to ask in the comments before and I’d be more than happy to fish out the relevant data for you.

About me

My name is Richard, I blog under the name of @nonzerosum. I’m a PhD student at the London School of Hygiene and Tropical Medicine. I write mostly on Public Health, Effective Altruism and The Psychology of Vaccine Hesitancy. If you’d like to read more on these topics in the future follow me here on Steemit or on Twitter @RichClarkePsy.

I'm also a proud member of @steemstem and you should be too! Find more information about their fine work here

References:

[1] Larson, Figueiredo, Karafllakis & Rawal (2018). The State of Vaccine Confidence In the EU 2018
[2] Larson, H. J., de Figueiredo, A., Xiahong, Z., Schulz, W. S., Verger, P., Johnston, I. G., ... & Jones, N. S. (2016). The state of vaccine confidence 2016: global insights through a 67-country survey. EBioMedicine, 12, 295-301.
[3] World Health Organization. (2014). Report of the SAGE working group on vaccine hesitancy. Geneva, Switzerland: WHO.
[4]The World Health Organisation: Measles cases hit record high in the European Region
[5] The Guardian: Low MMR uptake blamed for surge in measles cases across Europe
[6] The BBC: Pork gelatine use in NHS vaccines 'disappointing'
[7] Euronews: Thousands of people in Warsaw protested against compulsory vaccination