Vaccine confidence: early intervention is key

Dr-Heidi-Larson The same logic runs through a new initiative designed to understand and improve public confidence in vaccination, a factor which has been identified as key in ensuring good vaccine uptake.

Vaccines Today sat down with Dr Heidi Larson, an anthropologist at the London School of Hygiene and Tropical Medicine, who has just launched the Vaccine Confidence Project. The initiative will serve as a kind of early-warning system which flags breakdowns in public trust in vaccines before it’s too late. Without an early warning system, loss of trust in vaccines only becomes evident when disease outbreaks occur.

Listen, engage

“The Vaccine Confidence Project is an effort to monitor and detect emerging episodes of waning public confidence or public trust in vaccines,” explains Dr Larson, who has previously headed Global Communication for Immunization at UNICEF and Chaired the Advocacy Task Force for the Global Alliance for Vaccines and Immunization (GAVI).

Central to this is a sophisticated computerised tracking system that picks up media reports and online discussions about immunisation. Dr Larson’s team taps into everything from reports of suspected adverse events to specific concerns among particular communities.

This means, for example, that it is possible to detect the first signs of hesitancy about following the recommended vaccine schedule in a town in France and to step in with corrective measures before immunisation rates actually begin to drop.

Similarly, when inaccurate rumours about polio vaccines spread in northern Nigeria it led to a serious decline in immunisation rates followed by a surge in new cases. Advance notice of faltering levels of trust in vaccines or health authorities offers the opportunity for early outreach to address questions and concerns in the community.

‘Information surveillance’

“It’s about listening to the public’s levels of confidence, engaging to sustain confidence and responding where we need to build confidence,” says Dr Larson. “It’s information surveillance rather than disease surveillance.”

The project will help “to move towards [better] risk assessment and mitigation rather than waiting for a crisis to hit. It’s a more long-term approach which recognises that sentiments change”.

She says focusing on the minority of people who are strongly pro- or anti-vaccination has proven ineffective in the past. Instead, Dr Larson argues, the goal should be engaging with the middle “80%” who have questions about vaccines but have not made up their minds.

Monitoring changes in public confidence is an important component of the project. Dr Larson suggests that the key to improving vaccination rates is to deepen understanding of when and why people move from being ‘hesitant’ about immunisation towards the decision to vaccinate – or not. And, she says, public perceptions of vaccines are far from fixed:

“We shouldn’t take for granted that people who vaccinate will keep vaccinating. In the same way we shouldn’t assume that people who, for whatever reason, have missed or opted out of a particular vaccine will skip all vaccines forever.”

Find out more at Vaccine Confidence Project and read this full transcript of the interview

Vaccines Today: What is the Vaccine Confidence Project?

Dr Heidi Larson: The Vaccine Confidence Project is an effort to monitor and detect emerging episodes of waning public confidence public confidence or public trust in vaccines.

Too often in the past the immunisation community has waited and not taken public concerns seriously unless it was an overt adverse event. The point of the project is that we need to pay attention earlier, we need to listen to what the public is saying and, even if it’s not an explicit safety concern it can have an impact on the effectiveness of immunisation and vaccine acceptance.

It’s about listening to the public’s levels of confidence, engaging to sustain confidence and responding where we need to build confidence.

Vaccines Today: When you say ‘listening’, what do you mean?

Dr Heidi Larson: We have a global 24-hour, seven-days-a-week, global monitoring tool that we’re doing with ProMed and Health Map. We have multiple streams around the world tapping into public domain information on media, social media, listservs and other shared information to pick up on what’s being talked about.

It’s not just detecting problems. It looks at what’s out there about vaccines – by topic and by location. We’ve created 33 categories – topics of discussion and concern – and we look at what portion of public discourse is negative, hesitant or positive. So we’re constantly coding it and looking at how it changes over time.

It’s information surveillance rather than disease surveillance.

Vaccines Today: Is it automated?

Dr Heidi Larson: Yes. It’s an enormous project but we are expanding the language reach. We have Google Translate working on it and we are expanding search terms to include the five UN languages. We are starting to introduce sentiment analysis which is quite a fascinating new dimension of the project.

Vaccines Today: Might some people find it disconcerting to hear about this kind of ‘listening’ even though it’s information that is in the public domain?

Dr Heidi Larson: Well we’re not digging into anything beyond the public domain. We’re listening to be responsive we’re not listening to reprimand. We’re listening to learn.

Aside from the public domain stuff we’re also constantly looking at academic publications and have posted a map on our site which shows some of the emerging issues around the world. It’s not just about negative confidence it’s about expressions of concern.

Vaccines Today: What prompted the initiative in the first place?

Dr Heidi Larson: One of the drivers of this is that the world has been polarised from anti-vaccination and pro-vaccine. People say ‘You’re either pro or against’ and I just don’t think that’s how the world works. The project is trying to embrace the 80% of the population that is sitting in the middle and has some very healthy questions – which we encourage in democratic societies. One of the basic tenets of public trust is dialogue.

We’re not just out there trying to identify the enemy in any sense of the word. That’s why we include both positive discourse and negative, and everything in between. We need to listen.

Vaccines Today: When you talk about ‘engagement’ what form does that take?

Dr Heidi Larson: Aside from monitoring, reviewing and sharing what’s out there, we have a number of forums for engagement. I’ve recently been put on the World Health Organisation’s SAGE working group on vaccine hesitancy which was launched in March [2012]. We’re also sharing the work of the Confidence Project to help identify ways to measure and respond to concerns.

We get lots of calls – from countries, from civil society organisations, from individuals – for feedback, advice, guidance, thoughts, and we often get people asking us to address particular issues in our weekly commentary on the site. I also do quite a few media interviews and we have a space on our site where people can tell us about their concerns or interests. And we work very closely with international paediatric organisations, along with a network of colleagues and individuals around the world.

Vaccines Today: You talk about ‘vaccine hesitancy’ and ‘questioning’ – do you think the language has softened in this area in recent years? Has there been a move away from the more negative discussion about ‘anti-vaccine groups’ and ‘anti-anti-vaccine advocates’?

Dr Heidi Larson: Yes, and that’s happened for a couple of reasons. There’s recognition that the world isn’t divided into those extremes; and it was more alienating than productive.

We are increasingly recognising, as an immunisation community, that hesitancy doesn’t stay as hesitancy. It can either go positive or it risks falling more into the refusers [category]. If we are going to make a difference we need to have a dialogue with those in the hesitancy area to understand what tips it one way or the other.

Vaccines Today: So the focus is on early intervention or a preventative approach.

Dr Heidi Larson: Yes, rather than crisis management, we are more about risk assessment and engagement. We have an article coming out in the Journal of Drug Safety – a special on risk communication – and we talk about broadening the whole area of risk communication to move towards building the risk assessment and mitigation component rather than waiting for a crisis. It’s a more long-term approach that recognises that sentiments change.

Vaccines Today: You mentioned that people often start out with questions and then decide either to vaccinate or not. Do some people move in the opposite direction – do they go from initially viewing vaccines positively or negatively to having questions again?

Dr Heidi Larson: Absolutely. And that’s another reasons for the shift towards discussing hesitancy rather than the black-and-white – anti- or pro-.

Sometimes a mother vaccinates her first two children and then doesn’t vaccinate the third, or doesn’t follow the schedule for the first but then decides to vaccinate the next child in line with recommendations.

We shouldn’t take for granted that people who vaccinate will keep vaccinating. In the same way we shouldn’t assume that people who, for whatever reason, have missed or opted out of a particular vaccine will skip all vaccines forever.

Vaccines Today: You also pick up religious concerns or problems people discuss about accessing vaccines.

Dr Heidi Larson: That’s right. There are concerns based on religious or philosophical concerns, or access issues. But the biggest topic is about scheduling and recommendations. Most public discussion is about vaccination schedules. A lot of the hesitancy is about people delaying.

It’s a difficult issue because the vaccine schedules are not harmonised. Look at Europe, there are 32 different schedules. How can a physician say ‘This is the schedule which has been agreed for scientific reasons’ when if people move house three times in Euope and see three different schedules? Even if there’s a reason for the differences related to school timetables or specific immunity levels in the community, I think we have to be better at communicating why the schedules are different. For too long we’ve had the ‘Take this it’s good for you’ approach and that’s just not enough.

Vaccines Today: This is quite a large and sophisticated tool you have built. Are there other areas of health communication or risk communication where it could be used?

Dr Heidi Larson: Absolutely. We are starting to do new work about preparedness and anticipating public acceptance of anti-retroviral medicines in AIDS prevention. We are just starting to try and pick up what the public is saying so that we can decide how best to introduce it when it’s ready.

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