Immunisation has a long history, with early attempts to prevent illness involving the deliberate exposure of healthy individuals to smallpox in a practice known as variolation, which involved injecting material from an infected person into a healthy person. Some records suggest this method was used as early as 200 BC.
However, it is Dr Edward Jenner who is regarded as the pioneer of vaccination when he realised that people infected with cowpox were immune to smallpox. In 1796, he famously inoculated an-eight-year-old, James Phipps with material from a cowpox sore. Two months later Jenner inoculated James with smallpox. James did not get infected and is considered the first human to be vaccinated. Smallpox was a ghastly disease with fevers, vomiting, mouth ulcers and rapid death or permanent disability, so this marked a significant turning point in preventative health.
Distrust in vaccination is not a modern phenomenon with early critics claiming that smallpox vaccination risked turning people into cows. Despite the effectiveness of the smallpox vaccine and compulsory vaccination programmes in Britain and the USA in the mid nineteenth centuries, it was only in 1979 that smallpox was declared eradicated.
In 1974, WHO launched the Expanded Programme of Immunisation (EPI). A Lancet study fifty years later shows that this programme made the greatest contribution of any health intervention to mortality reduction and years of full health gained. Despite such data, vaccination remains an issue that provokes heated debate.
Confidence in childhood vaccines dropped from 93.8 per cent confidence pre-COVID to 86.3 per cent post-COVID in Australia while UNICEF data indicates that the pandemic caused the largest sustained drop globally in childhood immunisation levels in thirty years. In 2022, the number of measles outbreaks globally was double that of 2021 and there have been cases of polio identified in the United Kingdom, the USA and Israel in 2022, a reminder that preventable diseases still pose a risk that will increase if vaccination levels continue to drop.
The reasons behind the increase in distrust of vaccination is complex, The National Vaccination Insights Project was established to provide routine, systematic data and insights on vaccination barriers and drivers so that appropriate strategies could be put into place to improve uptake across Australia. Working as a GP, I often find myself face to face with parental anxiety about vaccination and in my experience, hesitancy is multi-layered with numerous social and psychological factors driving distrust.
Raising children in the era of intensive parenting in an individualistic society like ours is associated with high social pressures, particularly for women who feel responsible for their children’s intellectual, social, emotional, and health-related outcomes. There is an expectation that parents are informed and prepared to advocate for their children with anxiety driving them towards medical misinformation from questionable sources like social media. This is particularly evident with vaccination.
'Vaccination is a big topic and breaking it down over a few consultations, and addressing specific concerns one to one is an effective way to address vaccine hesitancy.'
Rose* was forty when she had her son, Miles after numerous cycles of IVF. ‘I’ve decided I want to stagger his vaccinations because I don’t want to weaken his immune system.’ She pulls out some information she printed out at home that presented an alternate vaccination regime that was more ‘natural,’ and ‘safer,’ for her baby. She is following an influencer who had a bad experience after vaccinating her first child and now posts articles to warn others about the risks.
Perceived dangers of vaccines, concerns about side effects, doubts about the long-term benefits and social media play a significant role in parents’ decisions on mandatory childhood vaccinations. A Flinders University study aimed to understand these factors influencing decision-making around this important issue.
I try to initiate discussions around vaccination when a woman is pregnant to ascertain her views on the topic. I can then provide appropriate information in small digestible increments. Women are recommended to have vaccinations for pertussis (whooping cough), influenza (seasonal) and more recently, respiratory syncytial virus (RSV), an ideal time to broach the topic of childhood vaccination. A study done during COVID assessed vaccine hesitancy and vaccine intent during pregnancy, with one in five women hesitant and one in ten intending to get vaccinated. There was a high correlation with socioeconomic status, indicating that women with lower incomes were more distrustful and less likely to vaccinate. Interestingly, women cared for by private obstetricians in Byron Bay and affluent suburbs in Sydney have higher vaccine hesitancy post-partum. This may reflect a desire for agency around their children’s health-related decisions.
Rose only recently moved to the area. I broach her concerns while I weigh and measure her son and check he is meeting his developmental milestones. I also discuss other important topics like breastfeeding, sleep, and the challenges of parenting, so that vaccination becomes just one of the topics raised. Rose’s greatest concern is safety. ‘I just don’t trust pharmaceutical companies. I worry that promoting vaccines is profit-driven and pushed by the government.’
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Rose’s fear is not unreasonable with pharmaceutical companies not always known for their altruism. I explain that childhood vaccines are free in Australia and undergo stringent testing through multiple phases of clinical trials. I focus on the benefits versus the risks of vaccination and provide her with some evidence-based resources to read. She asks me how vaccines work, and I explain that vaccines prompt the immune system to produce antibody-producing memory cells ensuring a rapid response to invading pathogens, enhancing, and not weakening our immune response.
I always tell hesitant patients that my three children are vaccinated and spend some time going through the side effects using an information sheet that they can take home. Vaccination is a big topic and breaking it down over a few consultations, and addressing specific concerns one to one is an effective way to address vaccine hesitancy.
The National Centre for Immunisation Research collected data on the drivers of under-vaccination in Australia and many of the reasons for the declining rates of vaccination are related to cost barriers and lack of access rather than scepticism or vaccine hesitancy. The early results from two thousand Australian parents of children under five show that 11 per cent could not afford the costs associated with vaccination, and 9.3 per cent had difficulties getting an appointment. Some of these costs were indirect and involved difficulty getting time off work or transport costs. It is too early for data on the social and behavioural drivers.
Although the rates of vaccination are declining, it seems that the causes are multifactorial and not all driven by hesitancy and refusal. Hard line vaccine refusal is less common with two to three percent of children in Australia not vaccinated due to conscientious objection although the rates vary between communities. These parents are less likely to engage in fruitful discussion.
After Rose opts to vaccinate Miles, I advise her that she is not only protecting him but helping to protect the whole community. When enough members of a community are vaccinated it can slow or stop the spread of diseases and protect the vulnerable. We need immunisation rates around ninety-five percent to achieve herd immunity for many infectious diseases.
Knowing that she is doing something beneficial for the community is motivating for Rose and makes her more confident that she has made the right decision. Even in our highly individualistic society, altruism can still be a powerful force for good and one I am happy to use when encouraging parents to protect not only their child but the community.
Names have been changed.
Jo Skinner is a Brisbane-based GP, women’s fiction author, freelance health writer and distance runner.
Main image: Chris Johnston illustration.