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Vaccine Safety in the Next Decade: Why We Need New Modes of Trust

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Vaccine Safety in the Next Decade: Why We Need New Modes of Trust Analysis Vaccine safety in the next decade: why BMJ Glob Health: first published as 10.1136/bmjgh-2020-003908 on 19 May 2021. Downloaded from we need new modes of trust building 1 2 2 Heidi J. Larson , Isabelle Sahinovic, Madhava Ram Balakrishnan, 3 Clarissa Simas To cite: Larson HJ, Sahinovic I, ABSTRACT Summary box Balakrishnan MR, et al. Vaccine Among the realm of highly varied vaccine perceptions safety in the next decade: why and concerns expressed by publics around the world, ► Confidence in vaccine safety varies across coun- we need new modes of trust vaccine safety is the most frequently cited. While many building. BMJ Global Health tries but public confidence in safety is consistently of the safety questions raised have substantial evidence 2021;6:e003908. doi:10.1136/ lower than overall confidence in the importance of to address the concerns, vaccines do have small risks, bmjgh-2020-003908 vaccines. and need vigilant and responsive systems to address ► The rise of internet-media ted communication them. With more and more new vaccines, combinations Handling editor Seye Abimbola has had a significant impact on how fast public of vaccines and new technologies to develop and deliver safety concerns can spread, including travelling them, new safety concerns will arise that need attention. Received 5 September 2020 transnationally. Revised 21 March 2021 Adding to this landscape is the dramatic impact which ► Typically, emotional contagion has been studied Accepted 23 March 2021 digital communication has had on how fast rumours and within small face- to- face networks but images, vid- vaccine concerns can spread, making the task of the public eo and even text sent through social media can also health and scientific community even more pressing. One provoke the spread of emotional states including of the more recently characterised vaccine safety issues, psychosomatic reactions to vaccination. now named ‘immunisation stress- related- response,’ has ► The Global Advisory Committee on Vaccine Safety gained particularly high visibility given these highly globally has recognised the importance of the phenome- connected social media networks. To better anticipate and non they have characterised as an ‘immunisation address these rapidly shared vaccine safety concerns, a stress- related response’ (ISRR). This is an interplay number of global efforts and local responses are being of contextual issues with individual psychologi- made. Co- created social media campaigns engaging cal vulnerability, knowledge and preparedness for parents and adolescents have been effective, while the immunisation. WHO’s Vaccine Safety Net (VSN) initiative has grown its ► Failure to differentiate between the clinical mani- global network to increase awareness about vaccines festations of ISSR—fainting, anxiety and associated http://gh.bmj.com/ and contribute to building confidence in vaccines. The hyperventilation following immunisation—and other VSN reviews websites around the world to assess their conditions such as anaphylaxis which has resulted quality and accuracy to ensure and promote access to in mismanagement of cases and avoidable harm. trustworthy and science- based information on vaccine ► Even when an adverse event following immunisation safety for internet users. These and the efforts of the is assessed as being unrelated to the vaccine, the multiple network partners are more crucial than ever to perception of a causal relationship can persist, and sustain public confidence in this evolving vaccine safety public anxieties need to be addressed. on October 2, 2021 by guest. Protected copyright. landscape. ► While social media has amplified fears, anxieties and © Author(s) (or their uncertainties, social media can also be successfully employer(s)) 2021. Re- use used to listen to and engage publics in positive ways. permitted under CC BY-NC. No commercial re- use. See rights and permissions. Published by BMJ. THE STATE OF CONFIDENCE IN VACCINE SAFETY one of the most frequently reported vaccine 2 3 1Infectious Disease In 2016, the Vaccine Confidence Project concerns. Epidemiology, London School of published a study on the global state of In 2018, the European Commission Hygiene and Tropical Medicine, vaccine confidence.1 One of the core ques- requested that the Vaccine Confidence Index London, UK 2 tions in the 67- country study asked whether used in the 67- country study, be run again in World Health Organization, respondents strongly agreed, tended to agree Geneve, Switzerland the 28 EU countries to be able to monitor 3Infectious Disease tended to disagree or strongly disagreed with any changes in sentiment. In only 2 years, Epidemiology, London School the statement ‘vaccines are safe’. The study there were already changes. Some countries of Hygiene & Tropical Medicine, found that confidence in vaccine safety varied became more confident and in others confi- London, UK considerably across countries but was consist- dence declined, reflecting the volatility of Correspondence to ently lower than reported confidence in the sentiment towards vaccines—and particularly Dr Heidi J. Larson; importance of vaccines. Other studies, too, vaccine safety. In the same year, the Wellcome heidi. larson@ lshtm. ac. uk have found that fear of vaccine side effects is Trust launched their first Global Monitor4 Larson HJ, et al. BMJ Global Health 2021;6:e003908. doi:10.1136/bmjgh-2020-003908 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2020-003908 on 19 May 2021. Downloaded from Figure 1 Across Africa, confidence in vaccine safety is well below perceived importance. study asking populations in 144 countries how they felt interplay between emotion and reason that is essential to about science and health. Amidst the many questions rational behaviour’6 In short, while reason and emotion related to trust, the Wellcome study included the VCI are often seen as different, sometimes conflicting, core questions. Consistent with the 2016 study, reported influences on behaviour, Slovic and a growing number confidence in the safety of vaccines was consistently lower of neurologists are stressing the inter-relatedness of than confidence in the importance and effectiveness emotions and reason on health decisions and outcomes.7 of vaccines. Even in Africa, where vaccine- preventable While some of the public concerns and anxieties about diseases are still a visible threat, the highest confidence in vaccine safety are driven by rumours and misinforma- vaccine safety was reported in Malawi at 89%, compared tion, some of the seeds of those emotions stem from the with the even higher 95% reporting confidence in the reality that vaccines do have their risks, as small as they importance of vaccines. Togo was the African country may seem relative to the public health benefits. And, where only 33% of those surveyed agreed that vaccines when trust in government, in the local health system or are safe, although a much higher 72% were confident in international stakeholders is weak, perceptions of even http://gh.bmj.com/ that vaccines are important figure 1. An even more the smallest risks are amplified.8 recent analysis published in 2020, investigating global Among the multiple safety concerns raised by different trends in vaccine confidence between 2015 and 2019, publics, the most recurring ones are about vaccine ingre- shows that some countries have improved in confidence dients (eg, thiomersal, adjuvants), perceptions about the over that time period, while others have declined. Across risks of autism and autoimmune conditions resulting the domains of confidence in the importance, effective- from vaccination, anxieties about too-many vaccines on October 2, 2021 by guest. Protected copyright. ness and safety of vaccines, safety again was the least to overloading the immune system, and non- specific effects improve globally and some countries showed declining of vaccination innovations and new technologies, such 5 confidence in vaccine safety over that time period. as the new COVID-19 vaccines using messenger RNA. In some of these cases, despite the available science assuring SCIENTIFICALLY ASSESSED SAFETY RISKS VS RISK the safety of a particular vaccine in question, perceptions PERCEPTIONS and anxieties about safety persist and can strongly affect 9 There is vaccine safety and there are perceptions of safety. individual and group vaccination decisions. There are scientific reports of adverse event following Some vaccine safety questions posed by the public immunisation (AEFI) and there are socially shared do need more scientific investigation. In May 2019, for reports of adverse events following immunisation. Both instance, around 30 vaccine safety experts gathered matter and both must be considered. Even when an AEFI at the Wellcome Trust to take a hard look at which of is investigated and officially deemed to be unrelated to a the persisting vaccine safety questions have clear scien- vaccine or vaccination the perception of a causal relation- tific answers, but need better communication, and ship between vaccination and a subsequent adverse event which questions actually need more scientific studies.10 can persist and needs to be addressed. As risk expert Paul Continuing efforts to stay on top of new questions as they Slovic characterised it, there is ‘risk as analysis’ as well as evolve, while also continuing to be responsive to public ‘risk as feelings’. He particularly points out the ‘complex concerns will be crucial moving forward. 2 Larson HJ, et al.
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