Master’s Thesis Medical Anthropology and Sociology Graduate School of Social Sciences Extending national immunization programmes: The case of varicella vaccination in the European Union Victoria Szerényke Boehm Amsterdam, 7th August 2020 Student ID number: 12757152 Contact: [email protected] Supervisor: Dr. Stuart Blume Second reader: Dr. Danny de Vries Science appears calm and triumphant when it is completed; but science in the process of being done is only contradiction and torment, hope and disappointment. - Pierre Paul Émile Roux, French physician, bacteriologist, and immunologist and developer of the first effective treatment for diphtheria1 1 as cited in Plotkin, 2009 2 Abstract The idea that, like medicine, health policymaking should be evidence-based has gained wide popularity and support. This is also the case for immunization policies. Despite the claim that the decision to include new vaccines in national immunization programmes is rational and based on objective evidence, countries often react very differently to new vaccines. Against this background, the question arises how and why vaccines are introduced into immunization programmes. The case of varicella/chickenpox vaccination is peculiar in this respect. Even though it has been available for thirty years and a wide range of evidence is accessible and despite a trend towards harmonizing vaccination programmes in the European Union, countries reach different conclusions about the vaccine. Historical research on the introduction of vaccines suggests that in addition to evidence, politics, perceptions, as well as public and professional opinions influence immunization policymaking. Drawing from that, this thesis explores why and how vaccines are included in national immunization programmes through the case of varicella decision-making in Germany, the United Kingdom, and the Netherlands. The research is based on method triangulation consisting of qualitative interviews with Dutch healthcare professionals, online research, and document analysis. Results from document analysis suggest that differences between countries in varicella related decision-making reflected in particular disease perceptions, the importance attached to certain considerations, the availability of evidence and its interpretation. Underlying these developments were contextual changes. In the countries studied social acceptance was not a crucial factor. I argue that it should be ascribed more importance, because a vaccination programme’s success is ultimately dependent upon its acceptance. The interviews and online data throw some light on public and professional opinions. Finally, I discuss possible influences on opinions about different vaccines, including familiarity, personal experiences, and trust. 3 Preface For the longest time I have not questioned vaccination recommendations and did not understand why some parents would refuse to vaccinate their children. It seemed so simple to me: In order to not get terrible diseases, you get some injections and on top of that you help to protect vulnerable groups as well. As I became more acquainted with the social sciences, I realised that hardly anything is simple and straightforward and especially not people’s points of view. During an inspiring class on contemporary topics in Medical Anthropology and Sociology the lecturer mentioned the reoccurrence of diseases due to declining vaccination rates and in that moment I decided that my final thesis would be about vaccination. I came across studies which showed that healthcare professionals are not always supportive of all vaccines and I was instantly captivated. Healthcare professionals are in direct contact with parents and as trusted advisors on children’s health their work does not seldom include answering questions and soothing doubts. Consequently, they play a crucial role in the implementation of national immunization programmes and preservation of immunization rates. This makes their perceptions a significant topic worth investigating. Chickenpox presented an interesting example to investigate vaccination perceptions because it is generally known as a harmless childhood disease, but it can have severe consequences for certain groups. The Netherlands portrayed an appealing site for research because chickenpox is currently a candidate for the national vaccination programme. A common concern with universal chickenpox immunization is the potential shift in age of infection from children to adolescents or adults due to suboptimal vaccination coverage. Such a development could lead to an increase of the disease burden. Therefore, insight into the willingness to vaccinate against chickenpox prior to its inclusion in the programme is essential. The initial goal of this thesis was to provide insight into Dutch healthcare professionals’ perceptions on chickenpox vaccination before its introduction into the vaccination programme and thus to open up the discussion about chickenpox from their perspectives, as well as to contribute to the considerations regarding the implementation of the chickenpox vaccine in the Netherlands. The primary research questions were the following: How do health care professionals in the Netherlands assess the need of the varicella/chickenpox vaccine in terms of risk and desirability? 4 - How do healthcare professionals assess the risks associated with varicella and the vaccine? - What is their attitude towards whether and how the varicella vaccine should be introduced into the Dutch immunization programme? - What is their position on vaccinating certain groups only? Are there particular groups they think should be vaccinated? The fieldwork process started in February 2020. At first it seemed feasible to stick to the original plans despite the increasing spread of the coronavirus (COVID-19), which was first identified in December 2019 in Wuhan, China. However, as the situation got worse it became clear at the beginning of March that gaining access to healthcare professionals was highly difficult and in mid-March the lockdown in the Netherlands began. In face of the rapidly changing situation it became apparent that my initial plans were not realisable. Therefore, the research focus needed to be adjusted in a way that would allow me to conduct research during a pandemic and global state of emergency. Inspired by the question why some countries introduce certain vaccines into their vaccination programmes while others do not, although all claim to base their decisions on scientific evidence, the following research question developed: How and why are vaccines added into national immunization programmes? Since it was difficult to find research participants it was necessary to incorporate a methodological approach which does not rely on people’s availability. Consequently, document analysis became the backbone of the new research plans. In an attempt to include the social dimension of the issue at hand, interviews via videoconference and online research on social media were included as well. Since chickenpox is generally not considered to be an urgent issue, I expected interest in my research to be especially low during a global crisis. However, reactions online were quite positive and those healthcare professionals who were willing to be interviewed found it rather interesting as well. I cannot deny that the pandemic influenced my work on a personal level as well. As a young scholar from Austria I had the privilege of growing up with the normality of open borders, freedom of travel, and not encountering crisis situations. Experiencing the rapid spread of a serious health threat, daily increasing mortality rates, and global lockdowns was simply shocking. As an international student away from home I felt vulnerable and looking back it almost seems like an understatement to say that I was worried about a variety of things. At 5 one point finishing this project and graduating seemed hardly possible. During this time the support of the university, friends, family, and particularly my supervisor put me at ease. Even though my research was not dependent on a location anymore, staying in the Netherlands made me feel closer to my project and after the initial shock proceeding seemed more manageable every day. Most likely under normal circumstances it would have been possible to go through with the initial plans and gather more data on people’s perceptions about chickenpox vaccination. Nevertheless, in the context of the COVID-19 pandemic this research project developed in interesting ways and discussions arose which would not have otherwise. After months of work and many unexpected events it is my pleasure to present the thesis at hand. 6 Acknowledgements Behind every project stand people who influence it in many ways. I would like to take the time here to acknowledge a few of them. Without their contributions this thesis would not have been possible. First, I would like to thank my parents and my brother for their unconditional support throughout my whole study period. When I started my bachelor’s in cultural and social anthropology back home in Vienna I was often faced with scepticism and lack of understanding for my plans, which to be fair were not very clear at that point. This changed over time and when I told you that I wanted to study medical anthropology and sociology abroad, there was not a second of hesitancy in your endorsement. I am truly grateful for everything you have done for me. You always have my back and help me grow. Without you this year would not have been