In Britain, public memory still persists of the infamous measles, mumps and rubella (MMR) controversy, arising from a now debunked 1998 Lancet article about a link to autism. MMR vaccine uptake plummeted during that time and since then there have been outbreaks of measles in Dublin in 1999 and Swansea in 2013, leading to four preventable deaths.
So what’s really going on?
It’s European Immunisation Week, a World Health Organisation initiative to raise awareness of the importance of immunisation. So, how is Europe doing on immunisation coverage? From the examples given it would appear not very well.
However, regardless of controversies and outbreaks, people who oppose vaccination are a small minority. A climate of scepticism rather than opposition is a more accurate description. Europe recently was found to be the least confident region globally regarding vaccine safety – and according to the Vaccine Confidence Project, France is the most sceptical country in the world.
Despite this, Europe still tends to have high vaccination rates, along with North America, Central America, and Asia. The success is due to easy access to vaccines – which is not the case for other regions. Saudi Arabia is one notable exception, as a country that reached full coverage in 1990 through an expanded programme of immunisation, better education, and increased wealth. The country also has one of the highest levels of confidence in vaccines with only 1% of the population disagreeing that vaccines are safe.
At the other end of the scale, the Indian sub-continent, Sub-Saharan Africa, and South-East Asia have low vaccination rates – largely because of poverty, and limited access to vaccination services and health education.
But not all European countries are uniformly high vaccinators. According to a study on vaccine performance, Denmark, Iceland, Romania, Austria, Moldova, San Marino and Ukraine have had the lowest vaccination coverage in Europe (since 2000).
Particularly high vaccination rates, meanwhile, can be found in Russia, Hungary and Slovakia – the legacy of former Eastern Bloc health policies, which enforced mass childhood immunisation campaigns. However, in some areas, the fall of communism either saw vaccination becoming a lower priority (Ukraine and Romania) or the collapse of vaccination services altogether (Georgia in the early 1990s).
Given Europe’s generally high vaccination rates, we might expect a corresponding belief among populations that vaccinations are safe and important. But as already noted, the continent remains the most sceptical region in the world.
Scepticism about vaccine safety does occasionally, but not always, tally with low uptake. France, Bosnia and Herzegovina, Russia and Slovenia, are among the least confident, but this is not strongly reflected in coverage rates, which are high.
In Ukraine, however, low uptake and low confidence appear to closely match, and the country saw outbreaks of polio in 2015 – in part, attributable to the recent conflict.
Elsewhere, countries with high confidence may be constrained by poor vaccination services, which prevent higher coverage. If vaccination is not offered at a high enough availability and standard, there is arguably less capacity for opposition. Still, there are cases (Afghanistan, Pakistan, Nigeria, Syria) where, besides technical and organisational constraints, political and social resistance has become a greater problem.
Researchers in global health and development, Kennedy and Michailidou, have argued that resistance to vaccination in Afghanistan, Pakistan, Nigeria and Syria, is better explained by the political conflicts there. Vaccination is therefore linked to concerns over interference, control and dominance by unwanted forces, whether internal or foreign.
In Europe, there are similarly pockets of resistance. Austria, Denmark, Germany, the Netherlands and the UK have had measles outbreaks associated with alternative views on lifestyle, education and medicine, as well as among some religious groups. These subgroups may better explain the recent outbreaks of measles in Europe than a widespread anti-vaccination movement.
Europe should not be complacent about its generally high coverage – but nor should it be alarmist. Access problems do persist – as seen in some of the former Eastern Bloc countries that once excelled at vaccine provision, or among vulnerable subgroups, such as Roma communities. However, the complicated relationship between vaccine uptake, beliefs, and attitudes means that there is not a ready-made formula to ensure children are protected from childhood diseases.
More than ever, in Europe as well as other regions, vaccination is inextricably tied to politics, lifestyles, principles and trust of authority rather than access alone. The situation needs careful monitoring.