Trust and Confidence in Vaccines: Tales of Three Vaccines, Lessons for Others

Public trust in vaccines and immunization programs is a dynamic and changing phenomenon. Seeming success in an immunization program can be disrupted by a confidence crisis more quickly than it can be rebuilt. Constant care and vigilance are needed to detect and address waning trust and confidence before they become a crisis. Fixing a crisis once does not mean that another one may not erupt—sometimes driven by the same underlying trust issues, but other times due to new factors which also need to be understood.

This chapter looks at a range of different vaccines and different settings where trust issues emerged for a variety of reasons, ranging from politics to socioeconomic marginalization to genuine safety concerns, and offers examples of how trust issues have been successfully addressed and overcome. It recognizes the importance of an ongoing process of building and sustaining trust to ensure the success of any immunization effort.

Antivaccine sentiment has been around for as long as there have been vaccines: A famous 1802 editorial cartoon from Great Britain titled “The Cow-Pock” showed a group of patients waiting to receive smallpox inoculations while surrounded by people with cows growing out of their bodies.

Then, as now, vaccine reluctance and refusal stemmed from a confluence of factors—some political and some cultural; some based on specific misinformation and some on anxiety about health and medicine more generally. The flourishing of panic about the safety and efficacy of vaccines is almost always followed by confusion and misunderstandings about the proper political and public health responses—and the proper way to craft these responses.

In this chapter, we discuss the importance of understanding the specific cultural, political, religious, and social forces that lead people to reject facts in favor of feelings. While evidence-based medical science plays an important role in confidence building, it is often insufficient to change views that can be driven by emotions, cultural connections, or politics. The following case studies tell stories where a complicated mix of factors drove vaccine hesitancy and distrust, many well beyond the usual scope of the immunization program.

1 Three case studies of vaccine hesitancy and distrust

1.1 The Disneyland Measles Outbreak

November 2014 brought bitter cold to much of the United States, with record low temperatures recorded from Colorado to North Carolina. Even locales with typically temperate climates such as Florida dipped below freezing. However, Southern California was spared from the winter’s arctic blasts. This must have made Disneyland, located in Anaheim, California, an especially appealing vacation destination for families looking for some relief from the winter weather. And indeed, more than 1.3 million people visited the 160-acre “Magic Kingdom” that December.

On any given day, thousands of those visitors likely had runny noses, nagging coughs, or the beginnings of a fever. Out of those thousands, perhaps a few hundred had recently traveled out of the country; of those, there might have only been a few dozen who hadn’t been vaccinated, and maybe only a handful who traveled to countries where measles is still endemic. Out of that small handful, a single person came to the resort with an active measles infection. It probably took several more weeks for the family of that still-unidentified patient to learn what was making him sick—and by that time, dozens of other children in California had been infected. By mid-January, the Centers for Disease Control and Prevention had linked 50 new measles cases to what had already become known as the Disneyland outbreak. By the time the outbreak ran its course, that lone case had led to an additional 113 infections; dozens of those had led to expensive and frightening hospitalizations. With the cost of containing each individual infection running as high as US$11,000, this was a public health catastrophe.

At the time, California was just emerging from a years-long budget crisis that had seen the state with billions of dollars of shortfall. What made this situation all the more painful was that it was entirely avoidable: The measles vaccine that is administered as part of the trivalent measles–mumps–rubella (MMR) vaccine is close to 100% effective. Unfortunately, California is one of the states that had seen a growth in the number of communities where vaccine uptake rates are so low—in some cases, as low as 60%—as to put herd immunity at risk. The parent of a child with leukemia highlighted an ethical issue created by this reality by making the point that her child’s life could be threatened by other children in his school who were unvaccinated. The Disneyland outbreak of 2014–15 prompted the state to pass a law that did away with religious and “personal belief” exemptions for vaccines. “The science is clear,” California governor Jerry Brown said at the law’s signing ceremony. “Vaccines dramatically protect children against a number of infectious and dangerous diseases.”

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