Global Health Nursing Action Paper: Vaccine Hesitancy

Abstract

Schedule delays or refusals of recommended vaccinations, otherwise known as vaccine hesitancy, has had tremendous impact on the resurgence of vaccine preventable diseases, such as measles (World Health Organization 2019). Due to the impacts on global health, the United Nations (2019) has linked vaccine hesitancy to their Sustainable Development Goals as a strategy to improve health throughout the world. The purpose of this paper is to describe how vaccine hesitancy has become global health threat to vulnerable populations. By examining the measles outbreak of Rockland County, New York in 2018-2019, the paper explores reasons why vaccine hesitancy is prominent and how it has affected children in this area. This paper also reviews specific nursing interventions that can be employed to combat vaccine hesitancy. Also included is an example of a community-based, health promotion project to implement nursing interventions that address vaccine hesitancy.

Key words: vaccine hesitancy, measles, herd immunity, MMR vaccine

Global Health Nursing Action Paper:

Vaccine Hesitancy

According to World Health Organization (WHO) (2019), vaccine hesitancy is one of the top ten global health threats for 2019. Defined as reluctance or refusal to vaccinate despite vaccine availability, vaccine hesitancy is responsible for the 30 percent global increase in confirmed measles cases over the last year (WHO, 2019). Measles kills more children than any other vaccine preventable disease and is a significant cause of worldwide childhood mortality and morbidity (WHO, n.d.). Because measles is so highly transmissible, almost all children who have not been vaccinated contract the disease if exposed (WHO, n.d.). In response to the increase in the prevalence of measles, concentrated efforts to increase adequate vaccination percentages has been listed as part of the United Nations’ (2019) Sustainable Development Goals. As nurses, we are also poised to tackle the challenge of vaccine hesitancy by disseminating evidence-based information about vaccination and the spread of preventable diseases.

One of the areas experiencing historic numbers of measles cases is Rockland County, New York, which has seen almost 300 cases since October 2018 (Gold and Pager, 2019). Most cases have been concentrated in children of the Orthodox Jewish communities, where vaccination rates are lower and anti-vaccine literature is widely spread (Gold and Pager, 2019). These cases have been traced to Orthodox Jewish families who traveled to Israel, where there were 4000 reported cases in 2018, and unvaccinated children contracted the disease and spread it to other unvaccinated children when families returned to the United States (Silverberg, Caceres, Greene, Hart, & Hennekens, in press). Officials were forced to take unconventional action in response to the outbreak by declaring a state of emergency and imposing a ban of unvaccinated minors in public places. Parents found to be in violation could face fines and jail time (Gold & Pager, 2019). Anti-vaccination is not an ordinance of the Jewish faith and many preeminent rabbi’s strongly advocate for mandated vaccination (Silverberg et al., in press). According to Silverberg et al. (in press), the common denominator for the Rockland County situation appears to be mistrust and misinformation, as evidenced by interviews with the community’s Jewish mothers who described a suspicion and animosity towards the vaccine, and a local cultural belief that God controls illness.

In epidemiology, a primary case refers to the individual believed to be the initial case of infection, while a secondary case refers to those who were infected by the primary case (Giesecke, 2014). According to Bernstein, Holroyd, Atwell, Ali and Limaye (2019), for measles, the average number of secondary cases as a result of a primary case is 12 to 18, and possibly higher is some settings. Herd immunity is the protection of those who are vulnerable to disease by preventing the disease’s transmission, usually by vaccination, and the more contagious a disease, the higher the herd immunity percentage is required (Oxford Vaccine Group, 2016). In order to sustain herd immunity for measles, 93 to 95 percent of the population must be immune (Bernstein et al., 2019). Therefore, when the average population immunity drops, it becomes difficult to control the spread of the disease. Before the widespread use the measles vaccine in the 1960s, 90 percent of children contracted the disease before age 10 (WHO, n.d). Those children who are malnourished, too young for the vaccine, or immunocompromised are at high risk of developing measles complications, or death, and are thus reliant on herd immunity.

In 2015 all member states of the United Nations (2019) voted to adopt 17 Sustainable Development Goals (SDG) as a universal call to action to end poverty, protect our planet, and ensure worldwide peace and prosperity by the year 2030. Goal number three strives to ensure general health and promote well-being of all ages by reducing the impact on morbidity and mortality of preventable diseases (United Nations, 2019). SDG three recognizes that immunizations are the most successful and cost-effective health interventions to prevent disease. By ensuring children receive the recommended two doses of the MMR vaccine, these goals have increased the measles vaccination coverage from 59 percent in 2015 to 67 percent in 2017 (United Nations, 2019).

According to a global survey conducted by the WHO, the top three cited reasons for vaccine hesitancy are scientific evidence of risk versus benefit, lack of knowledge of vaccine importance, and religious or cultural beliefs (Lane, MacDonald, Marti, & Dumolard, 2018). When the healthcare system fails to effectively inform the public about the risks and benefits of vaccination, the public’s confidence in healthcare decreases, resulting in a wariness of vaccines as well. Additional mistrust is created when healthcare providers lack the technical knowledge to address parental concerns about vaccines (Nayar et al., 2019). Therefore, open communication about vaccines from healthcare professionals to patients they treat is another helpful tool to tackle vaccine hesitancy (Goldstein, MacDonald, & Guirguis, 2015). As nurses, we should be fluent in the common misconceptions about vaccines and remain abreast of current vaccine knowledge so we are competent in answering any vaccination questions parents may have. Thus, nurses can strive to improve vaccination numbers by addressing the specific factors and concerns that influence vaccine uptake in a target population.

According to Gallup’s 2019 poll on ethics and honesty, nurses hold the top position as the most trusted profession in the United States for the 20th consecutive year (Stone, 2019). People look to nurses for honest answers and ethical guidance, giving nurses a high level of power in their ability to influence patient care. Also, community-based education programs that address parental concerns and provide education have been proven effective at increasing immunization rates (Willis et al., 2016). To make use of this power, a community-based health promotion project that nurses could implement to impact vaccination rates in Rockland County could be vaccine education forums. Most parents’ worries relate to vaccine safety, which have stemmed from social media, anti-vaccine groups, and a general mistrust of government policies (Bowling, 2019). The mission of this project would be to address parental concerns about vaccines, share data-supported evidence, and clarify any immunization misconceptions, which fall in line with public health guidelines to enhance children’s health and safety (Bowling, 2018). The forums would serve as an open and safe place for parents to voice their concerns about vaccination, receive validation of those concerns, and be provided fact-based information that addresses those concerns. Also, by incorporating members of the Jewish community into the leadership of the forums as a source of trust and translation of English to Yiddish, the forums will hopefully bridge some of the cultural barriers to vaccination as well (Silverberg et al., in press).

Community health nurses from the Rockland County Health Department, in cooperation with leaders of the local Orthodox Jewish community, would host the project’s forums. Current evidence points to the positive health impacts by community health workers who address the needs of individuals within a community by decreasing health disparities and achieving improved health outcomes (Brooks et al., 2018). Community health workers will be able to provide fact-based information, while Jewish community members will aid in translation of the information and serve of a beacon of trust for these community groups. Serving as a trusted source of information, the forums will seek to address parental concerns about vaccines in hopes of removing barriers to immunization in order to increase vaccination rates to 93 percent for herd immunity. The forums will take place in small community settings where community health nurses can sit among community members, creating a safe-feeling venue where people can feel comfortable voicing their opinions (United States Environmental Protection Agency [EPA], 2017). Venues can include community centers, education rooms at the health department, and Jewish community gathering places. The goal will be to conduct twice weekly education forums with day and evening meeting times so that everyone has an opportunity to attend.

A measles outbreak is considered to have ended with the passing of 42 days since the last confirmed case (Bernstein et al., 2019). To determine the forums’ effectiveness in increasing vaccination rates, no new measles cases will be discovered 42 days after the first meeting. Also, to verify the achievement of herd immunity percentages, a review of vaccination records of the county’s children, 12 months to 18 years old, must be conducted to assure at least 93 percent have received two doses of the MMR vaccine immune (Bernstein et al., 2019). An accomplishment of both goals will affirm the effectiveness of the education forums and that the project’s goals were achieved.

Ideally, to carry out the project there would need to be a special team created within the Rockland County Health Department. The team would be comprised of community health nurses employed by the Health Department. Prior to the first forum the team would develop a PowerPoint presentation that reviews recommended vaccine schedules, benefits and risks of recommended vaccines, and where to get vaccinations for children. The information displayed in the PowerPoint would also be converted into a handout and dispersed at forum sessions. At the end of the presentation there would be a portion dedicated to the addressing of parental concerns and barriers to vaccination. To assure their equitability in answering questions about vaccines, the team’s nurses would need to be up to date on all information about current vaccine research and recommendations (Nayar et al., 2019). In order to help facilitate forums with the community’s Orthodox Jews, the team would need nurses or respected members of the Jewish community, capable of speaking Yiddish, to provide insight into the understandings of the specific community’s culture. According Silverberg et al. (in press), the translation of presentations and handouts into Yiddish removes many barriers to understanding education previously faced by the Orthodox Jews in the Rockland community. Meetings should be kept short enough to keep everyone’s attention but long enough to convey the information needed; ideally no more than one hour (EPA, 2017) Simple public meetings can be conducted with minimal overhead, with most of the cost accrued from staff time (EPA, 2017). Project facilitators and community health workers would be employed by the county health department and be compensated as such for their additional time worked to carry out these forums. Additional cost sources could result from forum advertising and creation of informational handouts.

Should the project’s goal be met and 93 to 95 percent of children within Rockland County become fully vaccinated against measles, the hope is that these children will also become fully up to date on all vaccines in order to prevent the resurgence of measles or other vaccine-preventable disease. Because measles can have serious health impacts, not only during the active infection stage, but also later in life, the highly effective, two dose MMR vaccine can prevent most of these occurrences, by preventing a child from ever getting measles (Bernstein et al., 2019). Therefore, it is important to discredit myths about vaccines and increase the spread of evidence-based information so people can make a well-informed decision when deciding to immunize their child. This community health project seeks to be the source of that factual evidence-based information for Rockland County residents, because when the public is better informed, they make better health choices (Goldstein et al., 2015).

Because measles is easily transmitted, especially when people are confined to indoor spaces, transmission occurs more rapidly in the colder months (Yang, Fu, Dong, Hu, & Wang, 2014). For this reason, the project’s timeline will mimic influenza season from October to March, thus forums will continue twice weekly until warmer weather arrives. It is uncommon for public health officials to be fully assured of immunity because of the robust vaccine resistance by some groups, ineffective or improperly administered vaccines, departures from recommended vaccine schedules, or erroneous data (Peak, Reilly, Azman, & Buckee, 2018). Therefore, after this acute time period community health officials must provide continued immunization programs in conjunction with diligent surveillance and outbreak response capabilities in order to maintain high vaccine coverage (Peak et al., 2018)

Table 1 Components and details of Vaccine Education Forums

For a multitude of reasons parents are choosing not to vaccinate their children, which, as evidenced by the measles outbreak in Rockland County, New York, has been found to have disastrous consequences. If the increase in unvaccinated children continues, we could see the re-emergence of other once-extinct deadly diseases, such as polio. It comes as a surprise that most vaccine hesitancy from minority cultures, like the Orthodox Jews, is not due to religious beliefs but a mistrust due to misinformation about immunizations. As nurses bear the responsibility to provide parents with anticipatory guidance and education about the importance and safety of vaccines. Therefore, with the provision of proper education and avenues for parents to voice their concerns, community -based education projects, like one the proposed here, could decrease the number of unvaccinated children and help continue progress to the ultimate goal of eradication of vaccine-preventable diseases.

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