Education versus anti-vaxxers: evidence from Europe

Vaccine skepticism and hesitancy – the distrust and skepticism that some members of the public feel for vaccines, as well as for institutions that deliver and encourage vaccination – has emerged as a major threat to world health. Vaccine skepticism is not limited to any particular place; it has been observed across a range of countries, cultures, and levels of prosperity. Vaccine skeptics have made themselves known in Hollywood, led protests in Washington D.C., and lashed out violently against vaccination in Pakistan and Northern Nigeria. Vaccine skepticism has truly gone global.

Vaccine skepticism comes at odds with the proven benefits that vaccines have brought to humanity. The widespread adoption and use of vaccines and antibiotics led to sharp declines in the incidence of, and mortality caused by, infectious diseases. Except for the 1918 global flu epidemic, infectious disease mortality in the United States fell linearly before plateauing in the 1950s, at under one-tenth of the rate seen in 1900.

Vacine hesitancy threatens to reverse years of progress towards reducing measles deaths and ultimately eliminating measles as a threat, as immunization levels in many communities are at or below the 95% level required for herd immunity. In fact, the World Health Organization has seen more cases reported in the first half of 2019 than in any year since 2006. It is clearly time to reappraise vaccine policies and programs.

The role of education

Many people may find it difficult to understand and assess risks and benefits of vaccination, especially in the presence of Wakefield’s fraudulent argument that the MMR vaccine causes autism, while vaccines have been so successful that more people have seen autism than the diseases targeted by the vaccines.

Since one might hope that education can provide both the facts needed to make intelligent decisions about vaccination and the ability to reason, we ask here what is the relation between education and vaccine skepticism.

We use 2017 education data from the United Nations Development Program Human Development Reports, and data on vaccination attitudes from the Vaccine Confidence Project, published in 2016. These data include 28 European countries, with wide ranges in the prevalence of vaccine skepticism (13.5% in the median country did not agree that vaccines were safe, with a range from 4.2% in Portugal, to 51% in France) and years of education (16.4 in the median country, with a range from 12.7 in Azerbaijan to 19.8 in Belgium).

We found a weak (R2 = 0.1847) but statistically significant (p = 0.022) inverse relationship between education level and vaccine skepticism: by country vaccine skepticism decreased by about 2% for each additional year of education.

The relationship between years of schooling and vaccine skepticism, by country.

However, there are significant outliers, consistent with the low coefficient of correlation. For example, among the least educated countries, vaccine skepticism in Bosnia and Herzegovina is 36%, compared with 13% in the less educated Azerbaijan. Vaccine skepticism is 51% in France but 4.2% in Portugal, again despite similar educational levels (16.3 years in Portugal, 16.4 in France). Among the most educated countries, vaccine skepticism was 5.5% in Israel but 14% in the more educated Belgium.

Questions for research

It is clearly important to understand the cultural and other reasons behind the outliers in these data, in order to address the health challenge of vaccine skepticism. Here we offer some speculations and questions for further study.

The European countries with the best systems of education are generally those that were the first to industrialize, reach developed status, and adopt nationwide vaccination programs. As such, their present populations may be very historically removed from the infectious diseases that once plagued the European continent. As such, people in these countries may be less appreciative of the difference that vaccines have made, and more likely to be influenced by anti-vaccine messages.

Another factor to consider may be the politicization of anti-vaccine attitudes. It is possible that vaccine skepticism has become more prevalent simply because more people subscribe to political ideologies that are distrustful of the medical establishment and, more generally, institutions typically associated with their governments. France is again one such country where people are increasingly doubtful of their political institutions and are therefore wary of completely trusting ideas promoted by their government. This is more apparent than ever with the recent yellow vest protests seen across the country.

Distrust is often rooted in real instances of the abuse of public trust by, as well as the failure of, institutions, such as the Tuskegee syphilis trials, the Thalidomide birth defect crisis of the 50s and 60s, as well as unethical pharmaceutical trials that modern drug companies have carried out in developing countries, such the meningitis antibiotic trials that Pfizer carried out in Northern Nigeria during the mid 1990s. Vaccine skeptics have also lobbied for religious exemptions to be upheld in places that were considering their removal due to the resurgence of certain diseases like measles.

A study conducted in Romania concluded that unfavorable information spread by the media regarding vaccines was the lead cause in increasing vaccine skepticism in the country. With one third of the population being skeptical about vaccines, politicians and the reputation of the pharmaceutical industry were also named as reasons people feared vaccines.

In some countries, such as Greece and Romania, medical professionals have often been found to be skeptical of vaccines themselves. These health care workers have expressed concerns regarding the guilt they would feel if patients were to experience negative side effects after receiving vaccines, claiming that certain hepatitis and HPV vaccines have been banned in other countries due to fears of patients developing tumors and autism. These claims are reminiscent of Wakefield’s false and damaging claims that the MMR vaccine caused autism.

Residents of former Yugoslav countries, such as Bosnia and Herzegovina, have attributed lack of vaccine confidence to a discomfort with the relationship between physicians and patients. By evoking the times when the practice of immunization went unquestioned, physicians appear to be advocating the reestablishment of the authoritative power relationship between physicians and patients under socialism.

Given the well-documented strong evidence of the benefits of vaccines, we are left with a communication challenge – how to communicate key scientific facts needed for intelligent decision-making in a respectful, non-threating, non-condescending way.

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Rita Faria’s journal round-up for 26th August 2019

Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.

Vaccine hesitancy and (fake) news: quasi‐experimental evidence from Italy. Health Economics [PubMed] [RePEc] Published 20th August 2019

Has fake news led to fewer children being vaccinated? At least in Italy, the answer seems to be yes.

It’s shocking to read that the WHO has included the reluctance or refusal to vaccinate as one of the 10 threats to global health today. And many of us are asking: why has this happened and what can we do to address it? Vincenzo Carrieri, Leonardo Madio and Francesco Principe help answer this first question. They looked at how fake news affects the take-up of vaccines, assuming that exposure to fake news is proxied by access to broadband and within a difference-in-differences framework. They found that a 10% increase in broadband coverage is associated with a 1.2-1.6% reduction in vaccination rates.

The differences-in-differences method hinges on a court ruling in 2012 that accepted that the MMR vaccine causes autism. Following the ruling, fake news about vaccines spread across the internet. In parallel, broadband coverage increased over time due to a government programme, but it varied by region, depending on the existing infrastructure and geographical conditions. Broadband coverage, by itself, cannot lead to lower vaccination rates. So it makes sense to assume that broadband coverage leads to greater exposure to fake news about vaccines, which in turn leads to lower vaccination rates.

On the other hand, it may be that greater broadband coverage and lower vaccination rates are both caused by something else. The authors wrote a good introduction to justify the model assumptions and show a few robustness checks. Had they had more space, I would have like to read a bit more about the uncertainties around the model assumptions. This is a fantastic paper and good food for thought on the consequences of fake news. Great read!

The cost-effectiveness of one-time birth cohort screening for hepatitis C as part of the National Health Service Health Check programme in England. Value in Health Published 19th August 2019

Jack Williams and colleagues looked at the cost-effectiveness of one-time birth cohort screening for hepatitis C. As hepatitis C is usually asymptomatic before reaching its more advanced stages, people may not be aware that they are infected. Therefore, they may not get tested and treated, even though treatment is effective and cost-effective.

At the level of the individual eligible for testing, the ICERs were between £8k-£31k/QALY, with lower ICERs for younger birth cohorts. The ICERs also depended on the transition probabilities for the progression of the disease, with lower ICERs if progression is faster. Extensive sensitivity and value of information analyses indicate that the key cost-effectiveness drivers are the transition probabilities, probabilities of referral and of treatment post-referral, and the quality of life benefits of being cured.

This is a great example of a good quality applied cost-effectiveness analysis. The model is well justified, the results are thoroughly tested, and the discussion is meticulous. Well done!

NICE, in confidence: an assessment of redaction to obscure confidential information in Single Technology Appraisals by the National Institute for Health and Care Excellence. PharmacoEconomics [PubMed] Published 27th June 2019

NICE walks a fine line between making decisions transparent and protecting confidential information. Confidential information includes commercially sensitive information (e.g. discounts to the price paid by the NHS) and academic-in-confidence information, such as unpublished results of clinical trials. The problem is that the redacted information may preclude readers from understanding NICE decisions.

Ash Bullement and colleagues reviewed NICE appraisals of technologies with an approved price discount. Their goal was to understand the extent of redactions and their consequences on the transparency of NICE decisions. Of the 171 NICE appraisals, 118 had an approved commercial arrangement and 110 had a simple price discount. The type of redacted information varied. Some did not present the ICER, others presented ICERs but not the components of the ICERs, and others did not even present the estimates of life expectancy from the model. Remarkably, the confidential discount could be back-calculated in seven NICE appraisals! The authors also looked at the academic-in-confidence redactions. They found that 68 out of 86 appraisals published before 2018 still had academic-in-confidence information redacted. This made me wonder if NICE has a process to review these redactions and disclose them once the information is in the public domain.

As Ash and colleagues rightly conclude, this review shows that there does not seem to be a consistent process for redaction and disclosure. This is a compelling paper on the practicalities of the NICE process, and with useful reflections for HTA agencies around the world. The message for NICE is that it may be time to review the process to handle sensitive information.

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