Vaccine hesitancy: a state of denial

Earlier this year the World Health Organization listed vaccine hesitancy as one of the top threats to global health in 2019. Indeed, it’s a phenomenon we are seeing across the globe; despite increases in global vaccination rates, coverage is falling in some areas, leading to a resurgence of deadly diseases like measles. Just last week, a county in New York State that has been grappling with a measles outbreak declared it a public health emergency. But vaccine hesitancy is not just about the choices made by individual parents: it can even impact decisions by governments to introduce new vaccines in their national immunization programs. This is something I experienced first-hand in my previous role as Mission Director of the National Rural Health Mission, India’s flagship program to revitalise primary health care. 

At that time, Haemophilus influenzae type b, or Hib, was a leading cause of bacterial meningitis. This devastating disease kills 5-10% of people within 48 hours of contracting it and leaves a further 10-20% with permanent disabilities. Luckily, the world has had a hugely effective vaccine against the infection at its disposal since the 1990s. And thanks to the widespread roll-out of this vaccine - in which Gavi, the Vaccine Alliance, played a pivotal role - Hib has gone from being the leading cause of bacterial meningitis globally in 1990 to the least common cause today.

In 2017, 88% of children in India received Hib vaccination as part of the pentavalent 5-in-1 vaccine. Its impact has been huge, as a recent study in Tamil Nadu found: cases of this type of meningitis have fallen by nearly 80% within two years of introduction. Yet the journey to reach this point was far from easy.

When the introduction of the vaccine was first proposed, the government was taken to court. The petitioners claimed that the vaccine was unsafe, unnecessary and a drain on public resources. The legal challenge delayed the inclusion of the vaccine into India’s Universal Immunisation Programme, which helps ensure that every child, regardless of their background, has access to free vaccines. Ironically, the vaccine was already being widely prescribed by private practitioners but sold at a price far beyond the reach of the majority of families. This meant that while the rich could protect their children against this infection, the poor lacked access - despite being at higher risk.

For me, this was an equity issue. Once we drew the court’s attention to this disparity, we won the historic mandate to provide ‘free Hib vaccine to all children’ in India through the publicly funded immunisation program. And yet despite the court verdict, propaganda against this vaccine and the government decision continued unabated, requiring us to constantly fight misinformation.

We embarked on a phased roll out, beginning with Tamil Nadu and Kerala, and the vaccine was available in all states of the country by 2015. However, the delay caused by litigation meant that it wasn’t until 2011 that we were able to begin introducing the vaccine, making India one of the last Gavi-supported countries to do so. With nearly 26 million children born in India every year – the largest birth cohort of any country in the world – this means that millions and millions of children missed out on protection against this devastating disease.

This latest research from Tamil Nadu is validation of the impressive impact this vaccine has had in India and makes me extremely proud of the grit that we showed in its introduction. Yet the vaccine’s success is also bittersweet, when I think of the children who missed out on the vaccine - and potentially lost their lives - as a result of the unnecessary delay.