Vaccine Hesitancy Fuels Global Health Crisis Amidst Multidisease Outbreaks

Despite the development of life-saving vaccines, the resurgence of preventable diseases highlights the ongoing challenges posed by misinformation, resource disparities, and global health inequities. | Image Credit: MargJohnsonVA - stock.adobe.com

The public health field has grown significantly with the help of modern technology, new discoveries, and generations worth of research. However, modern medical practices, including immunizations, are struggling to protect the public’s health for various reasons, including widespread misinformation and lack of resources in underserved countries.

Rise of the Eradicated and Eliminated

Measles

The US eliminated measles in 2000, a monumental achievement made possible by consistent public vaccination. However, cases began to rise again in densely populated neighborhood communities that refused the measles, mumps, and rubella (MMR) vaccine.³

A study from 2013 found reports of measles in Williamsburg, Brooklyn, all of which were seen in members of the Orthodox Jewish community. The primary reasons participants did not receive vaccination was largely due to refusal (30%) and delay (27%).³

The rising suspicion of vaccines within communities, coupled with increased international travel, and US immigration centers that tend to keep individuals in close proximity fueled a resurgence of measles cases.⁴

Chicken Pox/Shingles

Since the introduction of the varicella vaccine in 1995, also known as the chicken pox vaccine, national cases have dropped an estimated 90%. The disease was not eradicated but it was on the path to becoming eliminated through an increasing vaccination rate.⁵

In October 2022, the New York City Department of Health and Mental Hygiene (NYC DOHMH) identified a varicella outbreak among individuals who had recently migrated from Central and South America. The outbreak spread rapidly among residents of NYC shelters and residential facilities. The majority of cases (92%) occurred in people without documented vaccination against varicella.⁶

To combat the outbreak, the NYC DOHMH has administered approximately 27,000 vaccine doses to recently arrived migrant children, adolescents, and adults.⁶ Prior to 2024, individual cases of varicella in NYC were not required to be reported by providers; they were only mandated to report 3 or more cases. Because of the 2022 outbreak, health officials are now required to report infectious diseases immediately upon suspicion and/or within 24 hours.⁷

Shingles and chicken pox are distinct illnesses caused by the varicella-zoster virus, which remains dormant in the body after a chicken pox infection. When reactivated, this virus triggers shingles, a rash that begins around the left or right side of the body. People with shingles typically experience pain from the rash, itchiness, and tingling. If shingles is not handled properly, it can cause serious long-term nerve pain known as postherpetic neuralgia.⁸

Typically, the shingles virus spreads through direct contact with the fluids from the rash blisters or by breathing in the virus particles that come from the blisters. To prevent shingles and its associated complications, the CDC recommends 2 doses of the recombinant zoster vaccine for adults aged 50 and over. They also suggest Shingrix, a recombinant zoster vaccine, targeted for adults 19 years and older with weakened immune systems due to disease or other therapeutic treatments.⁸

Influenza

Following the development of the influenza vaccine by Thomas Francis, MD, and Jonas Salk, MD, communities affected by the Spanish Flu experienced a dramatic decline in cases. However, subsequent pandemics were triggered by the influenza type A virus subtype H2N2 strain in the late 1950s and the H3N2 strain in the late 1960s and early 1970s, causing millions of deaths. The emergence of H1N1 and avian influenza in the 1970s and 1990s prompted the US to establish a comprehensive pandemic flu response plan.⁹

Starting in 2002, the Advisory Committee on Immunization Practices (ACIP) recommended annual flu vaccinations for children aged 23 months to 6 years; in 2008, ACIP expanded this recommendation to children aged 6 months to 18 years.⁹

For instance, as a response to the 2009 H1N1 flu pandemic, Mayo Clinic staff underwent infection control and prevention training to enhance flu planning discussions with clinical departments. The H1N1 vaccine became available later that year.⁹

By 2010, the ACIP suggested everyone 6 months and older get an annual flu vaccine, and in 2016, this became mandatory for health care providers as well.⁹

Despite the long history of the flu vaccine and the various strains it has been able to combat, the number of patients who receive flu vaccine doses is decreasing.² For example, from 2023 to 2024, vaccinations decreased by 7 million doses.¹⁰

Vaccine Hesitancy

Misinformation

The significant reduction in vaccination can largely be blamed on the spread of misinformation, especially during the COVID-19 pandemic.¹⁰ However, fraudulent science surrounding vaccines has existed since a former British doctor, Andrew Wakefield, and his team falsely linked the MMR vaccine to autism.¹¹ Although his medical license was revoked and his published paper was retracted, it took nearly 2 decades for immunization rates in the UK to recover.

Lately, social media outlets have amplified the vaccine-autism myth, especially since Wakefield continues to criticizes the CDC. Vaccine reluctance is high among millennials—the generation that came of age during Wakefield’s misinformation publication—leaving the majority of their children unvaccinated.¹¹

Experts emphasize the urgency of promptly addressing suspected scientific fraud. Despite concerns raised by multiple experts and a 2004 exposé revealing Wakefield's fraudulent actions, UK authorities failed to impose disciplinary measures, and the article was not officially retracted until 2010.¹¹

Years after Wakefield began a wave of fraudulent science, antivaccine campaigns fueled the return of measles.¹² Around a return of measles in 2019, aggressive antivaccination campaigns influenced the World Health Organization (WHO) to list vaccine hesitancy among the greatest threats to global public health.

The COVID-19 pandemic that began in 2020 proliferated antivaccine campaigns, leading to substantial increases in COVID-related illness and death. By the time COVID-19 reached pandemic status, social media was classified as the epicenter of misinformation leading to hesitancy.¹²

According to a 2021 randomized controlled trial, exposure to vaccine misinformation about COVID-19 influenced a lower intent to vaccinate, even among populations that originally reported they would “definitely” accept the vaccine prior to misinformation exposure. Social media outlets are largely to blame for exacerbating the sharing of misinformation, reduced vaccination rates, undermined trust in reliable information, magnified polarization, and damaged perceived credibility of institutions.¹²

Vaccine hesitancy caused by misinformation has been approached through vaccination mandates, regulations for health care professionals, incentives, public health communication campaigns, and engagement with trusted leaders. Other approaches include debunking or fact checking claims once they reach social media users and “pre-debunking,” a behavioral approach where users are taught how to identify fake news prior to exposure.¹²

These efforts have made progress in reducing disinformation and misinformation, ultimately altering people’s beliefs. Experts acknowledge the direct link between social media exposure and offline beliefs that vaccines are harmful. However, low trust in governments and health institutions can derail effective immunization programs as well.¹²

Kai Ruggeri, PhD, professor of health policy and management at the Columbia University Mailman School of Public Health, commented on this matter for The American Journal of Managed Care^®(AJMC^®), stating, “Highly trusted sources must be involved in any public health policies aimed at confronting high levels of vaccine hesitancy—whether they focus on personal, community, or financial benefits. Short of mandates, which can backfire on the appearance of being coercive, the most effective interventions engage trusted sources to deliver accurate, actionable, and encouraging information.

Lack of Resources

Vaccine hesitancy manifests differently outside the US, primarily due to resource scarcity and supply shortages.¹³ Although the COVID vaccine was freely accessible in US clinics and pharmacies, other countries faced severe distribution challenges. Residents in northern Yemen, for example, endured perilous 20-hour journeys through mountainous war zones, hoping for vaccine availability upon arrival. Yemen is one of 36 countries with vaccination rates below 10%, including Haiti, Ethiopia, Tanzania, Madagascar, Uganda, Syria, Senegal, Zambia, Ghana, Kenya, Afghanistan, and others.

Jeffrey A. Goad, PharmD, MPH, professor of pharmacy at the Chapman University School of Pharmacy in Irvine, California; a fellow of the American Society of Health-System Pharmacists; and 2024-2025 president of the National Foundation for Infectious Diseases, discussed immunization data in an interview with AJMC.¹⁴ Goad said, “There were 103 countries that were reported with outbreaks, and they all were largely attributed to low vaccine rates. So, half of these kids actually live in very low-income countries, where things like war, insecurity, lack of nutrition, and lack of adequate health care are really contributing to low immunization rates and really thus a resurgence of vaccine preventable diseases.”

African nations overall face significant delays in vaccine access due to limited availability and a global system that prioritizes wealthier countries. Despite increased vaccine deliveries, these often consist of haphazard shipments or near-expired doses. Although resource scarcity is a primary driver of vaccine hesitancy in underserved countries, prolonged wait times for supplies have also allowed misinformation to proliferate.¹³

Polio in Gaza

In war-torn areas, more recently Gaza, medical aid has struggled to reach civilians in times of need. A WHO official for Palestinian regions voiced concerns about polio and other communicable disease outbreaks in Gaza after traces of the virus were detected in sewage samples in the territory.¹⁵

Dehydration, lack of sanitation, and lack of access to health care could potentially lead to more people dying of communicable diseases than injuries from warfare. Health officials have expressed warning to manage the polio situation in Gaza before the outbreak spreads internationally.¹⁵

Rolando Gomez, spokesperson for the United Nations (UN) in Geneva, said, “[Israel] has a responsibility to ensure assistance reaches those in need in Gaza and to create an enabling environment for the UN and our partners to operate.”¹⁵

Recently, plans to vaccinate Israeli soldiers was announced, but the WHO emphasized the disruption in routine immunization programs in Gaza, leaving children at greater risk for polio.¹⁵

TB Vaccine Research

As immunization research continues, a new tuberculosis (TB) vaccine is urgently necessary to prevent a projected surge in cases by 2035.¹⁶ Currently, only a vaccine for infants and young children exists.¹⁶

According to the WHO, a TB vaccine targeted for all age groups could dramatically reduce global TB mortality and incidence by up to 95%. To achieve this goal, the WHO has outlined specific criteria for a new TB vaccine that surpasses the limitations of the current BCG vaccine.¹⁶

Conclusion

From the pioneering work of Jenner to the eradication of diseases like smallpox, vaccines have undeniably saved countless lives. However, the resurgence of preventable illnesses, particularly in the face of modern medical advancements, is a stark reminder of the challenges the scientific field continues to face.

Misinformation, fueled by social media and scientific misconduct, has eroded public trust in vaccines. Coupled with resource disparities and global health inequities, this has created a perfect storm for the spread of diseases. The global community must unite to address these complex issues through robust public health campaigns, improved access to vaccines, and stringent measures to combat misinformation. Only then can we hope to protect future generations from the devastating consequences of vaccine-preventable diseases.

References

1. A brief history of vaccination. World Health Organization. 2023. Accessed August 1, 2024. https://www.who.int/news-room/spotlight/history-of-vaccination/a-brief-history-of-vaccination#:~:text=Dr%20Edward%20Jenner%20created%20the

2. Global immunization efforts have saved at least 154 million lives over the past 50 years. World Health Organization. April 24, 2024. Accessed August 1, 2024. https://www.who.int/news/item/24-04-2024-global-immunization-efforts-have-saved-at-least-154-million-lives-over-the-past-50-years

3. CDC. Notes from the field: measles outbreak among members of a religious community – Brooklyn, New York, March-June 2013. MMWR Morb Mortal Wkly Rep. 2013;62(36):752-753.

4. Measles cases and outbreaks. CDC. July 26, 2024. Updated August 1, 2024. Accessed August 1, 2024. https://www.cdc.gov/measles/data-research/index.html#:~:text=Global%20measles%20activity%20is%20increasing

5. Eliminated vs. eradicated: erasing disease from history. Atlantic Health Partners. December 13, 2018. Accessed August 1, 2024. https://www.atlantichealthpartners.com/immunization-insights/eliminated-vs-eradicated-erasing-disease-from-history/2018/12/13#:~:text=Since%20the%20introduction%20of%20the

6. Graham KA, Arciuolo RJ, Matalka O, et al. Varicella outbreak among recent arrivals to New York City, 2022–2024. MMWR Morb Mortal Wkly Rep. 2024;73(21):478-483. doi:10.15585/mmwr.mm7321a1

7. Reporting disease and conditions. NYC Health. Accessed August 1, 2024. https://www.nyc.gov/site/doh/providers/reporting-and-services/notifiable-diseases-and-conditions-reporting-central.page

8. About shingles (herpes zoster). CDC. May 10, 2024. Accessed August 1, 2024. https://www.cdc.gov/shingles/about/index.html#:~:text=About%201%20in%20every%203%20people%20in

9. History of flu (influenza): outbreaks and vaccine timeline. Mayo Clinic. 2021. Accessed August 1, 2024. https://www.mayoclinic.org/diseases-conditions/history-disease-outbreaks-vaccine-timeline/flu

10. 2023-2024 flu vaccine coverage update (continued). CDC. February 2, 2024. Accessed August 1, 2024. https://www.cdc.gov/flu/spotlights/2023-2024/flu-coverage-update.htm

11. Quick JN, Larson H. The vaccine-autism myth started 20 years ago. here’s why it still endures today. Time. February 28, 2018. Accessed August 1, 2024. https://time.com/5175704/andrew-wakefield-vaccine-autism/

12. Ruggeri K, Vanderslott S, Yamada Y, et al. Behavioural interventions to reduce vaccine hesitancy driven by misinformation on social media. BMJ. 2024:e076542. doi:10.1136/bmj-2023-076542

13. Beaubien J. For the 36 countries with the lowest vaccination rates, supply isn’t the only issue. NPR. January 14, 2022. Accessed August 1, 2024. https://www.npr.org/sections/goatsandsoda/2022/01/14/1072188527/for-the-36-countries-with-the-lowest-vaccination-rates-supply-isnt-the-only-issu

14. Shaw M. Bridging the vaccination gap: Insights on global immunization challenges. The American Journal of Managed Care®. July 30, 2024. Accessed August 2, 2024. https://www.ajmc.com/view/bridging-the-vaccination-gap-insights-on-global-immunization-challenges

15. Top WHO official warns Gaza in danger of polio outbreak. The Times of Israel. July 23, 2024. Accessed August 1, 2024. https://www.timesofisrael.com/top-who-official-warns-gaza-in-danger-of-polio-outbreak/#:~:text=There%20have%20been%20no%20confirmed,an%20outbreak%20happening%20in%20Gaza

16. Global tuberculosis programme: new TB vaccine research. World Health Organization. Accessed August 2, 2024. https://www.who.int/teams/global-tuberculosis-programme/research-innovation/vaccines