Public Health Response to Influenza A(H1N1) as an Opportunity to Build Public Trust
Authors: Heidi J. Larson
Journal: JAMA (2010)

IN JUNE 2009, THE WORLD HEALTH ORGANIZATION (WHO) declared the 2009 influenza A(H1N1) pandemic and in October 2009, President Obama declared it a national emergency. The influenza A(H1N1) virus is being monitored around the world for changes in virulence or epidemiology. There has been a push to have vaccines ready, yet vaccine supply may be insufficient in some areas. The public wants to be assured that there is enough vaccine, but at the same time, some are questioning the safety and effectiveness of the vaccine. It is a time of uncertainty both for the public health community and for the public. Times of uncertainty and risk are times when public trust is most needed. But trust is built long before the time that trust matters most. As the public weighs the perceived risks of the A(H1N1) virus against the perceived risks of vaccination, they are taking into account multiple, often conflicting, sources of current and historic information, as well as their own personal experiences. Questioning the safety of A(H1N1) vaccines is for some influenced by memories of the 1976 US swine flu alert, of the follow-up swine flu vaccination campaign and the ensuing cases of GuillainBarre syndrome (GBS), and of a swine flu pandemic that never materialized. For others, questioning may come from memories of severe acute respiratory syndrome (SARS), which had severe but rapidly contained health effects; for others, questions may arise from warnings about avian influenza A(H5N1) and its continued pandemic threat. Perception of risk about A(H1N1) vaccination is also influenced by a broader environment of distrust and vocal antivaccine groups. Questioning and mistrust of the measles-mumpsrubella (MMR) vaccine in the United Kingdom that began during the late 1990s was prompted by the claimed association between the MMR vaccine, bowel disease, and autism. This claim came shortly after a loss of public trust around the government’s lack of transparency and understating of the risks of bovine spongiform encephalopathy. Even after clear evidence emerged that these claims about autism being related to vaccines were unfounded, historic levels of distrust, compounded by massive media coverage that amplified the unproven links between the MMR vaccine and bowel disease, played a role in contributing to lower vaccine coverage and consequent disease outbreaks. In France, public trust in hepatitis B vaccine plummeted after the government’s precautionary decision to stop the school vaccination program because of suspected, but not proven, links with multiple sclerosis, despite recommendations by WHO and French pediatricians to continue the program. This followed concerns over the French government’s management of the human immunodeficiency virus (HIV)–contaminated blood crisis in the mid-1980s, and public opposition and rumors associating hepatitis B vaccines with not only multiple sclerosis but also autism and leukemia led to low levels of hepatitis B vaccination. In Nigeria, the mistrust and 2003-2004 boycott of the polio vaccination program by predominantly Muslim states in Northern Nigeria emerged at a time when false rumors of the safety of polio vaccine—linked to HIV, hormonal contamination, or both—weakened trust in global initiatives such as polio eradication. This followed a 1996 drug trial of an antibiotic for meningitis in Nigeria in which children died. Adding to the mistrust, repeated door-to-door polio vaccination campaigns are thought to have increased levels of suspicion in historically marginalized states. In these states, health services are inadequate, immunization coverage is lower than in the rest of the country, and communities questioned why other diseases, perceived by them to be more important, continued to be neglected. The loss of public confidence and vaccination boycott led to a resurgence of polio cases in Nigeria. The Nigerian virus spread to more than 12 neighboring countries that had been certified as poliofree and polio caused by the Nigerian strain was traced as far as Indonesia. Significant efforts have since been made at the community level in Northern Nigeria to build public