Vaccination in a “me first” era
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2018)

In this month's issue, Kevin Ariën and Annelies Wilder-Smith outline the ideal attributes of a diagnostic test to identify previous exposure to dengue virus. The need for such an assay stems from the worrying revelation by Sanofi Pasteur last November that its licensed tetravalent vaccine, Dengvaxia, was associated with an increased risk of severe dengue in individuals who were seronegative for dengue virus at the time of vaccination. It was assumed that the vaccine, the efficacy of which is higher for serotypes 3 and 4 than for 1 and 2, was mimicking a primary infection, which is known to be a risk factor for future severe disease if the individual becomes infected with a different serotype at a later date. Sanofi Pasteur thus proposed a label change to the effect that vaccination should not be recommended in those who have not been previously infected. Further, in April, 2018, WHO's Strategic Advisory Group of Experts on Immunization (SAGE) released revised recommendations that also indicated a preferred strategy of prevaccination screening for previous exposure and vaccination only of seropositive individuals. SAGE additionally called for research into “development of a highly sensitive and specific rapid diagnostic test to determine serostatus”. In the Philippines—where the disease is highly prevalent and whose Government boldly announced a programme to vaccinate 830 000 schoolchildren in 2016—this transparent, cautious, and responsible approach to a safety concern was unfortunately lost amid an avalanche of alarmist governmental statements, screaming headlines, and law suits. The Government withdrew approval of the vaccine in December 2017. What can cause a public health programme to go so disastrously wrong and what can academics, health professionals, and communicators do to assuage concerns about vaccine safety? These were some of the questions put to a panel of experts at the International Society for Neglected Tropical Diseases (ISNTD) d3 meeting in London last month. Tikki Pangestu, professor at the Lee Kuan Yew School of Public Policy in Singapore and previously of WHO, highlighted what he saw as the “enabling environment” that led to the dengue vaccine saga. First, the immunisation programme was launched in the Philippines to much fanfare very swiftly after the vaccine's approval and during an election year. The Government's eagerness to introduce the programme could thus have been seen as politically motivated. Second, a failure of leadership saw public health officials join with anti-vaccine groups and a media focused on getting a juicy story to seed mass fear among parents. Finally, and common to all immunisation programmes, is the very concept of intervening medically in healthy children—an understandably combustible notion, the benefits, risks, and uncertainties of which are difficult to convey to a lay audience. Add to these general elements of distrust the tensions between individual rights and wider societal benefits, and religious and philosophical beliefs, and you have quite an explosive mix, added Pauline Paterson from the London School of Hygiene and Tropical Medicine's Vaccine Confidence Project. The answer? “Very difficult”, said Paterson. Psychological research shows that changing misconceptions is not easy, and that the mere process of debunking a myth can make the myth more prominent in the mind of the receiver. However, identifying susceptible populations, exploring the underlying reasons for non-vaccination, and designing evidence-informed responses are important features of success, she advised. Additionally, people are more likely to vaccinate or be vaccinated if a health-care provider recommends it, and vaccinated health-care providers are more likely to recommend vaccination to others. Some clear messages to health-care providers, then: acknowledge your patients' concerns, engage with them, recommend vaccination, and get yourself or your children vaccinated. And what about communicators? We are all communicators, insisted Sanofi Pasteur's Angus Thomson. Researchers, practitioners, editors, and policy makers can and should be part of the discussion, he said, offering evidence to counter misinformation where we encounter it on social media, helping journalists to understand complex risk-benefit scenarios, and assisting governments with risk management planning. “Don't wait for the crisis before you lean into the problem”, agreed Rachel Grant from the Coalition for Epidemic Preparedness Innovations (CEPI). Finally, we need to be prepared to meet individuals wherever their own personal beliefs lie and not simply try to convert them to our own mindset. Because one thing we cannot assume in this “me first” era is that every citizen will see the wider societal benefits as a good reason to take a personal risk, however small that may be in reality. Dengue vaccine: reliably determining previous exposureDengue fever is the most prevalent and widespread mosquito-borne viral disease, and can only be countered by integrated prevention and control strategies, including sustained vector control programmes, the best evidence-based clinical care, and vaccination. Full-Text PDF Open Access