The Role of Health Teams in Achieving

a Successful Vaccination Campaign

ANA MARÍA MORALES

The Role of Health Teams in Achieving a Successful Vaccination CampaignAna María MoralesJournalist and Communications Director, Institute of Public Policies in Health, San Sebastian University (IPSUSS), Santiago, Chile

Introduction

Are vaccines dangerous? Since Edward Jenner first entered this field through inoculation, and later on when

Louis Pasteur invented the first laboratory vaccine, there have always been critical voices second guessing their

safety and efficacy.

The fear of the unknown and the potential side effects were part of the arguments used in the anti-vaccine

campaigns at the beginning of the XIX century.1

In his work, The cow-pack or the wonderful effects of the new inoculation, in 1802, the English cartoonist

James Gillray represented how sensitive this topic was for the citizenry (Figure 1). Later on, when England

approved mandatory child vaccination in 1853 and imposed fines or even imprisonment on parents who

refused to have their children vaccinated, new counterarguments emerged, such as whether this measure was

a violation of the individual rights of people. In the early 1900’s, the first anti-vaccine leagues were born in New

England and New York.

Figure 1. Cartoon by James Gillray: The Cow-Pack or the Wonderful Effects of the New Inoculation (1802)

That debate is not very different from

the existing one. When analyzing news

headlines, in the various countries of the

region, it is possible to see the resistance

against vaccines (Figure 2). In particular,

this is due to dissenting opinions amongst

the political actors, opinion leaders and

technicians in this area, who act as points

of reference for the public.

Source: British Museum

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Figure 2. Vaccination Headlines in the Press in Latin America

This resistance is influenced by various factors: the decrease in risk perception of

diseases prevented by vaccines; overloaded immunization programs whose need

has not always been properly communicated to the public; greater knowledge about

side or adverse effects as well as accidents or errors in supply; pressure of opinion

leaders; lobbying by anti-vaccination groups and mistrust toward pharmaceutical

companies.

The media and social networks play a remarkable role in this situation, acting as a

sounding box, sometimes by disseminating information of dubious or contradictory

origin which impacts the decision-making process of the population.

All these elements contribute to a certain apprehension toward the health system,

represented by suppliers and policy makers.

In 2013, an example of the impact of anti-vaccination lobbying campaigns was

seen in Chile with the passing of the law prohibiting thimerosal as a preservative

in vaccines. The influence of these sectors resulted in a group of parliamentarians

from different political paths to present a bill that was approved by Congress,

notwithstanding the fact that stewardship around this issue belongs to the Ministry of Health. The initiative was

voted on without consideration for the concerns raised by the Pan American Health Organization (PAHO) and

the scientific associations.2 The law had to be vetoed by the President of the Republic; however, it led to a loss

of confidence in the national immunization program. This led to a decrease in coverage figures and, in many

cases there were legal disputes between parents who refused to have their children vaccinated and the health

services, which had to be settled in court.

ENGLISH TRANSLATIONS

1. Robert de Niro

controversially

supports

anti-vaccine

documentary.

2. Audit reveals

mistakes in Human

Papillomavirus

vaccination in RM

3. Scientist argues the

existence of links

between a vaccine

and autism.

4. Cancellation of

papilloma vaccines

at schools due to

rejection.

5. Ten communities

ignored the

recommendation to

vaccinate pregnant

women against

whooping cough.

6. Chile will be the

first country to pass

a law excluding

thimerosal.

7. More than 200

arrests in expired

vaccine scandal in

China.

8. Vaccines are

dangerous.

9. Jim Carrey stirs

controversy due

to criticism against

vaccines.

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Another well-known example includes recent events in Colombia with the introduction of the human

papillomavirus (HPV) vaccine. Opposing population groups, including support by religious sectors and

opinion leaders, argued unfoundedly that HPV vaccination in pre-adolescent girls would imply some sort of

permissiveness for early sexual initiation, which became a flag for their fight. This resulted in improper coverage

amongst the target group. Similar situations were replicated later on in other countries of the region.

A dominant factor contributing to this issue is the low-risk perception associated with vaccine-preventable

diseases, a situation that is shared in several countries of the Americas. In particular, this issue stands out within

sectors of the population that have the highest level of education or income, and have ceased to vaccinate their

children because they do not consider it a preventive action, such as the case with the bacille Calmette-Guérin

(BCG) vaccine. This is an alarming trend in a region where tuberculosis is still an existing public health problem,

and where the lack of acquired immunity from the vaccine may lead to more severe occurrences of the disease.

The Art of Persuasion

Trust in the immunization programs is not infinite. The successful actions carried out in recent decades to

control diseases such as smallpox or poliomyelitis are no longer sufficient as prevention policies.

Consequently, influenza vaccination coverage in adults over 65 years, in most countries, and in particular, in the

most developed countries, does not reach 80%, as reported in the 2015 Health Indicators of the Organization

for Economic Cooperation and Development (OECD). The success of a campaign depends in part on the level

of protection attained for its vulnerable population.

For individuals to be willing to be vaccinated, they need to understand that the benefit will be greater than the

cost of vaccine administration. Cost is not understood in monetary terms since the vaccines included in the

immunization programs from the various LAC countries are usually provided free of cost. Rather, cost is viewed

in terms of time spent on transfer, waiting, pain, some adverse effect, and/or a small scar on the arm.

How can this objective of vaccine uptake be attained? Based on the cultural changes that happened over recent

decades, the response is for people to not only be convinced of the value of vaccines for them or their children,

but also inclined to opt freely for vaccination.

Currently, there is a greater demand for information. Communities demand trustworthy and specialized

evidence regarding vaccines. There is greater social control on State policies and this transcends borders. For

the immunization programs this accounts for a true cultural revolution because there is a need to shift the

paradigm used over recent years, mainly to change the way public health communication takes place.

Failing to address this demand for more information has very high costs and immediate consequences for the

authorities or the officials who have a public role to fulfill.

It is essential for health sector workers to communicate effectively. Whenever problems are not anticipated,

there is no capacity to control them. The health of the population is strictly related to access and use of

information. However, information is not always available or it is not available in the proper form or of high

quality. Examples from the situation with the HPV vaccine in Colombia are telling.

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The most common mistakes made by the technical teams from the health sector entail assuming that

“individuals know” the importance of vaccination while health illiteracy amongst the members of our

populations is high, in particular amongst the groups with the lowest school attendance.3

The other mistaken assumption is that whatever worked in other countries is perfectly applicable to the local

situation, without considering the distinct idiosyncrasies at the local level. For example, the inclusion of a new

vaccine in an immunization plan, such as the HPV vaccine, without previously assessing all local scenarios

is setting up for failure. Cultural resistance by the most conservative groups of the population, the religious

sectors, the indigenous peoples, the anti-vaccination organizations, the youth who are the target population for

vaccination or even the offensive by the pharmaceutical industry itself, must be considered in advance.

If there is no rapid response capacity by the technical teams or the authorities, uncertainty and disinformation

will influence the opinion of citizens and regaining public trust becomes extremely difficult. Typically after such

situations, vaccination coverage does not reach the expected levels to guarantee the protection of the target

population, as well as the cost-effectiveness of the measure.

Paradigm Shift

It is erroneously believed that the population should be informed or educated through communications

campaigns with a spot on television, phrases on radio programs or information handouts. These approaches are

all merely instruments of a global strategy.

A paradigm shift involves abandoning that school of thinking and reformulating the way things are done. It

should be understood that it is not only a matter of knowledge but also beliefs. The communications strategy

should then be focused on stimulating, listening, learning and transferring responsibility for self-care to the

public.

The success of a vaccination campaign is conditioned by the responsibility people undertake to care for their

own health, which is strongly determined by the educational level they have attained and that of their family

environment. This is where there can be a significant inequality gap.

Individuals with low educational levels or poor health literacy are at greater risk of mortality, visit emergency

rooms more frequently due to a decompensation or severe impairment of their health (a condition that may

be irreversible in some cases) and have a higher-than-average hospitalization rate. Preventive care, such as

vaccinations or tests, is less frequent in these individuals.4

Therefore, there is a need to create opportunities for education. In the area of health care, teams of practitioners

make efforts to educate the population through promotional activities or during medical visits. However, this is

not always compatible with the demands of their work and the fulfillment of the health goals imposed on them.

Often times, targeting coverage indicators rather than education or health care quality indicators becomes the

priority.

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The communications strategy for a vaccination campaign should be complemented with the following:

� Review the situation before introducing a new vaccine into the immunization plan or changing a pre-

established schedule.

� Identify the problems and implement actions to anticipate an eventual challenge by other stakeholders

opposing the measure. Within this context, assess the level of prejudices in connection with the vaccines

within a specific population. Information disseminated on the radio, television and social networks

reaches everyone. It is naive to think that detractors of the vaccine have not done their homework.

� Define a work strategy with constant communication strategies to create conditions fostering a policy

change and a constant assessment of the actions.

� Identify strategic allies or partners to technically endorse the work being developed, such as international

agencies (WHO, PAHO, CDC, other Ministries of Health of the Region), scientific associations,

professional associations, civil society organizations or other public or private agents, to have them

participate in the campaigns and speak independently.

� Design the health network so that every technical team manages the same information promptly;

determine the tasks to be completed by the authorities and technical officials on the field.

� Design an activity program. The launch of a vaccination campaign is not sufficient. A set of actions to be

sequentially implemented is required. Hold a press conference to provide context for the significance of

vaccination and show cases of people impacted by the disease or the adverse effects; visit various health

centers to verify immunization coverage and focus the message on the groups that are lagging the most;

add credible spokespersons supportive of the initiative to the campaign.

� Promote strategies that bring vaccination closer to people, through discussions at schools or other

educational institutions, grassroots organizations, elderly care centers or patient associations for

individuals to ask questions and have their doubts answered.

� Vaccination on the field. Reach out to the target group rather than wait for the target group to go to

the health clinic. Depending on the intended target population, this can be achieved through mobile

vaccination units, visits to neonatal wards, preschools, schools or elderly care centers.

� Educate and constantly deliver information not only through the national media outlets but also through

the community media outlets to reach out to the public. Provide communications material for them to

use, promote interviews with technical spokespersons as part of mass programs on radio stations; and

develop key messages that can be replicated on social networks and web pages.

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Conclusion

To sum up, maintaining a population protected against preventable diseases for which effective vaccines

have been developed requires a profound change in the way things are done. Effective communication

and leadership amongst workers in the immunization programs are the most important. Work in the field is

an inescapable requirement as well as the knowledge of the population and their acceptance level of the

immunization plan. Prior to the vaccination period, the strategies described in this chapter should be developed

to excite, convince, and relate to community leaders. Each and every one is different from the next.

When communicating, the following is important to keep in mind:

� Concerns expressed by individuals need to be addressed in form and substance, and this entails active

listening.

� Use straightforward language.

� The message being conveyed needs to be straightforward and clear. Define key phrases for people to

remember, in particular, the importance of protecting the family.

� The spokesperson needs to be credible, empathetic, and honest when faced with an adverse situation.

Challenges need to be acknowledged.

A poorly-planned vaccination campaign- without awareness for the cultural environment or strong local leadership-

may risk failing to reach minimum coverage levels. A failed program will not only lead to direct losses in personnel

time, cost of vaccines and supplies, but also a great indirect cost: the emergence of cases of the disease intended to

be prevented, discredit for the health authority and uncertainty about the program as a whole.

References

1. Robert M Wolfe, assistant professor and Lisa K Sharp, assistant professor. Anti-vaccinationists past and present. https://www.ncbi.nlm.

nih.gov/pmc/articles/PMC1123944/

2. Statement on the elimination of the multi-dose vials of vaccines containing Thimerosal. Chilean Journal on Infectology 2013; 30 (4):

346-349. http://www.scielo.cl/pdf/rci/v30n4/art01.pdf

3. Monsalves, MJ., Durán, D., Romero, MI., Mañalich, J., (2015). Health literacy amongst chronic patients served in primary care, in four

Chilean communities. In the XXXII Chilean Meeting on Public Health. Santiago, Chile.

4. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, Holland A, Brasure M, Lohr KN, Harden E, Tant E,

Wallace I, Viswanathan M. Health Literacy Interventions and Outcomes: An Updated Systematic Review. http://www.ncbi.nlm.nih.gov/

pubmed/23126607.

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