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Public Health Notes – Vaccine declination or hesitancy

At the intersection of individual autonomy and the ethical obligation to promote the public good.

by Catherine Colquitt, MD

According to the World Health Organization (WHO): 

“Vaccination has greatly reduced the burden of infectious diseases. Only clean water, also considered to be a basic human right, performs better. Paradoxically, a vociferous antivaccine lobby thrives today in spite of the undeniable success of vaccination programs against formerly fearsome diseases that are now rare in developed countries.” ( 

Efforts by the WHO and its partners have helped increase global vaccination rates over the last two decades. From 2000 to 2014, annual world mortality from measles decreased from 546,800 deaths to 114,000, and an estimated 17.1 million measles deaths were prevented (MMWR 2015; 64:1246-1251).  Measles is highly infectious; one case produces an average of 18 cases through contact with the index case. The percentage of infants worldwide who received three DTPs before age one and one dose of measles vaccine before age two was 86 percent by the end of 2018.  

Experts estimate that from 2011 to 2020, 23.3 million deaths were averted by the increased vaccines in low-income countries, with the largest number of prevented deaths occurring through decreases in measles (13.5 million deaths prevented), Hepatitis B (4.8 million deaths prevented), Hemophilus influenza type B (1.4 million deaths prevented), and Streptococcus pneumoniae (1.5 million deaths prevented). (Vaccine 2013; 18:31 (Suppl 2): B61-72)

Now, the MCV 4 vaccine is widely used in central Africa as the first vaccine to gain approval outside the “cold chain,” meaning that its efficacy is preserved for up to four days without refrigeration and at temperatures up to 104 °F, allowing its delivery and administration in remote areas without access to refrigeration. 

Polio, once thought to be on the cusp of eradication worldwide, persists in Nigeria, Afghanistan, and Pakistan, but stakeholders are redoubling efforts to eradicate this scourge. The virus persists due to suspicion regarding its efficacy and intent, and myths about certain adverse effects.

Despite the successes of immunization programs, approximately 19.4 million children worldwide remain entirely unvaccinated by their first birthday, with 60 percent living in Angola, Brazil, Democratic Republic of Congo, Ethiopia, India, Indonesia, Nigeria, Pakistan, the Philippines, and Vietnam. Many are victims of drought, famine, political conflict, or internal/external displacement. 

Yet, in the face of these triumphs, measles is on the rise due to falling vaccination rates, now below the threshold needed for herd immunity—vaccine coverage of 83-94 percent (Doherty, M, et al Vaccine 34 (2016); 6707-6714). 

What are the root causes of vaccine declination and hesitancy in the face of obvious vaccination success? 

First, vaccine adverse effects, while rare, always get more publicity than successes (think swine flu of 1976). Then there are falsehoods and internet misinformation (think the disgraced British gastroenterologist who published two now-retracted papers in a British medical journal on a debunked link between MMR vaccine and autism for his own advancement). 

Vaccine hesitancy and declination can be reduced to cost, convenience, lack of confidence in the seasonal flu vaccine efficacy, concerns about potential side effects, and collective amnesia about how serious vaccine-preventable diseases can be. Many of us have never seen measles, rubella, Hemophilus B meningitis, and primary Varicella and don’t know what these diseases can do to infants, the immunocompromised, pregnant women, and persons on steroids, chemotherapy, and immunomodulating therapies. 

So what can we offer the vaccine-hesitant?

We can give them time-tested facts about vaccines, reassure them with the prospect of a longer life and lower healthcare costs. We can give them a chance to impact child mortality, play a role in slowing or reversing antimicrobial resistance and lessen the worldwide economic impact of vaccine-preventable diseases. Through vaccination, we can help them become healthier international travelers, and give them the satisfaction of knowing they are doing their part to make the world a healthier place for everyone. 

The WHO reminds us that “the benefits of vaccines extend beyond prevention of specific diseases in individuals. They enable a rich, multifaceted harvest of societies and nations. Vaccination makes good economic sense and meets the need to care for the weakest members of society.”  (

So far we have eradicated small pox and rinderpest (a veterinary pestilence).  

How about polio and measles next?  

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