Vaccine Refusal: A Major, Underestimated Obstacle for the Poliomyelitis Eradication Initiative

"Vertical strategies of vaccination and communication are doomed to fail."

In this commentary, Bernard Seytre critically examines the failure of the Global Polio Eradication Initiative (GPEI) to meet its original goal of eradication by 2000 (and then by 2004, 2008, 2012, 2018, and continuing). He points to vaccine refusal as a major problem reflective of a strategy that did not fit into local realities and that made adjustments too late. To secure vaccination adherence, he argues, national and international public health authorities and organisations must take into consideration the "health culture" of the intended population. This concept is at the centre of a framework to design an adapted public health communication strategy and includes health literacy and perceptions concerning both the health issue at stake and the promoters of the public health policy within local historical, ethnic, religious, social, and political contexts.

As of this writing, poliomyelitis is still endemic in two countries (Afghanistan and Pakistan), and wild poliovirus (WPV) and/or circulating vaccine-derived polioviruses (cVDPVs) have been reimported in almost three dozen developing and industrialised countries. When the GPEI was launched in 1988, memories of devastating polio epidemics, with adult patients lined up in iron lungs, were still vivid in industrialised countries, along with the successful polio vaccines that brought them to an end. The situation was different in developing countries, where polio was still a relatively rare childhood disease with few complications. Deprived of the most elementary health facilities, with very limited access to modern medicine, people in the economically poorest communities of the countries GPEI entered were understandably skeptical, Seytre suggests. "How could they make sense of the vaccinators who went door-to-door to find and vaccinate their children, when no effort was made to address ubiquitous diseases or to provide drinking water and sanitation?"

In fact, Seytre argues that the way oral polio vaccine (OPV) campaigns have been deployed has contributed to mistrust and hostility. For example, a common practice involved preparatory teams visiting households to count the number of children and then marking that number on their door. This activity could be perceived as lacking respect if the inhabitants were not informed and did not explicitly give consent. The negative reactions of some communities, expressed from the first vaccination campaigns, were belatedly considered, which gave time for rumours to flourish (e.g., that the campaigns were part of a Western plot to sterilise Muslims). In certain countries that were divided by political, ethnic, or religious conflicts, mainly Nigeria, India, Pakistan, and Afghanistan, the refusals turned into a wave of hostility, with massive refusal of vaccination and even cases of murder of the vaccinators.

Seytre notes that "major vaccine refusals developed in countries where Muslim communities have been in conflict with the central authorities. In contrast, the GPEI did not encounter significant difficulties in gaining adherence of the populations in mainly Muslim countries, such as those of North Africa and the Middle East. Vaccine refusal is concentrated in 'high-conflict areas'..."

Acknowledging that the causes of low immunisation can be multifactorial, Seytre points out that the GPEI, with more than 30 years of experience, deployed intense efforts in the concerned regions, yet such difficulties did not prevent the elimination of polio cases in other countries with similar challenges. Vaccine refusal appears to be a major factor. Accordingly, GPEI reports mentioned vaccination refusal caused by rumours and recommended involving community and religious leaders as early as 1999. However: "Additional steps could have been taken to identify the drivers of refusal, study the community perceptions of mass vaccination campaigns, and develop a program to win the support of local traditional and religious leaders in countries torn by ethnic, religious, and political conflicts."

It took years to truly address the drivers of vaccination refusal, as outlined here. As a result, local Muslim leaders of reluctant communities were finally convinced of the safety and efficacy of OPV and became promoters of vaccination. However, the distrust had spread over 10 years and has never completely vanished.

This failure underscores the importance of taking into account, before any vaccination campaign begins, each population's "health culture": their representations of the vaccines and the health authorities that promote vaccination, as well as their knowledge, fears, and hopes. Had this approach been central, per Seytre, "preventing and addressing vaccine refusal should have been a GPEI priority, with studies to evaluate the drivers of refusal launched at the onset of the eradication campaign....First, it was crucial to avoid fueling vaccine refusal. Second, once deeply rooted in some communities, vaccine refusal has a lasting effect and might never be fully eliminated, making it the most challenging barrier to high immunization levels. Third, foreseeing and managing refusal does not require substantial financial resources."

Ultimately: "Vaccination campaigns are not only a matter of furnishing the vaccines, logistics, and financial and human resources. Populations must agree to be vaccinated or to allow their children to be vaccinated."

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