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This year, the World Health Organization named vaccine hesitancy as one of the top 10 global health threats, alongside threats as grave as climate change, antimicrobial resistance, Ebola virus, and the next influenza pandemic. What happened? How did vaccine reluctance and refusal become such a major risk? The concerns driving antivaccine sentiment today are diverse. For example, from 2003 to 2004, a vaccine boycott in Nigeria's Kano State sparked the retransmission of polio across multiple countries as far as Indonesia. Rumors of vaccine contamination with antifertility agents contributed to distrust and reinforced the boycott, costing the Global Polio Eradication Initiative over U.S. $500 million to regain the progress that was lost. In Japan, vaccination against human papilloma virus plummeted to almost zero after young women complained of movement disorders and chronic pain, causing the government to suspend proactive recommendation of the vaccine nearly 6 years ago. Similar episodes occurred in Denmark, Ireland, and Colombia as YouTube videos of the girls' symptoms spread anxiety, despite evidence of the vaccine's safety. > “How did vaccine reluctance and refusal become such a major risk?” The global surge in measles outbreaks has been exacerbated by vaccine refusers. In 2015, the measles strain that sparked the Disneyland outbreak came from visitors from the Philippines, infecting people who had refused vaccination. And in Indonesia, Muslim leaders issued a fatwa against a measles vaccine containing “haram” porcine compounds, while naturopathic “cupping” methods were promoted on Facebook as an alternative to vaccination. In 2018, a mix of political, religious, and alternative health antivaccine messages circulated on WhatsApp and Facebook in Southern India, disrupting a local measles-rubella vaccination campaign. The phenomenon of vaccine dissent is not new. The pages of 18th-century London antivaccination pamphlets bristle with many of today's memes, but these ideas now spread over unprecedented distances with remarkable speed, clustering in online neighborhoods of shared beliefs. This clustering can tear the protective fabric—the “herd (community) immunity”—that the majority of vaccine acceptors have woven. As the portion of the community that is vaccinated decreases, there is less protection for others who may be too young, unable, or choose not to be vaccinated. For some diseases, it only takes a small minority to disrupt the protective cover. It is just over 20 years since British physician Andrew Wakefield sowed seeds of doubt about the safety of the MMR (measles, mumps, rubella) vaccine, suggesting a link between the vaccine and autism. Suspicions around the vaccine traveled globally, instilling anxiety among the most and least educated alike. The discredited Wakefield alone, though, cannot be blamed for today's waves of vaccine discontent. He seeded a message on the eve of a technological revolution that disrupted business, politics, societies, and global health. The same year that Wakefield published his research, Google opened its doors. The launches of Facebook, YouTube, Twitter, and Instagram soon followed. These social media platforms have magnified individual sentiments that might have stayed local. Emotions are particularly contagious on social media, where personal narrative, images, and videos are shared easily. Today's tech companies are now being called to account for their role in spreading vaccine dissent. Last month, the American Medical Association urged the chief executives of key technology companies to “ensure that users have access to scientifically valid information on vaccinations.” But this is not merely an issue of correcting misinformation. There are social networks in which vaccine views and information are circulating in online communities, where vaccine choices become part of one's overall identity. To mitigate the globalization of vaccine dissent, while respecting legitimate sharing of concerns and genuine questions, a mix of relevant expertise is needed. Technology experts, social scientists, vaccine and public health experts, and ethicists must convene and take a hard look at the different roles each group has in addressing this challenge. It needs everyone's attention.

Background Risk perception has been found to be a crucial factor explaining inconsistent or non-use of HIV prevention interventions. Considerations of risk need to expand beyond risk of infection to also include the personal, social, emotional, and economic risks associated with prevention intervention use. Objectives This systematic review of qualitative peer-reviewed literature from sub-Saharan Africa examines perceptions of risk associated with HIV infection and HIV prevention intervention use. Data sources We searched Medline, Embase, PsychInfo, Africa Wide Info, CINAHL, and Global Health for publications and screened them for relevance. Study eligibility criteria Peer-reviewed qualitative studies published since 2003 were eligible for inclusion if they examined risk perception or uncertainty in the context of a medically regulated intervention. Only studies focusing on adults were included. Study appraisal and synthesis methods Included publications were quality assessed using the Hawker method and coded thematically. Results 10318 unique papers were identified, of which 29 are included. Among the themes identified, a particularly salient one was the potential of HIV prevention interventions to threaten the stability of a relationship and impact on how and when people may—or may not—choose to use prevention interventions. Limitations This literature review excludes grey-literature, which may have distinct valuable insights. We also excluded quantitative studies that may have challenged or triangulated our findings. Conclusions and implications When considering the risk of HIV acquisition, it is insufficient to examine biological risk in isolation from the personal, relational and economic costs associated with intervention use. This loss of emotional, physical, or material support may be perceived as more consequential than the prevention of a potential infection.

Digital health has revolutionised healthcare, with implications for understanding public reactions to health emergencies and interventions, while real-time analysis provides a new opportunity for rapidly detecting changes in public confidence in vaccines. Medi+board implements tools for infectious disease surveillance and outbreak management, and the novel aim of the VAC medi+board is to design an interactive visualisation framework integrating heterogeneous real-time data streams with social network data, to meet information needs as articulated by the LSHTM Vaccine Confidence Project (VCP) investigators.

In March 2012, the SAGE Working Group on Vaccine Hesitancy was convened to define the term “vaccine hesitancy”, as well as to map the determinants of vaccine hesitancy and develop tools to measure and address the nature and scale of hesitancy in settings where it is becoming more evident.The definition of vaccine hesitancy and a matrix of determinants guided the development of a survey tool to assess the nature and scale of hesitancy issues. Additionally, vaccine hesitancy questions were piloted in the annual WHO-UNICEF joint reporting form, completed by National Immunization Managers globally. The objective of characterizing the nature and scale of vaccine hesitancy issues is to better inform the development of appropriate strategies and policies to address the concerns expressed, and to sustain confidence in vaccination.The Working Group developed a matrix of the determinants of vaccine hesitancy informed by a systematic review of peer reviewed and grey literature, and by the expertise of the working group. The matrix mapped the key factors influencing the decision to accept, delay or reject some or all vaccines under three categories: contextual, individual and group, and vaccine-specific. These categories framed the menu of survey questions presented in this paper to help diagnose and address vaccine hesitancy.

Background. Public confidence in vaccination is vital to the success of immunisation programmes worldwide. Understanding the dynamics of vaccine confidence is therefore of great importance for global public health. Few published studies permit global comparisons of vaccination sentiments and behaviours against a common metric. This article presents the findings of a multi-country survey of confidence in vaccines and immunisation programmes in Georgia, India, Nigeria, Pakistan, and the United Kingdom (UK) � these being the first results of a larger project to map vaccine confidence globally. Methods. Data were collected from a sample of the general population and from those with children under 5 years old against a core set of confidence questions. All surveys were conducted in the relevant local-language in Georgia, India, Nigeria, Pakistan, and the UK. We examine confidence in immunisation programmes as compared to confidence in other government health services, the relationships between confidence in the system and levels of vaccine hesitancy, reasons for vaccine hesitancy, ultimate vaccination decisions, and their variation based on country contexts and demographic factors. Results. The numbers of respondents by country were: Georgia (n=1000); India (n=1259); Pakistan (n=2609); UK (n=2055); Nigerian households (n=12554); and Nigerian health providers (n=1272). The UK respondents with children under five years of age were more likely to hesitate to vaccinate, compared to other countries. Confidence in immunisation programmes was more closely associated with confidence in the broader health system in the UK (Spearmans �i=0.5990), compared to Nigeria (�i=0.5477), Pakistan (�i=0.4491), and India (�i=0.4240), all of which ranked confidence in immunisation programmes higher than confidence in the broader health system. Georgia had the highest rate of vaccine refusals (6 %) among those who reported initial hesitation. In all other countries surveyed most respondents who reported hesitating to vaccinate went on to receive the vaccine except in Kano state, Nigeria, where the percentage of those who ultimately refused vaccination after initially hesitating was as high as 76%) Reported reasons for hesitancy in all countries were classified under the domains ofconfidence, � �convenience, � orcomplacency, � and confidence issues were found to be the primary driver of hesitancy in all countries surveyed. Abstract Background. Public confidence in vaccination is vital to the success of immunisation programmes worldwide. Understanding the dynamics of vaccine confidence is therefore of great importance for global public health. Few published studies permit global comparisons of vaccination sentiments and behaviours against a common metric. This article presents the findings of a multi-country survey of confidence in vaccines and immunisation programmes in Georgia, India, Nigeria, Pakistan, and the United Kingdom (UK) � these being the first results of a larger project to map vaccine confidence globally. Methods. Data were collected from a sample of the general population and from those with children under 5 years old against a core set of confidence questions. All surveys were conducted in the relevant local-language in Georgia, India, Nigeria, Pakistan, and the UK. We examine confidence in immunisation programmes as compared to confidence in other government health services, the relationships between confidence in the system and levels of vaccine hesitancy, reasons for vaccine hesitancy, ultimate vaccination decisions, and their variation based on country contexts and demographic factors. Results. The numbers of respondents by country were: Georgia (n=1000); India (n=1259); Pakistan (n=2609); UK (n=2055); Nigerian households (n=12554); and Nigerian health providers (n=1272). The UK respondents with children under five years of age were more likely to hesitate to vaccinate, compared to other countries. Confidence in immunisation programmes was more closely associated with confidence in the broader health system in the UK (Spearmans �i=0.5990), compared to Nigeria (�i=0.5477), Pakistan (�i=0.4491), and India (�i=0.4240), all of which ranked confidence in immunisation programmes higher than confidence in the broader health system. Georgia had the highest rate of vaccine refusals (6 %) among those who reported initial hesitation. In all other countries surveyed most respondents who reported hesitating to vaccinate went on to receive the vaccine except in Kano state, Nigeria, where the percentage of those who ultimately refused vaccination after initially hesitating was as high as 76%) Reported reasons for hesitancy in all countries were classified under the domains ofconfidence, � �convenience, � orcomplacency, � and confidence issues were found to be the primary driver of hesitancy in all countries surveyed. Abstract Background. Public confidence in vaccination is vital to the success of immunisation programmes worldwide. Understanding the dynamics of vaccine confidence is therefore of great importance for global public health. Few published studies permit global comparisons of vaccination sentiments and behaviours against a common metric. This article presents the findings of a multi-country survey of confidence in vaccines and immunisation programmes in Georgia, India, Nigeria, Pakistan, and the United Kingdom (UK) � these being the first results of a larger project to map vaccine confidence globally. Methods. Data were collected from a sample of the general population and from those with children under 5 years old against a core set of confidence questions. All surveys were conducted in the relevant local-language in Georgia, India, Nigeria, Pakistan, and the UK. We examine confidence in immunisation programmes as compared to confidence in other government health services, the relationships between confidence in the system and levels of vaccine hesitancy, reasons for vaccine hesitancy, ultimate vaccination decisions, and their variation based on country contexts and demographic factors. Results. The numbers of respondents by country were: Georgia (n=1000); India (n=1259); Pakistan (n=2609); UK (n=2055); Nigerian households (n=12554); and Nigerian health providers (n=1272). The UK respondents with children under five years of age were more likely to hesitate to vaccinate, compared to other countries. Confidence in immunisation programmes was more closely associated with confidence in the broader health system in the UK (Spearmans �i=0.5990), compared to Nigeria (�i=0.5477), Pakistan (�i=0.4491), and India (�i=0.4240), all of which ranked confidence in immunisation programmes higher than confidence in the broader health system. Georgia had the highest rate of vaccine refusals (6 %) among those who reported initial hesitation. In all other countries surveyed most respondents who reported hesitating to vaccinate went on to receive the vaccine except in Kano state, Nigeria, where the percentage of those who ultimately refused vaccination after initially hesitating was as high as 76%) Reported reasons for hesitancy in all countries were classified under the domains ofconfidence, � �convenience, � orcomplacency, � and confidence issues were found to be the primary driver of hesitancy in all countries surveyed.

International audience; Today, according to many public health experts, public confidence in vaccines is waning. The term “vaccine hesitancy” (VH) is increasingly used to describe the spread of such vaccine reluctance. But VH is an ambiguous notion and its theoretical background appears uncertain. To clarify this concept, we first review the current definitions of VH in the public health literature and examine its most prominent characteristics. VH has been defined as a set of beliefs, attitudes, or behaviours, or some combination of them, shared by a large and heterogeneous portion of the population and including people who exhibit reluctant conformism (they may either decline a vaccine, delay it or accept it despite their doubts) and vaccine-specific behaviours. Secondly, we underline some of the ambiguities of this notion and argue that it is more a catchall category than a real concept. We also call into question the usefulness of understanding VH as an intermediate position along a continuum ranging from anti-vaccine to pro-vaccine attitudes, and we discuss its qualification as a belief, attitude or behaviour. Thirdly, we propose a theoretical framework, based on previous literature and taking into account some major structural features of contemporary societies, that considers VH as a kind of decision-making process that depends on people’s level of commitment to healthism/risk culture and on their level of confidence in the health authorities and mainstream medicine.

Background Communication is of paramount importance in responding to health crises. We studied the media messages put forth by different stakeholders in two Ebola vaccine trials that became controversial in Ghana. These interactions between health authorities, political actors, and public citizens can offer key lessons for future research. Through an analysis of online media, we analyse stakeholder concerns and incentives, and the phases of the dispute, to understand how the dispute evolved to the point of the trials being suspended, and analyse what steps might have been taken to avert this outcome. Methods A web-based system was developed to download and analyse news reports relevant to Ebola vaccine trials. This included monitoring major online newspapers in each country with planned clinical trials, including Ghana. All news articles were downloaded, selecting out those containing variants of the words “Ebola,” and “vaccine,” which were analysed thematically by a team of three coders. Two types of themes were defined: critiques of the trials and rebuttals in favour of the trials. After reconciling differences between coders’ results, the data were visualised and reviewed to describe and interpret the debate. Results A total of 27,460 articles, published between 1 May and 30 July 2015, were collected from nine different newspapers in Ghana, of which 139 articles contained the keywords and met the inclusion criteria. The final codebook included 27 themes, comprising 16 critiques and 11 rebuttals. After coding and reconciliation, the main critiques (and their associated rebuttals) were selected for in-depth analysis, including statements about the trials being secret (mentioned in 21% of articles), claims that the vaccine trials would cause an Ebola outbreak in Ghana (33%), and the alleged impropriety of the incentives offered to participants (35%). Discussion Perceptions that the trials were “secret” arose from a combination of premature news reporting and the fact that the trials were prohibited from conducting any publicity before being approved at the time that the story came out, which created an impression of secrecy. Fears about Ebola being spread in Ghana appeared in two forms, the first alleging that scientists would intentionally infect Ghanaians with Ebola in order to test the vaccine, and the second suggesting that the vaccine might give trial participants Ebola as a side-effect – over the course of the debate, the latter became the more prominent of the two variants. The incentives were sometimes criticised for being coercively large, but were much more often criticised for being too small, which may have been related to a misperception that the incentives were meant as compensation for the trials’ risks, which were themselves exaggerated. Conclusion The rumours captured through this research indicate the variety of strong emotions drawn out by the trials, highlighting the importance of understanding the emotional and social context of such research. The uncertainty, fear, and distrust associated with the trials draw from the contemporary context of the Ebola outbreak, as well as longstanding historical issues in Ghana. By analysing the debate from its inception, we can see how the controversy unfolded, and identify points of concern that can inform health communication, suggesting that this tool may be valuable in future epidemics and crises. Electronic supplementary material The online version of this article (doi:10.1186/s12889-017-4618-8) contains supplementary material, which is available to authorized users.