Causes Of Vaccine Scepticism

Vaccines

Basic Drivers

Folk Biology

• "Contagion" - aversion to taking in something linked to a disease
• "Contamination" and "Inside/Outside Barrier" - aversion to injecting bad things into oneself

General List

• It involves harm to children.
• It involves science that most people do not understand.
• It involves using a painful method (a needle) to inject a foreign substance into our bodies.
• It is frightening.

Temporal associations are very suggestive of causation. A personal experience linking vaccination and an adverse medical event is a very powerful driver behind many vaccine sceptics.

People have a strong need for narrative coherence as applied to their lives. Vaccination as a cause of autism (or whatever other tragedy has struck) seems on its face to "make sense," especially to make sense of an otherwise unexplainable tragedy.

Often there is a strong sense of suspicion as to the motives of government, pharma, or both.

Confirmation Bias is a killer once you fail to assume good faith on the part of your opponents.

Risk Framing

Groups that oppose the dominant narrative on vaccination engage in very little direct ‘risk talk’. In other words, they do not make their case by arguing that the risks of vaccination outweigh the benefits or by challenging the comparative risk statistics put out by the Department of Health. Risk is relevant to an understanding of vaccination resistance, but only in the sense that the groups are engaged in challenging and reframing it. What is interesting is how this reframing is achieved. The analysis reveals that risk is talked about in several different ways (see Hobson-West 2005):

• risk (or, more accurately, risk information) is constructed as strategy, and is therefore not objective
• the benefits of vaccination and the dominant narrative of historical success are questioned
• the claim is made that vaccination creates new health risks (such as autism)
• risk is constructed as unknowns
• the relationship between individual and community risk is rendered complex.

So this means that the following are viewed very differently:

• statistical evidence: establishment large-scale studies on risk will be dismissed as having an agenda and/or being irrelevant to the real concerns
• vaccine benefit: eg saying vaccines are of trivial benefit and pro-vaccine claims incorrectly include benefits from sanitation etc
• vaccine risks: eg saying UK Urabe was a tragedy, Pendemrix means all flu vaccines are dangerous, autism, mercury, aluminium, etc
• individual vs group: both benefits and risks will be viewed as more of an individual than a group matter

Risk as unknowns

• the argument that we do not know the effects of vaccination because of insufficient safety trials, both pre- and post-licence.
  • The most common way this is expressed is by reference to aspects of the standard model of ‘good science’
    • Eg no double blind placebo controlled studies
  • insufficient length of follow-up (eg to spot feared gradual-onset autism etc)
  • The issue is less importantly about genuine belief that vaccines ‘cause’ XXX than the broader argument that ‘they are not taking an approach to it that could possibily expose that as being a risk’.
  • Eg this suggests is that the risk statistics used in vaccine promotion are considered more than just inaccurate: they are seen as irrelevant.
• The Radical groups are more likely to use a wider discourse of ignorance: "And I think the more you read on it, the more you realise what little we know about the body and health. There’s so much we still don’t understand (Informed Parent)"
• This collective lack of knowledge or discourse of ignorance is used by the groups to explain their wariness in openly advising against vaccination.
• As will be discussed later, the discourse adopted is instead about helping the parent to develop personal expertise and take responsibility for health and healthcare decision-making.

The groups express the impossibility of knowing what would have happened if society had taken a different path and not developed mass childhood vaccination. Together with the perceived lack of long-term testing or surveillance, the result is a situation characterised by unknowns, ignorance and uncertainty. This is very different from the way in which tables of risk statistics are usually used to imply certainty (Petersen and Lupton 1996: 38). In other words, by concentrating on unknowns and uncertainties, the Vaccine Critical groups undermine the value and relevance of official risk discourses.

Risk as non-random

In the light of the importance of herd immunity and accusations of selfishness, how do Vaccine Critical groups construct the relationship between individual and community risk?

This is complex. Mass vaccination is attacked from two sides: for being too concerned with the population level and ignoring individual characteristics, but also for not being ‘social’ enough.

First, the groups criticise the one-size-fits-all nature of mass childhood vaccination. There is advocacy for the development of a test to be administered to babies in order to screen out those with a ‘vulnerability’ or ‘immune fragility’ to vaccines and vaccine damage. This sub-set of children would not be given vaccines according to the standard/recommended schedule. This proposed test represents a technical solution to the problem of risk, by breaking down the population into several populations with different treatment needs. Behavioural, as well as technical solutions are also suggested.

Second, the "Radical" groups make a very different argument about the relationship between the individual and the community: vaccination functions as ‘just an elastoplast over social problems’... The Radical groups see problems of health and disease as social and cultural in nature, relating to broader structural inequalities of wealth, housing and education. These inequalities require significant and sustained involvement by the state, in contrast to the quick-fix technical solution to disease provided by mass vaccination.

In terms of risk what both discourses share is the construction of risk as essentially non-random; as having a direct relationship to the particular circumstances of each individual. The groups do not present themselves as the *defenders* of the individual. Rather, their critique is articulated through stressing the complex, multifaceted nature of both risk and health.

Example Of Risk Framing

Background

A discussion of the risks and benefits of administering Fluenz (a live trivalent flu vaccine) to healthy children between the ages of 2 and 16. At one point this turned to possible side-effects.

Original Text

EMC: Fluenz nasal spray suspension Influenza vaccine (live attenuated, nasal) Section 4.4 Special warnings and precautions for use

As with most vaccines, appropriate medical treatment and supervision should always be readily available in case of an anaphylactic event following the administration of FLUENZ.

FLUENZ should not be administered to children and adolescents with severe asthma or active wheezing because these individuals have not been adequately studied in clinical studies.

Do not administer FLUENZ to infants and toddlers younger than 12 months. In a clinical study, an increase in hospitalisations was observed in infants and toddlers younger than 12 months after vaccination (see section 4.8). It is not recommended to administer FLUENZ to infants and toddlers 12-23 months of age. In a clinical study, an increased rate of wheezing was observed in infants and toddlers 12-23 months of age after vaccination (see section 4.8).

Vaccine recipients should be informed that FLUENZ is an attenuated live virus vaccine and has the potential for transmission to immunocompromised contacts. Vaccine recipients should attempt to avoid, whenever possible, close association with severely immunocompromised individuals (e.g. bone marrow transplant recipients requiring isolation) for 1-2 weeks following vaccination. Peak incidence of vaccine virus recovery occurred 2-3 days post-vaccination in clinical studies. In circumstances where contact with severely immunocompromised individuals is unavoidable, the potential risk of transmission of the influenza vaccine virus should be weighed against the risk of acquiring and transmitting wild-type influenza virus.

FLUENZ should under no circumstances be injected.

No data exist regarding the safety of intranasal administration of FLUENZ in children with unrepaired craniofacial malformations.

A Genuine Vaccine Sceptic Interpretation

Point 4.4

Vaccine recipients should be informed that FLUENZ is an attenuated live virus vaccine and has the potential for transmission to immunocompromised contacts. ....... for 1-2 weeks following vaccination.

Also in this section,

Medical treatment and supervision should be available in case of an anaphylactic event.

should not be administered to children with severe asthma or active wheezing

increase in hospitalisation in children under 12 months (vaccine is not advised for under 24 months)

increase in rate of wheezing in children between 12 -24 months.

How The Vaccine Sceptic Interpretation Relates To The Full Text

As with most vaccines, appropriate medical treatment and supervision should always be readily available in case of an anaphylactic event following the administration of FLUENZ.

FLUENZ should not be administered to children and adolescents with severe asthma or active wheezing because these individuals have not been adequately studied in clinical studies.

Do not administer FLUENZ to infants and toddlers younger than 12 months. In a clinical study, an increase in hospitalisations was observed in infants and toddlers younger than 12 months after vaccination (see section 4.8). It is not recommended to administer FLUENZ to infants and toddlers 12-23 months of age. In a clinical study, an increased rate of wheezing was observed in infants and toddlers 12-23 months of age after vaccination (see section 4.8).

Vaccine recipients should be informed that FLUENZ is an attenuated live virus vaccine and has the potential for transmission to immunocompromised contacts. Vaccine recipients should attempt to avoid, whenever possible, close association with severely immunocompromised individuals (e.g. bone marrow transplant recipients requiring isolation) for 1-2 weeks following vaccination. Peak incidence of vaccine virus recovery occurred 2-3 days post-vaccination in clinical studies. In circumstances where contact with severely immunocompromised individuals is unavoidable, the potential risk of transmission of the influenza vaccine virus should be weighed against the risk of acquiring and transmitting wild-type influenza virus.

FLUENZ should under no circumstances be injected.

No data exist regarding the safety of intranasal administration of FLUENZ in children with unrepaired craniofacial malformations.

Analysis Of The Vaccine Sceptic Interpretation

Statements of risk are universalised and strengthened: stripped of qualifiers and context. This does not reflect any deliberate attempt to "cherry-pick" but rather reflects a view of the surrounding text around the statements of risk as being of minimal importance. The direct statements of risk are the essential truths - qualifiers and context merely window dressing.

Note that someone in the dominant discourse would not, by contrast, weigh every word in the text equally. Rather they would very likely do the reverse emphasis - to concentrate on the qualitifiers and context in order to minimise the risk - or would possibly not bother to read the text at all.

Further Reading

Risk and trust in vaccine decision making (Casiday, 2005)

Risk and trust in vaccine decision making, Rachel Casiday

Children's health and the social theory of risk: insights from the British measles, mumps and rubella (MMR) controversy (Casiday, 2007)

Casiday R. 2007. Children's health and the social theory of risk: insights from the British measles, mumps and rubella (MMR) controversy. Social science & medicine (1982) 65:1059-70

Recent debates in the United Kingdom about the measles, mumps and rubella (MMR) vaccine and its alleged link with autism have centred on contested notions of risk. This paper presents findings from 87 parents’ focus group and interview discussions of their decision-making about the vaccine in light of three streams of theoretical literature on risk (cultural theory, risk society, psychometric models of risk perception) and models of vaccination acceptance and resistance. In addition to the risks of infectious disease and autism, parents balanced other risk concerns—both biological and social—in making their decisions. Such decisions, made on behalf of children unable to choose for themselves, and in the midst of contradictory information and uncertainty, symbolised what it means to be a ‘good parent’. To cope with uncertainty, parents sought explanations for why some children seem to be more vulnerable to adverse outcomes than others. Debates about children's risks may need special theoretical consideration beyond that offered by the current risk literature. Specific aspects of the MMR debate, namely, selecting between potentially competing risks, making risk judgements on behalf of dependent others, and tensions between private and public good, provide a platform for exploring how social theories of risk might be adapted for children's health controversies.

'Trusting blindly can be the biggest risk of all': organised resistance to childhood vaccination in the UK (Hobson-West, 2007)

[http://onlinelibrary.wiley.com/doi/10.1111/j.1467-9566.2007.00544.x/pdf Hobson-West P. 2007. 'Trusting blindly can be the biggest risk of all': organised resistance to childhood vaccination in the UK. Sociology of health & illness 29:198-215

Reframing risk: How risk discourses are used by Vaccine Critical Groups in the UK (Hobson-West, 2008)

Hobson-West P. 2008. Reframing risk: How risk discourses are used by Vaccine Critical Groups in the UK. In Health, Risk, and Vulnerability, ed. API Wilkinson, pp. 143-59. Milton Park: Routledge

Parental Decision Making and Childhood Vaccination (MA Overview)

http://www.cwru.edu/med/epidbio/mphp439/PDMCVACC.pdf

"Parental Decision Making and Childhood Vaccination", Case Western Reserve University

Interface with Health Care:

The interaction that a parent or family has with their health care provider is an important determinant of health decision making. Studies looking at the acceptability of vaccines have noted that advice from a physician about a vaccine can weigh heavily on parents’ final vaccination decision (Dinh et al 2007). For example, Gust et al found that for parents who were resistant to vaccinating their children or delayed vaccination, the advice of a physician was the main factor that changed their minds (Gust et al 2008).

Personal/Parental Beliefs Related to Vaccination:

Anthropologist Emily Martin conducted a study that examined how the American public viewed the immune system. Among her other conclusions, she found that the way the public conceptualizes the immune system and how it works differs dramatically from the scientific understanding of immunity.

Social/Environmental Factors

Our peers have the ability to influence our choices on vaccination, and our knowledge of vaccines and the problems associated with them is informed by or peers and family. In Tickner et al 2007, she asked the participants about what influenced their decision to vaccinate, and many responded that it was due to the opinions of their families and friends (Tickner et al 2007).

Institutional

Ones opinion about the government can affect their view of vaccines. If parents have a positive view of the government, then they are more likely to support vaccine policies. If they have a negative view of the government, then they are less likely to view vaccination policy as being beneficial, and to see it as a means of the government to restrict personal choice and freedom (Martin, 1994). Mistrust in the government about non-vaccine related issues can affect how people perceive vaccination.

Omission over Commission

One of the heuristics that has been examined the most in the context of vaccine decision making is the omission bias. Omission bias, or the tendency to favor omission over commission, is the preference to not act ersus to act in situations when the outcomes of either choice is virtually the same, potentially making both commission and omission equivalent (Ritov 1990)... Applying this to the case of vaccination choice, someone displaying an mission bias would be more accepting of harm caused by the choice to not vaccinate than harm caused by the decision to vaccinate... Their decision could be explained by the feeling that many of the participants had that they would be more responsible for the deaths of those who received the vaccine because they made the decision to vaccinate.

Availability

One tool that people use when making a risky decision is the availability of an accessible and memorable event or ‘availability’ (Serpell & Green 2006). Availability is the number of examples that can be recalled and the ease of recollection which is then used to predict the outcome for a particular event (Serpell & Green 2006). The availability heuristic can be somewhat problematic. When rare events are repeated, the perception of the likelihood of an event occurring can become inflated, leading to inaccuracy in predictions of outcomes.

Ambiguity Aversion

When people are unable to measure the exact risks associated with an action, they are less likely to act, leading to an ambiguity aversion (Serpell & Green 2006). This inability to measure exact risks can be attributed in some circumstances to the perception that there is missing salient information, and this can lead to inaction until they can find the missing information and to feelings of dissatisfaction if the information isn’t available (Ritov 1990)... In studies of the media coverage of the MMR accination coverage controversy, some have argued that the balanced coverage lead to the perception that there was an argument going on in the medical community about the vaccination with support on each side. This made parents less sure of their personal choice due to lack of a clear consensus based opinion in the medical community (Serpell & Green 2006). Additionally, Meszaros et al posited that parents who are skeptical about medical or scientific information may be more susceptible to ambiguity aversion (Meszaros et al 1996).

Protected Values

Protected values are values that are “absolute and not amenable to intervention” (Sturm et al 2005). These are values viewed to be fundamental, and encompass values for the natural environment, human and animal rights, etc. (Ritov & Baron 1999). Protected values are believed to be relevant for actions not omissions, are not related to the quantity of a particular outcome, and are reliant on the participation of an actor in an action no matter what the outcomes (Ritov & Baron 1999). In the case of research on parental decision making and childhood vaccination, there are risks such as the possibility of damaging side effects or death that some parents are not willing to risk for their children or other children. Studies have shown that people who display this heuristic are more likely also display omission bias (Sturm et al 2005).

Other Cognitive Biases

Additional cognitive biases that have been explored in relation to vaccination decision making in hypothetical and real life scenarios include the naturalness bias and the optimism bias (Dibonaventura & Chapman 2008). The naturalness bias is a preference toward things that seem to be more natural than those things that do not. The optimism bias is the tendency to be more optimistic about ones circumstances or the likelihood of positive events occurring than not.

Risk Framing

Within the debate about vaccination risk is conceptualized in a broader context and, questions are raised about risk and the responsibility for risk. In her study examining parental decision making and the MMR (measles, mumps, rubella) vaccine, Casiday examines how the risk associated with the vaccine is articulated by parents (Casiday 2007). She describes three schools of thought in the social sciences concerning risk, the cultural theory of risk, the risk society, and psychometric models of public risk perception. In the cultural theory of risk, risk thought to be socially constructed, and the identification and determination of risk is reliant upon ones social outlook, which is culturally determined (Casiday 2007). In the risk society theory, current conceptions of risk and actual risks are products of the modern era brought about by the industrial revolution. In this model, increased awareness of risk results from a reflexive interaction between the new forms of risk and the social and political means people devise to cope with them (Casiday 2007). The number of things that pose potential risk is seen as being large and not in the realm of personal control due to the complexity of modern society. Pyschometric models of public risk perception view people’s perception of risk as being determined by many factors, i.e. social, psychological, institutional, that are able to be modeled and are quantifiable (Casiday 2007).

Pru-Hobson’s take on the resistance to vaccination as being a response to the way that vaccination risk is discussed in the “dominant expert discourse” (Hobson-West 2008). The perception of risk and the act of deeming something as a risk is seen as a result of social and political processes (Hobson-West 2008). She identified several themes that emerged in her research that contributed to the group members’ perceptions of vaccination risk; unknowns, distribution of risk, risk as strategy, and questioning of the reliability of historical success narratives. The theme of risk as unknowns emphasized two points; the true risk of vaccines especially in terms of side effects is unknown and the mechanisms of the body and how it fights disease are unknowns. The theme of distribution of risk focused on the idea that the distribution of risk for contracting a disease and the risk for being exposed to side effects because of vaccines is not distributed equally and is the result social problems, and the belief that the individual is not seen as being important by policy planners. Risk as strategy contradicts the theme of risk as unknown because it argues that the risk of vaccines is known but hidden from the public and also argues that public perception of risk is manipulated to cause fear which can influence vaccination choice. There was also questioning of the reliability of the historical narratives of vaccine success through arguments made that the successes attributed to innovations in vaccination were actually due to improved sanitation (Hobson-West 2008).

From the perspective of parents, risk associated with vaccination whether biological or social in nature, is risk that they have to manage for their children. Parents frame risk in terms of the risk it may present to their children instead of a view of risk which encompasses society, or an epidemiological view (Casiday 2007). In her research, Pru Hobson-West examines the discourse of various groups in the UK who are against vaccination and how risk is conceptualized within that discourse. The risk of vaccination is seen by some of the parents as being individualized; that is, the risk of vaccinating or not vaccinating is assumed by the parents themselves, not by society (Hobson-West 2008). There is also the contention that, because people are individuals and as such have unique bodies and states of health, vaccines are inadequate as a one size fits all treatment (Hobson-West 2008). The responsibility for the vaccination choice then lies with the parent including coping with any perceived possible outcomes of treatment (Casiday 2007; Hobson-West 2008).