Under-Vaccinations Can Be Reduced With Teamwork

Government's highest ethical duty is to safeguard public health through evidence-based policies
teamwork on a boat in the rapids
(Precision Vaccinations News)

Vaccination is among public health's greatest achievements, saving billions of lives. Childhood diseases, such as measles, mumps, and pertussis have substantially diminished through modern vaccination practices. 

But, a group of vaccination experts, including Dr. Peter Hoetz, Dean with the National School of Tropical Medicine, Baylor College of Medicine, Houston, TX, said in an article published in The Lancet on November 8, 2019, ‘about 20 percent of children worldwide are not fully protected.’

‘This under-vaccination results in 1.5 million child fatalities annually from diseases that are preventable by vaccination.’

“My particular concern is that antivaccine misinformation has reached a tipping point affecting the public health of nations. Measles has returned to Europe and America, and teenagers are now denied cancer prevention through HPV vaccinations.  We’re in a terrible new normal of vaccine refusal, said Peter Hoetz, M.D., Ph.D., FASTMH, FAAP.

Excerpts from The Lancet article are inserted below:

‘Millions more people have severe disabling illnesses, cancers, and disabilities from infections caused by under-immunization.

Many say ‘government's highest ethical duty is to safeguard the public's health through evidence-based policies.’

Ten highly populous countries with suboptimal immunization systems account for over 70 percent of the world's unvaccinated children.

There are no simple solutions to this problem, but innovative policies and programs working in concert would substantially increase vaccination rates. 

An effective response to under-vaccinations must be multidisciplinary, spanning governments, international organizations, the private sector, and civil society. 

This innovative plan begins with an examination of the underlying determinants of low vaccination rates.


  • Absolute expenditures on national vaccine systems rose between 2010 and 2017, but because of escalating costs, buying power fell nearly 27% over the same period.
  • Although childhood vaccines are cost-effective in preventing disease and death, high prices for some newer vaccines, driven by for-profit companies and associated administration costs, can overwhelm health budgets in low-income and middle-income countries (LMICs). 
  • In 2019, 58 LMICs were eligible for direct vaccine support through Gavi, the Vaccine Alliance. But, routine immunization levels stagnated or dropped in 54 of 85 middle-income countries that were too prosperous to qualify for Gavi support in 2019.
  • The US Centers for Disease Control and Prevention's (CDC) budget for direct purchases of vaccines through its Vaccines For Children program has increased as newer vaccines are licensed and recommended. However, CDC funding for vaccine infrastructure, surveillance, research, safety, and state grants have stagnated over the past two decades.

Vaccine confidence:

  • Based on the Vaccine Confidence Index, the 2018 Global Monitor survey by the Wellcome Trust, reported rises in vaccine hesitancy, with the erosion of public trust especially in high-income countries. 
  • Nearly half (48%) of Europeans said they mistrust vaccines. In France, nearly two-thirds of respondents disagreed that vaccines are safe.
  • Low-health literacy about vaccine risks, safety, and effectiveness at all income and education levels contributes to distrust; only seven countries worldwide reported no vaccine hesitancy in 2017.
  • And, negative media coverage can also skew public risk perception, with rare adverse effects after vaccination, whether actual or perceived, often well-publicized and salient.
  • Anti-vaccine messages often purport to come from reliable scientific sources or genuine anecdotes of children harmed.

Vaccination requirements:

  • Country laws designed to incentivize parents to vaccinate children for school attendance or in other close-knit environments are the gold standard.
  • All US states require vaccines for school attendance, including daycare, pre-school, primary, secondary, and tertiary education. The US Supreme Court has upheld school-based vaccine mandates, except for people with medical contraindications.
  • All but 5 USA states permit religious or conscientious exemptions to varying degrees. Lax enforcement of vaccination requirements and permissive rules for so-called opt-outs result in local clusters of religious or conscientious objectors. 
  • When California completely repealed its religious and conscientious exemptions in 2015, childhood immunization rates rose. However, higher vaccine rates were partly offset by increased medical exemptions—suggesting that doctors were overly permissive in and potentially profited from authorizing them.
  • Penalties might raise vaccination rates but can be counterproductive if excessive or infringe on human dignity and rights.

‘Under-immunisation is a global crisis requiring sustainable solutions. We offer a 3-pronged strategy: innovative financing for vaccine affordability, accessibility, and availability; evidence-based health communication campaigns at local, national, and global levels; and law reform that has public acceptance and is fairly implemented.’

‘Countless lives can be saved if the international community sustainably funds vaccination systems, assures reliable information, and safeguards the common good through meaningful law reform,’ concluded these health experts.

Contributors Declaration of interests - HJL reports grants and other funding from GlaxoSmithKline, outside the submitted work. DS reports personal fees from Merck & Co and previous grants from Walgreens, outside the submitted work. All other authors declare no competing interests.

We acknowledge Erica N White, Senior Legal Researcher, Center for Public Health Law and Policy, Sandra Day O'Connor College of Law, Arizona State University, Phoenix, AZ, for her research contributions.

Vaccine News published by Precision Vaccinations


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