Editorial
Vaccine hesitancy: An introduction to its concept
Reticencia vacunal: una introducción conceptual
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Unidad de Medicina Preventiva y Salud Pública. Facultad de Medicina y Ciencias de la Salud. Universidad de Barcelona" "etiqueta" => "a" "identificador" => "af0005" ] 1 => array:3 [ "entidad" => "CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain" "etiqueta" => "b" "identificador" => "af0010" ] 2 => array:3 [ "entidad" => "Servicio de Dermatología. Hospital del Sagrado Corazón, Barcelona, Spain" "etiqueta" => "c" "identificador" => "af0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cr0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "ca" => array:1 [ "titulo" => "Reticencia vacunal: una introducción conceptual" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="p0005" class="elsevierStylePara elsevierViewall">Vaccines are currently considered the most efficacious, effective, and efficient drug for the prevention of communicable infectious diseases.<a class="elsevierStyleCrossRefs" href="#bb0005"><span class="elsevierStyleSup">1–3</span></a> When applied systematically to the entire population as a public health programme, they have resulted in a very substantial reduction in the morbidity and mortality of many immune-preventable diseases.<a class="elsevierStyleCrossRef" href="#bb0015"><span class="elsevierStyleSup">3</span></a> It should be noted that this excellent result has been achieved not only through the direct effects on the vaccinated population, but also through the indirect effects on the non-vaccinated population, in the case of diseases whose reservoir is exclusively human and exclusively inter-human transmission (herd immunity).<a class="elsevierStyleCrossRef" href="#bb0020"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bb0025"><span class="elsevierStyleSup">5</span></a></p><p id="p0010" class="elsevierStylePara elsevierViewall">For such diseases, the implementation of well-designed vaccination programmes in which vaccines are administered to the entire population, except in the case of individual medical contraindications, also has great potential of managing to eliminate the disease from a given region or country, or even to eradicate it worldwide.<a class="elsevierStyleCrossRefs" href="#bb0015"><span class="elsevierStyleSup">3–6</span></a> To date, the only infectious communicable disease eradicated globally has been smallpox, which was achieved half a century ago thanks to the vaccine.<a class="elsevierStyleCrossRef" href="#bb0035"><span class="elsevierStyleSup">7</span></a> Other infectious diseases that can be vaccinated against can also be expected to be eliminated from many countries, and even eradicated worldwide.<a class="elsevierStyleCrossRef" href="#bb0015"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bb0030"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bb0040"><span class="elsevierStyleSup">8</span></a> Wild polio is likely to be the next to be eradicated, although mild clinical forms of polio may appear for some years in unvaccinated people, caused by vaccine viruses that have remained in immunocompromised patients since they were vaccinated with the live attenuated virus vaccine (Sabin vaccine). Diphtheria has also been eliminated from many countries.<a class="elsevierStyleCrossRef" href="#bb0030"><span class="elsevierStyleSup">6</span></a> In the case of measles, the issue of vaccine hesitancy, the subject of this article, is playing a particularly prominent role in the re-emergence of the disease in many countries from which it had already been eliminated.<a class="elsevierStyleCrossRef" href="#bb0045"><span class="elsevierStyleSup">9</span></a></p><p id="p0015" class="elsevierStylePara elsevierViewall">An added advantage of bacterial vaccinations is that they have recently been recognised as a cornerstone in the reduction of bacterial resistance to antibiotics, a major public health challenge.<a class="elsevierStyleCrossRef" href="#bb0050"><span class="elsevierStyleSup">10</span></a></p><p id="p0020" class="elsevierStylePara elsevierViewall">Like all drugs, vaccines can cause side effects and adverse reactions, most of which are mild and generally well tolerated by vaccinated individuals.<a class="elsevierStyleCrossRef" href="#bb0055"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bb0070"><span class="elsevierStyleSup">14</span></a> In rare cases, serious side effects and adverse reactions may develop. These must be weighed relative to the health as well as sometimes economic benefits of vaccinations.<a class="elsevierStyleCrossRef" href="#bb0055"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bb0060"><span class="elsevierStyleSup">12</span></a> With registered, commercially available vaccines, the equation is almost always in favour of vaccination and in many cases extremely favourable.<a class="elsevierStyleCrossRef" href="#bb0055"><span class="elsevierStyleSup">11</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bb0075"><span class="elsevierStyleSup">15</span></a></p><p id="p0025" class="elsevierStylePara elsevierViewall">Ever since the first vaccine became available, the smallpox vaccine introduced by Jenner in 1796, there have been individuals and groups who, for a variety of reasons, have questioned the need and suitability of administering new vaccines to their children or to themselves.<a class="elsevierStyleCrossRef" href="#bb0010"><span class="elsevierStyleSup">2</span></a></p><p id="p0030" class="elsevierStylePara elsevierViewall">In fact, the first disease to be eradicated worldwide was smallpox, and it took 180 years to do so. And all this despite the availability of a vaccine that was effective in preventing the disease, albeit with many side effects and complications, some serious (blindness) and even fatal.<a class="elsevierStyleCrossRefs" href="#bb0030"><span class="elsevierStyleSup">6–7</span></a> The smallpox vaccine would certainly not have passed the safety standards that the agencies currently require to register new vaccines.<a class="elsevierStyleCrossRef" href="#bb0055"><span class="elsevierStyleSup">11</span></a> In any case, despite the fact that there was much room for improvement of statistics at the time, the data available indicate that the cases and deaths observed among vaccinated individuals were much lower than those observed among the unvaccinated.</p><p id="p0035" class="elsevierStylePara elsevierViewall">In Europe, an estimated 400,000 people died each year from smallpox, most of them children, and one third of them became blind. The year the vaccine was discovered (1796), some 3000 people died in London and 35,000 in England as a whole. In spite of this, the introduction of the vaccine among the general population was remarkably slow, especially owing to the considerable doubts surrounding its safety.<a class="elsevierStyleCrossRef" href="#bb0035"><span class="elsevierStyleSup">7</span></a></p><p id="p0040" class="elsevierStylePara elsevierViewall">In Spain, the vaccine was introduced in 1800 by the Puigcerdà physician Francesc Piguillem.<a class="elsevierStyleCrossRef" href="#bb0080"><span class="elsevierStyleSup">16</span></a> From the outset, there were numerous debates in the scientific community of Barcelona over whether recommending the vaccination of the paediatric population was advisable. The members of the Royal Academy of Medicine of Barcelona were divided into those in favour of vaccination, the minority, and those who opposed vaccination, the majority. At that time, epidemiology did not yet exist as a scientific discipline and the discussions lacked a solid scientific basis.</p><p id="p0045" class="elsevierStylePara elsevierViewall">Doubts and discussions also reached the public and the press. The memoirs of the Baron de Maldá, a distinguished citizen of Barcelona, published at the beginning of the 19th century, refer to the death of the daughter of a well-known merchant of the city as a result of complications from vaccination.<a class="elsevierStyleCrossRef" href="#bb0030"><span class="elsevierStyleSup">6</span></a></p><p id="p0050" class="elsevierStylePara elsevierViewall">Likewise, doubts and debates also reached the European armies. In the Franco-Prussian war 1871–1872, the German soldiers, numbering some 800,000, were adequately vaccinated and revaccinated every seven years, while the French soldiers, a similar contingent, were not. The result was that the French army saw 112,500 cases of smallpox with a mortality rate of 18.7%, while in the Prussian army, there were only 840 cases and the mortality rate was much lower (5.4%).<a class="elsevierStyleCrossRef" href="#bb0035"><span class="elsevierStyleSup">7</span></a> These results convinced many scientists and governments of the need to launch smallpox vaccination programmes. Many countries made vaccination compulsory. In Spain, vaccination became mandatory a few years later, in 1906. It should also be noted that during this dispute, vaccinated people who were not protected and contracted the disease were shown for the first time to have milder forms of the disease and the risk of mortality was lower than in unvaccinated individuals. The phenomenon of reduced risk of severe forms of the disease and death has also been seen with many of the vaccines subsequently marketed (e.g. influenza and shingles vaccines).<a class="elsevierStyleCrossRef" href="#bb0065"><span class="elsevierStyleSup">13</span></a></p><p id="p0055" class="elsevierStylePara elsevierViewall">The results of the Franco-Prussian war and the discovery that vaccine lymph obtained from cows could be sterilised with glycerine further encouraged the dissemination of such vaccination, and by the early 20th century, most European and American countries were vaccinating all their children.</p><p id="p0060" class="elsevierStylePara elsevierViewall">The current success of vaccination programmes in developed countries is attributable to the high vaccination coverage achieved through routine vaccination of the general public. It is also due to the lower, albeit reasonable, vaccination coverage of adults and the elderly with the indicated vaccines (influenza, pneumococcal).<a class="elsevierStyleCrossRef" href="#bb0085"><span class="elsevierStyleSup">17</span></a> These coverage rates are an indicator that vaccines are generally well accepted by the population. Nevertheless, we must admit that for some vaccines the elevated vaccination coverage achieved in many countries conceals the existence of unvaccinated or under-vaccinated population groups for a variety of reasons, which in recent years have been responsible for major outbreaks of vaccine-eligible diseases (e.g. measles, diphtheria, pertussis, and polio).<a class="elsevierStyleCrossRef" href="#bb0090"><span class="elsevierStyleSup">18</span></a></p><p id="p0065" class="elsevierStylePara elsevierViewall">Until very recently, there has been no specific term to define the loss of public confidence in vaccines, primarily as a result of generally unjustified misgivings as to their safety, effectiveness, and necessity. Some pioneering works adopted terms such as “vaccine resistance” or “vaccine opposition”, but these were not accepted by the scientific community and were abandoned and replaced by the term “vaccine hesitancy” (literally, vaccine doubt or hesitation). The term was accepted by the scientific community and international bodies, but was soon found to be ambiguous and imprecise, and needed to be defined and clarified.<a class="elsevierStyleCrossRef" href="#bb0095"><span class="elsevierStyleSup">19</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bb0100"><span class="elsevierStyleSup">20</span></a> In 2014, the WHO commissioned the Organisation's <span class="elsevierStyleItalic">Strategic Working Group on Vaccine Hesitancy</span> (SAGE) to convene a specific meeting to discuss the matter with leading experts and arrive at a definition that would be operational and make it possible to gauge its drivers and the results of the interventions to be implemented to keep it in check. After many definitions and much debate, the Strategic Working Group agreed on the definition of “vaccine hesitancy” as the delay, non-acceptance, or refusal of vaccines despite the availability of vaccination services.<a class="elsevierStyleCrossRef" href="#bb0105"><span class="elsevierStyleSup">21</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bb0110"><span class="elsevierStyleSup">22</span></a> The Working Group itself acknowledged that it is a complex term, varying across geographies, populations, age groups, vaccines, etc. The WHO adopted this definition and subsequently, as the magnitude of vaccine refusal grew and vaccine coverage fell, it regarded “vaccine hesitancy” as one of the world's top 10 public health issues. It would constitute an unsafe or negative health behaviour or conduct, which, like all others, should be tackled by means of the instruments available in the field of public health, notably health education and legislation.<a class="elsevierStyleCrossRef" href="#bb0115"><span class="elsevierStyleSup">23</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bb0120"><span class="elsevierStyleSup">24</span></a></p><p id="p0070" class="elsevierStylePara elsevierViewall">In Spain, the definition was well accepted. The English term was generically translated as “dudas vacunales”, “indecisión vacunal” in some cases, and as “vaccine reluctance” in others. The third term is the one that appears to be gaining ground among vaccinologists and nursing staff. We believe it is appropriate and have adopted it in the heading of our article.</p><p id="p0075" class="elsevierStylePara elsevierViewall">It soon became clear that vaccine hesitancy is not a behaviour, but a far more complex phenomenon.<a class="elsevierStyleCrossRefs" href="#bb0125"><span class="elsevierStyleSup">25–28</span></a> In fact, it is a “continuum” that goes from accepting all or some vaccines, to the outright rejection of all or some vaccines. In the middle, there will be people who accept some vaccines and not others, who delay some and reject others. Finally, there will be those who, despite having made the corresponding decision and carried it out, still feel unsure.<a class="elsevierStyleCrossRef" href="#bb0140"><span class="elsevierStyleSup">28</span></a> At present, experts find the term “vaccine hesitancy” to be confusing and difficult to quantify, despite the fact that more and more vaccinologists and researchers accept it.</p><p id="p0080" class="elsevierStylePara elsevierViewall">Nowadays, the most widely accepted criterion is that it is not a static behaviour or psychological state, but a dynamic psychological state, influenced by numerous factors known to drive vaccine hesitancy. Several recent articles by expert psychologists have proposed a new definition, characterising it as “a psychological state of indecision concerning a vaccination decision”.<a class="elsevierStyleCrossRefs" href="#bb0125"><span class="elsevierStyleSup">25–28</span></a> It is not a behaviour or a behavioural response to vaccination. <a class="elsevierStyleCrossRefs" href="#bb0125"><span class="elsevierStyleSup">25–28</span></a> It is not a behaviour or conduct. The behaviour materialises when the decision is made and acted upon, barring the aforementioned possibility that the uncertainty remains despite making and acting upon the decision.<a class="elsevierStyleCrossRef" href="#bb0125"><span class="elsevierStyleSup">25</span></a> Other related terms that do not denote exactly the same thing are “vaccine confidence”, “vaccine acceptance”, or “vaccine refusal”.<a class="elsevierStyleCrossRef" href="#bb0145"><span class="elsevierStyleSup">29</span></a></p><p id="p0085" class="elsevierStylePara elsevierViewall">In Larson's view, the decision-making process along the dynamic psychological state of hesitancy, which may ultimately lead to accepting, delaying, or refusing vaccination, is akin to a journey that may have ups and downs in one sense or another and change over time as a consequence of negative influences of determinants or positive impacts of the various interventions designed to address the reluctance.<a class="elsevierStyleCrossRef" href="#bb0125"><span class="elsevierStyleSup">25</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bb0140"><span class="elsevierStyleSup">28</span></a> In some cases, the process may end with a decision. In others, it may be that no decision is made at all. For classical vaccines (measles, pertussis, polio, diphtheria, etc.), decision-making is easier than for new vaccines (e.g. COVID-19 vaccines), given that the characteristics of both the disease and the vaccines are generally well known. Only when there is an important novelty, which may be false, as in the case of the measles vaccine and autism, the dissemination of information in the media can lead to vaccine hesitancy arising in the public.<a class="elsevierStyleCrossRef" href="#bb0125"><span class="elsevierStyleSup">25</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bb0130"><span class="elsevierStyleSup">26</span></a></p><p id="p0090" class="elsevierStylePara elsevierViewall">In contrast, for COVID-19 vaccines, the variables that have played a role in the misperception of the risk and protective value and safety of the various vaccines include the registration and marketing in a short period of time, much shorter than for other vaccines, the availability of several vaccines with different levels of efficacy and safety, the changing severity of the disease with increasingly mild and less lethal cases, the changing information provided by official agencies and the misinformation offered by the media, especially on the Internet and by organised anti-vaccine groups, and have all contributed to the relatively low vaccination coverage rates achieved.<a class="elsevierStyleCrossRef" href="#bb0125"><span class="elsevierStyleSup">25</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bb0140"><span class="elsevierStyleSup">28</span></a></p><p id="p0095" class="elsevierStylePara elsevierViewall">In the last 10 years, research has flourished around the world focusing on vaccine reluctance and its determinants, as well as strategies to counter it, especially after the first COVID-19 vaccines were developed and marketed in the late 2020s. This monographic issue of the journal “VACUNAS” addresses some of these topics in several articles written by experts from different countries.</p><span id="sec2005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st2005">Funding</span><p id="p2110" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec2005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="np4005">Please cite this article as: Salleras L, Salleras M, Toledo D, Domínguez À. Reticencia vacunal: una introducción conceptual. 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