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Photo: Jonne Renvall

Trust is vital for successful vaccination programmes

Very few people do not receive vaccines in Finland, but unvaccinated children in India number in the millions.
7 min
Tiina Lankinen

Statistics produced by the National Institute for Health and Welfare (THL) show that Finland’s vaccination coverage is very good. Only around one per cent of children are not given any of the vaccinations included in the National Vaccination Programme for Children and Adolescents. 

Nevertheless, localised measles epidemics have emerged in certain parts of Ostrobothnia in northern Finland, where the coverage of the measles, mumps, and rubella (MMR) vaccine has decreased. In 2019, the World Health Organization (WHO) listed vaccine hesitancy as one of the greatest threats to global health, and this has made people sit up and pay attention internationally.  

However, the WHO’s list does not seem to have caused much concern in Finland. THL reported in February 2019 that vaccine coverage in Ostrobothnia had clearly improved since the measles case was reported there last November. 

Professor Tapio Vesikari, Director of the Vaccine Research Center at Tampere University, does not consider vaccine hesitancy a significant problem in Finland. The Vaccine Research Center is continuously engaged in clinical trials, and its volunteers are immunised at clinics across the country. A small number of narcolepsy cases associated with a swine flu vaccine in 2009 resulted in a temporary drop in volunteers, but numbers have since returned to normal.  

“According to recent statistics, only about 1% of Finnish children are not vaccinated. We concentrate on the 99 per cent who are,” Vesikari says. 

Lack of information prevents vaccinations 

Finland has well-functioning health services, a high-quality system of child health clinics, and strong public trust in the health authorities. These are some of the prerequisites for extending vaccine coverage to all children. 

In India, where 27 million children are born annually, only about 60 per cent receive all the immunisations included in the vaccine programme for the first year of life. This means that about nine million infants in India do not receive some or all of the recommended vaccinations in their first year of life, the age at which they are the most vulnerable. 

“Every year, nearly half a million Indian children die of diseases that vaccines could prevent,” says Doctoral Researcher Mark Francis, who is working on his PhD dissertation on epidemiology at Tampere University. 

Francis’s dissertation aims to evaluate vaccination coverage and identify the parental characteristics that influence the demand for routine childhood vaccinations at both the regional and national level in India. 

His research shows that a major reason for the low rate of immunisation is a lack of information. Either the necessity of childhood vaccinations is not understood or it is unclear to parents when and where to take their child to get vaccinated. Other significant reasons for non-immunisation include the fear of side effects and difficulties in accessing vaccination services. 

Fears are increasing in India 

Fears about vaccines appeared to increase from 1998 to 2008, the period for which Francis analysed data from three Indian Demographic & Health Surveys. There are many reasons for vaccine hesitancy and suspicions, and religion and caste are not the only contributory factors.  

“Thus far, the grey area between vaccine acceptance and total refusal has not been studied. There is plenty to explore in this field, not only in India, but also in the rest of the world,” Francis says.  

“The problem is that we do not know when parental decision-making for childhood vaccinations begins. It is important to understand how and where parents seek or receive information on childhood vaccinations and how these influence their ultimate decision to approve, delay or reject vaccinations for their children,” he adds. 

In 2015, India’s government launched a national programme that aimed to raise the country’s vaccination coverage to 90 per cent by 2020. The coverage has begun to grow, but according to Francis’s study, it is still suboptimal among migrant and nomadic groups in Vellore, southern India.  

“The government assumes that the only problems are either the availability of services or the lack of information. However, awareness is not sufficient on its own because trust must also be built,” Francis explains. 

Francis studies this topic in collaboration with the Christian Medical College, Vellore, and the Vaccine Confidence Project, which is based at the London School of Hygiene and Tropical Medicine.

Mark Francis  ja Pekka Nuorti
Doctoral Researcher Mark Francis and professor Pekka Nuorti.Photo: Jonne Renvall

Vaccine safety is rigorously studied 

Researchers try to respond to vaccine hesitancy and suspicions using scientific research results. The experts’ main message is that just like all medical treatments, vaccines may also have side effects. However, the side effects associated with vaccines are rare, mild and well-known.  

For those working with vaccines, the advantages so far outweigh the potential disadvantages that the decision to immunise should be straightforward. 

“Immunisations are very safe all along the line,” says Heikki Hyöty, professor of virology. 

“Perhaps we researchers should voice a stronger message: scientific research is the only way to get reliable information on any phenomenon. If research results prove that something is harmless, you should believe them, just as you should when studies show that something is harmful,” Hyöty explains. 

Vaccines undergo accurate and extensive trials before they are administered to people. Nonetheless, very rare side effects – if there are any – are only revealed when the vaccinations are used in the general population. In Finland, the most famous vaccine problem of recent years relates to the swine flu vaccine mentioned above.  

“The narcolepsy cases were a total surprise that we were unable to predict in any way. That side effect was so rare,” Hyöty says. 

“The introduction of vaccines may also result in positive surprises,” points out Pekka Nuorti, professor of epidemiology at Tampere University.  

One such surprise occurred with the pneumococcal conjugate vaccine that was added to the childhood vaccination programme in 2010. In addition to protecting children against pneumococcal diseases, the vaccine also reduced the carriage of bacteria in the children’s noses and, consequently, transmission to non-vaccinated persons, such as parents and grandparents. This phenomenon is called herd immunity. 

“In adults, hospitalisations for pneumonia have decreased by about 15 per cent since the vaccine was included in the infant vaccination programme. Previously, pneumonia hospitalisations were increasing, especially among the elderly. This demonstrates how some of the most important effects of vaccines can only be detected by monitoring their population effects after large-scale use,” Nuorti says. 

Pekka Nuorti
Professor Pekka Nuorti.Photo: Jonne Renvall

Evidence from across the world 

Professor Nuorti leads an international research group at Tampere University, which is studying the epidemiology of infectious diseases, the population-level effects of vaccination programmes and the effectiveness and safety of vaccines. He also works as an expert on health safety at THL and is a member of the expert panel on vaccines in Finland.  

Nuorti’s extensive public health studies are carried out with a network of collaborators, including national public health institutes, other universities, research institutes and national health authorities. 

“Decision-makers use the research findings on disease burden and the effects of vaccinations in developing vaccine recommendations. It is therefore easy to see the connection of vaccination research with the wider impact on society” Nuorti says. 

International research provides important new information on vaccines and vaccinations. Doctoral Researcher Wendi Wu is analysing the Chinese national system for monitoring the side effects of vaccines. The Western scientific community has been very interested in her results. 

Approximately 1.7 million children are born annually in China, which follows the WHO’s recommendations for routine immunisation. The country is also one of the world’s largest vaccine manufacturers, and it uses primarily domestically produced vaccines in its immunisation programme.  

“The studies did not reveal any major safety concerns with specific vaccines or other adverse outcomes – the occurrence of adverse effects was similar to those in comparison countries,” says Nuorti, who is supervising Wu’s dissertation.

Few totally refuse 

In Finland, babies generally receive vaccines administered by nurses at a child health clinic. 

Vaccination does not only mean administering an injection. 

“Anyone trained to give an injection is able to administer a vaccine. However, immunisation not only involves technical mastery but also knowledge about vaccine safety and the ability to advise clients,” says Irmeli Nieminen, Senior Lecturer in the Degree Programme in Public Health Nursing at Tampere University of Applied Sciences. 

Vaccinators must be familiar with both the vaccine and the disease against which it is administered. They must know what to do if the vaccine causes an allergic reaction, as it is their responsibility to provide parents with neutral, scientific information about the benefits and adverse effects of immunisation, especially when the parents are vaccine hesitant.  

Parents ultimately make the decision as to whether their children are vaccinated, and that decision is respected. 

“The parents’ worries and fears must be taken seriously, and their feelings are accepted without making them feel guilty,” says Jasmin Kaljadin, a student in the Master’s Programme in Health Sciences at Tampere University. 

It is important for nurses to understand the reasons behind the parents’ hesitancy.  

“Listening to the client is very important, and sufficient time must be reserved for that,” Nieminen says.  

Sometimes the mere fact that their fears can be aired can help. It is sometimes decided that the vaccination programme is carried out according to a nonstandard pace. 

“For example, the parents might wish that the child receives vaccines individually, so a personal schedule may be made for the child. This helps to ease the parents’ worries. The main thing is that the child eventually gets all the recommended vaccines,” Kaljadin says. 

Nieminen and Kaljadin do not find it at all bad that parents are interested in what vaccines are administered to children and what effects they have. 

“Healthy criticism is good, because it challenges us professionals in a positive way. People have the right to receive reliable, neutral information about vaccines,” Nieminen points out.  

Photo: Jonne Renvall

No cause for alarm in Finland 

  • Vaccination coverage in Finland is very good, and it has even increased recently.  

  • The coverage of the MMR vaccine for mumps, measles and rubella has improved the most. About 96 % of those born in 2016 received this vaccination, an increase of almost two per cent compared to 2015.  

  • It is very rare to be completely unvaccinated in Finland. Only around 1 % of children have received none of the vaccinations included in the National Vaccination Programme for Children and Adolescents by the age of three. By the time they are of school age (seven years), only 0.5 % of children have not received the basic vaccines. 

Source: National Institute for Health and Welfare. ”Lasten rokotuskattavuus parantunut – suoja tuhkarokkoa vastaan noussut eniten” 2/2019.