How We Can Prevent Public Health Crises

What happens when we ignore signs of trouble and what to do about it.

Posted Oct 04, 2017

On August 25, as many Americans were gearing up for the last long weekend of the summer, health officials in Minnesota were busy getting ready to declare that the measles outbreak that had plagued the state for months was “over.” All told, this was the largest outbreak of measles in Minnesota since 1990, with 79 confirmed cases, 22 people hospitalized. It cost the Minnesota Health Department more than $900,000 and Hennepin County about $400,000 to contain and control the outbreak.

While some might think the end of the outbreak is cause for immediate celebration, others of us, still feeling uneasy, are left thinking “so now what?”

This is not to say that the containment of the outbreak isn’t good news. Of course, the fact that the state can now declare an outbreak of a virulent infectious disease over is always wonderful news. But those of us who have been watching these types of outbreaks pop in and out of the news cycle increasingly over the past few years know what generally happens next and know that it’s not the right response.

What happens next is that we walk away, pat ourselves on the back, and immediately become consumed by something else, because there’s always another crisis. Meanwhile, vaccine hesitancy is still rampant across the country and around the world, and, as we saw in the case of the Somali-American community in Minnesota, devoted anti-vaxxers are undoubtedly already on their way to seize on other vulnerable communities with their conspiracy theories. If you don’t believe us, you might want to follow the national tour of the recent “documentary” Vaxxed, which involves a bus full of devoted anti-vaxxers driving around the country and spreading dangerous misinformation about life-saving vaccines.

The fact of the matter is, it will only be a matter of time before we have a repeat of what happened in Minnesota. While 79 cases of measles might not seem like a lot to some, when you consider the fact that that number can and should be zero and when you understand that the cost of containing an outbreak like this is actually quite high, suddenly 79 cases is a very big deal. When the outbreak started, it quickly became clear that this situation was brewing in Somali-American communities in Minnesota for years. The beginnings of the distrust of vaccination go all the way back to 2008. So the real question is: How did we go 9 whole years without realizing that something was going on in this community? Couldn’t we have prevented this entire situation? If so, how?

Vaccine Fears Spread in India

Before we tackle these difficult but important questions, it’s important to understand something about vaccine hesitancy: it’s not just a developed world phenomenon. Many people assume that hesitancy and fear about vaccines exists only among highly wealthy individuals in developed countries such as the U.S. and many countries in Europe. In reality, we see varying degrees of vaccine hesitancy and public distrust of vaccines everywhere. The misperception seems to come from the idea that vaccine hesitancy is caused by people perceiving less risk of infectious diseases that are very rare in developed contexts. This view tends to lead to a sense that vaccine hesitancy cannot exist in developing countries, where many of the infectious diseases that are rare in places like the U.S. are still relatively common.

We have always thought that this is an over-simplified view of vaccine hesitancy, which is a complex social and psychological phenomenon that cannot be reduced to one cause. In fact, when surveys such as the Vaccine Confidence Survey are done in a variety of countries with a variety of income levels, we do see that vaccine hesitancy is, in fact, a global phenomenon that cuts across both developed and developing countries.

A relatively recent example of the global nature of vaccine hesitancy comes from India. Earlier this year, India launched a campaign to vaccinate 35 million children against measles and rubella. A few weeks into the campaign, the effort was already struggling. Misinformation and conspiracy theories had gone “viral” on social media, causing a backlash against the vaccine. The content of the conspiracy theories and false safety concerns spanned from the notion that the vaccine was being used to sterilize children to concerns over autism to a claim that the vaccine had been taken off the market in the U.S. due to safety concerns.

Source: Shutterstock

While unpacking the conspiracy and false safety claims is essential and could easily become the topic of an entire dissertation, what’s important to note here is that, as Heidi Larson astutely points out, the “signal” of this widespread hesitancy and fear was already there. As Larson explains, there had been clues in a survey done a year earlier in India that clearly showed dwindling levels of confidence in vaccines among residents of the same state (Tamil Nadu) in which there was the most resistance to the vaccine. In other words, health officials in India knew there was a problem on the horizon, but they didn’t act on the signal immediately. Instead, they tried to simply operate as if that hesitancy and distrust weren’t a factor and they ended up being thwarted by the very thing they were essentially trying to ignore.

There’s a common saying in statistics and data analysis about the importance of separating the “signal” from the “noise.” This refers to the fact that surveys like the one conducted by the Indian health authorities and other forms of research return heaps of data, much of which looks like it’s communicating something significant but really is just random variation rather than actual evidence of a trend or change. It is common in medicine and public health to mistake pure noise for a signal. Sometimes we see these errors getting swept up in press releases and headlines that are nothing short of hyperbolic. So we are taught to guard against this and remain skeptical at all times.

But sometimes we have a different problem. Sometimes a signal really is a signal, but we fail to pay attention to it because perhaps it’s not the most urgent matter at the moment, perhaps we don’t have funding to pursue it, or perhaps we simply don’t know what to do about it. It’s difficult to fully understand all of the motivations and factors behind a failure to take action when a warning signal such as flagging vaccine confidence in parts of India or growing unease about vaccines among Somali-Americans becomes apparent. But failure to act in these cases is really not an option. And this brings us back to our initial questions: what can we do to ensure that the recognition of the signal turns into real action.

Detecting Vaccine Fears Early and Taking Action

When the Indian government undertook the survey that told them that vaccine rates were falling in various parts of their country, it would have been wise to follow up with a more detailed assessment of why this was happening. If they had done so, they most likely would have found that a number of people were becoming suspicious of routine vaccines and were spreading their suspicions via social media. They would also have discovered more about the content of these suspicions and which ones were most prominent.

Unfortunately, we tend not to fund or spend much time on assessments like the one I described above. Despite the creation of the vaccine confidence index, for example, we don’t use this excellent tool nearly enough to get an early read on vaccine hesitancy issues cropping up in different populations. Even when we do inquiries like this, we have a tendency to ignore the results.

A good example of this comes from Ukraine. In 2014, the Global Polio Eradication’s International Monitoring Board (IMB) sounded the alarm bell about a potential situation in Ukraine. The IMB noted that there was a strong anti-vaccination sentiment in Ukraine and that those attitudes combined with vaccine shortages and armed conflict might result in what they called the “perfect storm.” This 2014 warning was largely ignored, and sure enough, in 2015 several children were paralyzed by polio, creating widespread fear that the virus could re-emerge in Ukraine. The fact of the matter is, as with the situation in Minnesota, we should have seen this coming. Not only that but we should have done something about it immediately.

But what needs to be in place to ensure that we can be much more proactive in these situations? A lot is needed, but we’ll leave you with what we think is at least the bare minimum here. We need much more global and local commitment to the overall issue of confidence in modern medicine and public health. We need to invest more in not just picking up the signals but knowing what to do about them and being prepared to act both early and immediately in case of a crisis. It took far too long for local Minnesota health officials to finally come around to the fact that talking to imams would help convince Somali-Americans to get their children vaccinated. Far too many people had already gotten measles at that point, even though this strategy did work eventually.

These strategies need to be readily accessible to everyone, and we need to invest much more money in testing other new strategies. Psychological resistance to vaccines and other medical technologies is a complex phenomenon, and it’s not always obvious what to do about it. Our approach to this issue needs to be rigorous, scientific, and adequately resourced and prioritized. Our only other option is to watch more people become sickened and even die from diseases we know we could have prevented.