Vaccine hesitancy: a growing concern

In an increasingly digitalised world, general practice nurses must employ nuanced methods to restore confidence in one of medicine’s greatest achievements. But what is vaccine hesitancy, where did it come from, and how has it evolved?

Recent years have seen vaccine hesitancy emerge as a significant concern in healthcare systems worldwide. One can be forgiven for being surprised at this trend, given the watershed success of vaccines in curbing the COVID-19 pandemic just five years ago. Yet the World Health Organization’s (WHO) recent announcement of measles cases doubling in Europe underscores the urgency of addressing vaccine hesitancy across all sectors.¹ Complex factors including political polarisation, widespread misinformation on social media platforms, and lingering concerns about the rapid development timeline of COVID-19 vaccines, have all contributed to a resurgence in scepticism. Healthcare systems now face the challenging task of rebuilding trust among the public.

WHAT IS VACCINE HESITANCY?

Vaccine hesitancy is defined by the WHO as the ‘delay in acceptance or refusal of safe vaccines despite availability of vaccination services’. It is one of the most complex health challenges in our time: despite overwhelming scientific consensus supporting the safety and efficacy of vaccines, a substantial portion of the global population remains reluctant or is outright opposed to vaccination. In 2019, vaccine hesitancy was identified as one of the WHO’s top ten global health threats.² This phenomenon exists on a spectrum, from those who have health and religious reasons not to vaccinate, through to specific concerns about particular vaccines or those who reject vaccination entirely. Many express diminished trust in healthcare systems, pharmaceutical companies or government institutions. In some cultures, particularly those emphasising individualism, vaccination mandates can trigger resistance based on principles of bodily autonomy and freedom of choice.

A CENTURIES-OLD STORY

Resistance to vaccination is not new. The first smallpox vaccine was developed by English physician Edward Jenner in 1796, representing a revolutionary medical breakthrough. However, as vaccination campaigns expanded and gained governmental support throughout the early 19th century, organised opposition emerged concurrently across multiple countries, reflecting social anxieties about this novel medical intervention.

The first formal anti-vaccination organisations were established around the 1860s, with notable examples including the Anti-Compulsory Vaccination League in England and similar groups in the United States.³ These early movements often published pamphlets, organised public demonstrations, and lobbied against mandatory vaccination laws. In Leicester, England, resistance was particularly strong, with thousands participating in protest marches against the Vaccination Act of 1853, which had made smallpox vaccination for infants compulsory.⁴

Early anti-vaccination sentiments stemmed from diverse concerns: religious objections regarding interference with divine will, political unease about government overreach into personal liberties, and misconceptions about the science of vaccines itself. Many feared the practice of introducing cowpox material into human bodies may cause ‘bovine transformations’ or other imagined horrors, misconceptions that persisted despite scientific evidence to the contrary.

THE WAKEFIELD EFFECT

No discussion of modern vaccine hesitancy would be complete without addressing Andrew Wakefield’s profound impact. In 1998, the former British gastroenterologist published a now-retracted study in The Lancet, falsely linking the MMR vaccine to autism.5 Despite the paper’s small sample size (just 12 children) and serious methodological flaws, it sparked worldwide concern that continues to reverberate today. Subsequent investigations revealed Wakefield had undisclosed financial conflicts of interest and committed ethical violations during his research. The Lancet retracted the paper in 2010, and Wakefield was struck off the UK medical register.⁶

Despite overwhelming scientific evidence disproving his claims through numerous large-scale studies, Wakefield’s impact persists and remains a powerful case study in how a single scientific publication can fuel lasting vaccine hesitancy. His claims gained traction through sensationalist reporting that prioritised alarming headlines over scientific consensus. Anti-vaccination groups portrayed Wakefield as a whistleblower silenced by pharmaceutical interests rather than a researcher whose work failed scientific scrutiny. This narrative resonated with parents seeking explanations for their children’s diagnoses, and with those already distrustful of medical establishments. The Wakefield case demonstrates how scientific misconduct, amplified by media coverage, can undermine public health messaging for decades after the original claims have been thoroughly discredited by the scientific community.

THE DIGITAL AGE

What distinguishes today’s anti-vaccination movement from its historical predecessors is the unprecedented velocity and global reach with which misinformation propagates through digital platforms.⁷ The modern social media infrastructure has created echo chambers that can rapidly reinforce misinformed views. What was once localised resistance has solidified into international movements, allowing anti-vaccine narratives to evolve and adapt faster than public health messaging can respond.

Social media platforms tend to amplify emotionally charged content regardless of factual accuracy, while recommendation algorithms often lead users deeper into ideological echo chambers. A Massachusetts Institute of Technology (MIT) study has shown false news stories are 70% more likely to be reshared than true stories, with true stories taking six times as long than false stories to reach 1,500 people.8 Healthcare professionals now find themselves competing not just with misinformation but with sophisticated counter-narratives that cherry-pick data to create compelling alternative explanations.

SAMOA AND MEASLES

The 2019 Samoa measles outbreak stands as one of the most devastating real-world consequences of vaccine hesitancy and misinformation. This public health crisis claimed 83 lives, predominantly children under five years old. In total, 5,700 people were infected out of a population of just a little over 200,000.⁹

At the heart of this tragedy was a precipitous decline in vaccination rates. Measles immunisation coverage in Samoa had plummeted from approximately 74% in 2017 to just 31% in 2018, creating ideal conditions for an epidemic.¹⁰ This dramatic drop stood in stark contrast to neighbouring Pacific islands which maintained vaccination rates near 99%.¹¹ In July 2018, two Samoan infants died after receiving MMR vaccines that had been incorrectly prepared by nurses who mixed the vaccine powder with expired muscle relaxant instead of sterile water. This medical error created fertile ground for anti-vaccine activists to exploit.

In June 2019, several months before the outbreak, prominent anti-vaccine proponent Robert F. Kennedy Jr. visited Samoa. A well-known public figure, he met with and lent international credibility to local anti-vaccination activists, including Edwin Tamasese, whom he called a ‘medical freedom hero’.¹² Kennedy also discussed vaccines with then-Prime Minister Tuilaepa Sa’ilele Malielegaoi and campaigned against the vaccine on social media.

After the outbreak occurred, Kennedy attributed the measles deaths to poverty and malnutrition or to the vaccine, though he provided no evidence supporting these claims. Kennedy wrote a letter to the Prime Minister urging him to consider if children’s deaths were caused by a ‘defective’ vaccine or a ‘mutant strain’ of measles caused by it; neither of which is plausible.^13,14 Samoa’s Ministry of Health cited Kennedy’s visit and his rhetoric as exacerbating vaccine hesitancy. A recent Lancet article further highlights Kennedy’s non-profit, Children’s Health Defense, as having also contributed to the atmosphere of mistrust just months before the outbreak.¹⁵

On the 5th and 6th of December 2019, the Samoan government imposed a curfew and reposted civil servants to the vaccination campaign. Upon the vaccination programme reaching an estimated 90% of the population, the curfew was lifted. Edwin Tamasese was arrested and charged with ‘incitement against a government order’ and by 22 December 2019, an estimated 94% of the eligible population had been vaccinated.¹⁶ Kennedy now serves as United States Secretary of Health and Human Services.

THE COVID-19 PARADOX

It has been estimated that COVID-19 vaccines saved at least an estimated 14.4 million lives worldwide in 2021. Yet ironically, the COVID-19 pandemic also brought vaccine hesitancy into sharp focus. The unprecedented speed of vaccine development, coupled with the politicisation of public health measures, created new dimensions of hesitancy in the global population. Emergency use authorisations, novel mRNA technology used for the vaccines, and rapidly evolving public health guidance catalysed uncertainty.

Consequences of widespread vaccine refusal became quickly apparent, with significantly higher mortality rates among unvaccinated populations during various waves of the pandemic. Unfortunately, hesitancy extended to healthcare professionals, with over 1 in 5 nurses worldwide refusing to take the COVID-19 vaccination.¹⁷

In August 2020, Russia became the first country in the world to approve a COVID-19 vaccine. One year later, only 19% of the population was vaccinated.¹⁸ Indeed, while other countries struggled to meet vaccine demands, Russia faced the opposite problem of excess supply due to a deeply hesitant population.

Despite vaccines saving millions of lives during the pandemic, COVID-19 ironically intensified vaccine hesitancy worldwide.

RETURN OF MEASLES

In 2000, the United States declared that measles had been eliminated. As of May 2025, a total of 1,046 confirmed measles cases were reported by 30 states.¹⁹ Similarly, Europe has recently reported its highest number of measles cases in over 25 years, with infections doubling compared to previous years.¹ According to the WHO, global gaps in vaccination coverage have contributed to 57 countries experiencing large or disruptive measles outbreaks in 2023, representing a nearly 60% increase from 36 countries in the previous year.²⁰

This alarming global resurgence of measles represents a major public health setback in regions previously declared measles-free. A New York Times article reporting on the death of a child in Texas from measles has linked this to increasing vaccine hesitancy over many years.²¹

There is hope, however. The end of 2024 saw Brazil reverified as having eliminated measles, making the WHO Americas Region once again free of endemic measles.²⁰ Nevertheless, the path forward globally requires urgent recommitment to evidence-based public health measures.‘The measles vaccine is our best protection against the virus, and we must continue to invest in efforts to increase access,’ Centers for Disease Control and Prevention (CDC) Director Mandy Cohen said.²⁰

THE COST OF HESITANCY

While saving lives of course remains the most important priority of vaccination, the economic burden of vaccine-preventable disease outbreaks is substantial. ‘Each measles case can be $30,000 to $50,000 for public health response work, and that adds up quite quickly,’ says Dr David Sugarman, senior scientist at the CDC.²² The 2019 Samoa measles outbreak discussed earlier resulted in GDP losses of $22 million, as reported by the Samoa Observer.23 In England, a recent study estimated a loss of £292 million over a 20-year period, with 26% attributable to healthcare costs and 74% to productivity losses for patients and their carers.²⁴ Public health economists consistently demonstrate that vaccination programmes offer exceptional return-on-investment ratios, with every one dollar spent yielding up to $44 in economic benefits.²⁵

HOW CAN GPNs ADDRESS HESITANCY?

General practice nurses (GPNs) occupy a unique position in addressing vaccine hesitancy due to their role as a trusted healthcare professional and their sustained contact with patient healthcare settings. Unlike physicians who may have limited time with patients, GPNs often develop deeper relationships that foster open communication about health concerns, including vaccination fears.²⁶

Of course, this trusted position comes with distinct challenges, as GPNs must navigate personal relationships with patients while upholding evidence-based practice standards. Effective vaccine hesitancy interventions must acknowledge the frontline role of GPNs in vaccine education and provide specialised communication tools that leverage their unique relationship-based approach to patient care. Here are some important points to keep in mind:

Building trust: Healthcare providers remain the most trusted source of vaccine information. To do this, it is important to actively listen to concerns without judgement, as well as acknowledge fears and uncertainties as valid feelings. Healthcare professionals must also be forthright about the benefits and potential risks of vaccines.

Tailoring communication: Digital tools such as websites and mobile apps allow for a broader reach, while traditional print materials remain important for those with limited digital access. In addition, sharing both personal and statistical perspectives enables a more rounded rapport to develop with patients (e.g., ‘I received this vaccine myself’ alongside efficacy data). It is important to remember different hesitant groups require different approaches.

Continuous education: With new vaccines being developed every year, it is important for healthcare professionals to be updated on latest vaccine research and guidelines. It is also critical to understand that vaccine hesitancy does necessarily indicate a lack of information. GPNs must be prepared for ‘informed hesitancy’ which inevitably requires more nuanced conversations around benefit/risk ratios.

Above all, it is important to remain empathetic to patients and their families. As Dr Adam Ratner, director of the Division of Pediatric Infectious Diseases at New York University explains: ‘Vaccine hesitant parents are not parents who don’t love their kids. They’re parents who are trying to do the right thing for their kids.’²⁷

CONCLUSION

Vaccine hesitancy is a centuries-old story that is almost as old as vaccines themselves. However, in today’s digitalised world, it is a rapidly mounting public health challenge that threatens to undermine one of medicine’s greatest achievements. Addressing it effectively requires understanding its complex roots and avoiding the temptation to dismiss concerns or stigmatise hesitant individuals. As we navigate ongoing and future public health challenges, finding the balance between individual autonomy and community protection will remain a critical societal conversation; one that demands both scientific rigor and genuine human connection.

REFERENCES

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