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Vaccines have been recognized as one of the top public health achievements of the twentieth century. Dramatic declines in the morbidity and mortality of vaccine-preventable diseases have been observed, and the contribution of vaccines to the elimination, control, and prevention of infectious disease cannot be overstated. However, opposition and hesitancy to vaccines exist and are not new. Vaccine hesitancy has existed since Edward Jenner introduced the first vaccine against smallpox in the eighteenth century. So why did the World Health Organization rank these attitudes as one of the ten greatest threats to public health in 2019? Are current opposition and hesitancy any different from what has been seen before? Many sociologists, public health experts, and health care providers (HCPs) argue yes. Recent social and cultural trends, combined with new communication formats, have converged to create a particularly potent form of hesitancy and what some have labeled a crisis of confidence. This crisis manifests as a lack of trust in specific vaccines, vaccine programs, researchers, HCPs, the health care system, pharmaceutical companies, academics, policymakers, governments, and authority in general. (See “Focus: COVID-19 Vaccine Hesitancy,” below.)

The roots of modern vaccine hesitancy and opposition—defined as delay or rejection of vaccines in spite of availability—vary depending on the place and the population. For some individuals and communities, pseudoscience and false claims about the safety of existing vaccines (e.g., an unsupported link between measles vaccine and autism) have driven fears, increased hesitancy, and decreased acceptance. For others, real safety events, such as the association of narcolepsy with a specific pandemic influenza vaccine (Pandemrix), have justified concerns. In a few locations (e.g., Ukraine, Pakistan), vaccine hesitancy is the result of failed health systems or even state failures. Finally, for some groups, including some fundamentalist religious groups and alternative-culture communities, vaccine hesitancy and opposition reflect exclusion from and rejection of mainstream society and allopathic health care and manifest as a deep distrust of these institutions and their HCPs. Although the genesis of modern vaccine hesitancy is multifactorial, its outcomes are uniform: a decrease in vaccine demand and uptake, a decrease in coverage by childhood and adult vaccines, and an increase in vaccine-preventable diseases, outbreaks, and epidemics of disease. Addressing this crisis and moving people from vaccine hesitancy and refusal to acceptance and active demand require intervention at multiple levels: the individual, the health system (including public health), and the state.

This chapter will define vaccine hesitancy and briefly describe its determinants and effects in North America (the United States and Canada). Physicians and other HCPs are well positioned to address the crisis of confidence many patients feel toward HCPs and the health care system. Studies demonstrate that an unambiguous, strong recommendation by trusted HCPs is most often the reason that patients, including those who are vaccine hesitant, choose to vaccinate. Strategies for counseling vaccine-hesitant and vaccine-resistant patients will be presented and examples of strong vaccine recommendations provided. Presenting strategies ...

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