The determinants of vaccine hesitancy in China: A cross-sectional study following the Changchun Changsheng vaccine incident

doi:10.1016/j.vaccine.2020.09.075

Vaccine

Volume 38, Issue 47, 3 November 2020, Pages 7464-7471

https://doi.org/10.1016/j.vaccine.2020.09.075 Get rights and content

Abstract

Introduction

Vaccine hesitancy is cited as one of the top threats to global health. The Changchun Changsheng Biotechnology Company was found to have violated good manufacturing practices in July 2018, leading to widespread distribution of sub-potent vaccines in China. We estimated the prevalence and determinants of vaccine hesitancy following the Changchun Changsheng vaccine incident (CCVI).

Methods

We conducted a cross-sectional survey in China in January 2019, and 2,124 caregivers of children < 6 years old completed self-administered questionnaires. Multinomial logistic regression was used to assess the determinants of vaccine hesitancy; the potential determinants included demographics, socioeconomic status, vaccine confidence, and knowledge of the CCVI. Adjusted Odds Ratios (AORs) and 95% confidence intervals (CI) are reported.

Results

Around 89% of caregivers had heard of the CCVI. Although 83% and 88% of caregivers agreed that vaccines are safe and effective, respectively, 60% expressed some hesitancy about vaccination. Of those hesitant, 26% vaccinated their children at times with doubts, 31% delayed vaccination and 3% refused specific vaccines. Multinomial regression analysis showed that confidence in vaccine safety was associated with a reduced odds of doubts on vaccination (AOR = 0.64; 95%CI = 0.44–0.94), whereas caregivers who had heard of the CCVI had a significantly higher odds of doubts on vaccination (AOR = 1.61; 95%CI = 1.05–2.45). Confidence in the vaccine delivery system and government were associated with a lower odds of vaccine hesitancy. Caregivers with higher education and Buddhism or other religions were significantly more hesitant to vaccinate their children.

Conclusion

Vaccine hesitancy was prevalent following the CCVI. Over half the caregivers either accepted childhood vaccination with doubts or delayed vaccines; only a small number were active refusers. Our findings highlight the importance of addressing vaccine hesitancy, especially following vaccine incidents. Tailored communications are needed to reduce vaccine hesitancy, especially among the highly educated and Buddhist caregivers.

Introduction

Vaccination is often cited as one of the most effective achievements of public health to prevent infectious diseases. However, this success is being challenged by individuals and groups with negative attitudes toward immunization and those who may choose to delay or refuse vaccines [1], [2], [3]. Over the past decades, reluctance concerning vaccination has proliferated, and vaccine hesitancy has grown into an issue warranting global attention [4], [5]. In 2012 the World Health Organization (WHO) Strategic Advisory Group of Experts (SAGE) on Immunization established a ‘Working Group on Vaccine Hesitancy’, and in 2019 vaccine hesitancy was cited by WHO as one of the top ten threats to global health [6].

Vaccine hesitancy can be defined as “delay in acceptance or refusal of vaccination despite the availability of vaccination services” [7] and covers a continuum of individuals who accept all vaccines with doubts to those who completely refuse vaccines [8]. Vaccine hesitancy is a complex and context specific issue that varies across time, place, and vaccines [7]. Studies that have estimated the prevalence and drivers of vaccine hesitancy indicate different levels of vaccine hesitancy across countries. For example, the prevalence of vaccine hesitancy was 31.8% in the US (2014) [9], 45.8% in France (2016) [5], 24.6% in Italy (2017) [2], 23.0% in Brazil (2016) [10] and 11.6% in Malaysia (2016) [11]. Vaccine hesitancy appears to be more prevalent in developed countries than developing countries. According to the SAGE Working Group, vaccine hesitancy is determined by contextual (e.g., culture, gender, socio-economic group and geographic barriers), individual and social or group influences (e.g., belief, attitudes, knowledge and experiences with vaccination), and vaccine and vaccination-specific issues (e.g., costs, mode of administration and delivery) [3].

China initiated its Expanded Program of Immunization (EPI) in 1978 [12]. Coverage of EPI vaccines has consistently been over 90% in the last decade, but the coverage of non-EPI vaccines is lower [13]. Many vaccine incidents such as psychogenic reactions associated with a school-based hepatitis A vaccination campaign in Anhui province in 2005 [14], media reports of child deaths or disability following vaccination in Shanxi province in 2010 [15], coincidental infant deaths following hepatitis B vaccination in 2013 [16], and the illegal sale of vaccines in Shandong in 2016 [17] have occurred in the recent past. The most recent vaccine-related incident involved the Changchun Changsheng Biotechnology Company, which was found to have violated the Good Manufacturing Practice standards in manufacturing diphtheria, pertussis, and acellular tetanus (DTaP) vaccines and rabies vaccines in July 2018 [18]. A total of 499,800 doses of substandard DTaP vaccines were produced and entered into the market [18]. Vaccine incidents have the potential to raise public concern and doubts about vaccination. Studies have shown that the hepatitis B vaccine incident in 2013 significantly decreased parental confidence in childhood vaccines [19], and the Shandong vaccine incident reduced uptake of both childhood and adult vaccines [17].

Estimates of the prevalence of vaccine hesitancy among Chinese caregivers are sparse and are especially important in the light of the Changchun Changsheng vaccine incident (CCVI) [3]. Previous studies in China have focused on the influence of individual-level knowledge, attitudes and beliefs on vaccination behavior [16], [17], [18], [19]. Besides individual-level factors, vaccine hesitancy is also known to be influenced by contextual and social or group influences, which are often understudied. A few older studies have attempted to quantify the effect of the CCVI on vaccine confidence, reporting reduced public trust in vaccines following the CCVI [18], [20], [21], [22], [23]. Our study aimed to provide updated estimates of the prevalence of vaccine hesitancy following the CCVI, and to assess the determinants and reasons for vaccine hesitancy among Chinese caregivers.

Section snippets

Study design and data collection

We conducted a cross-sectional survey in January 2019, six months after the CCVI. Data was collected in the Shenzhen megacity in Guangdong province, Anhui province and Shaanxi province, located in the East, Middle and West areas of China, respectively. We selected one urban district and one rural county in Anhui and Shaanxi provinces, and one urban district in Shenzhen megacity. The caregivers (parents or guardians) of children < 6 years old were enrolled through a two-stage, cluster sampling

Participant characteristics

Caregivers’ socio-demographic characteristics are presented in Table 2. The average age of caregivers was 34 years old (standard deviation = 7.6), 61.0% of caregivers lived in urban areas, and 71.1% were mothers. Around one-third (35.1%) had a bachelor degree or higher education, 18.6% were internal migrants, and 7.8% reported having a religious faith, predominantly Buddhism.

Vaccine confidence and hesitancy

A significant majority (96.0%) of caregivers agreed that vaccines are important for children with 82.7% and 88.2%

Discussion

We investigated the prevalence of vaccine hesitancy and its determinants from data collected in three provinces of China. Approximately 60% of caregivers of children < 6 years old were hesitant about vaccinating their children. Hearing of the CCVI and lower confidence in the safety of vaccines, the vaccine delivery system, and the government were associated with odds of being vaccine hesitant. More educated caregivers and those reporting Buddhism or other religious beliefs were also

Conclusions

Vaccine hesitancy was prevalent among Chinese caregivers of young children following the CCVI. Over half of caregivers in our study either accepted childhood vaccination with doubts or delayed vaccination; only a small number were active refusers. Our findings highlight the importance of addressing vaccine hesitancy, especially following vaccine incidents. Tailored communications are needed to reduce vaccine hesitancy, especially among the highly educated and Buddhist caregivers. Timely,

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Author Contributions

ZH led the study design, guided the data analysis, and co-wrote the manuscript. FD analyzed data and wrote the manuscript. TC co-led the study design and revised the manuscript. MF revised the manuscript. FYS, XZ, KH, LR, HY participated in the study design. ST, HL co-led the study design and reviewed the manuscript.

Acknowledgements

We thank the data collection teams from Fudan University, China CDC, the provincial and county level CDCs, vaccination clinics who facilitated the research fieldwork, and all the

References (35)

A. Bianco et al.
Parent perspectives on childhood vaccination: How to deal with vaccine hesitancy and refusal?
Vaccine
(2019)
H.J. Larson et al.
Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: A systematic review of published literature, 2007–2012
Vaccine
(2014)
H.J. Larson et al.
Measuring vaccine hesitancy: The development of a survey tool
Vaccine
(2015)
A. Bocquier et al.
Social differentiation of vaccine hesitancy among French parents and the mediating role of trust and commitment to health: A nationwide cross-sectional study
Vaccine
(2018)
N.E. MacDonald
Vaccine hesitancy: Definition, scope and determinants
Vaccine
(2015)
F.S. Mohd Azizi et al.
Vaccine hesitancy among parents in a multi-ethnic country, Malaysia
Vaccine
(2017)
B. Chen et al.
Media and public reactions toward vaccination during the 'hepatitis B vaccine crisis' in China
Vaccine
(2015)
B. Han et al.
Has the public lost confidence in vaccines because of a vaccine scandal in China
Vaccine
(2019)
D. Hu et al.
Chinese social media suggest decreased vaccine acceptance in China: An observational study on Weibo following the 2018 Changchun Changsheng vaccine incident
Vaccine
(2020)
M. Zhou et al.
Trust collapse caused by the Changsheng vaccine crisis in China
Vaccine
(2019)

H.J. Larson et al.

The state of vaccine confidence 2016: global insights through a 67-country survey

Ebiomedicine

(2016)

A.S. Wallace et al.

Development of a valid and reliable scale to assess parents’ beliefs and attitudes about childhood vaccines and their association with vaccination uptake and delay in Ghana

Vaccine

(2019)

M.B. Gilkey et al.

Forgone vaccination during childhood and adolescence: findings of a statewide survey of parents

Prev Med

(2013)

S. Lane et al.

Vaccine hesitancy around the globe: Analysis of three years of WHO/UNICEF Joint Reporting Form data-2015–2017

Vaccine

(2018)

F.E. Andre et al.

Vaccination greatly reduces disease, disability, death and inequity worldwide

B World Health Organ

(2008)

Ten threats to global health in 2019....

Meeting of the Strategic Advisory Group of Experts on immunization, October 2014 - conclusions and recommendations....

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