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Which parts of Europe are likely to be most hesitant about a COVID-19 vaccine?

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By Lauren Chadwick  & Lillo Montalto Monella
People receives flu vaccine at the Museum of science and technology in Milan, Italy, Wednesday, Nov. 4, 2020.
People receives flu vaccine at the Museum of science and technology in Milan, Italy, Wednesday, Nov. 4, 2020.   -   Copyright  Luca Bruno/AP Photo
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Europe may follow the UK and approve a COVID-19 vaccine in the coming weeks.

With the huge hurdle of finding a vaccine now likely overcome, the next challenge looms on the horizon.

That is persuading enough people to take it.

Experts say up to 70% of the population needs to be vaccinated for COVID-19 to be eradicated.

So how much confidence are Europeans likely to have in any vaccine and will they be willing to take it when it comes available?

Europeans among the most vaccine sceptical

Multiple surveys show that Europeans are among the most sceptical of vaccines.

A recent survey of more than 13,400 people in 19 countries found that people in Poland, for instance, reported the most negative responses for whether people would get a COVID-19 vaccine.

France is also among the most sceptical, with just 59% stating that if there was a COVID-19 vaccine that was proven to be safe and effective, they would take it.

Sweden, Germany and Spain also showed more scepticism than other developed countries such as the United States and South Korea.

It's not the first poll to show European citizens have some of the largest concerns about vaccines.

A recent survey by the World Economic Forum (WEF) and Ipsos also found that people in France were the least likely to say that they would receive a COVID-19 vaccine once one is approved. Spain and Italy were also more sceptical than other countries according to the WEF-Ipsos survey.

The survey results were largely in line with a 2019 global survey by non-profit organisation Wellcome and the Vaccine Confidence Project which found that European countries were less likely to have trust in vaccines.

"The broad trend our survey showed across the whole world was that the richer a country is and the more economically developed it is, the less confidence people tend to have in vaccines in those countries," said Imran Khan, the head of public engagement at the Wellcome Trust.

He added that an "important caveat" is that it's still uncertain whether this confidence relates to "uptake in vaccines", meaning many of these countries have more access to vaccines and mandatory childhood inoculations.

In some countries with higher trust in vaccines, there are lower rates of vaccination due to accessibility.

Still, the World Health Organization listed vaccine hesitancy as one of the major threats to global health in 2019, explaining that some countries that were on track to eliminate measles have seen a resurgence.

Is vaccine scepticism linked to trust in government?

The most recent Nature global survey found that people reporting high levels of trust in government information were more likely to accept a vaccine.

"It comes down to the fact that vaccines are globally highly regulated by government, recommended by government, sometimes required or mandated by government," said Dr Heidi Larson, director of the Vaccine Confidence Project at the London School of Hygiene & Tropical Medicine.

"If you have any issues with government or distrust in the way you’ve been treated as a marginalised group or just the particular political leadership and charge, you felt you’ve been betrayed by it, you’ll think twice before you accept a vaccine that they are deciding on, they’re regulating and they may be requiring," Larson, one of the authors of the Nature study, added.

The WEF-Ipsos survey shows that confidence is waning among populations over the COVID-19 vaccine, for instance.

"If in the first wave Italians have placed a lot of confidence in the experts and the government and institutions, civil protection, in the second wave the level of confidence has largely deteriorated," explains University of Bergamo researcher Dr Andrea Rubin.

France's vaccine paradox?

France is a country with particularly low confidence in vaccines, which could be linked to public opinion of government and pharmaceutical companies.

Lucie Guimier is a geopolitical expert specialising in public health at the University of Paris' Institute of Geopolitics and has studied anti-vaccine sentiment in France.

She said that there were several reasons why France was consistently among the most vaccine-hesitant countries.

"It relates on the one hand to our social and political history. It is true that in France we expect a lot from the state and at the same time we are very critical of the state," Guimier said.

Beyond a fear of vaccines, the vaccine resistance in the country "is the defence of individual freedoms, it is the refusal of the intrusion of the state into our private lives," Guimier said, calling it a "French paradox" as the country is also one of the top consumers of medicine globally.

Despite those concerns, this year there were restocking issues for the flu vaccine due to increased demand. France also made seven additional vaccines mandatory in 2018 for children, bringing the total of mandatory childhood jabs to eleven.

Public opinion has likely also been impacted by different health scandals.

Many examples exist including the early 1990s blood scandal when the public learned that more than 1,000 haemophiliacs in France had received HIV infected blood.

Then in several countries, the Hepatitis B vaccine was at one point thought to be linked to multiple sclerosis, a connection that has since been disproven.

More recently the country's officials came under fire for an purchasing an oversupply of H1N1 vaccines.

"After large health scandals, there is a decline in confidence in vaccines," Guimier explains, even if unfounded.

For COVID-19 vaccines so far, French President Emmanuel Macron has repeatedly said that the country will not make the vaccines mandatory.

Vaccine scepticism and the legacy of communism

In Poland, getting vaccinated because it's required by government is "an uncomfortable echoing of the past regime," said Larson, who explained that the country also has a highly organised anti-vaccination movement.

The number of people refusing to vaccinate their children, however, increased between 2007 and 2016, according to the Polish National Institute of Public Health. The number of people refusing any vaccine for children increased from 4,893 in 2007 to 23,147 in 2016.

The percentage of children covered by the MMR vaccine also went down: in 2018 the vaccination rate was 92.9% for the basic dose of MMR vaccine and 92.4% for the booster dose, under the 95% needed for population immunity.

But a recent 2019 study of vaccine confidence in the country found that confidence is rising in the country. In that study, 74.6% of Poles said that mandatory vaccines were safe.

"In Central and Eastern Europe, attitudes towards vaccination may be partly shaped by past experience of the communist period and the organisation of the healthcare system prior to 1989," the authors wrote.

Younger generations were often more hesitant, something that could be related to internet access, the authors said.

The survey found that typically people trusted their doctors but were less trustful of the government to recommend vaccines.

There are currently eleven mandatory vaccines for children in the country.

Concerns about vaccine safety

Another main concern people may have about vaccines is related to safety.

A 2016 survey in Italy of parents of children aged 16-36 months found that safety concerns were the most important reason for refusing or interruption children's vaccinations.

"The main factors associated with hesitancy were found to be: not having received from a paediatrician a recommendation to fully vaccinate their child, having received discordant opinions on vaccinations, having met parents of children who experienced serious adverse reactions, and mainly using non-traditional medical treatments," said Aurea Oradini, at the Vita-Salute San Raffaele University's School of Public Health in Milan.

Italy has historically been more sceptical of vaccines, with declining vaccinations between 2013 and 2016. Since, the country extended the number of mandatory vaccines from four to ten, which did increase childhood coverage. The University of Bergamo's Rubin says that vaccine confidence has increased in Italy since then.

But these safety concerns can also vary by country and depend on what studies or reports arise for particular vaccines.

Dr Xavier Bosch, an adjunct professor at the Open University of Catalonia's Faculty of Health Sciences, said that vaccinations against HPV, which causes cervical cancer, were influenced by reports that girls were falling ill in Valencia, Spain, despite the cause being psychological.

Now, he says, "HPV vaccine coverage is estimated to be in the 70% range."

One of the big influences on anti-vaccination campaigns was a 1998 study by British surgeon Andrew Wakefield. The study suggested that the measles, mumps and rubella (MMR) vaccine could pre-dispose children to developmental disorders such as autism.

Experts say that the publication of this study subsequently influenced measles vaccination rates as it received a great deal of media attention despite its speculative nature and subsequent retraction.

Wakefield was struck off the UK medical register after the study was found to be fraudulent.

The European Centre for Disease Control and Prevention (ECDC) has said a common misperception is that measles itself is a harmless disease, which is likely a myth that comes from the success of vaccination campaigns that lowered deaths from millions per year in the 1980s to some 122,000 in 2012.

Still, last year, EU countries reported some 13,200 cases of measles, according to the ECDC.

Timing and safety of COVID-19 vaccines

Bosch points out that "with COVID we will face another situation in which we will introduce the vaccine in the elderly and fragile" which he says means that "vaccine-related side effects will multiply" bringing back "safety" concerns to news headlines.

The WEF-Ipsos survey on the new COVID-19 vaccines found that 34% of people globally were in part concerned about side effects and 33% cited the speed of clinical trials as a concern.

That survey found that in France and Spain "fewer than four in 10 people" would get vaccinated within three months of the COVID-19 vaccine becoming available, for instance.

Experts say the vaccines will not be approved unless they are safe and that the rapid timeline is due to a multitude of factors.

"It’s partly because there’s so much COVID around that we were able to test these quicker than we would test normal vaccinations," explains Khan.

"So normally when a disease isn’t quite so prevalent, it takes a lot longer to do the trials because it takes longer for enough people to become infected for you to test whether it was safe or not."

This, in addition to high levels of funding and administration shortcuts contributed to the speed of the vaccines as well.

But "another issue with vaccines globally is that we’re very dependent on big business for global health. And for some people who have issues with big business and particularly private sector, that’s another weak point in our trust chain," Dr Larson explained, even though the cooperation between government and business from a public health point of view the coalition is helpful.

What are the most important factors in building public confidence in vaccines?

Many experts say that it's important to build confidence by listening to people's concerns and being transparent about public health information.

Social media can often play an adverse role, experts say, with misinformation and negative opinions about vaccines more readily available than positive information.

"Platforms like Facebook are getting better at shutting down false information about vaccines. But it is a concern that it is so easy for misinformation about vaccines to spread," said Khan at the Wellcome Trust.

But most importantly, "the active recommendation of the physician is the strongest determinant of a child getting vaccinated," said Bosch at the Open University of Catalonia.

Larson says that experts need to understand why people are concerned and where they are most concerned.

We need to be "engaging with people so that they know that you care and that you’re interested in their views," she said.

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