Master’s Thesis
Medical Anthropology and Sociology
Graduate School of Social Sciences
Extending national immunization programmes:
The case of varicella vaccination in the European Union
Victoria Szerényke Boehm
Amsterdam, 7th August 2020
Student ID number: 12757152
Contact: boehm.victoria@outlook.com Supervisor: Dr. Stuart Blume
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Science appears calm and triumphant when it is completed; but science in the process of being done is only contradiction and torment, hope and disappointment.
- Pierre Paul Émile Roux, French physician, bacteriologist, and immunologist and developer of the first effective treatment for diphtheria1
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Abstract
The idea that, like medicine, health policymaking should be evidence-based has gained wide popularity and support. This is also the case for immunization policies. Despite the claim that the decision to include new vaccines in national immunization programmes is rational and based on objective evidence, countries often react very differently to new vaccines. Against this background, the question arises how and why vaccines are introduced into immunization programmes. The case of varicella/chickenpox vaccination is peculiar in this respect. Even though it has been available for thirty years and a wide range of evidence is accessible and despite a trend towards harmonizing vaccination programmes in the European Union, countries reach different conclusions about the vaccine. Historical research on the introduction of vaccines suggests that in addition to evidence, politics, perceptions, as well as public and professional opinions influence immunization policymaking. Drawing from that, this thesis explores why and how vaccines are included in national immunization programmes through the case of varicella decision-making in Germany, the United Kingdom, and the Netherlands. The research is based on method triangulation consisting of qualitative interviews with Dutch healthcare professionals, online research, and document analysis. Results from document analysis suggest that differences between countries in varicella related decision-making reflected in particular disease perceptions, the importance attached to certain considerations, the availability of evidence and its interpretation. Underlying these developments were contextual changes. In the countries studied social acceptance was not a crucial factor. I argue that it should be ascribed more importance, because a vaccination programme’s success is ultimately dependent upon its acceptance. The interviews and online data throw some light on public and professional opinions. Finally, I discuss possible influences on opinions about different vaccines, including familiarity, personal experiences, and trust.
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Preface
For the longest time I have not questioned vaccination recommendations and did not understand why some parents would refuse to vaccinate their children. It seemed so simple to me: In order to not get terrible diseases, you get some injections and on top of that you help to protect vulnerable groups as well. As I became more acquainted with the social sciences, I realised that hardly anything is simple and straightforward and especially not people’s points of view. During an inspiring class on contemporary topics in Medical Anthropology and Sociology the lecturer mentioned the reoccurrence of diseases due to declining vaccination rates and in that moment I decided that my final thesis would be about vaccination. I came across studies which showed that healthcare professionals are not always supportive of all vaccines and I was instantly captivated.
Healthcare professionals are in direct contact with parents and as trusted advisors on children’s health their work does not seldom include answering questions and soothing doubts. Consequently, they play a crucial role in the implementation of national immunization programmes and preservation of immunization rates. This makes their perceptions a significant topic worth investigating.
Chickenpox presented an interesting example to investigate vaccination perceptions because it is generally known as a harmless childhood disease, but it can have severe consequences for certain groups. The Netherlands portrayed an appealing site for research because chickenpox is currently a candidate for the national vaccination programme. A common concern with universal chickenpox immunization is the potential shift in age of infection from children to adolescents or adults due to suboptimal vaccination coverage. Such a development could lead to an increase of the disease burden. Therefore, insight into the willingness to vaccinate against chickenpox prior to its inclusion in the programme is essential.
The initial goal of this thesis was to provide insight into Dutch healthcare professionals’ perceptions on chickenpox vaccination before its introduction into the vaccination programme and thus to open up the discussion about chickenpox from their perspectives, as well as to contribute to the considerations regarding the implementation of the chickenpox vaccine in the Netherlands. The primary research questions were the following:
How do health care professionals in the Netherlands assess the need of the varicella/chickenpox vaccine in terms of risk and desirability?
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- How do healthcare professionals assess the risks associated with varicella and the vaccine?
- What is their attitude towards whether and how the varicella vaccine should be introduced into the Dutch immunization programme?
- What is their position on vaccinating certain groups only? Are there particular groups they think should be vaccinated?
The fieldwork process started in February 2020. At first it seemed feasible to stick to the original plans despite the increasing spread of the coronavirus (COVID-19), which was first identified in December 2019 in Wuhan, China. However, as the situation got worse it became clear at the beginning of March that gaining access to healthcare professionals was highly difficult and in mid-March the lockdown in the Netherlands began. In face of the rapidly changing situation it became apparent that my initial plans were not realisable. Therefore, the research focus needed to be adjusted in a way that would allow me to conduct research during a pandemic and global state of emergency. Inspired by the question why some countries introduce certain vaccines into their vaccination programmes while others do not, although all claim to base their decisions on scientific evidence, the following research question developed: How and why are vaccines added into national immunization programmes? Since it was difficult to find research participants it was necessary to incorporate a methodological approach which does not rely on people’s availability. Consequently, document analysis became the backbone of the new research plans. In an attempt to include the social dimension of the issue at hand, interviews via videoconference and online research on social media were included as well. Since chickenpox is generally not considered to be an urgent issue, I expected interest in my research to be especially low during a global crisis. However, reactions online were quite positive and those healthcare professionals who were willing to be interviewed found it rather interesting as well.
I cannot deny that the pandemic influenced my work on a personal level as well. As a young scholar from Austria I had the privilege of growing up with the normality of open borders, freedom of travel, and not encountering crisis situations. Experiencing the rapid spread of a serious health threat, daily increasing mortality rates, and global lockdowns was simply shocking. As an international student away from home I felt vulnerable and looking back it almost seems like an understatement to say that I was worried about a variety of things. At
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one point finishing this project and graduating seemed hardly possible. During this time the support of the university, friends, family, and particularly my supervisor put me at ease. Even though my research was not dependent on a location anymore, staying in the Netherlands made me feel closer to my project and after the initial shock proceeding seemed more manageable every day.
Most likely under normal circumstances it would have been possible to go through with the initial plans and gather more data on people’s perceptions about chickenpox vaccination. Nevertheless, in the context of the COVID-19 pandemic this research project developed in interesting ways and discussions arose which would not have otherwise. After months of work and many unexpected events it is my pleasure to present the thesis at hand.
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Acknowledgements
Behind every project stand people who influence it in many ways. I would like to take the time here to acknowledge a few of them. Without their contributions this thesis would not have been possible.
First, I would like to thank my parents and my brother for their unconditional support throughout my whole study period. When I started my bachelor’s in cultural and social anthropology back home in Vienna I was often faced with scepticism and lack of understanding for my plans, which to be fair were not very clear at that point. This changed over time and when I told you that I wanted to study medical anthropology and sociology abroad, there was not a second of hesitancy in your endorsement. I am truly grateful for everything you have done for me. You always have my back and help me grow. Without you this year would not have been possible, and I would certainly not be the person I am today. Second, I would like to thank my supervisor Dr. Stuart Blume for all his efforts to guide me through the biggest project I have done so far. Conducting fieldwork and writing a master’s thesis is a challenge in and of itself but doing so during a global pandemic and lockdown is a different story. Thank you for your patience, input, encouragements, and guiding me into a direction that allowed me to finish my thesis under these extraordinary circumstances. A special acknowledgement and gratitude go to the participants of this study, who took the time to talk to me and in doing so helped me graduate. It is not self-evident to participate in a master’s project, and especially not as healthcare professionals during a state of health emergency. I highly appreciate your time and effort. Of course, the same goes for the online participants who shared their thoughts and experiences with me even though I was a stranger on the internet.
I would also like to thank my boyfriend Daniel for always having an open ear for me, talking me out of uncertainties, thinking through ideas and struggles with me, and acting as proof-reader whenever I needed one.
Last, but certainly not least, a big thank you to my peers for the constant exchange of ideas and motivation. Our study sessions kept me on track and beyond that you made me feel at home in a foreign city. Without you this year would not have been as exciting.
8 Table of contents Abstract ... 3 Preface ... 4 Acknowledgements ... 7 List of abbreviations ... 10 List of Figures ... 11 1. Introduction ... 12 1.1 Background ... 12
1.2 Problem statement and research questions ... 14
2. Methodological and theoretical inspirations ... 16
3. Research methodology ... 22
3.1 Qualitative interviews ... 23
3.2 Online research ... 24
3.3 Document analysis ... 25
3.4 Analysis of interviews and online data ... 26
3.5 Ethical considerations ... 27
4. Varicella: Pathology, epidemiology and development of a vaccine ... 29
5. Varicella immunization decision-making in the EU ... 32
5.1 Germany ... 36
5.2 The United Kingdom ... 40
5.3 The Netherlands ... 45
5.4 Discussion ... 49
6. Social acceptance of varicella vaccination: Public and professional opinions ... 49
6.1 Chickenpox – a normal part of childhood? ... 50
6.2 Balancing risks and preserving the national immunization programme ... 55
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7. Conclusion ... 60
8. Personal reflections and limitations ... 68
9. References ... 70
10. List of documents used for document analysis ... 77
11. Annex ... 82
11.1 Fieldwork process overview ... 82
11.2 Coding scheme for document analysis ... 83
11.3 Network interviews and online data themes ... 84
11.4 Interviews and online data analysis mind map ... 85
11.5 Linear scheme social acceptance chapter ... 86
11.6 Post vaccine introduction discussions in Germany ... 87
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List of abbreviations
BCG Bacillus Calmette-Guérin
ECDC European Centre for Disease Prevention and Control EU European Union
GP General practitioner HC Health Council
HCPs Healthcare professionals HZ Herpes zoster
JCVI Joint Committee of Vaccinations and Immunizations MMR Measles mumps rubella
MMRV Measles mumps rubella varicella NHS National Health Service
NIP National immunization programme
NITAGs National Immunization Technical Advisory Groups NPT Normalisation process theory
PHN Post-herpetic neuralgia RKI Robert Koch Institute STIKO Ständige Impfkommission UK United Kingdom
USA United States of America
VENICE Vaccine European New Integrated Collaboration Effort VZV Varicella-zoster virus
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List of Figures
Figure 1. Conceptual framework for context-based evidence-based decision-making. ... 20 Figure 2. Implementation of chickenpox vaccination in the EU timeline. ... 35
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1. Introduction 1.1 Background
Vaccines are reckoned to be a major tool for public health success (Yaqub, Castle-Clarke, Sevdalis, & Chataway, 2014). The global vaccination narrative is shaped by victory stories of saving millions of lives every year (e.g. Jakab, 2020; Orenstein & Ahmed, 2017). Despite these stories it seems that increasingly more people are questioning the safety and/or benefits of vaccination. Lack of trust, uncertainties, sometimes inconsistencies in vaccine data, and the spread of information that contradicts biomedical data results in parents questioning or even refusing certain vaccines or whole vaccination programmes (Yaqub et al., 2014). In 2019 the World Health Organization (WHO) announced “vaccine hesitancy” as one of the ten threats to global health. The term refers to “[t]he reluctance or refusal to vaccinate despite the availability of vaccines” (WHO, 2019). This description concerns individual decision-making. Against this background it is interesting to observe that national responses towards vaccines are often diverse.
Technologies, targets, and the global perspective have become central to international health policy. It is taken for granted that new vaccines recommended by the WHO should be introduced rapidly into national immunization programmes (NIPs). The failure to do so is perceived as deviant behaviour that needs to be justified. This means that national performances are evaluated through comparison with international and global dimensions (Blume, Roalkvam & McNeill, 2013). Additionally, the erosion of public confidence in NIPs and the institutions involved confronts policymakers with challenges. Since immunization affects whole populations and particularly their most vulnerable members, it has always been subject to public scrutiny. In the face of growing scepticism, immunization policies need to be justified to new extent (Blume & Tump, 2010).
To ensure transparency and soothe public doubts the argument of rational and evidence-based decisions is highly appealing (Blume & Tump, 2010). This coincides with the general claim that like medical practice, health policy should be evidence based (Berridge & Stanton 1999; Niessen, Grijseels & Rutten, 2000). To introduce new vaccines such evidence should include especially disease burden, as well as the safety, efficacy and cost-effectiveness of the vaccine. Mathematic modelling which incorporates this evidence is used to investigate the impact of potential vaccination programmes (Salisbury, Beverley & Miller, 2002). In spite of the evidence-based narrative historical analyses of immunization policymaking point towards
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the non-determinant character of scientific and medical data and show that this process is more complex. Immunization policymaking is driven by local, national, and international politics, ideologies, financial arguments, public demand, social acceptability, and processes of legitimization (Hagen-Berg & Blume, 2020).
Furthermore, vaccines have become to inhabit a social role. Not only are they interwoven in a complicated nexus between science and policymaking, they have also become some kind of technological fix which provides prospects of preventing and even eliminating diseases and consequently saving lives. The current case of the COVID-19 pandemic illustrates the social value of vaccines which goes beyond biomedical effectiveness. It seems the whole world is waiting for a vaccine and holding on to the idea that it will bring back normality. In this sense the vaccine becomes a symbol for global hope. COVID-19 is a particular and contextual example, however, research on previous implementations of vaccines shows that faith in vaccines is a historical and social construct (Blume, 2020).
In summary, decisions about immunization policies are embedded in national and international contexts. The globalism of today’s vaccine system resonates with a trend towards harmonisation and the political pressures to conform to international guidelines. Decision-makers face the challenge to conform to such guidelines and global interests, while dealing with public opinions.
The discourse about vaccination has become affected by notions of morality and responsibility. Parents are faced with accusations regarding their children’s best interest. Since vaccination aims to protect not only individuals, but whole populations, the argument of a collective moral obligation to contribute to herd immunity and protect those who cannot be immunized is prominent. Regarding community level it is also possible that benefits arise from financial savings as a result of vaccination and that resources could be saved (Dawson, 2011). States are perceived as having the responsibility “[t]o protect and promote individuals’ health, especially that of the most vulnerable people” (Giubilini, 2019 p. 54) and therefore ought to implement vaccination policies that ensure so. Due to these underlying notions, debates about vaccination are often charged with emotions and strong criticism, particularly of negative vaccination decisions, is not uncommon. This contributes to the challenges policymakers face.
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On the premise that evidence is not as determinant as claimed and immunization policymaking is influenced by multiple factors, the following research question arises: How
and why are vaccines added into national immunization programmes? This question is the
starting point for the thesis at hand and will be illustrated through the varicella vaccine in the European Union (EU) as a case study.
1.2 Problem statement and research questions
“Varicella”, also known as “chickenpox”, is caused by the varicella-zoster virus (VZV). Generally known as a childhood disease, its effects are usually not severe. The typical symptoms resemble the common cold, followed by a high temperature and a blister-like rash. Nevertheless, complications such as infections of the skin, lungs, and brain can occur. Groups most at risk for complications include pregnant women, immunocompromised individuals, infants, and adults (European Centre for Disease Prevention and Control [ECDC], 2019). Patients usually develop a lifelong immunity to the virus after recovery. However, the virus can be reactivated and result in the condition called “shingles” (herpes zoster, HZ). The symptoms of shingles usually start with pain in the area of the affected nerve, followed by a rash of blisters (ECDC, 2019).
With the development of the Oka-strain based vaccine in 1974 varicella has become a preventable disease. The first country to implement universal childhood vaccination was the United States of America (USA) in 1996. Several varicella vaccines are currently authorized in the EU. Nonetheless, the use of varicella vaccination is quite heterogeneous. While some countries recommend universal vaccination in children at national or regional level, others recommend immunization only in high-risk groups or have no recommendation at all (Carrillo-Santisteve & Lopalco, 2014; ECDC, 2015a).
The trend towards harmonising NIPs is especially strong in the EU and essentially relates to the interconnectedness of the member states, as the following argument by the Vaccine European New Integrated Collaboration Effort (VENICE) III project shows: “[t]he impact of a vaccination programme has an impact beyond political borders of a state, especially in the European context where people migrate and travel freely” (n.d.). Despite this, European countries reach different conclusions regarding the necessity of varicella immunization. From an anthropological and sociological perspective these differences make varicella an interesting
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and relevant example to explore immunization decision-making on policy level. If, as policymakers tend to claim, immunization policymaking is based on objective criteria and evidence, why do countries come to different decisions about varicella vaccination?
This thesis explores national decision-making processes about varicella in Germany, the United Kingdom (UK), and the Netherlands. In view of aforementioned arguments regarding possible influences upon immunization policies, the following sub-questions will be discussed:
- How did the selected EU states reach their conclusions about (not) introducing the
varicella vaccine?
- What was the role of evidence as well as professional and public opinion in
decision-making processes about (not) adding the vaccine into national immunization programmes?
- What are the public’s and healthcare professionals’ perception on the varicella
vaccine in terms of risk and desirability?
At the time of writing the UK is no longer part of the EU. However, the decision about varicella vaccination was reached before Brexit took place. Therefore, the UK illustrates a legitimate example for this research. Special attention will be devoted to the Netherlands because the Dutch Health Council (HC) is currently preparing its advice on varicella vaccination. A decision is expected to be made in the second half of 2020.
The elaborations in this thesis are based on methodological triangulation. Drawing upon historical research, qualitative document analysis is used to examine previous decision-making. To give insight into professional and public opinions about varicella immunization a small scale qualitative online research and semi-structured interviews with Dutch healthcare professionals (HCPs) were conducted.
The conceptual framework for evidence-based decision-making proposed by Dobrow, Goel and Upshur (2004) is used to explore the utilization of evidence in varicella related decision-making. Their “practical operational” approach allows for understanding evidence as contextual and subjective, which provides a foundation to analyse how the selected countries reached different conclusions, even though all legitimise their decision through reference to evidence. Klein’s (2000) approach to think of policies as experiments is used to shed light on varying implementation practices. The relational theory of risk, borrowed from Boholm and Corvellec (2011), is introduced to make sense of perceived risk dynamics. This approach
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understands risk as culturally informed and allows for the examination of the interpretative nature of risk. To further analyse social desirability and acceptance beyond risk perceptions, Nichter’s (1995) distinction between “active demand” and “passive acceptance” is utilised. Implications from the normalisation process theory (NPT) (May & Finch, 2009) are used to frame social acceptance of vaccines over time.
The goal of this thesis is to contribute to the current vaccination discourse with a focus on policy decision-making. It also aims to open up the discussion about chickenpox vaccination from HCPs and the public’s perspective and thus give insight into aspects that might be relevant to consider before including the varicella vaccine in NIPs.
In the second chapter previous research in the domain of immunization policymaking and vaccination perspectives, as well as the concepts used for analysis are reviewed. The third chapter presents methodological and ethical considerations. Chapter four discusses the epidemiology of varicella and the emergence of the vaccine. Chapter five and six illustrate the heart of this thesis and consist of the presentation of the research findings. The thesis concludes with interpretations and implications drawn from this research and a discussion of its limitations.
2. Methodological and theoretical inspirations
Building upon an earlier trend towards evidence-based medicine, evidence-based approaches became prominent in health policy and health research during the 1990s and have gained wide popularity since then. One reason for this development is that these approaches provide information and tools to help with setting priorities (Niessen et al., 2000). They have become essential for the goal of increasing effectiveness and efficiency of health services in accordance with financial considerations. Underlying this notion are positivist models of science and rational models of policymaking. Advocates of the evidence-based narrative argue that properly funded and correctly positioned scientific research can and should have an influence on medicine and health policy. In this context clinical research based on the methodology of the randomised controlled trial has come to inhabit a superior position over other types of evidence and knowledge (Berridge & Stanton, 1999).
Klein (2000) explains the sentiment behind the idea of evidence-based health polices as follows:
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“The notion is as seductive as it is simple: if evidencebased medicine […] is desirable then so, by definition, is evidence-based policy […]. Just as no-one would argue that clinicians should practise medicine without regard to evidence, so it would seem an incontestable, self-evident proposition that policymakers should base their decisions on evidence. If anything, it would seem even more important for national policy-makers, as distinct from individual clinicians or local managers, to depend on the best available evidence in making their decisions since these are likely to have greater impact” (p. 65).
He then, however, goes on and explains why the concept of evidence-based policies is contestable and misguided for two reasons. First, the concept of evidence is perceived as unproblematic. Second, the notion is based on a simplistic view of the policy process because it assumes that policymaking can and should be separated from politics.
Klein is not alone in this opinion. Various scholars criticise the narrow scientific conception of evidence and point out prominent hierarchies (e.g. Dobrow et al., 2004; Miles et al., 2000) Nevertheless, the argument of evidence-based decisions is especially appealing for immunization policymakers. Among the wide range of available and often expensive vaccines, prioritisation is necessary, and a standard set of criteria based on scientific data provides a framework for such. Moreover, policymakers are faced with the challenge of legitimating their decisions towards the public, but also the international community. Especially delays in the introduction of new vaccines have become subject to criticism and need to be justified. In this regard the reference to evidence can support decisions in that it (allegedly) provides transparency of the decision-making process and soothe doubts (Blume & Tump, 2010). Historical studies on previous introductions of vaccines show how multifaceted this process is and how factors besides evidence play a crucial role. NIPs are embedded in social, economic, and political histories, as well as linked to ideologies, and notions of identity (Holmberg, Blume & Greenough, 2017). They are further shaped by contemporary local, national, and international politics, economic arguments, as well as social demand and acceptance. Therefore, contrary to the rational evidence narrative, immunization policy decisions are most definitely not based solely on objective and measurable criteria (Hagen-Berg & Blume, 2020). In addition to that, various scholars point towards the non-determinant character of scientific and medical data.
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In this regard, Bryder’s (1999) work on the Bacillus Calmette-Guérin (BCG) vaccine against tuberculosis is highly insightful. In her analysis she focuses on the different responses to the vaccine in Scandinavia, Britain and the USA. BCG was discovered in 1921 in France and while Scandinavia soon adopted the vaccine with enthusiasm, it was not introduced in Britain until 1950 and never used on a large scale in the USA. Bryder discusses how all three countries claimed that their policies were rooted in scientific research and how the interpretation of the same data, combined with some locally conducted research, lead to such different results. She concludes that the different approaches were driven by social policies and their underlying ideologies. Nationalism combined with scepticism towards research conducted abroad and consequent competitiveness within the scientific community, as well as central institutions and their (non) preparedness to alter their foci played a role. Essentially, the different approaches towards the vaccine seemed to mirror the welfare traditions and systems of the countries.
Blume and Tump (2010) emphasise the contextual nature of evidence and its use in policymaking. Based on document analysis of the introduction of the measles, mumps and rubella (MMR) vaccine in the Netherlands the authors make two claims. First, the significance attached to certain forms of evidence may change in the course of decision-making processes, because the decision-making context changes. Second, during the decision-making process results from international data became gradually more important than locally gathered evidence. This increasingly international orientation influenced national scientific competences.
Premised on comparative analysis of the introduction of the MMR vaccine in Denmark and the Netherlands, Hagen-Berg and Blume (2020) aim to take aforementioned arguments further. Both countries introduced the MMR vaccine in 1987, a full decade after the USA, even though they both were small welfare states with well organised NIPs. The authors suggest that this delay came about due to reasonable reflection of each country’s concerns, disease perceptions, and already adopted technological approaches. The countries’ decisions were influenced by political and ideological changes of that time, which included a growing emphasis on costs and benefits, and the growing influence of the international context. Hagen-Berg and Blume’s conclusions relate to Wiese-Posselt, Reiter, Gilsdorf, and Krause’s (2009) discussion about unifying immunisation schedules in the EU. The authors suggest that reasons for reaching different recommendations despite using the same evidence are based
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on country specific values and goals, epidemiological situations, healthcare delivery systems, logistics of vaccine delivery, and economic situations.
Inspired by Blume and Tump (2010), this thesis incorporates the conceptual framework proposed by Dobrow et al. (2004) to make sense of the contextual nature of evidence. This framework for evidence-based decision-making focuses on “[h]ow context impacts on what constitutes evidence and how that evidence is utilised” (p. 208). Fundamental for their approach is the notion that based policy is qualitatively different from evidence-based medicine in that the decision-making context shifts from individual clinical level to population-policy level. Consequently, it becomes more uncertain, variable and complex, and because it affects larger numbers of people, explicit justification of decisions is needed. Their framework is based on what they term “the practical-operational orientation”. Contrary to the conventional normative evidence-based mindset which focuses on standardised characteristics such as reliability and validity, the practical-operational view claims that evidence is defined with respect to specific decision-making contexts and thus what constitutes evidence is inherently context based. Evidence in this sense is emergent and provisional and therefore incomplete and inconclusive. In summary, this orientation assumes that multiple factors contribute to a decision outcome and evidence is not defined by its quality, but by “[i]ts relevance applicability or generalisability to a specific context” (p. 209). The authors differentiate between internal and external context and divide the process of evidence utilisation into three stages: introduction, interpretation, and application of evidence. The internal context refers to the environment in which a decision is made. It includes the purpose for decision-making activities, the role of participants, and the processes used to attain an outcome. The internal context can be manipulated and controlled, unlike the external one. The external context accounts for the environment in which a decision is applied. This includes disease specific, extra-jurisdictional, and political factors. Both contexts influence decision-making in different ways at the various stages. The introduction of evidence refers to the ways in which evidence is identified and the channels through which it is brought into the decision-making process. In the interpretation stage the evidence is evaluated on its quality and generalisability. Finally, in the application stage the evidence is applied to support or justify a decision. Figure 1 illustrates this framework.
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It is also helpful to think of policies as experiments, as Klein (2000) suggests. As aforementioned, Klein criticises the common understanding of evidence-based policies, because it is based on a misunderstanding of policy processes and an exaggerated claim about what research can deliver. He claims, however, that policy processes are indeed driven by evidence, just not the kind that the scientific community seeks to favour. If we think of policies as experiments, we can understand how they produce evidence about their feasibility and effectiveness during the implementation process. This kind of evidence is based on experience and not scientific per se, but this does not make it less legitimate for policies. While administrative channels provide evidence about the implementability of policies, the political channels provide evidence about their acceptability. This kind of evidence is determining for policies. As Klein puts it: “[i]f a policy is not implementable or acceptable, then self-evidently it is not worth pursuing - whatever research may say” (p. 65). This is especially relevant for immunization policies, because their success is ultimately dependent on people’s acceptance and can therefore not be neglected. Furthermore, due to the increasing international orientation in immunization policymaking, other countries’ experiences with certain vaccination policies have become relevant for national decision-making.
The importance of people’s opinions about vaccines is reflected in the broad spectrum of available studies. Previous research on vaccination attitudes is generally prone to focus on parents. However, research on the perception of HCPs has been conducted too. The research focus varies, while some studies focus on the perception of one specific vaccine, others provide a general assessment (e.g. Yaqub et al., 2014; Mills, Jadad, Ross & Wilson, 2005;
Figure 1. Conceptual framework for context-based evidence-based decision-making. Reprinted from
“Evidence-based health policy: Context and utilisation”, by M. Dobrow., V. Goel. & R. Upshur, 2004,
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Wallace et al., 2014; Eritsyan, Antonova & Tsvetkova, 2017). Some research includes qualitative methods, however, most studies that give insight into opinions about vaccination tend to be of quantitative nature.
As Eritsyan et al. (2017) point out, a qualitative approach can reveal other factors playing a role in vaccination attitudes, besides cognitive beliefs. Inspired by this, this thesis makes use of a qualitative approach.
Against common assumptions, some studies showed that reasons for vaccination attitudes do not necessarily relate to misinformation or lack of awareness. Reasons that relate to mistrust are more common than reasons due to information deficit. In this context, trust refers to trust in HCPs, but also trust in institutions through which information about vaccines is delivered (Yaqub et al. 2014). However, work that sheds light on misconceptions and lack of information has also been conducted (Hollmeyer, Hayden, Poland, & Buchholz, 2009). Another factor that influences the acceptance of vaccines are risk perceptions regarding the vaccine and the disease it aims to prevent (Lagoe & Farrar, 2015).
Research on HCPs’ vaccination attitudes and behaviours suggests that their perceptions may influence their recommendations for patients (Paterson et al., 2016). This makes their opinions an important factor to consider when introducing a new vaccine. Hence, the semi-structured interviews for this research were conducted with HCPs.
To make sense of influential aspects on people’s perceptions of vaccines Nichter’s approach and the relational theory of risk by Boholm and Corvellec are helpful. In the context of introducing new vaccines Nichter (1995) distinguishes between active demand and passive acceptance. Active demand refers to the benefits of and need for specific vaccinations, while passive acceptance implies compliance and yielding to recommendations and social pressure. Central concepts for active demand are trust and legitimacy of policymakers’ decisions, meaning that if these aspects are lacking, people tend to feel the need to reinterpret information about vaccination or seek additional sources of information. This approach is useful for exploring the dynamics of desirability of varicella vaccination. It was developed in relation to lay populations and the concept of trust has mainly been used to understand vaccine hesitancy of lay people as well. Through applying this approach to the semi-structured interviews, I aim to expand the discussion to HCPs.
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As part of the relational theory of risk Boholm and Corvellec (2011) differentiate between a risk object and an object at risk. The relation between the two is described as follows: “[r]isk emerges from situated cognition that establishes a relationship of risk between a risk object and an object at risk, so that the risk object is considered, under certain contingent circumstances and in some causal way, to threaten the valued object at risk” (p.175). This approach understands risk situations as culturally informed. It further allows for the examination of the interpretative nature of risk and sheds light on the questions of how and why something is considered a risk. This is applicable for not only understanding the perspectives of groups, but also for making sense of individual assessments. In respect to vaccination, the relational theory of risk allows for analysing different attitudes towards the relationship between the virus/disease and the vaccine, but also the relation between new vaccines and existing programmes. This is highly relevant for varicella, because of its epidemiology and reputation as mild disease.
Social acceptance is a complex and dynamic process (Wolsink, 2018). The normalisation process theory (NPT) is an attempt to explain how some practices become normalised while others do not. It is a middle-ranged action theory and the proposed model consists of three stages: implementation, embedding, and integration. The focus lies upon how actors actively work to integrate and sustain new technologies into routine (May & Finch, 2009). Since neither the research questions, nor the data address how involved actors work on normalizing vaccines, the theory cannot be applied in this sense. However, the framework is borrowed to explore gradual acceptance of vaccines over time. Although this research focuses on perceptions and not actions, it cannot be denied that a variety of actors is constantly involved in routinising and sustaining vaccination, especially policymakers and HCPs.
3. Research methodology
At the beginning of fieldwork, I conducted informal interview in order to get familiar with the field. Subsequently, data collection for this thesis was based on the following three methodological pillars: five semi-structured in-depth interviews with Dutch HCPs, online research on the social media platform Reddit, and qualitative document analysis. This combination allowed me to gather data, while not solely depending on the availability of
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research participants and face-to-face conversations, which was fundamental for conducting feasible research during the COVID-19 outbreak2.
3.1 Qualitative interviews
Green and Thorogood (2004) define interviews as a “[p]articular kind of conversation” (p. 79), which is directed towards the researcher’s need for data. According to their elaborations on qualitative methods for health research, the informal interview resembles natural conversations in which data is gathered opportunistically, meaning that these interactions are not thoroughly structured and prepared.
Attitudes and language are not only individual but can also differ considerably among professions. Since I do not have a medical background, but aimed to work with medical professionals, it was necessary to get used to talking about my research to people who received biomedical training. Hence, an essential step at the beginning of fieldwork was familiarising myself with the field in a practical manner. In order to do so, I conducted three informal interviews with people from my personal network who study or have studied medicine in the Netherlands. These conversations provided me with valuable input on the role of vaccination in the broad spectrum of (Dutch) medical education and were highly insightful in order to further specify the target groups. Additionally, they were useful to get a sense for the visibility of the research topic for HCPs and allowed for discussing aspects which I have not thought of before. In that sense they were also a suitable preparation for the interviews that followed.
The first of the three main methodological pillars this research is built upon is the semi-structured in-depth interview. “Semi-semi-structured” implies that the researcher sets the agenda regarding the topics that should be covered in the conversation. However, ultimately it is the interviewee’s responses that determine what kind of information is produced about the topics and the relation of their importance (Green &Thorogood, 2004). This means that even though I did have expectations based on the literature and theoretical assumptions, I tried to avoid leading the conversations into a certain direction. “In-depth” indicates that the interviewees
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should have enough time to “develop their own accounts of the issues important to them” (Green &Thorogood, 2004, p. 80).
I conducted five semi-structured in-depth interviews with Dutch HCPs. The interviewees consisted of two general practitioners (GPs), two nurses working in child health clinics (consultatiebureaus), and one GP in the second year of training (arts in opleiding). I was able to get into contact with the interviewees through my personal network, e-mail, and snowball sampling. In preparation of these interviews I created an interview guide which was based on issues that came up during the informal conversations, literature, and the research questions. Rather than predetermining the conversations, this guide was used as a reminder for relevant issues.
The semi-structured in-depth interview was highly eligible for exploring HCPs’ opinion about varicella vaccination, because it allows space for the interviewees to answer on their own terms. Through covering the same topics or even questions, some structure for comparison is provided as well (Edwards & Holland, 2013). The interviews were documented in agreement with the respondents. Since face-to-face conversations were hardly possible during the COVID-19 pandemic, all interviews but the first (which took place before official measures were implemented) were conducted over the video conference software Zoom. As with any form of online communication, some difficulties arose from technical issues and influenced the conversations. However, ultimately there were no severe issues.
3.2 Online research
The understanding of online research in this thesis is based upon Hooley, Marriott and Wellens’ (2012) elaborations. They describe online research methods as “[a]n approach to finding out about people and the social world they inhabit, using the internet” (p. 3). The social media platform used for this part of the research was Reddit, where (mainly anonymous) users submit content in the form of links, text posts, and images. This content can then be rated and commented by other members. The posts are organized by subject into user-created communities which are called “subreddits”. As with any community, when trying to get in contact with members one should be aware of common rules and language and in this case it was no different. Having never used Reddit before, I needed to familiarise myself with the way things work and users interact with each other first (depending on the community the rules
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and language can be quite different). Eventually, four medical communities and one Dutch community seemed to be fitting for the research.
I created posts in the chosen communities to which other users could respond through comments, to which I could respond again and so on. In these posts I introduced myself as a medical anthropology and sociology student at the University of Amsterdam who writes her master’s thesis on what people think about the chickenpox vaccine, included a brief summary of the research background (that there is a discussion on whether it makes sense to implement it in NIPs and that policies vary between EU countries) and asked what the users think about that. In the Dutch community I mentioned that chickenpox is a candidate for the Dutch immunization programme and asked what the users think about including it. In terms of privacy and transparency I ensured that I would not use anyone’s username in my thesis and invited people to ask questions about my project. Contrary to my assumption that there might be little interest in discussing chickenpox during the COVID-19 outbreak, there were several responses. The interactions occurred mainly between me and individual users directly, in-depth discussion among other users did not spark.
This course of action can best be described with what Keim-Malpass, Steeves and Kennedy (2014) term “self-identified active analysis”. In this approach the researchers identify themselves and their research interests a priori. Due to transparency and ethical considerations, self-identified active analysis seemed to be the most appropriate way to go about online research.
Initially, I planned to use online research as inspiration for the semi-structured in-depth interviews and to get insight into relevant issues regarding the primary research questions. However, after adjustment of the research focus, it proved to be a valuable and feasible method in order to explore public attitudes towards varicella vaccination during a global state of emergency when face-to-face interaction was not possible.
3.3 Document analysis
According to Bowen (2009) document analysis involves skimming (superficial examination), reading (thorough examination), and interpretation. He further points out that although documents can be a rich source of data, they should not be treated as necessarily precise, accurate, or complete recordings of events.
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Following his approach, I began with a preliminary skimming of sources. This enabled me to determine which documents are relevant for the research and need further assessment. It also provided an overview of relevant issues and arguments. To then examine the documents thoroughly, I made use of deductive and inductive coding. For this step the qualitative analysis software ATLAS.ti was used. Based on the literature I was familiar with pertinent issues that commonly arise during the implementation process of new vaccines. A network with these subjects served as visualization of potentially important categories and as initial coding scheme. I used inductive coding to identify further categories and continuously expanded the scheme while reading3. Through this combination it was possible to organise the data in
accordance with the research questions without reducing them to presupposed categories. Simultaneously, I took notes and created timelines to acquire an overview of the developments in each country. The interpretation built upon the frameworks for contextualizing evidence and understanding policies as experiments.
3.4 Analysis of interviews and online data
To make sense of the data thematic analysis (Braun & Clarke, 2006) was used. The first step of the analytical process was to transcribe the recorded interviews using the software f4transkript. For this purpose, Dresing and Pehl’s (2018) elaborations on a semantic-content transcription system provided guidance. This approach enabled me to focus on the content of the conversations while also including non-verbal information to capture the interview dynamics. Due to limited time, practicalities, and considerations regarding representation I did, however, not stick entirely to the rules suggested by the authors. For example, I did not smooth out language as much as advocated. At this point I would like to highlight that transcription is essentially selective and brings with it the risk of biasing (Kowal & O’Connell 2014). Despite my endeavours to restrict my influence through careful listening and transcribing, including non-verbal elements, and reflection of the co-construction of the data, this applies to this thesis as well and the transcriptions should not be accepted uncritically as complete representation of the interviewees’ perspective and performances, but rather as means to gain insights into those.
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To get an overview of the data the second step was to go through the transcriptions and to identify re-occurring themes. Afterwards, I used inductive coding to organise the data in detail and to allow unexpected issues to be brought to attention. Next, I used screenshots to record the online data and proceeded to code them openly as well. For the coding process ATLAS.ti was used again.
In a following step I identified themes in more detail through grouping the codes. Subsequently, I created a network with the themes to map out how they relate to each other and to visualise these connections. A mind map followed by a linear scheme helped to delve further into these connections and elaborate on the structure of the respective chapters4.
Although described chronologically, the data analysis was ultimately a recursive process going back and forth between the phases. Similarly, the interpretation process consisted of going back and forth between the data, chosen literature, and theoretical concepts.
3.5 Ethical considerations
The statement on ethics by the American Anthropological Association (2012) and the ethical guidelines for student research by the Graduate School of Social Sciences, University of Amsterdam (2019/20) served as basis for ethical reflections during this research. I did not work with highly vulnerable groups. Nevertheless, the participants can be exposed to social harm, such as consequences regarding their career or social scrutiny. Therefore, the main ethical issues for this research included informed consent, anonymity, and data protection. The specific measures taken to handle these issues varied according to the used method. For the semi-structured in-depth interviews consent was obtained in written form. In this respect, I always tried to be transparent about my intentions and openly discuss them. The interviewees received an information letter and consent form before the interview took place and during the interview I asked whether they have any questions regarding myself or the research project. The following subjects were included in the consent form:
- Information about myself and contact details - Topic and aim of my research
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- Information on the possibility to withdraw from the study at all times without reason
- Transparency about the methods used (recording of the interview audio,if the interviewee agrees)
- Information about how long the data will be stored and how I will ensure data protection
- Information on what will happen to the data (including the intention of publishing and using quotes)
In order to minimise risk, the participants, affiliations, and locations were anonymised from the time of transcription onwards and the participants have been assigned pseudonyms5.
Additionally, I tried to ensure data protection to my best abilities. This included keeping the signed consent forms separate from the gathered data so that connections cannot be made easily, refraining from uploading data to online clouds or other platforms, and encryption of files and folders.
While the mentioned guidelines apply to online research as well, the practicalities of ethical decision-making regarding this part of the research were not as straight forward. Online research takes place in different dimensions than traditional research. Even though I considered the same issues as with the interviews, I had to think them through differently. In this regard the ethical recommendations by the Association of Internet researchers (2012) and a lecture on digital ethics in online ethnography by Hupli (2020) were helpful. Additionally, I had the opportunity to get direct input on uncertainties from the lecturer Aleksi Hupli. Ultimately, I decided to obtain consent through my post on Reddit. As aforementioned, I introduced myself as a student, included information on my project, and invited people to ask me about it should they have any questions. Based on this, I considered people’s participation itself as a form of consent. I did, however, not include my name and I am aware that this is a point of criticism. I decided to do so because it is highly uncommon to reveal one’s name on Reddit and I also considered potential consequences for myself. Nonetheless, should someone be interested in my work, connections can be made, and I am of course transparent if someone asks me about it.
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The issue of participants’ anonymity regarding online research is more complex. On the one hand, I did not want to expose any participants. On the other hand, Reddit users are aware that this platform is a public space where posts and comments can be accessed easily and use pseudonyms. Based on that I tried to find a middle ground. I made clear in my post that I would not quote anyone’s username. Nevertheless, due to reasons of transparency I decided to not delete the data after my thesis is finished, which means that readers can look up the online discussions. The participants deliberately wrote about their thoughts and (sometimes very personal) experiences regarding varicella vaccination and can delete their comments should they wish to do so. Deleting the posts myself would feel like disrespecting their decision to share and taking away their choice on whether their comments should stay public.
Even though the discussed issues were dealt with in certain ways, the ethical process is still ongoing. The responsibility of confidentiality and data protection does not stop with the final version of this thesis and new issues might arise even after the research project and thesis are finished.
4. Varicella: Pathology, epidemiology and development of a vaccine
The VZV is a neurotropic human virus and member of the herpesvirus family (Warren-Gash, Forbes, & Breuer, 2017). Like other herpesviruses, VZV can persist in the body as a latent infection after primary infection, in this case in the sensory nerve ganglia (CDC, 2015). VZV is endemic to all countries worldwide, with some geographic differences (Warren-Gash et al., 2017). It is highly contagious, resulting in about 96% of people who are not immune developing the disease when exposed to this virus. Since the virus is airborne, transmission occurs through mouth and nose, but infection can also be contracted through direct contact with skin lesions. If a pregnant woman has varicella, the virus can be transmitted to the baby during pregnancy and birth (ECDC, 2019).
The first infection leads to varicella, also known as chickenpox. Generally known as a childhood disease, the effects of varicella are usually not severe. Around 90% of cases affect children under the age of fifteen, the majority of whom recovers quickly (ECDC, 2019). The incubation period ranges from 10 to 21 days, with 14 to 16 being the most common. It can be prolonged in immunocompromised patients and through postexposure treatment with a varicella antibody containing product (CDC, 2015). The typical symptoms resemble the common cold,
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followed by a high temperature and a very itchy, vesicular rash. Nevertheless, complications such as infections of the skin, lungs (pneumonia), and brain (encephalitis) can occur. Groups most at risk for complications include pregnant women, immunocompromised individuals, infants, and adults (ECDC, 2019). Affected patients are infectious from one to two days before the rash develops and until the vesicles are dry (PHE, 2019).
After recovering from varicella, patients usually develop a lifelong immunity to the virus. However, the reactivation of the virus can result in HZ, otherwise called shingles. This reactivation can be caused by weakened immune defences due to stress, illness, and medication. The most common reason for reactivation is old age (Harvard Health Publishing, 2019). HZ can occur in children and is common in immunocompromised individuals of any age. The virus can be transmitted from HZ lesions to susceptible individuals and cause chickenpox, but so far there is no confirmation that HZ can be acquired from individuals with chickenpox (PHE, 2019). The symptoms of shingles usually start with pain in the area of the affected nerve, followed by a rash of blisters. While the rash normally lasts around seven days, the pain can last longer (ECDC, 2019). As with varicella, complications in HZ can arise. These include post-herpetic neuralgia (PHN, a debilitating neuropathic pain syndrome), ophthalmic involvement, neurological complications, exacerbations of underlying cardiovascular disease causing stroke and myocardial infarction, as well as the possibility of disseminated disease. The treatment for VZV infection in immunocompetent patients is usually symptomatic (Warren-Gash et al., 2017).
While clinical descriptions of HZ infection go back to antiquity, chickenpox was characterized as a form of smallpox in the 17th century. The distinction between chickenpox and smallpox
was made at the end of the 19th century. Even though varicella and HZ were investigated
continuously, and there was an explosion of medical writings on both in the 18th and 19th
century, their relation was not clarified until the second half of the 20th century.
Simultaneously, inspired by Michiaki Takahashi's observations of a family member with severe chickenpox and fever, Takahashi and colleagues generated the first varicella vaccine in 1974 in Japan (Galetta & Gilden, 2015). The so-called vOka vaccine is a live attenuated varicella vaccine, meaning that it derived from Oka strain from wild type VZV. Initially developed to prevent severe or fatal varicella among immunocompromised children, the vaccine showed to be safe and effective, which is why it is now incorporated in NIPs in some countries. Since this vaccine is attenuated, it establishes latency like the wild type VZV and therefore has the
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potential to reactivate and cause HZ (Warren-Gash et al., 2017). Additionally, it is contraindicated in immunocompromised individuals and during pregnancy (WHO, 2014b). In those cases, varicella immunoglobulin provides an alternative for acquiring immunity. Based on the vOka vaccine, the HZ vaccine Zostavax was developed in 1992 (Galetta & Gilden, 2015). Zostavax is live attenuated as well and more concentrated than vOka (Warren-Gash et al., 2017). A recent development in HZ prevention has been the inactivated vaccine Shingrix, which is eligible for immunocompromised people (Galetta & Gilden, 2015). Prior to vaccination VZV lead to almost universal infection. With the development of vaccines, the VZV has become the only human herpesvirus infection that can largely be prevented (Warren-Gash et al., 2017).
Several monovalent (only varicella) and combined (with MMR) vaccines are currently authorized in the EU. Even though the vaccines have shown to be safe, there are several uncertainties and concerns regarding their implementation into NIPs. Controlled clinical studies showed that monovalent and combined vaccines are highly immunogenic and efficacious in preventing varicella disease. Vaccine efficacy is higher against severe varicella than against less severe varicella. Nonetheless, breakthrough infections can arise. These are cases of wild type varicella that occur in a vaccinated person more than 42 days after vaccination following exposure to the wild-type virus. Uncertainties regarding varicella vaccination include the duration of immunity, the risk of breakthrough cases many years after vaccination, the need and optimal timing of a second dose, and long-term effects of varicella immunization further than fourteen years (ECDC, 2015a).
A common concern regarding the implementation of varicella immunization is the possibility of a shift in age of infection from children to adolescents or adults due to suboptimal vaccination coverage. A decreased exposure to VZV in the population could induce an older age distribution of the remaining cases (WHO, 2014b). Since older individuals are prone to develop a more severe course of disease, such a development would result in a higher disease burden. In this regard the WHO states that vaccination coverage that remains under 80% may “[r]esult in an increase of morbidity and mortality despite reduction in total numbers of cases” (2014b, p. 284). Additionally, uncertainties regarding how VZV vaccination influences HZ incidence exist. As aforementioned, the vOka vaccine establishes latency and reactivation can cause HZ. However, vOka is less likely to reactivate than the wild type virus (Sadaoka et al., 2016). One argument against universal vaccination is that immunity may be boosted by
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exposure to the virus. If this assumption proves to be correct, low exposure to wild type VZV could potentially lead to an increase in shingles. Nonetheless, so far countries with varicella immunization programmes have not shown a shift in the age of infection or an increase in HZ incidence (Carrillo-Santisteve & Lopalco, 2014).
Further concerns include the lack of data on the incidence of varicella complications to inform cost-effectiveness models (Warren-Gash et al., 2017). Currently there is no standardized case definition for varicella at EU/EEA level. Consequently, countries use various definitions and (if existent) varicella surveillance systems. These circumstances may not only limit cost-effectiveness modelling, but also the evaluation of varicella vaccination programmes and their effects (Carrillo-Santisteve & Lopalco, 2014).
5. Varicella immunization decision-making in the EU
Efforts towards standardising immunization programmes among the member states are continuing in the EU. This trend aligns with general cooperation endeavours and collaborative goals and is linked to the sentiment that diseases do not stop at political borders. In consideration of freedom of travel and high migration rates the cross-state impact of NIPs is recognised and harmonisation of such has become desirable. Nevertheless, vaccination policies are still quite diverse, and the introduction of new vaccines is not homogeneous among member states (VENICE III, n.d.).
Both the WHO and the ECDC emphasise that the introduction of new vaccines should be an evidence-based decision. However, they also state that context specific factors need to be recognized as well. This includes local cultural values, social norms, prevailing attitudes, and preferences on vaccination. Additionally, the WHO accentuates that the systematic decision-making process should also incorporate long-term financial and other consequences of introducing the vaccine, which involves considering whether adding a new vaccine may cause burdens and thus worsen the whole programme’s performance (ECDC, 2015b; WHO, 2014a). In the majority of industrialised countries so-called “National Immunization Technical Advisory Groups” (NITAGs) inform the decision-making about new vaccines (Duclos et al., 2012). NITAGs are expert advisory committees which are supposed to be independent and provide “[e]vidence-based recommendations to the ministry of health […], policymakers and program managers to guide policies and formulate strategies” (Blau et al, 2013, p. 2653). The role and
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tasks of NITAGs can, however, differ considerable between countries (ECDC, 2015b) and it has been suggested that these differences could potentially explain the disparities in access to vaccinations and immunization programs across Europe (Ricciardi et al., 2015).
Varicella is one example for diverse vaccination recommendations among EU members. While some recommend universal vaccination in children at national or regional level, others recommend vaccination for high-risk groups only or have no recommendation at all (Carrillo-Santisteve & Lopalco, 2014).
Immunization programmes tend to focus on the paediatric setting. In face of demographic changes towards older populations, increased vulnerability to severe infections and complications with age, it has been argued that vaccination provides a key element for healthy aging. However, vaccinating seniors raises different issues than vaccinating children and the potential of widespread vaccination of the elderly is rarely realised (Doherty et al., 2018). Due to age-related changes of the immune system most vaccines are less efficient in the elderly. Lower effectiveness in seniors impact cost-effectiveness analyses which makes vaccination programmes for this group a less attractive intervention for healthcare providers and may also affect people’s perceptions on the benefits of vaccination (de Gomensoro, Del Giudice & Doherty, 2018). Furthermore, most countries have little experience with vaccination programmes for seniors. The most common one is influenza, and some countries include pneumococcal disease and HZ as well. Compared to vaccination rates in children, the coverage rates of seniors are considerably lower. Reasons for this include low public awareness, lack of knowledge, poor infrastructure for adult vaccination, uncertainties, inconsistent recommendations by HCPs (de Gomensoro et al., 2018; Doherty et al., 2018) but also living alone, which points towards the social dimension of this issue (Jain, van Hoek, Boccia & Thomas, 2017). Against this background varicella related immunization policymaking depicts an interesting case study, because it targets both children and seniors.
Figure 2 was created for this thesis and provides a visual overview of historical developments regarding varicella vaccination with focus on its introduction into NIPs in the EU. In the following chapters the reasons for the varying decisions in Germany, the UK, and the Netherlands will be explored in detail. Each country represents a different situation regarding varicella vaccination, which makes them relevant examples for the research question at hand.
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In Germany universal varicella vaccination was implemented in 2004, which makes it the most experienced country among EU member states (ECDC, 2015a). In addition to that, shingles vaccination is offered to seniors aged 60 or older (RKI, 2019a). In the UK varicella is not part of the childhood immunization programme. The vaccine is only offered to people who are likely to encounter persons who are vulnerable to chickenpox. The shingles vaccine, however, is included for all seniors in their 70s (NHS, n.d.). At the time of writing neither varicella nor HZ vaccination are included in the Dutch immunization programme (RIVM, 2020). Based on the analysis of relevant documents, the distinct introduction-decisions relating to paediatric varicella and senior HZ will be discussed for each country in the following chapters.
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