- bOPV —
- bivalent live oral attenuated polio vaccine
- IPV —
- inactivated polio vaccine
- OPV —
- oral polio vaccine
- WPV1 —
- wild poliovirus type 1
The May 28, 2013 isolation of wild poliovirus type 1 (WPV1) in routine sewage samples signaled the beginning of the first protracted incident of WPV1 transmission in Israel since 1988. A door-to-door catch-up vaccination program with inactivated polio vaccine (IPV) was initiated in the area where the isolations were first identified. Although no cases of paralytic illness were diagnosed, evidence of continued and widespread transmission among children <9 years old necessitated the reintroduction of live oral attenuated polio vaccine in a country-wide campaign on August 18.1 To maximize safety, the bivalent live oral attenuated polio vaccine (bOPV) used in 2013 was given only to children previously immunized with IPV.2
The campaign was accompanied by extensive public discussion, particularly in the online social networks. The authors describe their experience answering vaccine-related questions online from June through October 2013, 1 (K.L.) as a volunteer and the other (L.R.) as a representative of the Ministry of Health.
The Vaccine Campaign
The campaign posed several challenges to winning public confidence: the reintroduction of a previously discontinued vaccine, the silent nature of the transmission, and the targeting of children who were already protected to protect others.1 Initially, the Ministry of Health allocated resources to traditional media to address these issues; the social networks were neglected. Meanwhile, individuals and groups with an antivaccine agenda began in June to flood the Hebrew-language Internet with postings that denied the significance of WPV1 in the sewage, decried the use of live vaccine, and rallied to stop the “dangerous” campaign. The Ministry of Health opened a dedicated Web site to address public concerns, but more was needed in the age of social networking. Between May and August 2013 this gap was filled by independent blogs of individual doctors, microbiologists, and skeptics.
In August, antivaccination activists opened a Facebook group dedicated to stopping the vaccination campaign. A provaccine group countered by opening alternative group hosting volunteer doctors, scientists, and health professionals. Each day hundreds of new posts were answered. Considerable discussion was also taking place in general parenting groups. The online presence of provaccine activists attracted a vigorous response from antivaccine activists. Parents participating in the general forums read the experts answers side by side with the views of the antivaccine activists who monitored the same groups. In late August official public health staff were recruited by the ministry to join the volunteers in responding to issues raised in these Facebook groups.
The need for individualization3 was probably the most prevalent theme raised in the hundreds of posts on hundreds of threads that we answered over the next few months, sometimes >10 hours a day including weekends. Parents repeatedly questioned whether population-based recommendations were appropriate for their individual child. Explanations directed to the general public were often perceived as irrelevant to parents’ individual concerns. Facebook provided a critical venue where parents felt that they could be heard. That required answering hundreds of questions repeatedly, avoiding “copy and paste” that could cause loss of trust from the parents.
Parents were most interested in protecting their own children. They were reluctant to accept any level of risk to protect others. The role of vaccines in interrupting disease transmission in addition to providing individual protection had to be explained repeatedly.
The epidemiologic situation was novel and evolving. The spread of viral isolations and the changes in the vaccination campaign from IPV to oral polio vaccine (OPV) and from local to national required the public health staff to adjust messages over time. They may have been perceived as sending inconsistent messages and even being evasive when, in reality, this adjustment reflected recalibrations necessitated by the complexity surrounding the issues. We needed to learn to convey concepts of statistics, probability, vaccine efficacy, and risk assessment in the terse communications common in social networks.
The forums became venues to report adverse events in real time. Posts describing events occurring after receipt of the vaccine were transmitted to thousands of listening mothers and created an atmosphere of distrust toward the vaccine. This perception was in contrast to the actual 183 events that were reported among 105 children after 1 million doses. Our presence required us to simultaneously express empathy, maintain confidentiality and trust, and request more information, all the while trying to dispel unnecessary fears.
After the campaign, parents continue to turn to these forums with questions about vaccines. Although the ultimate contribution of our online activity to the 70% coverage (above the projected coverage) achieved for the campaign was not quantified, the quantity of posts, the number of participants, and their continuing use suggest that the professional presence on the forums played an important role in addressing public concerns.
The public increasingly looks for answers to their medical questions online, where every opinion is presented and given the same weight, from science-based medicine to misconceptions and lies.4 The immediate nature of social networks means that any question left unanswered by a professional will soon be answered by someone else. Maintaining an online presence was time consuming; for us it was a temporary but full-time job in addition to our regular work responsibilities. Moreover, the public is knowledgeable, and many of the questions raised were highly challenging.5 Questions about the epidemiology of polio and outbreaks were common and often difficult to answer. For some questions there were no answers. The authors spent hours researching the literature for evidence-based answers.
Were we to do it again, we would recommend getting involved from the outset. Social networks provide alternative and informal avenues for the dissemination of scientific medical information. Independent experts rely on receiving professional information in a timely and comprehensive manner from the organizations responsible for immunization policy. Professionals participating in the public discourse need access to as much information as possible. Questions about vaccine licensure and safety are particular areas of concern, where the official stance is of particular relevance. It is important that health professionals not shy away from the public discussion of immunizations to provide accurate and trustworthy information.4,6 We propose conducting regular public briefings for professionals regarding epidemiologic updates and current issues that concern the public.
There is a need to address the social vaccine concept directly and often. Vaccines work by providing individual-level protection and by interrupting transmission. Many immunizations work to protect the people not directly immunized; the rubella vaccine for infants and children and the pertussis vaccine for pregnant women and mothers are just 2 examples. Giving a greater and clearer voice to the role of vaccines in protecting the unimmunized is critical. If it were clear from the outset that vaccines work to prevent transmission to others, in times when it is particularly important to stress this role, this message would be more acceptable.4,6
Were we to do this again, we would suggest earlier involvement in social networks, regular briefing of knowledgeable professionals, and recruiting more professionals.
Social networks are an increasingly important4,7 but time-consuming medium for addressing vaccine concerns. Participating in these forums both addresses parental concerns and helps identify relevant concerns in a timely manner for policymakers. We posit that responses similar to those we describe will be crucial for public health campaigns and should be an integral part of future vaccine introductions. We encourage every health care worker to get involved in social networks, despite their challenges, to help bring medically accurate, science-based medicine to the general public in a nonmediated manner.
Example of a discussion in the provaccine Facebook group:
Mother: Is the state of carriage is for life? Is it limited? Is it a single event or can it repeat? Is catching polio from a person who is vaccinated with the OPV just like being vaccinated yourself?
K.L.: Carriage means carrying the virus in a person’s intestines. Not being sick.
Mother: Which means he is dangerous to others and not himself?
[personal questions to K.L.]
K.L.: Let’s compare it to soldiers. OK?
K.L.: Let’s pretend that our body is Israel and the antibodies are our soldiers. Assume all soldiers are located south of Tel Aviv. That means an invading army can get all the way to Tel Aviv. The soldiers will stop them there but not in Haifa, because there are no soldiers in Haifa (in this story).
The same happens in our body. The virus comes from the intestines. If there are no antibodies there, it can multiply with nothing to stop it. The antibodies will only stop it when it reaches the blood.
Mother: But it doesn’t stay in the intestines forever. The person isn’t sick.
K.L.: This is a different point of view. The important part is that during this time your child turns into a biologic weapon. The wild polio virus is using your child to get to a weak population.
Mother: You mean the virus is using my child to hurt others.
[Discussion related to other topics]
Mother: You wrote that a person needs 4 doses to be protected for life, but my child only got 2 doses of IPV.
K.L.: After 2 doses of IPV your child is protected from polio disease, but not from being a carrier, and is protected from OPV’s side effects. This protection needs another boost to be effective for a lifetime.
Mother: So he is protected from polio, even though he didn’t finish all the vaccines?
Mother: Thank you, I’m not worried anymore.
- Accepted May 16, 2016.
- Address correspondence to Keren Landsman, MD, MPH, Department of Community Medicine, Lady Davis Carmel Medical Center, 7th Michal St, Haifa, Israel, 3436212. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- Copyright © 2016 by the American Academy of Pediatrics