Author: Heidi Larson, March 7 2017 - It is not just in the US [United States] and Europe, where wealthier populations are among the most vaccine questioning. India recently launched a one-month campaign to vaccinate over 35 million 9-month to 15-year old children with a measles-rubella [MR] vaccine across five states. The campaign marked the start of a two-year initiative aiming to vaccinate over 400 million children across India - part of a larger global effort to eliminate measles and rubella.

By the end of first month of the campaign, it became clear that it was struggling to meet its goal. A different kind of campaign - fuelling a mix of conspiracy theories, safety concerns, and questioning around why the vaccine and the campaign were needed - was circulating on WhatsApp and Facebook. What's more, the rumours were taking hold in the wealthier southern states with generally the best education and health indicators in the country.

Last year, though, there were already signals of waning confidence reported in the newly launched National Family Health Survey (NFHS 2015-2016). While showing progress in immunization uptake in the poorer states, where an extra effort had been made, wealthier states were reported to have declining coverage. The most dramatic drop in immunization coverage was in Tamil Nadu - a decline of 10% over the past decade.

Perhaps it should have been no surprise that Tamil Nadu has struggled the most in the current measles-rubella vaccination campaign. The signals were there.

One official from the Ministry of Health and Family Welfare commented on the situation, noting that while Goa managed 90% vaccine coverage and Karnataka reached above 85%, Tamil Nadu only reached 50% of the children they were aiming to vaccinate, with considerably higher rates of non-acceptance in urban Chennai than in less social media-saturated rural areas. Private schools in Chennai posed a particular challenge, with parents there reporting anxieties about the safety of and need for the vaccine.

Every year in India, measles kills nearly 49,000 children, and approximately 40,000 children become deaf or blind because of rubella-related birth defects. The public health rationale for introducing the measles-rubella vaccine seemed clear. And, for those who don't trust interventions coming from afar, this vaccine was made in India.

Nonetheless, the rumours and misinformation went viral, provoking fears of sterilization and side effects as well as distrust of the motives of the campaign. Reflecting her uncertainty, one mother in Bengaluru was quoted in The Hindu expressing her concern that "It is worrying as to why the government is pushing vaccination on such a large scale." Although not specific to the vaccination campaign, coinciding widespread media coverage about Union Minister Kirin Rijiju's tweets saying that the Hindu population was getting smaller, added fuel to Muslim communities' suspicions about the motives of the MR vaccination campaign. Other concerns ranged from autism anxieties, to perceptions that the vaccine had been banned in the US and sent instead to India.

With such clear evidence of waning vaccine confidence reported earlier in the same year, an extra effort to dialogue with already known-to-be-hesitant communities before the campaign launched, may have helped to build trust and allow for higher rates of vaccine acceptance.

Perhaps.

Click here to access this blog as it was originally posted on the Vaccine Confidence Project website.

Image credit: NOAH SEELAM/Getty, via BBC News.

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