“Vaccine hesitancy” was declared one of the top 10 threats to global health by the World Health Organisation (WHO) in 2019. A year later, the Covid-19 pandemic began to accelerate the trend of more parents reluctant or declining to avail of immunisations for their children. Now the world waits to see what the impact will be of vaccine sceptic Robert F Kennedy jnr in his new role of US health secretary at a time when once seemingly extinguished infectious childhood diseases are re-emerging amid declining vaccination rates.
“This is a disaster waiting to happen, and it will happen,” Paul Offit, a leading vaccine expert at the Children’s Hospital of Philadelphia, told the AFP news agency. Kennedy says he has only advocated for “common sense” policies on vaccine testing and safety.
The Republic was one of 52 out of 55 countries where the public perception of the importance of childhood vaccines fell after the start of the Covid pandemic, according to the children’s charity Unicef. It dropped 6 per cent in the State from 91.5 per cent to 85.5 per cent between 2019 and 2021. However, that was relatively modest when compared with, say, a tumble of more than 30 per cent in Japan to just 54 per cent.
“More than a decade of hard-earned gains in routine childhood immunisation have been eroded,” the 2023 Unicef report, For Every Child, Vaccination said. With confidence in vaccines appearing to be waning in many countries, particularly among younger age groups, “getting back on track will be challenging”, it warned.
Although the vast majority of children in Ireland continue to receive immunisations recommended by the HSE from the age of two months onwards, there has been significant slippage in uptake since 2020. This has consequences for the whole population, not to mention any child who might suffer distressing symptoms, lifelong complications or even death from vaccine-preventable illness.
These diseases have not gone away, says Dr Chantal Migone, consultant in public health medicine at the National Immunisation Office (NIO). Measles and whooping cough are a current case in point.
It is just 10 years since Ireland “eliminated” measles from the population for the first time in 2015, having met the WHO eradication target of fewer than one case per million of the population. Despite an outbreak the following year, linked to a single imported case, annual notified figures then dropped to under half a dozen for a few years before shooting up to 208 last year from just four in 2023.
Pertussis, commonly known as whooping cough, has surged from 18 recorded cases in 2023 to 713 last year, the Health Protection Surveillance Centre has said. But these are only cases confirmed by laboratory testing, generally just done for hospital patients. The actual numbers are likely to be far higher.
Vaccine hesitancy is complex, spanning a spectrum from those who accept immunisations with some doubts to those who do not but still wonder if they have made the right decision. Confidence is just one of three influential “C” factors, along with complacency about the risks of childhood diseases and the question of convenience of access.
The NIO wants to understand better the uptake decline in the Statein the wake of the pandemic. For example, Health Protection Surveillance Centre data shows the uptake of the measles, mumps and rubella (MMR) vaccine for junior infants dropped from 91.2 per cent in 2018/2019 to 87.5 per cent in 2021/2022. They recovered slightly to 89.8 per cent in the latest figures for 2022/2023, but are still considerably short of the 95 per cent needed for “herd” immunity.
“Is that just a little bit of what they call ‘vaccine fatigue’?” Migone suggests. “Or maybe we didn’t put as much emphasis in promoting childhood vaccines, understandably, during the pandemic because we were very focused on Covid-19.” The NIO is partnering with the Economic and Social Research Institute (ESRI) to “tease out what might influence parents' decisions to attend for vaccination ... and go into that in a little bit more depth”, she says. Issues arising can then be addressed.
Meanwhile, the HSE is offering parents additional vaccines for their babies. A pilot RSV (respiratory syncytial virus) immunisation programme for newborns between last September and up to the end of this month is showing significantly reduced infections. From the start of the scheme to the beginning of t December, 24 babies with the respiratory illness needed to be admitted to hospital, compared with 413 over that same period in 2023. Then, for babies born on October 1st last onwards, the chickenpox vaccine has been added into the free immunisation schedule at 12 months.
Migone believes that in general people who are uncertain about having their children immunised are not anti-vaccine. Those hesitating may have concerns, she says, but there can also be practical reasons such as struggling to get to appointments for babies and preschool children. “They have other things going on in their lives, which makes it difficult for them to bring their children for vaccination.” School-based immunisation programmes that kick in from junior infants onwards are much more convenient for parents – they just have to remember to sign the permission slips.
“We always say it’s okay to ask questions, but just get your information from someone that you can trust like your GP or your public health nurse,” Migone says.
There is always going to be a small number of people, young and old, who cannot be vaccinated for medical reasons, such as being immunosuppressed. Or some individuals’ immune system may not respond to a vaccine. “They rely on those around them to be vaccinated. If we get 95 per cent coverage, for example for the MMR vaccine, then measles doesn’t spread in the community.”
Analysis of the 2016 measles outbreak in Ireland, published in The Lancet in 2018, illustrates how easily such an infectious disease finds chinks. The first case confirmed, in May 2016, was in an adult who had returned to Ireland from Hungary three weeks previously and then travelled extensively in the southwest. It transpired, through tracing, he had contracted the infection from a Romanian child with measles flying to Dublin via Budapest on the same flight.
By September of that year, 40 linked cases had been reported, scattered through five of the eight public health regions. The vaccination status was known for 34 of those cases, of whom 31 were unvaccinated.
Vaccination is the single most important thing that we can do to prevent infection and to prevent against severe complications of infection including sepsis
— Dr Ellen Hayes
“The outbreak highlighted the ongoing susceptibility of the Irish population to measles due to persistent immunity gaps among children, young adults and particularly among vulnerable minority groups,” said the paper’s authors, led by Dr Peter Barrett of HSE South. This was demonstrated again by the bigger resurgence here last year.
GPs and their practice nurses have a vital role in informing and reassuring, particularly first-time parents. Co Waterford GP Dr Ellen Hayes says: “Vaccination is the single most important thing that we can do to prevent infection and to prevent against severe complications of infection including sepsis.” The routine two- and six-week check-ups after a baby’s birth are an ideal opportunity to discuss the issue.
In her experience there will always be some parents who are worried. “There’s a lot of disinformation about vaccines on the internet and that can lead to hesitancy about vaccination. You might often hear a mum saying, ‘I was at a mother-and-baby group and someone said to me that I shouldn’t have such and such a vaccine’.”
Hayes urges people to speak to someone with the required experience and knowledge about their concerns, such as a GP. There is also extensive, easy-to-follow information on hse.ie.
Common fears include babies being vaccinated so young and too many vaccines being given together. Babies at two months receive four vaccines, including the “6 in 1″ to protect against diphtheria, haemophilus influenzae b (Hib), hepatitis B, pertussis (whooping cough), polio and tetanus.
“Studies have shown that they’re just as safe and effective when they’re given together as given separately,” Hayes says. It also means the child is protected at a younger age and needs fewer injections. “I think it’s a really good thing that vaccines are given at such an early age because we know that infants and younger children are one of the most vulnerable peoples in our society.”
The dramatic increase in whooping cough means it is infants who are most likely to become seriously ill from this highly contagious infection of the respiratory tract, she says. They are at risk of severe complications such as pneumonia, seizures and inability to breathe. Not only is it important that they be vaccinated at two months, but their mothers should also have a pertussis vaccination between 16 and 36 weeks of pregnancy, which will protect their newborn from birth.
Hayes still sees hesitancy around MMR vaccine, due to “bad science”, she says. Discredited work led by Andrew Wakefield in the 1990s suggested a possible link between the vaccine and autism, spooking many parents and causing a slump in uptake.
Vaccination of babies and preschool children is mostly done by nurses in GP practices. They want parents to make informed choices, says advanced nurse practitioner Sharon Kinsella, who is public relations officer of the Irish General Practice Nurses Educational Association. “It’s very important that we listen to the parents and give them the information.”
Kinsella likes to remind parents how vaccinations have hugely decreased mortality and morbidity from common diseases. (Before the introduction of a vaccine in 1963, measles killed an estimated 2.6 million people globally every year, mostly children. By 2023, that had fallen to 107,500.)
I got measles. I ended up in hospital ... in an oxygen tent
— Advanced nurse practitioner Sharon Kinsella
While parents might worry about potential side effects, doing nothing about immunisations carries higher risks. As a child, Kinsella herself was not vaccinated because her own mother had a huge fear of potential side effects. “I got measles; I ended up in hospital ... in an oxygen tent.” She and siblings also got very sick with smallpox and her brother was hospitalised. She still has scar tissue on her lungs due to whooping cough.
By sharing this with new parents, “it sometimes brings home the importance of availing of immunisations, when there is a person sitting in front of them who had those diseases”.
Nurses like to allow extra time if possible for a parent bringing a baby for vaccinations for the first time, to help make the visit as calm as possible. They go through common side effects such as a high temperature or lump on the leg, and encourage parents to ring in if worried. Concerns they have the next day could create a cycle, she suggests, of them not being happy to return for future vaccinations.
Kinsella, who works in a Dublin GP practice, has had parents asking if they could wait another month before a baby starts immunisations. She always makes it clear that is their choice but warns that, in the interim, their baby is vulnerable. “What you don’t want is a parent saying, ‘You let me wait the month and then my child got meningitis and you never told me’.”
In relation to the relatively low uptake of the children’s influenza vaccine, which was reported as just 16 per cent at the start of December, Hayes wants parents to be aware that while most children will only get mild symptoms, some develop serious complications. In 2023, as many as 1,274 under-15s were admitted to hospital with flu.
In addition to the nasal flu-vaccine giving direct protection to children, there is also indirect protection for the extended family and the wider community. With 75 per cent of flu being asymptomatic, she says, “we can pass it on to the most vulnerable people, ie our older relatives or people who are ill, undergoing chemotherapy or are on immunosuppressant therapy”.
Mother of three and yoga teacher Ava Cummins did not hesitate to bring her children, now aged eight, six and four, for their immunisations. “I believe in science,” she says. But she listens with interest to other parents’ attitudes during the five-week courses on yoga and wellbeing for babies and parents that she runs in Waterford. It is a topic she introduces at the second weekly class and, in what is intended as a safe space, parents are encouraged to talk freely without fear of judgment.
In three years, Cummins has only heard two mothers say they were declining childhood vaccinations – and both occasions were in 2024. One mother said she had made that decision for her third child after her second child was diagnosed as being on the autism spectrum; the second mother did not wish to share her reasons.
Some, Cummins says, are apprehensive about side effects such as vomiting, diarrhoea, fever and being cranky. Others believe there are compelling practical considerations such as not being able to get their child into a creche without proof of vaccination. However, although all registered childcare providers are required to maintain an up-to-date record of the vaccines a child has received and may well ask to see their HSE immunisation passport, a decision not to take in unvaccinated children would be up to each independent service.
An Early Childhood Ireland spokeswoman says: “We have not heard of this forming part of an enrolment policy, so it would probably not be common practice.” But it is important providers know which children attending their service have been vaccinated and which have not, she says, “so that those children who are not vaccinated can be best protected if an infectious disease occurs within the service”.
Although it is 20 years since Cummins has lived in her native Poland, she says she believes there is more “scaremongering” about vaccines there. Her eldest child has a congenital eye condition that was only noticed when she was one years old, coincidentally soon after a round of immunisations, “and some extended family in Poland was already thinking, yes, that was the last vaccination”.
One mother, Elena, who describes herself as vaccine hesitant, was happy to allow her three children to have the standard immunisations as babies, including the MMR. “I felt it was around a long time and you could get unlucky, there was always that risk, but I did feel it was probably more necessary. But, with the Covid vaccine, I had a different take.”
Believing its development was too rushed and was being rolled out for such a large volume of people, Elena was adamant she would not have it. She did not allow her youngest child, who was y 10, to be vaccinated, but the two older ones no longer needed her consent.
The newness of the human papillomavirus (HPV) vaccine also worried her. She chose not to give permission, first for her daughter and then for her youngest after it was introduced for first-year boys in secondary school in 2019. Her daughter has since said she should have been vaccinated when it was offered to protect her against the risk of cervical cancer.
If one of my kids stood on a nail, I’d have to get them a tetanus injection. But I wouldn’t give it to them until they stood on a nail
A long-time practitioner of Chinese medicine, who spoke to The Irish Times on condition of anonymity due to a feared backlash, says he believes there is stifling of debate within the media, where a “particular narrative is spun” about vaccines. “It’s a tragedy, because if there was transparency, vaccine risks could be mitigated.”
He would argue for single-form vaccines, for instance. He says he has seen “lots of kids damaged by the MMR”, but “this sort of thing isn’t really kosher to talk about”.
Having trained in China in traditional medicine, which focuses on stimulating the body’s immune system, he decided against getting his children vaccinated, opting to treat them with homeopathy.
“I would prefer to wait until people get sick and then treat, rather than take the risk [of vaccines],” he says. “If one of my kids stood on a nail, I’d have to get them a tetanus injection. But I wouldn’t give it to them until they stood on a nail.”
He says most of the business at his Dublin practice is through word of mouth. Those who believe they or their children are suffering side effects of vaccines, predominantly the Covid-19 vaccine, “come as a last resort” because their own doctors will not countenance a link.
“The most poignant emotion I have picked up from concerned parents over the years,” he says, “is a sense of dismay and helplessness.”
Overall, though, trust in vaccines remains very high in Ireland but, Migone says, “it takes a lot of work by everybody to maintain that”. The NIO is well aware that, in the words of Unicef, “vaccine confidence is notoriously volatile”.
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