Vaccination: who is best equipped in the era of postmodern mistrust?

Public health is a science and profession with an impressive track record. It saved mankind from the horrors of smallpox and helps in preventing diseases and avoiding all kinds of health hazards. The Netherlands is currently going through a period of declining vaccination rates. Vaccination against human papillomavirus (HPV) as well as Herpes Zoster and Rotavirus is met with great suspicion and has become controversial, even among some health professionals.

In the public debate, the confidence in public health authorities is being questioned. There is a great deal of mistrust by a seemingly growing number of people, some of whom allege that the interest of the population at large seems to prevail over that of the individual. Some of the so-called ‘anti-vaxxers’ believe that measles vaccination may cause autism, pointing their fingers at the pharmaceutical companies for ignoring such claims. These perceptions are difficult to combat. Drastic solutions like making vaccination obligatory may help a bit, as well as improving patient-centred counselling, but they do not fundamentally tackle the root of the problem.

The underlying problem is predominantly mistrust. We, the Working Party for Family Physicians and International Health (in Dutch: WHIG), recommend that people who have a medical condition obtain their vaccination from their family practice. Family Physicians (FPs) in the Netherlands are independent professionals who provide continuous integrated care. They are expected to adhere to guidelines established by their professional organization (NHG, the Dutch College of General Practitioners). The fact that they are seen as independent creates trust among their patients, which justifies a stronger role for FPs in the provision of vaccinations.

For other public health activities, such as the provision of flu vaccination and cervical cancer screening, FPs receive a decent financial compensation and this has resulted in high coverage rates. This shows that general practices are already an appropriate place of choice for vaccination of specific target groups, including patients with some kind of health conditions (immune suppression, chronic diseases). In case patients are hesitant to get vaccinated, FPs commonly use instruments such as counselling and shared decision making. The benefits of vaccination need to be weighed against someone’s resistance to perceived intrusion or loss of body integrity. Sometimes people are even challenged to give up their religious principles against vaccination. Ideally, vaccination should be considered a positive choice, weighing the public interest of protecting society (as in the case of measles) against an individual’s desire for autonomy. Unless public health practitioners lend an ear to people’s concerns and objections and unless parents who worry about the possible side-effects of vaccination for their young children are taken seriously, popular support for vaccination will dwindle.

We as FPs postulate that some of the current policies inhibit optimal service provision and are not as effective as one would wish. Some examples:

• As family physicians and members of WHIG, we strongly believe in the benefits of travel advice in general practice as a low-threshold service for people intending to travel abroad. Many travelers go on holiday insufficiently vaccinated or counselled on other preventive measures. This is true in spite of the availability of excellent scientific advice from the LCR (National Coordination Centre for Travel Advice). Precisely here a FP can make a difference. We think it is a missed opportunity that FPs are not facilitated in providing travel advice services. This is also becoming increasingly relevant, as many (elderly) people with chronic conditions undertake trips that are not without risk. Certain occupational health services (KLM, etc.) and specialist clinics are undisputedly more specialized in providing travel advice than FPs. However, FPs have the advantage of having a long-term relation with their clients and being more familiar with their family situation, which is all the more relevant in case people return from abroad with an illness.
• In the HPV vaccination campaign, girls at the sensitive age of 13 years often received their shot in a sports hall, with several of them crying and giving the creeps to other girls. The logistics were technically safe, but the circumstances were rather off-putting for young girls. Such an impersonal approach may be necessary for a serious disease outbreak but not in this case. Why not opt for the intimacy of the general practice? Most practices can easily handle the relatively small numbers involved in an inexpensive manner, integrating this type of vaccination into their daily routine. Because of their personal relation with their clients, FPs are perfectly capable of managing girls’ (and boys’) and parents’ mistrust, if any.
• For flu vaccination, it seems logical that multiple target populations are served by different care providers. Occupational health services offer vaccination to employees, but often with disappointing vaccination rates of below 50%. Inviting employees to get vaccination from their FPs, with whom they can discuss vaccine requirements, could result in a better coverage.
• Future vaccines for pneumococci and herpes zoster could also best be administered by FPs.

The interest of the client should prevail when deciding who is best placed to provide vaccination services. That seems common sense. The Dutch health care system has become a marketplace since 2006, with quite some competition, commercial interests, fragmentation, and incoherence. This has caused confusion and undermined the public’s confidence, leading to suboptimal vaccination rates. FPs are best placed to maintain and update their clients’ personal medical files, including their vaccination status. For children below five years of age, the national vaccination programme (RVP) in the Netherlands is well established and effective. However, for adult vaccination programmes, there is no overarching policy of the Dutch government on who should be in the lead or do what. The Ministry of Health (VWS) seems to rely on free market forces. There is a divide between the municipal health services (GGD) and general practitioners, which is a tragic flaw of our (privatized) health system. In national health services of countries like the UK, Portugal and Spain, this is not so much the case. The divide in the Netherlands not only affects the organisation of adult vaccination but also cripples other preventive health measures.

Accepting that general practices run by FPs are an appropriate platform for providing comprehensive health services is in the clients’ interest and may eventually be the most (cost-) effective strategy to provide vaccination and other preventive measures. We hope that the Dutch College of Family Health Physicians (NHG) and the Association of FPs (LHV), the National Institute for Public Health and the Environment (RIVM), the Netherlands Institute for Control of Infectious diseases (NIVB), and patient interest organisations will endorse our plea.

Note: another article, in Dutch, on the same topic was recently published by Pieter van den Hombergh and Ted van Essen, under the title ‘De huisarts heeft de beste papieren om te vaccineren’ (Medisch Contact 46, 14 november 2019).