Public confidence in vaccines varies widely between countries and regions around the world, and the European region is the most sceptical about vaccine safety, according to the largest ever global survey of confidence in vaccines.  With recent disease outbreaks triggered by people refusing vaccination, the authors believe the findings provide valuable insights, which could help policymakers identify and address issues.
The new study, published in EBioMedicine, is led by researchers from the Vaccine Confidence Project at the London School of Hygiene & Tropical Medicine, together with co-authors at Imperial College London and the Saw Swee Hock School of Public Health, National University of Singapore.
Nearly 66,000 people were surveyed across 67 countries to discover their views on whether vaccines are important, safe, effective, and compatible with their religious beliefs. 
Although overall sentiment towards vaccines was positive across the countries surveyed, the researchers found significant variation in attitudes around the world.
The European region had seven of the ten countries in the global sample that were the least confident in vaccine safety (France, Bosnia & Herzegovina, Russia, Ukraine, Greece, Armenia and Slovenia). France was the country least confident in safety, with 41% of those surveyed disagreeing that vaccines are safe, more than three times the global average of 12%. France was followed by Bosnia & Herzegovina (36%), Russia (28%) and Mongolia (27%), with Greece, Japan and Ukraine not far behind (25%). 
The Southeast Asian region was most confident in vaccine safety across countries, including Bangladesh (fewer than 1% did not think vaccines are safe), Indonesia (3%) and Thailand (6%).
The authors say the negative attitudes in France may come as a result of a number of controversies in the country over the past two decades, including controversy over suspected side effects of the Hepatitis B and HPV vaccines, and hesitancy among a significant proportion of GPs as to the usefulness of some vaccines.
Public trust in immunisation is an increasingly important global health issue. Decreases in confidence can lead to people refusing vaccines, which in turn has triggered disease outbreaks such as measles in the US, Europe, Asia, the Pacific and Africa. It has also caused setbacks to the global polio eradication programme. The World Health Organization's Strategic Advisory Group of Experts on Immunization has called for improved monitoring of vaccine confidence and hesitancy to help prevent these damaging public health consequences.
Study lead author, Dr Heidi Larson from the London School of Hygiene & Tropical Medicine, said: "Our findings give an insight into public opinion about vaccines on an unprecedented scale. It is vital to global public health that we regularly monitor attitudes towards vaccines so that we can quickly identify countries or groups with declining confidence. We can then act swiftly to investigate what is driving the shift in attitudes. This gives us the best chance of preventing possible outbreaks of diseases like measles, polio and meningitis which can cause illness, life-long disability and death.
"It's striking that Europe stands out as the region most sceptical about vaccine safety. And, in a world where the internet means beliefs and concerns about vaccines can be shared in an instant, we should not underestimate the influence this can have on other countries around the world."
The findings show that many countries (particularly France, Bosnia & Herzegovina, Japan, Iran, Mongolia and Vietnam), display much greater confidence in the importance of vaccines than in their safety. This suggests that people do not necessarily dismiss the value of vaccination even if they have doubts about how safe vaccines are.
Dr Larson added: "Our study suggests that the public largely understands the importance of vaccines, but safety is their primary concern. This could reflect a worrying confidence gap and shows that vaccine acceptance is precarious. The findings underline that the scientific and public health community needs to do much better at building public trust in the safety of vaccination."
Bangladesh, Iran and Ecuador had the highest proportion of people who agreed that vaccines are important, while Russia, Italy and Azerbaijan reported most scepticism around their importance.
Although the researchers found that in some countries particular religious groups were more sceptical of vaccines than others were, no single religion was associated with negative attitudes worldwide. They say this indicates that the impact religion has on attitudes towards vaccines is dependent on the local context, rather than being driven by the religious doctrine itself.
Another finding suggested that older people (aged 65 and over) globally had more positive views on vaccines than other age groups.
WIN/Gallup International Association collected the data as part of their annual end-of-year survey. Survey responses were either collected through face-to-face interviews, telephone or online, based on phone and internet availability in each country.
The researchers note that the findings cannot reveal whether attitudes were related to specific vaccines, or give reasons behind the attitudes expressed. They hope future surveys will provide these insights, and that this study can be used as a baseline to monitor change in attitudes towards vaccines over time.
Additional key country and regional data available in notes to editors.
Notes to editors:
* Heidi J Larson, Alexandre de Figueiredo, Zhao Xiahong, William S Schulz, Pierre Verger, Iain G. Johnston, Alex R Cook, Nick S Jones,The State of Vaccine Confidence 2016: Global insights through a 67-country survey, EbioMedicine. DOI: 10.1016/j.ebiom.2016.08.042
 World regions are categorised by World Health Organization region according to definitions at http://www.
 The WIN/Gallup International Association has been conducting an annual survey since 1977. For this study WIN/Gallup International extended their 14 question survey in 67 countries to include four questions related to attitudes towards vaccines. A total of 65,819 people were interviewed globally, with a sample of around 500 men and 500 women interviewed either face-to-face in each country, via telephone or online. Each respondent was asked to rate - on the five-point Likert scale: strongly agree, tend to agree, do not know, tend to disagree, strongly disagree. Questions were: "vaccines are important for children to have"; "overall I think vaccines are safe"; "overall I think vaccines are effective"; and "vaccines are compatible with my religious beliefs".
 Figures used based on raw data which includes 'do not know/no response' survey responses (as used in paper abstract). Both raw and normalised data (with 'do not know/no response' responses removed) for each country are available in the Supplementary Materials (Table S1).
Key country and regional data
Regions ranked by confidence in the safety of vaccines
- Southeast Asian Region (4.4% of people disagree that vaccines are safe) - most confident
- African Region (7.4%)
- American Region (8.3%)
- Eastern Mediterranean Region (9.4%)
- Western Pacific Region (15.0%)
- European Region (15.8%) - least confident
Countries most confident in the safety of vaccines
- Bangladesh (Fewer than 1% of people surveyed disagreed that vaccines are safe) - most confident
- Saudi Arabia (1%)
- Argentina (1%)
- Philippines (2%)
- Ecuador (3%)
Countries least confident in the safety of vaccines
- France (41% of people surveyed disagreed that vaccines are safe) - least confident
- Bosnia & Herzegovina (36%)
- Russia (28%)
- Mongolia (27%)
- Greece (25%) [tied with Japan and Ukraine, also 25%]
Regions ranked by confidence in the importance of vaccines
- Southeast Asian Region (2.3% of people disagree that vaccines are important) - most confident
- Eastern Mediterranean Region (3.4%)
- African Region (3.5%)
- American Region (4.0%)
- Western Pacific Region (6.2%)
- European Region (7.7% of people disagree that vaccines are important) - least confident
Countries most confident in the importance of vaccines
- Bangladesh (Fewer than 1% of people surveyed disagreed that vaccines are important) - most confident
- Iran (Fewer than 1%)
- Ecuador (Fewer than 1%)
- Philippines (Fewer than 1%)
- Argentina (Fewer than 1%)
Countries least confident in the importance of vaccines
- Russia (16% of people surveyed disagreed that vaccines are important) - least confident
- Italy (15%)
- Azerbaijan (14%)
- China (14%)
- Slovenia (13%)
About the London School of Hygiene & Tropical Medicine
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