In Barbados, starting school means having your uniform, school supplies and up-to-date vaccination book. This scenario is so routine that many parents and children view it as a regular part of growing up.
This tradition aided in the elimination of smallpox, measles, mumps and rubella. Despite this norm, some parents are going against the zeitgeist and delaying or opting out of vaccinating their children. This small shift is creating fear among doctors that once-eradicated diseases can resurge.
Paediatrician/Neonatologist Dr Clyde Cave leans slightly in his seat to express how this resurgence can happen.
“When you lose herd immunity, what will happen is when a virus is now introduced to that community, it will spread much faster. Herd immunity is like the brakes slowing it down. So it affects one person, but if the people around them are immunised, it stops. If they’re not, it spreads.”
When asked about the downward trend, the Chief Medical Officer in Barbados, Dr Kenneth George, also voices his concern.
“We had noticed it. This was in the pre-COVID period because we would like our vaccination rates for measles to be 95% to get herd immunity.”
So why are some parents hesitant about these vaccinations? Did the debate surrounding COVID-19 vaccines affect their decision?
During an interview with the Barbadian newspaper, Nationnews, a sceptical parent exclaimed to the reporter.
“I have a couple of friends who are paediatricians and doctors, and they didn’t vaccinate their children early either, saying from their medical knowledge, vaccinating an infant too early bombards the child with a cornucopia of chemicals with the risk of adverse effects.”
Another parent stated, “I do not trust the ingredients in those vaccines, and I don’t trust Western medicine.”
These fervently held beliefs are not the majority in Barbados but add to a concerning downward trend from a near-perfect childhood vaccine acceptance rate.
This drop is not unique to Barbados. In the United Nations Children Fund’s (UNICEF) “2023 State of the World’s Children Report: For Every Child, Vaccination”, the Executive Director, Catherine Russell, in her foreword, soberly claimed that “Despite decades of progress in childhood immunisation, our collective efforts are falling short.”
Based on the report’s findings, the number of “zero-dosed” children started climbing from 15.4 million in 2010 to 18.2 in 2021. The stark rise in vaccine hesitancy, apathy and compliancy correlated to the start of the COVID-19 pandemic. Parents’ concerns and difficulties with the childhood vaccination programme came to light or intensified.
Graph information from the United Nations Children Fund’s (UNICEF) “2023 State of the World’s Children Report: For Every Child, Vaccination – sources cited at the bottom (4 slides).
“UNICEF hasn’t just examined COVID vaccines. But for the first time, UNICEF has examined routine vaccines and trends related to children”.
Further in the launch, the UNICEF Representative for the Eastern Caribbean Area, Pieter Bult, put into focus the realities of the research.
“This year’s report shines the spotlight on routine childhood vaccinations in an environment where 67 million children across the world missed out on critical vaccines over the last three years. Major drops in immunisation coverage in countries that have already achieved very good coverage, combined with increasing vaccine hesitancy around the world, are forcing us to ring the alarm bell.”
This trend was not always the case.
History of Vaccination in Barbados and the Region
Historically, the region and Barbados, in particular, adopted a rigorous immunisation programme. According to original research conducted by the Pan American Health Organization (PAHO)’s 2022 paper, “A Review of Immunization Legislation for Children in English-and Dutch-speaking Caribbean Countries”, many Caribbean nations drafted health bills that required immunisation for children before entering school and at other key academic points in a child’s life.
Chart and statistics from the Ministry of Health and Wellness, presentation to Paediatricians and Private Doctors in the EPI Programme – February 21, 2023.
According to the report, enacting public health legislation put the Caribbean in good stead to eradicate childhood diseases.
The dedicated public health programme started in Barbados in 1969 with the Health Services Act. This Act outlined the requirement for immunisation against childhood diseases, set aside funds for obtaining vaccines and indicated the grounds for any exceptions.
The Immunization Legislation Review also shows that Barbados started increasing their vaccination programmes by rolling out the Expanded Program on Immunisation (EPI) in 1977. The EPI used “measures to strengthen the institutional structures of immunisation and surveillance programs at national and regional levels as well as systematic activities and campaigns to eliminate these diseases.”
This intense EPI programme eliminated polio, measles, diphtheria, congenital rubella syndrome, neonatal tetanus and rubella.
Graph information “Recent Advances in Immunization, 2nd Edition” – Jon Kim Andrus, MD and Ciro A. de Quadros, MD, MPH (3 slides).
The Chief Medical Officer currently boasts a strong immunisation programme in Barbados.
“Barbados has had one of the most comprehensive vaccine programmes. We give vaccines that are not given in other regions of the world. We give meningococcal. We give hepatitis vaccines. We give HPV vaccines in preteens.”
Any deterioration of this historically strong foundation is cause for exploration. Physicians like Dr Cave know what it means when there are cracks.
“Some parents seem to argue that the diseases are not so bad and you haven’t seen them for a long time. I understand that. But it’s because a lot of people were vaccinated. People get paralysed by polio. They can die from tetanus. Measles can make you deaf or die. Mumps can make you sterile.”
Falling Short of 95% Coverage
The term “anti-vaxxer” gained popularity with the advent of COVID-19 vaccines. Lines of people waited for their first doses, while others felt the vaccine came out too soon and publicly demonstrated their fears at Town Hall Meetings and in the streets.
Vaccine information swirled online, making distinguishing what was genuine from disinformation difficult.
However, the compact intensity of the COVID-19 pandemic only served to highlight some sentiments about the immunisation programme in general.
The report of the Pan American Health Organization Thirty-fifth Meeting of Managers of the Caribbean Expanded Program on Immunization, Final Report, Virtual Meeting, 3–5 November 2021, cited in “Immunization Legislation Review”, backs this reality.
“Traditionally high immunisation coverage in the Caribbean has declined from 2015–2020, with many districts reporting coverage of childhood vaccines below 80%. The decline in immunisation coverage has been exacerbated by the COVID-19 pandemic”.
Further, the Legislation Review document also cites “Implications of Philosophical and Personal Belief Exemptions on Re-emergence of Vaccine-Preventable Disease: The Role of Spatial Clustering in Under-Vaccination.
“Vaccine misinformation, manipulated information, and conflicting information promoted on digital platforms during the COVID-19 pandemic potentially reduced confidence in vaccines. Prior to the COVID-19 pandemic, a social movement opposing public health vaccinations resulted in the increased allowance of nonmedical exemptions (NMEs) and the re-emergence of vaccine-preventable diseases (VPD),” it claims.
Minister of Health and Wellness Dr Jerome Walcott, in his address at the “State of the Children World Report launch, admits this decline and ponders if it is complacency.
“The traditionally high immunisation coverage in the Caribbean has declined, with too many countries reporting coverage of childhood vaccines below 80%. This decline in immunisation coverage was noted in 2017. We were doing too well, which was then exacerbated by the COVID-19 pandemic.”
Causes of Vaccine Hesitancy
Navigating parenthood is often quite tricky. There is no set style because all children are different. Trying to understand the best way forward can send parents to seek methods they believe are the least risky for their children’s health.
The Executive Director of the Caribbean Public Health Agency (CARPHA), Dr Joy St. John, whose agency “liaises with PAHO” and conducts testing if vaccine-preventable diseases as suspected, hears some parents’ misgivings.
“There is concern about complications and defects. I have heard of groups of people who say they will not use any vaccines from the usual sources but will use a herbal equivalent. Some people are saying all you need is a strong immune system. It shows that there is a lack of understanding of the immune responses in the body.”
Priest Ras I’an, a leader in the Rastafarian community, farmer and entrepreneur, believes in being informed and the healing power of nature. Although he and his children have their childhood vaccinations, he understands why some members undergo the exemption process.
“In my day, as a youth, you could have had more confidence in the production. But now, with the competitiveness in the market, you can’t have that surety. I remember it used to be more security checks and more informative. Although we live in a more informed society, it is still less information pertaining to what these vaccines consist of.”
As in the Rastafarian community, some in the Muslim faith choose the exemption route. Imam Aakil Bhula at the Jama Masjid Mosque in Barbados, explains that although some parents choose exemption, the teachings of the Holy Qur’an do not prohibit childhood vaccinations.
Sitting in his living room while his son sneaks a peek from the kitchen, the Islamic teacher explains that his role is to guide parents according to what is “permissible” or “impermissible”.
“In passing, I’ve had conversations (Parents say) we don’t believe it is necessary. There seems to be more harm in these immunisations than good. It’s all part of a ploy. There are a lot of theories people will have. And that’s up to each individual to make their own decision.”
Much like religious leaders, primary care nurses and paediatricians interact with parents. They administer the vaccines and are at the front of the Extended Programme on Immunisation (EPI).
Paediatricians Dr Clyde Cave and Dr Anne St. John rarely encounter parents who are against vaccination. However, when they do, parents usually have various reasons.
“What happens is that they know somebody down the road whose cousin or aunt or grandmother had something after they were vaccinated. Well, we know you can be vaccinated across the road and get knocked down by a bus. And you could say that was vaccine related, but it’s not. So you have to separate which is fact and evidence base from fiction, or rumour, or association.” Dr Anne St. John likes to remind parents while she counsels them towards vaccine acceptance.
For Dr Cave, he claims that the few parents who do not vaccinate tend not to return, but he notices that some of those parents fall into a particular grouping.
“I have seen some expats who have come to live here. Some even in paramedical professions, you know, osteopaths and naturalists, that kind of thing.”
In public polyclinics such as Brandford Taitt, the Government of Barbados provides Primary Health Care services free of cost to its citizens. Part of the polyclinic’s mandate is to keep children up-to-date on the vaccine regimen.
Between patients at the busy Wednesday child vaccination clinic, Health Sister Simone Leacock explains why some parents have reservations.
“(If) they decide not to have the vaccine, most of the time they will say religious reasons. And some people just believe that the vaccine is a money-making thing, and they just don’t want their children to have the vaccine,” she says.
“Most of the time, it is the daddies persuading the mommies not to have, and then they go through the [exemption] process, and then later, mommies will come back and say, ‘but I want my child to have the vaccines me and daddy we are no longer together.’”
The COVID-19 Influence on Childhood Vaccinations
Regardless of the pre-pandemic slight dip in childhood vaccine coverage, the programme took a hit when COVID-19 forced the country to lock down in March 2020.
“The impact of the COVID-19 pandemic has set back childhood immunisation worldwide,” Dr Walcott said.
“The pandemic also exacerbated existing shortages of healthcare workers and caused disruption to health services. National lockdowns and fear of contracting the virus from healthcare facilities led families to delay vaccinating their children.”
For Senior Health Sister Julyette Serrano, who oversees the vaccine programme at the Brandford Taitt Polyclinic, now is the time to catch up and encourages parents to get back on track.
In her tiny office, Nurse Serrano outlines some of the obstacles to this process amid some polite interruptions by junior nurses and the telephone.
“The need to make the sacrifice and coming to the clinic, in some cases, is not that critical (for parents),” she says.
“When you look at the human resources in primary health care, we had a significant number of public health nurses (before 2011). Right now, that number has more or less cut in half.”
She adds: “Each polyclinic is divided into catchments, and a health sister is responsible for a catchment. Right now, we don’t have the human resources to do that. And through COVID, that was even more [noticeable] because resources went into giving the vaccines.”
According to UNICEF’S “Barbados COVID-19 Vaccine Hesitancy Survey Report 2022, there are some vaccine hesitancy overlaps, but it is in the minority. Generally speaking, Barbadians trust childhood vaccinations; however, care personnel must continuously remind, educate and be aware that the “health” information landscape has many players.
Barbados on a Path to Reverse the Trend
This year’s Vaccination Week of the Americas #EachVaccineCounts by the PAHO marked the re-commitment to arrest the childhood vaccination dip and a renewed campaign to educate and encourage.
CARPHA’s Executive Director, Dr. Joy St. John, stresses not losing the momentum after Vaccination Week.
“We need to reintroduce intensified vaccination awareness campaigns. So they understand what are the dangers of not vaccinating. So they see the plus side of vaccination and get around the fears,” she said.
The different mediums used by the Barbados Ministry of Health and Wellness and Regional/International Health Organisations to get the message out to parents on the importance of childhood vaccinations. A. PAHO bus stop advertisement for the importance of the COVID-19 vaccine. (Photo by Esther Jones) B. The Barbados Ministry of Health and Wellness social media postings to remind parents of immunisation clinics on the Barbados Government Information Service’s social media and web platforms. C/D. FAQ brochure for parents on childhood vaccinations designed by PAHO. (4 slides)
The country’s CMO, Dr George, also notes the re-emphasis on immunisations and ensuring children who missed the critical stages get back on schedule.
“Wherever there is a chance for interaction on the primary care level, we tend to follow in that direction to check the children’s immunisation card. We have started to do work in schools to make sure, and then we do our childhood clinics, we make sure that persons are immunised,” he said.
*Special thanks to Richie Ferrol, who interviewed CARPHA’s Executive Director, Dr Joy St. John.
- Expanded Programme on Immunization (EPI): A Review of Activities in 1984 & Programme for 1985 – H.C. Smith, PAHO/WHO
- Progress & Challenges with Achieving Universal Immunization Coverage 2021: Estimates of National Immunization Coverage, WHO/UNICEF
- Recent Advances in Immunization 2nd Edition – Scientific Publication No. 619, Jon Kim Andrus, MD, Ciro A deQuadros, MD, PAHO/WHO
- Regional Framework for the Monitoring & Re-verification of Measles, Rubella and Congenital Rubella–Syndrome Elimination in the Americas, PAHO/WHO
- The Expanded Programme on Immunisation (EPI), Henry Smith
- Vaccination as a Driver for Socio-economic Recover in Barbados and the Easter Caribbean, Lucia Alonso, Berta Tarrats, Clara Marin, UNDP/RED2RED/Institute for Global Health
This reporting was supported by the International Women’s Media Foundation’s Global Health Reporting Initiative: Vaccines and Immunization in the Caribbean, in partnership with Sabin Vaccine Institute.