Barriers to measles mumps rubella vaccine acceptance in the three southern border provinces of Thailand

Vaccines are currently necessary for controlling the onset and prevalence of infectious diseases [1]. In 2018, data from the Thai Bureau of Epidemiology indicated that there was a major outbreak of measles in the lower part of the southern region of Thailand with a total of 4,450 reported cases of fever or suspected measles. The three southern border provinces with the Muslim majority populations had the highest number of suspected measles cases (n=3,898). There were 1,621 cases and 10 deaths (307.42 per 100,000 population), 1,788 cases and 10 deaths (251.90 per 100,000 population), and 489 cases and 1 death (61.41 per 100,000 population) in the Yala, Pattani, and Narathiwat provinces, respectively [2]. This notification activated authorities to promptly investigate the cause of the outbreak and to provide proper recommendations. A report and relevant study illustrated that incomplete measles vaccine or vaccine for measles, mumps, and rubella (MMR) in children due to parental vaccine refusal was the major cause of the problem [3]. A report from the Department of Disease Control, Ministry of Public Health, indicated that between 1 January and 31 December 2020, 89% of 336 patients with measles dwelling in the deep south of Thailand had not received MMR vaccines [4]. Previous studies indicated that in the Muslim majority region containing the three southern border provinces of Thailand, aside from violent conflict and situations, individual beliefs and social context were the important factors affecting parental vaccine acceptance [3]. After a major outbreak of measles, it was evident that there was a scarcity of information about the major causes of parental vaccine refusal and hesitancy in the Muslim majority provinces, especially from the perspectives of health personnel. Thus, a qualitative phenomenological study regarding barriers to MMR vaccine acceptance through the experience of health personnel was needed. The study findings could be effectively applied to improve vaccination uptake in a Muslim majority context.

This study employed a qualitative phenomenological methodology as described in greater detail throughout this section to depict parental MMR vaccine acceptance through the work experiences of health personnel [5].

Four main themes and four sub-themes surrounding the reasons for parental vaccine refusal and hesitancy were identified as the major issues hindering the willingness of parents to vaccinate their children against measles.

Our study findings concluded that considering religious beliefs is essential for understanding vaccine refusal among Muslim parents. Because the MMR vaccine contains gelatin as a stabilizer, vaccine-hesitant parents are concerned that the vaccine may contain gelatin derived from pig products. Most relevant studies concluded that perceived religious prohibition is one of the most important reasons for refusal to vaccinate among Muslim parents [7, 8]. Wong et al. [7] in 2020 illustrated that perceived religious prohibition is one important reason for refusal to vaccinate among vaccine-hesitant parents in Malaysia. They believed that vaccines were haram because they contained porcine ingredients [7]. Several studies, nevertheless, illustrated that vaccination is permitted whether it contains porcine substances or not due to the exceptional circumstances [9, 10, 11, 12]. As Padela et al. [10] in 2013 revealed, one group of Islamic jurisconsults hold that using vaccines with porcine products is allowed on the determination when it reaches the state of “darurah” or necessity. Also, Elkalmi et al. [11] in 2021 concluded that vaccines with non-halal ingredients are permissible in the absence of other equivalent halal products. Consistent with the study by Grabenstein [12] in 2013, vaccines could be used if necessary. According to the Qur’an, a person is not guilty of sin in an exceptional circumstance where the scarcity of a halal alternative creates a necessity to make an undesirable consumption, which is otherwise haram (Qur’an 2:173) [12].

In fact, Thailand imports measles vaccine products that do not contain pig products including porcine gelatin according to Thai health official, Dr. Vichan Pawan, Director of the Division of Communicable Diseases, Ministry of Public Health, Thailand [13]. Misconceptions, in terms of the vaccine ingredients among vaccination-refusing parents, was a major concern of vaccine hesitancy and refusal, not only in Thailand but also in many Muslim majority countries. Khan and Sahibzada [14] studied the refusal of oral polio vaccination among Islamic parents in Pakistan. They found that the parents believed that the oral poliovirus vaccine was not permitted in Islam because it contained the blood of monkeys and pigs called haram ingredients [14]. In the meantime, halal certification of the vaccine was required from Muslim parents to ensure that vaccine had been approved for Muslims. Previous studies confirmed that the halal status of vaccines is the most important factor for Muslims in considering whether to accept vaccinations or not [14, 15, 16]. The broad topic of vaccine production and halal certification of vaccines has been discussed. Khoo et al. [16] in 2019 stated that the demand for halal pharmaceutical products in the future will definitely escalate. Malaysia has cooperatively collaborated with a Saudi Arabian private startup company to launch a program named “Self-Reliance in Vaccine Production,” which targets inadequately supplied Halal vaccines. The process of the halal vaccine has been underway to meet the qualifications for approval from a drug regulatory agency or the World Health Organization. These steps need to be met before the products are released to the public [16].

In Thailand, however, due to the absence of halal labeling, community and religious leaders play an important role in endorsing the use of vaccines including advocacy for immunization. They could inform and educate community members. They could share information about the manufacturing process along with assurances that no trace of the porcine substance remains in the products, so that community members have less doubt about getting the vaccines [9]. Furthermore, health education and engagement by religious leaders to endorse the vaccination and bridge the gap between religious beliefs and vaccine acceptance is needed to overcome this issue.

In addition, a lack of knowledge and positive attitudes concerning immunizations of vaccine-hesitant parents were also found as predominant reasons for incomplete childhood immunizations in the deep south of Thailand. The negative attitude towards vaccination of people who refused to be vaccinated stemmed from poor knowledge or misconceptions. These misconceptions may positively change after parents receive the right information [17]. Consistent with many relevant studies, for instance, Yigit et al. [18] in 2021 concluded that participants were hesitant about childhood vaccines because of the side effects of vaccinations. Also, they perceived that the vaccines may cause autism due to the chemical ingredients contained in the vaccines [18]. Finally, vaccine refusal and hesitancy may be fueled by health information and education obtained from a variety of sources, traditional media outlets, social media platforms, and interpersonal information sharing. Thus, these same information outlets can be utilized to encourage more positive attitudes regarding vaccines in local communities [19, 20].

In conclusion, religious beliefs and a lack of knowledge including negative attitudes concerning immunizations were the predominant causes of parental vaccine refusal in the deep south of Thailand. Community and religious leaders play an important role in endorsing the use of vaccines including advocacy for immunization. The negative attitude towards vaccination by people who refused to be vaccinated stemmed from poor knowledge or misconceptions. Both knowledge and perception may positively change after parents are provided the right information. Finally, information released through traditional media outlets, social media platforms, and interpersonal information sharing can encourage more positive attitudes regarding vaccines in local communities.