Vaccine Confidence

Vaccine confidence concerns the belief that vaccination – and by extension the providers and range of private sector and political entities behind it – serves the best health interests of the public and its constituents. The Oxford English Dictionary defines confidence as “the mental attitude of trusting in or relying on a person or thing”.  In light of that, we are not examining the well-studied domain of supply and access barriers to vaccination, but rather what is typically called the “demand” side of immunisation. However, our focus on confidence takes the “demand” rubric a step further than the more traditional notion of building demand through increasing knowledge and awareness of vaccines and immunisation to understanding what else drives confidence in vaccines, and the willingness to accept a vaccine, when supply, access and information are available. In other words, understanding vaccine confidence means understanding the more difficult belief-based, emotional, ideological and contextual factors whose influences often live outside an immunisation or even health programme but affect both confidence in and acceptance of vaccines.

VCP Mission

The purpose of the project is to monitor public confidence in immunisation programmes by building an information surveillance system for early detection of public concerns around vaccines; by applying a diagnostic tool to data collected to determine the risk level of public concerns in terms of their potential to disrupt vaccine programmes; and, finally, to provide analysis and guidance for early response and engagement with the public to ensure sustained confidence in vaccines and immunisation. This initiative also defines a Vaccine Confidence Index™ (VCI) as a tool for mapping confidence globally.

The VCI is a measure, based on a select number of factors identified from extensive analysis of areas of both low and high vaccine coverage. This index is useful for informing the design of immunisation programmes and strategies and understanding more explicitly where to target both human and financial resources, which will allow for more efficiency. The VCI is an important tool for routine immunisation as well as the introduction of new and underutilised vaccines.  Further information is available on our research page.

Despite the historic success of immunisation in reducing the burden of childhood illness and death, episodes of public concerns and rumours around vaccines have occurred around the world, spreading quickly and sometimes seriously eroding public confidence in immunisation and ultimately leading to vaccine refusals and disease outbreaks.

Although reports of public concerns and questions around the safety and relevance of vaccines have been on the increase, aside from monitoring of adverse events following immunisation (AEFI), there is neither a systematic monitoring of broader public vaccine concerns nor a tool to assess risk levels of rumours and concerns to potential programme disruptions, vaccine refusals and potential disease outbreaks.

This project seeks to address these unmet needs and monitor public confidence in immunisation programs by listening for early signals of public distrust and questioning and providing risk analysis and guidance to engage the public early and pre-empting potential programme disruptions.

Research Team

Prof. Heidi Larson

Prof. Heidi J. Larson is an anthropologist and Director of The Vaccine Confidence Project™ (VCP); Professor of Anthropology, Risk and Decision Science, Dept. Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine; Clinical Professor, Institute of Health Metrics & Evaluation, University of Washington; and Chatham House Centre on Global Health Security Fellow. Dr. Larson previously headed Global Immunisation Communication at UNICEF, chaired GAVI’s Advocacy Task Force, and served on the WHO SAGE Working Group on vaccine hesitancy. The VCP is a WHO Centre of Excellence on addressing Vaccine Hesitancy.

Prof. Larson’s research focuses on the analysis of social and political factors that can affect uptake of health interventions and influence policies. Her particular interest is on risk and rumour management from clinical trials to delivery – and building public trust.  She served on the FDA Medical Countermeasure (MCM) Emergency Communication Expert Working Group, and is Principle Investigator of the EU-funded (EBODAC) project on the deployment, acceptance and compliance of an Ebola vaccine trial in Sierra Leone.

Prof. Larson has recently joined the Centre for the Evaluation of Vaccination (CEV) (University of Antwerp) as associate professor, as the CEV at the Antwerp University will host the European regional Office of the Vaccine Confidence Project as of May 15, 2019, and will closely collaborate with Vaccine Confidence Project partners at European level on implementing the Vaccine Confidence Index™ and developing and evaluating interventions to address vaccine hesitancy.

Dr. Pauline Paterson

Dr. Pauline Paterson is an Assistant Professor and co-director of The Vaccine Confidence Project™ at the London School of Hygiene & Tropical Medicine. Dr. Paterson, together with Dr. Larson, established a global, internet-based information surveillance system on public concerns around vaccines and vaccination programmes. The Vaccine Confidence research group has been conducting qualitative research on specific vaccine confidence issues and risk perceptions globally since 2010.

Dr. Paterson is a member of the NIHR Health Protection Research Unit in Immunisation and has an honorary academic contract with Public Health England. Specific research activities include qualitative analysis of parental reasons for not vaccinating their child with influenza vaccine in England, analysis of concerns surrounding HPV vaccine in India and Japan, and a systematic review on public trust in vaccination. Dr. Paterson previously worked in strategy at The Global Fund to Fight AIDS, Tuberculosis and Malaria, and carried out her MBA project in Thailand in collaboration with WHO. Dr. Paterson has a PhD in Epidemiology, MBA and MSc from Imperial College London.

Valerie Heywood

Since, 2010, Valerie has been working for the London School of Hygiene & Tropical Medicine. First, before joining in October 2016, as a Project Coordinator/Manager, the VCP team (EPH-IDE), Valerie monitored and managed large and complex grant’s budgets (5m to 10m) within the EHG in ITD for several years.  Currently, Valerie manages the administration of our Research Team and coordinate the small and large grants for our growing team, including the multi-millions and partners EBODAC Project.

Jay Dowle

Jay Dowle is a former journalist who worked on national newspapers and magazines in London, Hong Kong and Australia before starting a medical publishing business. In 1999, he moved to Geneva to work as a communications/publications office for WHO (malaria), moving to New York to work for UNICEF in New York (immunisation) before returning to Geneva to work for UNDP (environmental and climate change issues) and UNEP (Green Economy). More recently he worked at the Global Institute for Health (AIDS/HIV) before joining the Vaccine Confidence Project™ part-time.

Emilie Karafillakis

Emilie is a Research Fellow for the Vaccine Confidence Project™. She has a background in public health, infectious disease control, and health systems and policies and holds a Master’s degree in the Control of Infectious Diseases from LSHTM. Her work focuses on understanding determinants of vaccine hesitancy in European populations, including healthcare workers, and strategies to effectively address concerns about vaccination. Emilie is also a PhD Candidate at the school – her research focuses on adolescent girls’ decision-making processes with regards to HPV vaccination in France.

Clarissa Simas

Clarissa is a Psychologist and Research Fellow for the Vaccine Confidence Project™. She has a professional background in Global Health and Development and holds an MSc in Medical Anthropology from University College London (UCL) and a BSc in Psychology from University of Brasília. She is currently investigating social impacts of the Zika epidemic in Brazil, the Ebola vaccine trial  deployment, acceptance and compliance, impact of new digital technology in health communication, public acceptance of health interventions, with a particular focus on vaccine confidence in South America, outbreak preparedness, risk perception and its impact in decision making, psychogenic adverse reactions to vaccines globally, and have investigated acceptance of HIV/STI prevention interventions amongst European youth. Her research interests include risk perception, rumours, trust and mistrust dynamics, health psychology, vaccines, Medical Anthropology, Postcolonialism, structural violence, digital epidemiology, community engagement, health communication, and new social media.

Dr. Alex de Figueiredo

Alex conducts mathematical and statistical analyses for the Vaccine Confidence Project™. Alex’s background lies in physics (MSci, Imperial College) and mathematical and statistical modelling (PhD, Imperial College; MSc, University of Oxford) and harnessing tools from these fields to model vaccine confidence data. Alex’s research interests lie in probing ties between socioeconomic data and national coverage rates and vaccine confidence levels; on forecasting national and sub-national immunisation rates; and on the large-scale inference of vaccine attitudes in the absence of survey data. Alex holds a doctorate from Imperial College London with the PhD thesis: “A mathematical assessment of the global state of vaccine coverage and confidence.”

Fiona Sun

Fiona is a Research Fellow for the Vaccine Confidence Project™. She received an Honours Bachelor’s degree in Global Health and Biology from the University of Toronto and a Master’s Degree in Epidemiology from the London School of Hygiene & Tropical Medicine. Prior to joining the Vaccine Confidence Project™, Fiona has worked with the World Health Organisation, UNAIDS, the Ministry of Health of China, China National Centre for Cardiovascular Diseases, and the Department of Public Health at Beijing University. Her previous work involved evaluating multiple vaccination programs and health insurance schemes in China; developing maternal and child nutrition profiles of Central and Western China; implementing a Chinese- African Health Cooperation Programme affiliated malaria eradication project in Malawi; as well as contributing as a writing group member for aLancet Commission report on China’s Primary Health Care. Fiona’s work at VCP aims to monitor vaccine confidence in China and assess the capacity of the Chinese public health system to deliver current and planned vaccines.

Sara Dada

Sara is a Research Fellow for the Vaccine Confidence Project™. Her background is in public policy and economics and graduated with a BS Public Policy with highest honours from the Georgia Institute of Technology. As the first Fulbright Scholar at the Royal Veterinary College, Sara completed her MSc in One Health (Infectious Disease) in a joint program with the London School of Hygiene and Tropical Medicine. For her dissertation research project, Sara investigated the role and structure of a community engagement programme in the Ebola vaccine trials in Sierra Leone and proposed a framework for future community engagement programmes in biomedical research settings. Sara’s primary research interests include AMR, community engagement, health communication, medical anthropology, outbreak mitigation, trust and vaccines.

Dr. Sam Martin

Dr. Sam Martin is a Digital Sociologist specialising in research at the intersection of Digital Health and Data Science. She joined LSHTM as a Research Fellow (Media Monitoring) for the Vaccine Confidence Project™ in 2019. Prior to joining the team, she gained her PhD in Digital Health, Social Media Analytics and Coeliac Disease at the University of Warwick, as well as an MSc in Digital Sociology (Distinction) from the University of Goldsmiths, and an undergraduate Law degree from the University of Oxford. Sam’s research critically analyses and visualises text and image data output from digital health apps and social media. Her research and teaching activities focus on the use of advanced digital research methods to explore how social media engages with cultural and sociological issues. Sam has designed digital health research apps and games for visualising the embodiment of chronic illness and has investigated the use of 3D printing techniques to create badges that reflect the digital selfhood of users discussing chronic illness.

Mark Francis

Mark joined the Vaccine Confidence Project™ as a Research Fellow in 2019. He is also a PhD candidate in Epidemiology (2015 – ) at the Tampere University, Finland and his dissertation utilizes primary and secondary data to estimate routine childhood vaccination coverage and examine the parental characteristics associated with incomplete or delayed vaccination in India. Prior to beginning his doctoral studies, Mark was awarded a Wellcome Trust Master’s Fellowship in Public Health & Tropical Medicine (2012 – 15) which supported master’s studies in Epidemiology at the London School of Hygiene & Tropical Medicine and a yearlong community intervention trial to determine the effectiveness and feasibility of membrane filtration for safe drinking water provision in rural southern India conducted at the Christian Medical College, Vellore. Mark has worked in various capacities through his nearly decade long research career and is excited to use novel analytical methods and tools to improve the delivery and uptake of large-scale public health interventions such as maternal and childhood vaccination worldwide.

Daria Tserkovnaya

Daria is a Research Assistant for the Vaccine Confidence Project™. She has a professional background in qualitative, quantitative and medical research as well as online data analytics. She holds BSc in Journalism with a focus on medical and scientific journalism and is currently pursuing her MSc in Public Health at the School. Her research interests include HPV and related conditions, STI, public health intelligence, epidemiology and dynamics of infectious diseases including emerging infections, vaccines and AMR. She is currently investigating reasons behind vaccine mistrust and local and multinational approaches to understanding dynamics of the confidence in vaccines. In her most recent study “Epidemiology, awareness and attitudes towards HPV and related conditions in healthcare workers in Ghana” she explored HPV related cancer distribution in the region, as well as awareness in healthcare workers within the local health system.

Kristen De Graaf

Kristen is a Research Assistant for the Vaccine Confidence Project™and joined the team in 2019. She has a professional background in nursing across a variety of disciplines including public health, paediatrics, infectious diseases and sexual health. Kristen holds a MSc in Reproductive and Sexual Health Research and a Diploma in Tropical Nursing from the London School of Hygiene & Tropical Medicine. Prior to working for the VCP, her work involved advancing gender equality and human rights in the HIV response through advocacy and research and creating spaces for adolescent girls and young women to develop and implement their own solutions specific to their communities and contexts. Kristen is currently working on the Learning Network for Countries in Transition (LNCT) vaccine hesitancy workstream to support countries in assessing and addressing their vaccine hesitancy issues and in building vaccine confidence capabilities.

PhD Students

Dr. Antonis Kousoulis

Dr. Antonis Kousoulis is the Associate Director of Research & Development at the Mental Health Foundation, leading the public health research, development and delivery functions across England and Wales. Previously, he led the development team at the data research centre of the UK Department of Health. Antonis is a clinician with an academic background in public health and his experience includes time in industry and academia, including collaborations with the Harvard School of Public Health and University College London. He has published, peer reviewed and presented extensively, held editorial appointments for multiple publications, including The Lancet, as well as various visiting teaching appointments, including at Oxford University and the London School of Hygiene & Tropical Medicine. His work at the School and the Vaccine Confidence Project™ focuses on risk and emotional determinants of pandemics.

Gillian McKay
Gillian McKay, MScPH, RN is a DrPH candidate at the London School of Hygiene and Tropical Medicine, where she focuses on policy for resilient family planning services in epidemic crises.  Gillian‘s passion for humanitarian work has been demonstrated in Sierra Leone, South Sudan, Haiti, Syria and Ethiopia. She has 6+ years of experience working for NGOs and research institutions in health, nutrition, WASH, and gender.  Active engagement with networks and communities of global health practice in Africa, Europe, and North America ensures she contributes to research and policy in the fields of epidemic disease, maternal health, gender and rights, and the health impacts of global trends. Gillian holds a BSN from the University of British Columbia and an MScPH from LSHTM.
Penda Johm

Penda Johm is a social scientist working within the discipline of medical anthropology at the Medical Research Council Unit The Gambia at the London School of Hygiene at Tropical Medicine (MRCG at LSHTM). She holds an MSc in Medicine, Science and Society from King’s College London. Penda is currently registered as a PhD student with the LSHTM under the supervision of Professors Heidi Larson and Beate Kampmann. For her PhD research, she is investigating women in both urban and rural Gambia’s acceptance and uptake of maternal immunizations as well as related health system factors. Penda hopes to make a positive impact by informing understandings of local perceptions of health and improving health interventions and health systems in The Gambia.

Richard Clarke

Richard is currently conducting his PhD research on the information seeking behaviours of mothers as they make a vaccine decision during pregnancy. In his studies Richard applies research from the psychology of decision making, trust and the field of information science to quantitatively investigate how mothers engage in information gathering to aid decision making with respect to the pertussis vaccine currently offered during pregnancy. Prior to starting the PhD Richard worked as a psychology lab technician, aided in the design of psychology experiments, and lectured and ran seminars on an undergraduate psychology programme. In 2010 he received an MSc in Psychological Research Methods from The University of Exeter.   

Suzanne Hurst

Suzanne Hurst has lived and worked in sub-Saharan Africa for 25 years. In her work with a faith-based organization, she engages with local faith groups on community health and health promotion projects. Suzanne holds a Bachelors of Science in Nursing and received a Masters in Public Health from Johns Hopkins University in Baltimore, Maryland – USA. She is currently working on her DrPH, through the London School of Hygiene & Tropical Medicine under the supervision of Heidi Larson. Suzanne’s research interest is in the barriers and facilitators of African church engagement in community health issues. Her research centers on church responses in the context of the Ebola outbreak in Monrovia, Liberia.   


Journal articles

Larson HJ; Clarke RM; Jarrett C; Eckersberger E; Levine Z; Schulz WS; Paterson P; (2018) Measuring trust in vaccination: A systematic review. Human vaccines & immunotherapeutics. pp. 1-31.  

Karafillakis E.; Larson H.J.; on behalf of the ADVANCE consortium. 2017. The benefit of the doubt or doubts over benefits? A systematic literature review of perceived risks of vaccines in European populations. Vaccine 35(37):4840-50.

Kummervold P.E.; Schulz W.S.; Smout E.; Fernandez-Luque L.; Larson H.J. 2017. Controversial Ebola vaccine trials in Ghana: a thematic analysis of critiques and rebuttals in digital news. BMC Public Health 17:642.

Paterson P.; Meurice F.; Stanberry L.R.; Glismann S.; Rosenthal S.L.; Larson H. Vaccine hesitancy and healthcare providers. Vaccine. (2016) 34 (52): 6700-6706.

Philip, R.K.; Shapiro, M.; Paterson, P.; Glismann, S.; Van Damme, P. Is it time for vaccination to ‘go viral’? The Pediatric Infectious Disease Journal. (2016) 35 (12): 1343-1349.

Becker, B.F.; Larson, H.J.; Bonhoeffer, J.; van Mulligen, E.M.; Kors, J.A.; Sturkenboom, M.C. Evaluation of a multinational, multilingual vaccine debate on Twitter. Vaccine, 2016.

Karafillakis, E.; Dinca, I.; Apfel, F.; Cecconi, S.; Wűrz, A.; Takacs, J.; Suk, J.; Celentano, L.P.; Kramarz, P.; Larson, H.J. Vaccine hesitancy among healthcare workers in Europe: A qualitative study. Vaccine, 2016.

Peprah, D.; Palmer, J.J.; Rubin, G.J.; Abubakar, A.; Costa, A.; Martin, S.; Perea, W.; Larson, H.J. Perceptions of oral cholera vaccine and reasons for full, partial and non-acceptance during a humanitarian crisis in South Sudan. Vaccine, 2016; 34(33):3823-7.

Enria, L.; Lees, S.; Smout, E.; Mooney, T.; Tengbeh, A.F.; Leigh, B.; Greenwood, B.; Watson-Jones, D.; Larson, H.  Power, fairness and trust: understanding and engaging with vaccine trial participants and communities in the setting up the EBOVAC-Salone vaccine trial in Sierra Leone. BMC Public Health, 2016; 16(1):1140.

Larson, H.J.; de Figueiredo, A.; Xiahong, Z.; Schulz, W.S.; Verger, P.; Johnston, I.G.; Cook, A.R.; Jones, N.S.  The State of Vaccine Confidence 2016: Global Insights Through a 67-Country Survey.  EBioMedicine, 2016.

de Figueiredo, A.; Johnston, I.G.; Smith, D.M.; Agarwal, S.; Larson, H.J.; Jones, N.S.  Forecasted trends in vaccination coverage and correlations with socioeconomic factors: a global time-series analysis over 30 years. Lancet Glob Health, 2016.

Larson, H.J.; Schulz, W.S.; Tucker, J.D.; Smith, D.M.  Measuring vaccine confidence: introducing a global vaccine confidence index. PLoS Curr, 2015; 7.

Peretti-Watel, P.; Larson, H.J.; Ward, J.K.; Schulz, W.S.; Verger, P.  Vaccine hesitancy: clarifying a theoretical framework for an ambiguous notion. PLoS Curr, 2015; 7.

Wilson, R.J.; Paterson, P.; Jarrett, C.; Larson, H.J.  Understanding factors influencing vaccination acceptance during pregnancy globally: A literature review. Vaccine (2015) ; DOI: 10.1016/j.vaccine.2015.08.046; PMID: 26320417.

Jarrett, C.; Wilson, R.; O’Leary, M.; Eckersberger, E.; Larson, H.J.; SAGE Working Group on Vaccine Hesitancy; COLLABORATORS: Eskola, J.; Liang, X.; Chaudhuri, M.; Dubé, E.; Gellin, B.; Goldstein, S.; Larson, H.; MacDonald, N.; Manzo, M.L.; Reingold, A.; Tshering, K.; Zhou, Y.; Butler, R.; Duclos, P.; Guirguis, S.; Hickler, B.; Schuster, M.  Strategies for addressing vaccine hesitancy – A systematic review. Vaccine, 2015; 33(34):4180-90.

Larson, H.J.; Jarrett, C.; Schulz, W.S.; Chaudhuri, M.; Zhou, Y.; Dube, E.; Schuster, M.; MacDonald, N.E.; Wilson, R.; SAGE Working Group on Vaccine Hesitancy; COLLABORATORS: Eskola, J.; Liang, X.; Chaudhuri, M.; Dubé, E.; Gellin, B.; Goldstein, S.; Larson, H.; MacDonald, N.; Manzo, M.L.; Reingold, A.; Tshering, K.; Zhou, Y.; Butler, R.; Duclos, P.; Guirguis, S.; Hickler, B.; Schuster, M.  Measuring vaccine hesitancy: The development of a survey tool. Vaccine, 2015; 33(34):4165-75.

Karafillakis, E.; Hassounah, S.; Atchison, C.  Effectiveness and impact of rotavirus vaccines in Europe, 2006-2014. Vaccine, 2015; 33(18):2097-107.

Hawkes, S.; Kismödi, E.; Larson, H.; Buse, K.  Vaccines to promote and protect sexual health: Policy challenges and opportunities. Vaccine, 2014; 32(14):1610-5.

Larson, H.J.; Jarrett, C.; Eckersberger, E.; Smith, D.M.; Paterson, P.  Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: A systematic review of published literature, 2007-2012. Vaccine (2014) ; DOI: 10.1016/j.vaccine.2014.01.081; PMID: 24598724.

Larson, H.J.; Wilson, R.; Hanley, S.; Parys, A.; Paterson, P.  Tracking the global spread of vaccine sentiments: The global response to Japan’s suspension of its HPV vaccine recommendation. Hum Vaccin Immunother (2014) :1-8; DOI: 10.4161/21645515.2014.969618; PMID: 25483472


Apfel, F.; Cecconi, S.; Oprandi, N.; Larson, H.; Karafillakis, E.  Let’s talk about hesitancy. Enhancing confidence in vaccination and uptake. Practical guide for public health programme managers and communicators. 2016. PDF

Larson, H.; Karafillakis, E.  Rapid literature review on motivating hesitant population groups in Europe to vaccinate. ECDC Technical Report. 2015. PDF

Larson, H.; Schulz, W.  The state of vaccine confidence 2015. 2015. PDF

Wilson, R.; Paterson, P.; Chiu, J.; Schulz, W.; Larson, H. HPV Vaccination in Japan. The Continuing Debate and Global Impacts. A Report of the CSIS Global Health Policy Center. April 2015. Center for Strategic & International Studies. PDF

Wilson, R.; Paterson, P.; Larson, H.J. The HPV Vaccination in Japan. Issues and Options. A Report of the CSIS Global Health Policy Center. Center for Strategic & International Studies. May 2014.  PDF


Brighton Collaboration
Chatham House
European Commission
European Medicines Agency
Gallup International
Imperial College London
International Pediatric Association
International Vaccine Institute
LVCT Kenya

National University of Singapore
Public Health Foundation of India
Sabin Vaccine Institute
University College London
University of Washington, Seattle
World Health Organization




European Centre for Disease Prevention and Control (ECDC)
European Commission
European Federation of Pharmaceutical Industries and Associations (EFPIA)
GlaxoSmithKline (GSK)

King Baudouin Foundation (KBF)
Innovative Medicines Initiative (IMI)
National Institute for Health Research (NIHR)
Results 4 Development (R4D)

Videos Video archive

The World Health Organization (WHO) and the European Commission joined forces to tackle the issue at the first global vaccination summit. Although many of them live in developing countries with poor access to vaccines, scientists are worried that anti-vaccination campaigners in the developed world are spreading misinformation on social media. So what’s the cure for their scepticism?

Emilie Karafillakis, research fellow for the Vaccine Confidence Project, speaks to France 24 about the rising anti-vaccination sentiment that is rising throughout Europe, especially in France where a recent study revealed 1 in 3 citizens believe vaccines are unsafe.

In this episode of Take as Directed, J. Stephen Morrison speaks with Dr. Heidi Larson on why vaccine confidence is currently in crisis, and how this has fueled outbreaks such as measles and the persistence of polio in Afghanistan and Pakistan.

Literature Literature archive

Biswal . 2019 NEJM DOI: 10.1056/NEJMoa1903869
Piot P, Larson HJ, O'Brian KL, et al 2019 NATURE Vol. 575, pages119–129.
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The Vaccine Knowledge Project at the Oxford Vaccine Group