Shakib Sana has been working as a general practitioner for fourteen years. In all those years, he has not once had a patient with measles – until recently several children with measles symptoms suddenly came into his consultation room in Leerdam. “To be sure it was measles, I had to look at the medical manual and consult with a colleague and a pediatrician,” says Sana.
Measles is back in the Netherlands, including an outbreak in Eindhoven in March. Whooping cough is also on the rise and will now kill four babies in 2024. “Last year we had one case of whooping cough in Amsterdam in the first quarter,” says councilor Alexander Scholtes (Public Health, D66). “This year we already have 250 cases in the same period.”
This is because too few children have been vaccinated with the MMR injection (mumps, measles, rubella) and the DKTP injection (diphtheria, whooping cough, tetanus, polio). Only if nine out of ten children have been vaccinated will there be sufficient group protection – also for babies, who can only be vaccinated after nine months. In Amsterdam, Rotterdam, The Hague and Utrecht, the vaccination rate among two-year-old children is below the critical limit of 90 percent.
The differences are large within the major cities. In 40 of the 136 districts, the vaccination rate is below the critical limit, an overview shows NRC made. A district in Amsterdam-West even scores 69.5 percent (DKTP) and 64.6 percent (BMR). Only in ten neighborhoods in the major cities, including one in Amsterdam-Centre, does the vaccination rate for measles (MMR) exceed the ideal limit of 95 percent.
Because measles is such a contagious disease, 95 out of 100 children should actually be vaccinated against it. “We are almost waiting for a measles outbreak to occur here too,” says Amsterdam councilor Scholtes. “Measles and whooping cough are the first diseases to break through with a low vaccination rate, the tip of the iceberg of all infectious diseases.”
That is why The Hague councilor Hilbert Bredemeijer (Youth, CDA) was recently the first to have a report drawn up on the vaccination rate at district level. In some neighborhoods of The Hague it has fallen below 80 percent. Subsequently, the three other major cities gave up at the request of NRC also the vaccination figures per district. “The vaccination rate is now at a very worrying level,” says Bredemeijer. “We as a society need to have a good discussion about this theme. This starts with finding out in which neighborhoods the vaccination rate is too low.”
Poor neighborhoods
Why do so few parents vaccinate their children? The National Institute for Public Health and the Environment (RIVM) gives some rather different explanations in its latest report on the National Vaccination Program. Since the corona pandemic, citizens’ confidence in the government has declined. Fables about the harmful effects of the vaccines are circulating on social media. Quite a few parents mistook the letter about the MMR and DKTP shots for a call for the corona shot and threw it away unopened.
It sounds familiar to Shakib Sana. As a general practitioner in the Rotterdam district of Delfshaven (DKTP: 76 percent, BMR: 79 percent), where he worked until recently, he has spoken a lot with patients and colleagues about whether or not to vaccinate. During the corona pandemic, Sana even talked to strangers at the market about their doubts about the vaccination against corona. He was one of the founders of the Doubt Telephone, where people can ask medical students questions about all kinds of health issues.
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“In my experience, there are roughly three types of vaccine refusers,” says Sana, who obtained her PhD on health differences in disadvantaged neighborhoods. “One: people with religious arguments, often orthodox Protestants. Two: people who consciously decide that it is better not to vaccinate their child, but to let them go through childhood illnesses. Three: people with a migration background.” He notes about the latter people: “This is not because of their culture or religion, but because of their weak socio-economic position.”
Anyone who compares the figures on vaccinations in a neighborhood with those on incomes there will see that a low vaccination rate indeed often goes hand in hand with poverty. The Amsterdam district with the low vaccination score is also one of the poorest neighborhoods in the Netherlands. The neighborhoods that score unsatisfactory in Rotterdam, The Hague and Utrecht are predominantly the neighborhoods with many poor residents.
‘Booster’
Why are low-income people so reluctant to vaccinate? “That is not a matter of not wanting, but mainly of not knowing,” says Aziz Kalla. He is a community nurse at Kleurrijk Zorg in Utrecht and works in the Overvecht district (DKTP: 86.4 percent, BMR: 85.9 percent). “You could also say that people do not get around to properly delving into vaccinations.”
Many people with a migration background and little money live in Overvecht. “The corona pandemic has had a major impact,” says Kalla. “Residents then remained isolated and lonely. Then inflation made groceries more expensive. Many people are concerned with survival. There is often not much room in the head for thoughts about vaccinations.”
Then, according to Kalla, all that has to happen is that people will think: just leave the vaccination alone. “The repeat injection was stated in an invitation letter booster named. This has not gone down well with a number of people, because they think of the corona vaccine when they hear this word.” Kalla heard the fable several times that a vaccine can cause autism. “People often say: ‘Things are going well, aren’t they? Aren’t there hardly any diseases left anymore?’ Then I say: ‘That’s because so many parents have their children vaccinated’.”
Key persons
Kalla conducts these types of conversations under the wings of the Utrecht Key Persons Foundation (SSU), which is active in several neighborhoods with a subsidy from the municipality. “Key people like Aziz Kalla know the neighborhood, the workplace of society,” says Utrecht councilor Eelco Eerenberg (Public Health, D66). “They understand the dilemmas of the residents and can help to remove the doubts of parents.”
Kalla, who grew up in Overvecht, campaigned for vaccination during the corona pandemic. “Residents mainly asked me: ‘Aziz, did you take it yourself?’ They trust me because they know me.” Kalla now makes educational films in which he interviews GGD doctors, for example: “Of course you can also make a video with just the expert, but it helps that people see that I ask those questions.”
Utrecht would also like to remove practical obstacles, says councilor Eerenberg: “For someone living in Overvecht, a vaccination in the Jaarbeurs is far away. Ideally, we will soon have a small-scale location near a shopping center, just like during corona, where you can, so to speak, combine shopping with getting a shot.” Utrecht has so far made money available for only three such locations.
Amsterdam has already made progress with such a small-scale approach, with weekly and monthly drop-in consultations for children and young people at twenty locations. “I know an example of a mother from Zuidoost who did not come to the Ziggo Dome with her three children in the metro, but did go to the walk-in consultation hours in the area,” says councilor Scholtes. In addition, the GGD has sent new calls for catch-up injections.
The approach works, in combination with additional information and the deployment of key people. Participation has increased significantly for the DKTP and MMR vaccinations – although not yet sufficiently. The extra effort cost Amsterdam an extra eight thousand euros last year. “Many municipalities cannot pay such an amount,” says Scholtes. Municipalities receive money for the basics – inviting and vaccinating – and, according to him, should receive extra money from the government for additional efforts: “It is the government’s vaccination program.” In a letter to the cabinet, the responsible councilors of the four large municipalities recently asked for extra money for their campaigns in the neighborhoods.
These campaigns are sometimes a difficult puzzle, because not all neighborhoods fit the pattern of the poorer, the fewer injections. The Amsterdam district of Geuzenbuurt is poor but has a high vaccination rate (DKTP: 96.8 percent, BMR 90.3 percent). The traditionally poor Zeeheldenkwartier has more and more residents with a good income, but has only seen the vaccination rate decrease since the corona pandemic (DKTP: 80.5 percent, BMR: 79.3 percent). “That is a neighborhood with an average of highly educated young professionals,” says Hague councilor Bredemeijer. “These residents are really a new target group that we need to delve deeper into.” Disinformation may play a role here.
Municipalities have to solve that puzzle themselves, because no additional money is coming from the government for the time being. “Very sad,” says Bredemeijer. “It is about the health of our children.” Four dead babies due to whooping cough may not seem like much, says GP Sana: “They had a whole life ahead of them, about eighty years. That is, as doctors often say, 320 years of life lost.”
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