A second opinion

Attitudes towards vaccinations in Japan

November 2019 Feature / Text by Justin McCurry

Japan is struggling to shake off its image as a vaccination backwater. Even though it has made progress in closing the “vaccination gap” with the US and the EU over the past decade, and most children here undergo routine inoculations, Japan is still perceived as dragging its heels on the availability of vaccines that are widely used elsewhere. This perception can be attributed to a mere six letters: MMR (mumps, measles and rubella) and HPV (human papillomavirus).

Japan stopped using the combination MMR vaccine in 1993, becoming one of only a few developed nations to shun the jab. The Ministry of Health, Labour and Welfare (MHLW) made that decision after a number of children suffered adverse reactions to the combined vaccine. The government then lost a series of high-profile compensation cases brought by the families of children who had died or been left with serious disabilities.

Although a combined inoculation for measles and rubella is part of the national immunisation programme (NIP) today, parents must pay for their child to be protected against mumps.

“There was a surge in public attention towards the adverse effects of the MMR vaccine a few decades ago,” says Dr Shuichiro Hayashi, director of the immunisation office at the MHLW. “And it’s true that the MMR vaccines initially used in Japan are associated with adverse effects. That means that expectations for the safety of the MMR vaccine are so high that we are still unable to introduce it.

“The MMR episode made the government very cautious and reluctant to introduce new vaccines until 2009, when people became aware of the vaccine gap between Japan and countries in Europe. Since then, our priority has been to resolve the gap and introduce new vaccines.”

The government added the HPV vaccine to the NIP in 2013, with the cost of inoculations covered by the state, not individuals. But after some recipients complained of severe side effects, the government stopped conducting activities to promote the vaccine, such as sending letters recommending it to girls in their early teens, while officially keeping it on the NIP recommendation list.

More recently, the fate of the HPV vaccine is closely associated with Riko Muranaka, a physician and medical writer who was found guilty of defamation early this year after claiming that a neurologist had fabricated data showing a link between the vaccine and brain damage.

While the lawsuit did not address the veracity of the data, the ruling caused further damage to the vaccine’s reputation: the HPV vaccine is still part of the NIP, but the vaccination rate has plummeted from 70% for girls born in the mid-1990s to around 1% today.

Representatives of European pharmaceutical companies in Japan said the widespread attention given to the MMR and HPV vaccines has fuelled unfair claims that Japan lags behind comparable countries when it comes to official and public attitudes towards vaccinations.

Instead, take-up rates are more influenced by whether or not a particular vaccine is “routine” as part of the state-funded NIP, or “voluntary”, meaning it must be paid for by individuals, according to Jun Honda, chair of the Biologics Committee of the European Federation of Pharmaceutical Industries and Associations (EFPIA) Japan.

“The take-up rate of paid-for inoculations is dramatically lower than for those that are part of the national programme,” Honda says. “NIP vaccines for children have an average 95% take-up rate, but for mumps, which has to be paid for by individuals, it is estimated at 30% to 40%.

“Our perception is that the anti-vax movement is not as active in Japan as it is in other countries, more that it’s the lack of information and communication with the potential recipients of those vaccines.”

In addition to noting that the rotavirus and mumps vaccines are the only World Health Organization-recommended vaccines that are not part of Japan’s NIP, EFPIA stated in its contribution to the 2018 white paper published by the European Business Council in Japan that “access to vaccines in Japan started to improve rapidly from 2008 onwards, following the sequential introduction of several new vaccines.

“By October 2016, many vaccines had been designated an integral part of ‘routine immunisation’, and they are, therefore, included in the suite of vaccines strongly recommended, as well as funded, by the government.”

While generally positive about the progress made by Japan’s health authorities, the white paper identified one remaining area of the vaccine gap.

Japan’s citizens, it said, would benefit from the introduction of more combination vaccines — those that target multiple conditions with a single jab — thereby relieving the congested immunisation schedule for children. The white paper noted, for example, that (the MMR aside) combination vaccines for half a dozen diseases, including hepatitis B and polio, were still not available in Japan.

One solution would be the introduction of combination vaccines manufactured in Europe by companies with an established reputation in the Japanese market, such as the British firm GlaxoSmithKline and the French company Sanofi.

Honda, however, believes that imports of certain vaccines, particularly those that are also being developed in Japan, are some way off.

“I think the Japanese government is more willing to accept vaccines from outside Japan than before, which is a good thing but, of course, that’s for vaccines that are not available from domestic manufacturers,” he says.

There are signs that Japan will continue to close the vaccine gap. European companies report a greater willingness among Japanese firms and regulators to engage in dialogue, while the political momentum is moving in the right direction under a new study group on vaccine policies.

Honda notes that European firms are also attempting to promote the idea of life-course immunisation to cover at-risk people spanning the generations.

“There is a notion that vaccines are only for children, but that’s not the case,” he says. “There are several vaccines for adults that should be promoted: for influenza, pneumococcal diseases and shingles, for example.

“As an industry we are saying that vaccines for adults and the elderly are as important as vaccines for children. Measles and rubella are spreading among males who were not vaccinated … and flu and pneumococcal vaccines can be effective against pneumonia, one of the main causes of death among older people.”  •