Background and Challenges

The World Health Organization (WHO) states that vaccination is the most cost-effective public health intervention when considering health, social, economic, and educational impacts. Nevertheless, 1.5 million people worldwide are affected by vaccine-preventable diseases (VPD) each year due to lack of or inability to vaccinate. In Japan, society has reacted strongly to health hazards related to vaccination, and there have been cases where immunization policies have had to be reconsidered due to media reports and lawsuits. There is also a phenomenon known as vaccine hesitancy, where people hesitate or refuse to vaccinate themselves or their children. This has led to a situation where routine immunizations cannot be provided to the public on schedule. In addition, VPDs are still being reported in Japan due to changes in the system.

In recent years, in light of advances in science and technology and the diversification of lifestyles, international organizations and immunization policies in other countries have increasingly emphasized the importance of the life-course approach to immunization, with immunizations taking place not only during childhood, but throughout adolescence, middle age, and old age. In addition, in order to respond to the trend of vaccine hesitancy, Japan has been implementing various initiatives, such as disseminating scientific evidence on the efficacy, safety, and necessity of vaccinations in an easy-to-understand manner and introducing a catch-up system for the unvaccinated. In Japan, the life-course approach has not always been sufficiently implemented because of the design of the immunization system, the perception of the government, and the perception of health care providers.

As of early May 2021, a novel coronavirus infection (COVID-19: Coronavirus Disease 2019) has claimed the lives of approximately 3 million people and caused global economic and social disruption. As some countries move toward the end of the pandemic, expectations for effective and safe vaccines as well as the establishment of treatment methods are increasing worldwide. In Japan, along with a growing sense of urgency regarding infectious diseases, there is a growing interest among all generations in the domestic situation surrounding immunization and vaccination.

As described above, as society’s interest in immunization and vaccination policy grows, it is important that each citizen deepens their understanding of the value that immunization brings to individuals and society throughout one’s life course, across all generations. Japan is expected to implement policies for life-course-based immunization and vaccinate the unimmunized generation.

Thoughts and challenges relating to immunization policy in Japan

In the “Basic Plan for Immunization” established by the Ministry of Health, Labour and Welfare (MHLW), it is clearly stated that since the enactment of the Immunization Law in 1948, vaccines have been remarkably effective in improving the level of public health and maintaining the health of the people, and have made significant contributions to humanity, such as the control of smallpox, which was once a threat to humanity, and the eradication of polio in the Western Pacific region. On the other hand, it is also mentioned that the public’s concerns about adverse effects of immunization have not been dispelled for a long time, and that the number of publicly administered vaccines is low compared to other developed countries (vaccine gap).

(From “Basic Plan on Immunization,” Ministry of Health, Labour and Welfare website)

What does immunization and vaccination mean?

The Tokyo Metropolitan Medical Association’s website, What is immunization?, explains that “Immunization is the process of making a person less susceptible to a disease by administering a less virulent pathogen (virus or bacteria) or toxin in advance. The term ‘vaccination’ is used to describe the administration of a vaccine or toxoid.”

(From “What is vaccination?”, Tokyo Metropolitan Medical Association website)

In other words, “immunization” refers to the “act” and “vaccine” refers to the “thing” used for immunization. There are three main types of vaccines: live-attenuated vaccines, inactivated vaccines, and toxoids. That being said, technological progress has been remarkable in recent years, as evidenced by the response to COVID-19.

Routine and Voluntary Immunization

In addition, the Immunization Law, which is enforced for the purpose of preventing the outbreak and spread of potentially contagious diseases, creates two categories of immunization: “routine” and “voluntary.” The measures have been changed based on the idea that there are two types of diseases: Class A diseases, which focus on group prevention and prevention of serious diseases, and for which the government actively recommends and the individual (guardian) is obliged to make efforts, and Class B diseases, which focus on individual prevention and for which the individual (guardian) is not obliged to make efforts. Therefore, the immunization process varies greatly depending on whether the vaccine is classified as routine or voluntary.

Routine VaccinationsObjective to Protect Public Health (Category I)Hib VaccineHib (Bacterial meningitis, epiglottitis)
Pediatric Pneumococcal VaccinePediatric Pneumococcal (Bacterial Meningitis, Sepsis, Pneumonia)
Hepatitis B VaccineHepatitis B
Rotavirus VaccineInfectious Gastroenteritis
DPT/IPVDiphtheria, Pertussis, Tetanus, Polio
MR (Measles, Rubella) VaccineMeasles, Rubella
Chicken Pox VaccineChicken Pox
Japanese Encephalitis VaccineJapanese Encephalitis
HPV (Human Papillomavirus) VaccineHuman Papillomavirus (Cervical Cancer)
Objective to Protect Individual's Health (Category II)Influenza Vaccine (For the Elderly)Influenza
Adult Pneumococcal Vaccine (For the Elderly)Adult Pneumococcal Disease
Voluntary VaccinationsMumps VaccineMumps (Epidemic Parotitis)
DPTDiphtheria, Pertussis, Tetanus
Influenza VaccineInfluenza
Hepatitis A VaccineHepatitis A
Meningococcus VaccineMeningococcus

Live-attenuated VaccinesInactivated VaccinesToxoid Vaccines
MeaslesPertussis (DPT-PIV: Diphtheria, Pertussis, Tetanus, Inactivated Poliovirus Vaccine)Diphtheria & Tetanus
RubellaJapanese Encephalitis DT Toxoid
Chicken PoxInfluenzaDPT-IPV
MumpsType A Pneumonia Adult Diphtheria
Yellow FeverType B Pneumonia Tetanus
BCG​Haemophilus Influenzae Type B (Hib)
Rotavirus13-valent Pneumococcal Conjugate
23-valent Pneumococcal Polysaccharide
Human Papillomavirus (HPV)
Inactivated Poliovirus Vaccine

(From “What is immunization?” Tokyo Metropolitan Medical Association website)

Challenges with Japan’s immunization and vaccination policy

In Japan, vaccination rates in infancy are extremely high, but vaccine hesitancy, or the failure of public awareness campaigns to raise vaccination rates, tends to prevent vaccination rates from rising as much as expected, especially among adolescents and those who have reached an age when they can make their own decisions. Major examples include the human papillomavirus (HPV) vaccine and the influenza and pneumococcal vaccines in the elderly.

As for the HPV vaccine, the vaccination rate in Japan is extremely low compared to other countries. According to WHO estimates for 2019, the percentage of women aged 15 who have been vaccinated is 0.3% in Japan, compared to 55% in the US and 80% in Australia. It is believed that one of the reasons for the significant decline in vaccination rates in Japan is the discontinuation of “positive recommendations” by the Ministry of Health, Labour and Welfare, along with reports of various adverse reactions. This was a decision made at the time due to reports of serious adverse reactions that could not be attributed to HPV vaccination. At present (May 2021), there is an increasing number of calls for the “MHLW’s suspension of active recommendations” to be reversed and recommendations to be resumed.

Vaccination coverage among the elderly in Japan is also lower than in other countries, despite the availability of free and reduced copayment support. The influenza vaccine coverage rate is 50.2%, about half of all elderly, and the pneumococcal vaccine coverage rate is even lower at 37.8%.

One of the reasons why the vaccination rate has not increased, despite the measures taken by local governments and the national government, is due in part to adverse reactions, but also to a lack of communication with the target population, leaving lots of room for improvement. The tendency for people to avoid vaccines mainly stems from concerns about side effects, but in order to gain understanding of vaccines, careful dialogue is required, based on acceptance and respect for their concerns and intentions, rather than one-sidedly conveying their efficacy and forcing vaccination.

The following is a summary of the 17 key findings that the Institute for Public Relations (IPR) recommends to guide communication relating to the COVID-19 vaccine. Although this summary relates to the COVID-19 vaccine, some statements are applicable to all vaccine measures.

No.Key Finding
1Vaccine hesitancy is not due to a lack of information. Vaccine hesitancy, or the reluctance or refusal to vaccinate despite vaccine availability, is a threat to global health. Attitudes toward vaccines typically fall on a continuum (rather than being only “pro” or “anti” vaccinations). Vaccine hesitancy is not due to a lack of information, and sending out information about vaccines alone does not increase vaccine uptake (or taking the vaccine). People who are vaccine-hesitant should be treated with compassion, sensitivity, and respect. Perceptions of risk and safety are two of the main concerns people have about vaccinations. People more willing to be vaccinated are more likely to believe that they are at risk of contracting COVID-19, that the impact can be severe, and that the vaccine is safe and effective.
2Transparency is key. Being transparent and keeping audiences updated is critically important for building trust and confidence. People are concerned about the “rushed” vaccine process so these concerns need to be addressed. Additionally, people should be given Vaccine Information Statements (VIS) as well as Vaccine Adverse Event Reporting System (VAERS) summary data. The potential adverse effects of a vaccine should be disclosed to patients. Keep it simple or detailed analyses and jargon will dissuade people.
3Tailoring communication with each audience is critical. Attitudes and perspectives on vaccinations can vary widely depending on demographics, at-risk factors, religion, psychographics, culture, political views, news consumption, geographic locations, technographic factors, among others. A one-size-fits-all approach will not be as effective. Communicators should conduct research about their specific audiences to better understand them. Messaging should be pre-tested and made available in multiple languages. Deploying insights should be done responsibly and ethically.
4Use theories and models to guide communication planning as well as strategies and tactics. Understanding behavioral intentions, how people think and feel, and the determinants of behavior change can make or break a campaign’s success. For example, using the COM-B model of behavior by applying the Behavior Change Wheel can increase vaccine uptake.
5Marginalized groups have lower vaccine confidence. Communities of color have lower confidence in vaccines due to historic and systemic racism, discrimination, and inequities within the healthcare system and government. Messaging and education related to COVID-19 vaccinations must specifically focus on these communities with input from people within those communities. Cultural humility is important.
6Trust doctors and nurses. Healthcare providers (HCPs) are the most important source for many to increase vaccine uptake. Research shows that HCPs must be confident in the vaccine and have the resources, knowledge, and tools to effectively communicate with their patients and communities.
7Opinion leaders for target audiences should be defined. Just as audiences and their needs vary widely, so do their opinion leaders. Identifying and employing effective opinion leaders and influencers increases uptake. Vaccinate credible influencers within defined communities to demonstrate vaccine confidence. Per social contagion theory, people have a tendency to think and act like their friends and family, which encourages adoption of behaviors. Family and friends are one of the most trusted sources of information.
8The anti-vaccination movement should not be ignored. While communicators are unlikely to change the minds of those in the anti-vaccination movement, the anti-vaccination community is influential to those who are undecided about vaccinations. This could decrease vaccine confidence within the critically-important, undecided community.
9Tell stories, not statistics. Stories and anecdotes about those affected positively by vaccinations are more likely to be effective than statistics. First-person testimony can help increase confidence. The COVID-19 vaccination should be framed as another important action to take with hand washing, mask-wearing, and physical distancing to prevent COVID-19. Official communications about vaccines should have a clear take-home message, tell a memorable story, and elicit feelings.
10Agencies must be aligned. All agencies (government, the healthcare community, federal agencies, companies, etc.) must provide clear and consistent messaging to increase public trust and confidence.
11Misinformation should not be repeated. Communicators must be careful to not amplify misinformation when they are rebutting or correcting it. Multiple sources providing accurate information is better than a single source. While research about the impact of the backfire effect has seen mixed results, communicators do not want people to reject credible information presented to them and strengthen their original stance on an issue. Also, do not respond to trolls.
12Inoculate people against misinformation. Inoculation theory suggests false claims should be debunked before people encounter them. Inoculating against misinformation, or “prebunking,” by warning people about potential misinformation can be effective.
13Understand biases. Omission bias indicates a strong preference for inaction even when taking action is more beneficial. Optimism bias means people believe they have a lower chance of contracting COVID-19 than they actually do. Confirmation bias, or seeking information that only confirms one’s beliefs, may lead to polarization and echo chambers. Understanding biases can equip communicators with strategies for overcoming them.
14Help encourage health literacy. Cultivate critical thinking by increasing the knowledge of employees and the community about health information to help them make appropriate health decisions. Low health literacy is more prevalent among older adults, minority populations, those with low socioeconomic status, and medically underserved people. Offer programs and workshops to help employees become more health literate. It also helps protect against misinformation.
15Language matters. Avoid using loaded terms that can turn people off. Some of these include “conspiracy theories” or “anti-vaxxers.” Also, “Operation Warp Speed” or a “rushed” vaccine approval process may impact people’s perception of the vaccine’s safety. “Public health agencies” is better than “federal” or “government” to not elicit a feeling of red tape.
16Listen. Listen to people’s and HCP’s concerns about the vaccine to increase vaccine uptake. Listening to rumors also can help identify deeper issues.
17Technology can help increase uptake. Digital push technologies, such as text messaging, have been effective at increasing uptake (including for a series vaccination like the COVID-19 vaccine) for some audiences. Gamification is also effective for changing attitudes and behavior, such as identifying and dismissing disinformation. Also, do not forget to track and measure communication efforts.
(From the Institute for Public Relations, “A Communicator’s Guide to COVID-19 Vaccination (17 Keys”)

Policy Trends

Global Vaccine Action Plan (GVAP)

The World Health Organization’s (WHO) GVAP is a vision of global immunization and vaccine issues to be addressed over the 10-year period 2011–2020. In it, the overriding goal was to achieve “a life free of vaccine-preventable diseases for all individuals and communities.” With GVAP as a guide for global action, the Strategic Advisory Group of Experts (SAGE) published an evaluation report in June 2020, which made 15 recommendations were implemented.

April 2020|Immunization Agenda 2030 (IA2030)

IA2030 serves as the overarching global vision and strategy for vaccines and immunization for the decade 2021–2030. It aims to build on lessons learned, recognize the continuing and emerging challenges posed by infectious diseases, and encourage the use of new opportunities to address these challenges. IA2030 identifies immunization as a major contributor to people’s fundamental right to the enjoyment of the best attainable physical and mental health. In addition, the focus of future activities is taken to ensure that no one is left behind, no matter what the situation or stage of life.

Vaccine Industry Vision (Ministry of Health, Labour and Welfare)

  1. Objectives of the Vaccine Industry Vision
  2. Environment Surrounding the Vaccine Industry
  3. Current Status and Challenges in the Vaccine Industry
  4. Expected Needs of the Vaccine Industry
  5. Basic Approach to Vaccine Industry Policy
  6. Action Plan

Review of the Immunization System (First Proposal) (Ministry of Health, Labour and Welfare)

  1. Creation of a new model of temporary vaccinations
  2. Response to a global pandemic such as a new strain of influenza
  3. Making the novel influenza vaccine a routine vaccination
  4. Matters considered to require discussion

Review of the Immunization System (Second Proposal) (Ministry of Health, Labour and Welfare)

  1. Purpose of the review
  2. Plan for the comprehensive promotion of immunization (tentative name)
  3. Addition of diseases and vaccines covered by the Immunization Law
  4. Classification of diseases under the Immunization Law
  5. How to bear the cost of vaccination
  6. Vaccine prices and other vaccination costs
  7. Evaluation and review organization for immunization
  8. Division of roles among the parties involved
  9. Adverse reaction reporting system, health damage relief system
  10. Vaccination methods, vaccination records and information
  11. Infectious disease surveillance
  12. Promote research and development of vaccines and secure the production base

2016|Vaccine and Blood Products Industry Task Force (Ministry of Health, Labour and Welfare)

  1. Vaccines
  2. Blood products
  3. Strengthening Governance

HGPI’s Involvement

In the case of the Coronavirus Disease 2019 (COVID-19), which is currently a global threat, national attention is focused on the development of a vaccine and its widespread use. Opinion leaders from civil society, industry, government, academia, and the private sector have come together to form an advisory board and hold a series of meetings to have open, constructive discussions related to vaccination policy issues in Japan. The objective of this project is to identify issues and come up with a plan for solving them.

  • August 2020: The First Advisory Board Meeting for the Immunization and Vaccination Policy Promotion Project, “Charting the Way Forward on Immunization Policy: International Trends and the Situation in Japan”
  • September 2020: The Second Advisory Board Meeting for the Immunization and Vaccination Policy Promotion Project, “Charting the Way Forward on Immunization Policy: International Trends and the Situation in Japan”
  • September 2020: Proposal on a Global Procurement System for Coronavirus Disease 2019 (COVID-19) Vaccines
  • November 2020: The Third Advisory Board Meeting for the Immunization and Vaccination Policy Promotion Project, “Charting the Way Forward on Immunization Policy: International Trends and the Situation in Japan”
  • December 2020: The Global Expert Meeting on the Way Forward for a Life Course Approach to Immunization and Vaccination Policy
  • February 2021: The Fourth Advisory Board Meeting for the Immunization and Vaccination Policy Promotion Project, “Communication Strategy for Promoting Public Understanding and Enlightenment of Vaccine and Immunization”

Last Modified: June 2021