Voluntary Vaccination Research Articles

A nationwide population-based surveillance of invasive Haemophilus influenzae diseases in children after the introduction of the Haemophilus influenzae type b vaccine in Japan

BackgroundHaemophilus influenzae type b (Hib) vaccine was introduced as a voluntary vaccine in December 2008 and was included in the national routine immunization program in April 2013 in Japan. Currently, no nationwide data are available to evaluate the effectiveness of Hib vaccine in Japan. MethodsTo evaluate the effectiveness of Hib vaccine in Japan, nationwide active population-based surveillance of culture-proven invasive infections caused by H. influenzae in children was performed in 2008–2017 in 10 prefectures in Japan (covering approximately 23% of the total Japanese population). Clinical data were recorded on a standardized case report form. Capsular type and antimicrobial susceptibility of the H. influenzae isolates were examined. The incidence rate ratio (IRR) and its confidence interval (CI) were calculated to compare data from 5 years before and that from after the introduction of the national routine Hib vaccine immunization program. ResultsDuring the 10-year study period, 566 invasive H. influenzae disease cases including 336 meningitis cases were identified. The average number of invasive H. influenzae disease cases among children <5 years of age during 2013–2017 decreased by 93% (IRR: 0.07, 95%CI 0.05–0.10, p < 0.001) compared with those occurring during 2008–2012. Hib strains have not been isolated from invasive H. influenzae disease cases since 2014; however, non-typeable H. influenzae and H. influenzae type f isolates have been noted as causes of invasive H. influenzae diseases among children <5 years in the post-Hib vaccine era. ConclusionsAfter the governmental subsidization of the Hib vaccine, invasive Hib disease cases decreased dramatically in the study population, as per our surveillance. Continuous surveillance is necessary to monitor the effectiveness of Hib vaccine and for detecting any emerging invasive capsular types.

Progress and challenges for the Japanese immunization program: Beyond the “vaccine gap”

The Japanese immunization program has made considerable recent progress. The introduction of several new vaccines, especially foreign-produced vaccines, and the inclusion of important new vaccines in the National Immunization Program (NIP) are closing the “vaccine gap”, i.e., the delay in the Japanese immunization program relative to programs in other developed countries. Major progress in the Japanese immunization program since 2014 includes (1) elimination of measles in March 2015, (2) introduction of a varicella vaccine as a routine immunization in the NIP in October 2015, and (3) introduction of hepatitis B virus vaccines as routine immunizations in the NIP in October 2016. Despite these promising developments, important issues remain. First, the government withdrew the active recommendation for human papilloma virus vaccines temporarily in 2013. The withdrawal has continued and unresolved despite new scientific evidence confirming the safety of these vaccines. Second, a few important voluntary vaccines, including vaccines for mumps and rotavirus, have not been included in the NIP since their introduction to Japan. Finally, there are concerns related to a shortage of mandatory domestic vaccines, which was caused by a natural disaster in the area where a vaccine-producing factory was located. Additionally, the manufacturer included unauthorized additives in some vaccine products with falsifying the production-process records. To avoid problems related to vaccine shortages, essential vaccines need to be stockpiled, and the future vaccine needs for children should to be discussed. New initiatives must continue to close the vaccine gap, as this will protect children living in Japan from vaccine-preventable diseases.

Ethical considerations in the uptake of influenza vaccination by healthcare workers

ObjectivesThe World Health Organization (WHO) recommends annual seasonal influenza vaccination of healthcare workers (HCWs). Under the current voluntary scheme in England, uptake of vaccine in this group remains well below the 75% target. A mandatory scheme may improve rates, but raises the ethical issue of imposed vaccination. However, the existing voluntary scheme could also potentially infringe autonomy if those not wanting to join feel pressured or coerced into vaccination. The aim of this study was to explore HCW views and experiences with the current influenza vaccination programme. Study designQuestionnaire survey. MethodsBetween March 2015 and April 2016, a total of 140 questionnaires were completed across seven HCW groups, with the demographic, vaccination and opinion data statistically analysed using the chi-squared test, Kruskal-Wallis test and Mann–Whitney U-test as appropriate. ResultsNo staff group met the national influenza vaccination target of 75% and vaccination rates varied between HCW groups. All groups reported some degree of external pressure to be vaccinated and there were mixed views on the concept of mandatory vaccination, with a lack of certainty over the vaccine's efficacy and/or a lack of information the most common reasons for not supporting it. ConclusionThe current voluntary influenza vaccination scheme has a number of flaws. Improvements in the quality and availability of information provided to employees may help Trusts increase vaccination rates, or achieve acceptance of any proposed mandatory programme.

Subsidy strategy based on history information can stimulate voluntary vaccination behaviors on seasonal diseases

Subsidy policies are always used to offer some incentive for individual voluntary vaccination behaviors. The selection of subsidized individuals in proposed policies, such as random subsidy (RAN) and target subsidy (TAR), do not always consider an individual’s history of vaccination behaviors. In this paper, we studied a seasonal influenza-like disease model and proposed two history information-based subsidy policies in which individuals are selected as donees based on vaccination information in the previous seasons: HI-RAN randomly selects individuals who did not voluntarily vaccinate in the previous season, and HI-TAR combines the degree centrality on this basis. Simulations in different networks show that the two proposed subsidy policies both limit the extent of an epidemic outbreak, and the HI-TAR policy is more effective. Moreover, both of our proposed policies are most effective when only one step history information is considered. Through microscopic analysis of the evolution of vaccination behaviors, we found history information-based subsidy policies can enhance the vaccination probability of non-hub nodes. Our work is expected to provide valuable information for vaccination policymaking by considering vaccination history behaviors.

Voluntary vaccinations and vaccine shortages: A theoretical analysis

A simple dynamic model of vaccination is presented and analyzed to study how the amount of vaccines available affects people’s vaccination decisions. In addition, the model is used to examine how the level of vaccination in equilibrium compares to the efficient or socially optimal level. It is shown that, when the stock of vaccines is large so that a shortage could never arise, an equilibrium is generically unique, and there is too little vaccination compared to the social optimum. When the stock of vaccines is small so that not everyone in a population could get vaccinated, a shortage could occur in equilibrium. Moreover, the occurrence of a shortage could be self-fulfilling: when agents expect a shortage to develop, they have a greater incentive to demand the vaccine right away, which increases the likelihood that a shortage will result; and when agents do not expect a shortage to arise, they are more willing to delay their vaccination decision, which reduces the likelihood of a shortage developing. This leads to the possible co-existence of multiple equilibria that differ in the level of vaccination. Multiple equilibria can arise, however, only if agents are uncertain about the cost of being infected – if agents are sufficiently certain about the cost of infection, then an equilibrium is unique. Furthermore, when the stock of vaccines is small, an equilibrium level of vaccination may be too high relative to the socially optimal level. Increasing the vaccine stock could have ambiguous effects on the level of vaccination in equilibrium but unambiguously increases social welfare.

Optimising cost-effectiveness of freedom from disease surveillance—Bluetongue Virus Serotype 8 as an example

The aim of this study was to propose a procedure for optimising the cost-effectiveness of vector borne disease surveillance using a scenario tree model and cost-effectiveness analysis. The surveillance systems for Bluetongue Virus serotype 8 (BTV-8) implemented in Switzerland and Belgium were used as examples. In twenty four different, simulated population structures, passive surveillance and five designs of active surveillance were investigated. The influence of surveillance system design and parameters such as farmer disease awareness, veterinary disease awareness, herd and within-herd design prevalence on the overall surveillance system sensitivity were assessed. Furthermore, the cost-effectiveness of mandatory and voluntary vaccination regimes in relation to disease surveillance was investigated.Under the assumption that BTV-8 manifests clinically, freedom from disease in a population can be established with almost certainty over the period of one year using clinical surveillance alone. Additional investment in active surveillance would therefore economically only be justified, if no clinical manifestation is suspected or other surveillance objectives are to be provided such as early detection. The best cost-effectiveness is obtained by sampling more herds rather than more animals within a herd. Mandatory vaccination reduces the cost of surveillance by 0.26 € per vaccine and voluntary vaccination only marginally reduces the cost of risk-based surveillance, by reducing the population at risk. Finally, in populations with predominantly dairy cattle, bulk-tank milk testing is the method of choice to actively demonstrate freedom from disease.

Knowledge, Attitudes and Practices (KAP) toward seasonal influenza vaccine among young workers in South China

ABSTRACTBackground: Vaccination against seasonal influenza is usually very protective. However, coverage in service workers is low due to the large population density and high turnover. The aim of this study was to document the knowledge, attitudes and practices towards the influenza vaccine among young service workers.Methods: A face-to-face interview and questionnaire were administered at the Guangzhou Center for Disease Control and Prevention (GZCDC) clinic. The questionnaires were analyzed to evaluate knowledge, attitudes and willingness to vaccinate in the service industry population.Results: Overall, the response rate was 81.37% (1035/1272). Most of the participants had faith in the efficacy (94.20%) and safety (94.88%) of the influenza vaccine. A total of 88.7% of the respondents confirmed that children needed to be vaccinated compared to other subjects, including those who work with baby and children (45.89%), elderly people (38.95%), medical staff (38.95%) and chronic disease patients (27.33%). Only 6.47% of the respondents were clearly aware of the vaccination timeframe. One-fifth of the respondents (18.16%) reported being vaccinated within the last three years, representing a low voluntary vaccination rate (23.94%) and a high irregular vaccination rate (77.13%). The primary reason for ignoring the importance of vaccination was that the respondents believed that they were strong enough to not require immunization (42.19%). In the multivariate analysis, the main determinants of the participants' willingness to continue to vaccinate were their beliefs in vaccine protection, a high education level, vaccination behavior over the last 3 years and belief in the necessity of annual vaccinations.Conclusion: Our findings provide insights into the knowledge, attitudes and practices of the service industry population prior to vaccination season in Guangzhou City. Most participants had a passive attitude toward the influenza vaccine, but there was still relatively low knowledge and implementation of the vaccine. Governments and health departments at all levels should develop a long-term strategy for fiscal subsidy policies and new health education patterns to enhance both the recognition and coverage of the influenza vaccine and to protect the citizens as a whole from infection. There is an urgent need for the pharmaceutical industries to develop a universal vaccine and to enhance the efficacy of vaccination.

Ebola could be eradicated through voluntary vaccination.

Ebola virus disease (EVD) is a severe infection with an extremely high fatality rate spread through direct contact with body fluids. A promising Ebola vaccine (rVSV-ZEBOV) may soon become universally available. We constructed a game-theoretic model of Ebola incorporating individual decisions to vaccinate. We found that if a population adopts selfishly optimal vaccination strategies, then the population vaccination coverage falls negligibly short of the herd immunity level. We concluded that eradication of Ebola is feasible if voluntary vaccination programmes are coupled with focused public education efforts. We conducted uncertainty and sensitivity analysis to demonstrate that our findings do not depend on the choice of the epidemiological model parameters.

Effect of noise-perturbing intermediate defense measures in voluntary vaccination games

Recently, a new vaccination game model was proposed, where an intermediate defense measure besides two fundamental strategies; committing vaccination that leads to a perfect immunity and not committing vaccination, was introduced as third strategy. We explore what happens if both effectiveness and cost of an intermediate defense measure stochastically perturbing on the viewpoint of whether or not the third strategy helping to improve total social payoff. We found that unlike resonance effect by adding noise to payoff matrix in case of spatial prisoner's dilemma (SPD) games, adding time-varying noise on both effectiveness and cost does not make difference from the default setting without perturbation to the third strategy. However, if the noise initially given to each agent is frozen, we found the third strategy becoming robust to survive. In particular, if the strategy updating rule allows a more advantageous third strategy can be more commonly shared among agents through copying, the total social payoff is significantly improved.

Voluntary vaccination dilemma with evolving psychological perceptions

Voluntary vaccination is a universal control protocol for infectious diseases. Yet there exists a social dilemma between individual benefits and public health: non-vaccinators free ride via the herd immunity from adequate vaccinators who bear vaccination cost. This is due to the interplay between disease prevalence and individual vaccinating behavior. To complicate matters further, individual vaccinating behavior depends on the perceived vaccination cost rather than the actual one. The perception of vaccination cost is an individual trait, which varies from person to person, and evolves in response to the disease prevalence and vaccination coverage. To explore how evolving perception shapes individual vaccinating behavior and thus the vaccination dynamics, we provide a model combining epidemic dynamics with evolutionary game theory which captures the voluntary vaccination dilemma. In particular, individuals adjust their perception based on the inertia effect in psychology and then update their vaccinating behavior through imitating the behavior of a more successful peer. We find that i) vaccination is acceptable when the expected vaccination cost considering perception and actual vaccination cost is less than the maximum of the expected non-vaccination cost; ii) the evolution of perception is a “double-edged sword” for vaccination dynamics: it can improve vaccination coverage when most individuals perceive exaggerated vaccination cost, and it inhibits vaccination coverage in the other cases.

Farmers’ Preferences For Bluetongue Vaccination Scheme Attributes: An Integrated Choice and Latent Variable Approach

AbstractRe‐emergence of the bluetongue disease in Europe poses a continuous threat to European livestock production. Large‐scale vaccination is the most effective intervention to control virus spread. Compared to command‐and‐control approaches, voluntary vaccination approaches can be effective at lower costs, provided that farmers are willing to participate. We use a discrete choice experiment to estimate the preferences for vaccination scheme attributes, accounting for preference heterogeneity via an integrated choice and latent variable approach. In designing livestock disease control schemes, it is often argued that governments should use financial, incentive‐based policy instruments to compensate farmers for externalities, assuming they act in rational self‐interest. Our results suggest that in addition to economic motives, farmers can have intrinsic or social motives to invest in livestock disease control. Implications for the effectiveness of providing subsidy or information to motivate voluntary participation are discussed.

Identification of vaccine-derived rotavirus strains in children with acute gastroenteritis in Japan, 2012-2015.

Two live attenuated oral rotavirus vaccines, Rotarix and RotaTeq, have been introduced as voluntary vaccination in Japan since 2011 and 2012, respectively. Effectiveness of the vaccines has been confirmed, whereas concerns such as shedding of the vaccine strains and gastroenteritis cases caused by vaccine strains are not well assessed. We aimed to identify the vaccine strains in children with acute gastroenteritis (AGE) to investigate the prevalence of AGE caused by vaccination or horizontal transmission of vaccine strains. A total of 1,824 stool samples were collected from children with AGE at six outpatient clinics in 2012–2015. Among all, 372 group A rotavirus (RVA) positive samples were screened for vaccine components by real-time RT-PCR which were designed to differentiate vaccine strains from rotavirus wild-type strains with high specificity. For samples possessing both vaccine and wild-type strains, analyses by next-generation sequencing (NGS) were conducted to characterize viruses existed in the intestine. As a result, Rotarix-derived strains were identified in 6 of 372 (1.6%) RVA positive samples whereas no RotaTeq strain was detected. Among six samples, four possessed Rotarix-derived strains while two possessed both Rotarix-derived strains and wild-type strains. In addition, other pathogens such as norovirus, enterovirus and E.coli were detected in four samples. The contribution of these vaccine strains to each patient’s symptoms was unclear as all of the cases were vaccinated 2–14 days before sample collection. Proportion of average coverage for each segmented gene by NGS strongly suggested the concurrent infection of the vaccine-derived strain and the wild-type strain rather than reassortment of these two strains in one sample. This is the first study to report the prevalence of vaccine-derived strains in patients with RVA AGE in Japan as 1.6% without evidence of horizontal transmission. The results emphasized the importance of continuous monitoring on vaccine strains and their clinical impacts on children.

Prevention and assessment of infectious diseases among children and adult migrants arriving to the European Union/European Economic Association: a protocol for a suite of systematic reviews for public health and health systems

IntroductionThe European Centre for Disease Prevention and Control is developing evidence-based guidance for voluntary screening, treatment and vaccine prevention of infectious diseases for newly arriving migrants to the European Union/European...

Prevention of treatable infectious diseases: A game-theoretic approach.

We model outcomes of voluntary prevention using an imperfect vaccine, which confers protection only to a fraction of vaccinees for a limited duration. Our mathematical model combines a single-player game for the individual-level decision to get vaccinated, and a compartmental model for the epidemic dynamics. Mathematical analysis yields a characterization for the effective vaccination coverage, as a function of the relative cost of prevention versus treatment; note that cost may involve monetary as well as non-monetary aspects. Three behaviors are possible. First, the relative cost may be too high, so individuals do not get vaccinated. Second, the relative cost may be moderate, such that some individuals get vaccinated and voluntary vaccination alleviates the epidemic. In this case, the vaccination coverage grows steadily with decreasing relative cost of vaccination versus treatment. Unlike previous studies, we find a third case where relative cost is sufficiently low so epidemics may be averted through the use of prevention, even for an imperfect vaccine. However, we also found that disease elimination is only temporary-as no equilibrium exists for the individual strategy in this third case-and, with increasing perceived cost of vaccination versus treatment, the situation may be reversed toward the epidemic edge, where the effective reproductive number is 1. Thus, maintaining relative cost sufficiently low will be the main challenge to maintain disease elimination. Furthermore, our model offers insight on vaccine parameters, which are otherwise difficult to estimate. We apply our findings to the epidemiology of measles.

Voluntary Vaccination through Self-organizing Behaviors on Locally-mixed Social Networks

Voluntary vaccination reflects how individuals weigh the risk of infection and the cost of vaccination against the spread of vaccine-preventable diseases, such as smallpox and measles. In a homogeneously mixing population, the infection risk of an individual depends largely on the proportion of vaccinated individuals due to the effects of herd immunity. While in a structured population, the infection risk can also be affected by the structure of individuals’ social network. In this paper, we focus on studying individuals’ self-organizing behaviors under the circumstance of voluntary vaccination in different types of social networks. Specifically, we assume that each individual together with his/her neighbors forms a local well-mixed environment, where individuals meet equally often as long as they have a common neighbor. We carry out simulations on four types of locally-mixed social networks to investigate the network effects on voluntary vaccination. Furthermore, we also evaluate individuals’ vaccinating decisions through interacting with their “neighbors of neighbors”. The results and findings of this paper provide a new perspective for vaccination policy-making by taking into consideration human responses in complex social networks.

Voluntary vaccination: the pandemic effect.

Justification of a voluntary vaccination policy in England and Wales rests on tenuous foundations. Two arguments against voluntary vaccination are gaining ground. The first is that globalisation necessitates preparedness strategies for pandemics. Assuming sufficient supply, compulsory vaccination of adults and children constitutes a potential policy option in the context of a severe, vaccine‐preventable pandemic outbreak. The second argument is that children have a right to preventive medicine and thus to vaccination. The influence of the UN Convention on the Rights of the Child and its emphasis on parents as the trustees of their children's best interests, and the increasingly global nature of our collective and individual responsibilities with respect to the transmission of vaccine‐preventable disease present challenges to the right to refuse vaccination on our own behalf and on behalf of our children. Exploring methods of compulsion and persuasion utilised across Europe, the USA and Australia, this paper argues that necessity and proportionality must be reassessed, and national public health law and policy setting out a graduated and proportionate approach to compulsory vaccination developed as a matter of priority.

Changes in the numbers of patients with acute gastroenteritis after voluntary introduction of the rotavirus vaccine in a Japanese children\u2019s primary emergency medical center

BackgroundAcute gastroenteritis (AGE) is a major reason for presentation to pediatric primary emergency medical centers. Because rotavirus vaccines were introduced in November 2011 for voluntary vaccination in Japan, we analyzed the changes in the numbers of AGE patients.MethodsThe number and proportion of patients visiting Kobe children’s primary emergency medical center from January 2011 to February 2015 due to AGE, out of all visiting children, were investigated retrospectively. The rotavirus and norovirus epidemic periods were defined as the periods from March to June and from November to February, respectively, based on their disease prevalence.ResultsIn patients ≤2 years of age, the numbers and proportions of patients with AGE were significantly decreased from 2464/14098 (17%) in 2011 to 1888/12321 (15%) in 2014 (p < 0.01). In patients ≤2 and 3–5 years of age, significant decreases in AGE patients between 2011 and 2014 were observed during the rotavirus season (from 20% [1090/5329] to 14% [642/4482] in patients aged ≤2 years and from 23% [704/3047] to 20% [572/2807] in patients aged 3–5 years, p < 0.01 and p < 0.05, respectively), but not during the norovirus season (from 19% [834/4436] to 19% [797/4160] in patients aged ≤2 years and from 20% [679/3334] to 25% [710/2852] in patients aged 3–5 years).ConclusionsThe estimated rotavirus vaccine coverage in our area increased from 1% in 2011 to 49% in 2014; this coverage may have resulted in a reduction in AGE patients, both directly and indirectly, in our Japanese children’s primary emergency medical center.

Legislative activity related to the human papillomavirus (HPV) vaccine in the United States (2006-2015): a need for evidence-based policy.

State-based policies to mandate HPV vaccination are politically challenging and have received broad criticisms. There is a critical need to understand the legislative activities that underpin subsequent policy implementation. The objective of this policy analysis was to analyze state legislation that focused on HPV vaccination from 2006–2015. A content analysis was conducted among primary sources of legislative data from HPV vaccine-related bills, including using the National Conference of State Legislatures as a search-source. Findings reveal that much of the legislative activity occurred early after the HPV vaccination was introduced, and focused on increased information for parents, public financing, awareness campaigns, etc. Far fewer states focused on voluntary or mandatory vaccination. Understanding the barriers to achieving mandatory vaccination policy and implementation of such policies for HPV vaccines remains a public health priority.

Influenza Vaccination of Healthcare Workers: Critical Analysis of the Evidence for Patient Benefit Underpinning Policies of Enforcement.

BackgroundFour cluster randomized controlled trials (cRCTs) conducted in long-term care facilities (LTCFs) have reported reductions in patient risk through increased healthcare worker (HCW) influenza vaccination. This evidence has led to expansive policies of enforcement that include all staff of acute care hospitals and other healthcare settings beyond LTCFs. We critique and quantify the cRCT evidence for indirect patient benefit underpinning policies of mandatory HCW influenza vaccination.MethodsPlausibility of the four cRCT findings attributing indirect patient benefits to HCW influenza vaccination was assessed by comparing percentage reductions in patient risk reported by the cRCTs to predicted values. Plausibly predicted values were derived according to the basic mathematical principle of dilution, taking into account HCW influenza vaccine coverage and the specificity of patient outcomes for influenza. Accordingly, predicted values were calculated as a function of relevant compound probabilities including vaccine efficacy (ranging 40–60% in HCWs and favourably assuming the same indirect protection conferred through them to patients) × change in proportionate HCW influenza vaccine coverage (as reported by each cRCT) × percentage of a given patient outcome (e.g. influenza-like illness (ILI) or all-cause mortality) plausibly due to influenza virus. The number needed to vaccinate (NNV) for HCWs to indirectly prevent patient death was recalibrated based on real patient data of hospital-acquired influenza, with adjustment for potential under-detection (5.2-fold), and using favourable assumptions of HCW-attributable risk (ranging 60–80%).ResultsIn attributing patient benefit to increased HCW influenza vaccine coverage, each cRCT was found to violate the basic mathematical principle of dilution by reporting greater percentage reductions with less influenza-specific patient outcomes (i.e., all-cause mortality > ILI > laboratory-confirmed influenza) and/or patient mortality reductions exceeding even favourably-derived predicted values by at least 6- to 15-fold. If extrapolated to all LTCF and hospital staff in the United States, the prior cRCT-claimed NNV of 8 would implausibly mean >200,000 and >675,000 patient deaths, respectively, could be prevented annually by HCW influenza vaccination, inconceivably exceeding total US population mortality estimates due to seasonal influenza each year, or during the 1918 pandemic, respectively. More realistic recalibration based on actual patient data instead shows that at least 6000 to 32,000 hospital workers would need to be vaccinated before a single patient death could potentially be averted.ConclusionsThe four cRCTs underpinning policies of enforced HCW influenza vaccination attribute implausibly large reductions in patient risk to HCW vaccination, casting serious doubts on their validity. The impression that unvaccinated HCWs place their patients at great influenza peril is exaggerated. Instead, the HCW-attributable risk and vaccine-preventable fraction both remain unknown and the NNV to achieve patient benefit still requires better understanding. Although current scientific data are inadequate to support the ethical implementation of enforced HCW influenza vaccination, they do not refute approaches to support voluntary vaccination or other more broadly protective practices, such as staying home or masking when acutely ill.

Evolutionary vaccination dynamics with internal support mechanisms

This paper reports internal support mechanisms (i.e., without external intervention) to enhance the vaccine coverage in the evolutionary vaccination dynamics. We present two internal support mechanisms, one is global support mechanism in which each individual pays a support cost to build up a public fund and then the public fund is divided by all vaccinated individuals, while another is local support mechanism in which each individual pays a support cost and then this support cost will be divided by its immediate vaccinated neighbors. By means of extensive computer simulations, we show that, in the same strength of support cost, the heterogeneous (local) support mechanism can encourage more people to take vaccination than the homogeneous (global) support mechanism. And then, we study the most general case that includes supporters and troublemakers together, where supporters (troublemakers) mean that the individuals join (do not join) the internal support mechanism, in the population. We surprisingly find that, in scale-free networks, the voluntary vaccination dynamics with the local support mechanism will not degrade into the original voluntary vaccination dynamics, and the vaccination level can still be effectively improved. In view of most social networks are of scale-free degree distribution, we study further in empirical networks and find that the vaccination level can still be improved in the absence of external intervention.