21 OCTOBER 2020

COVID-19 vaccine deployment:

Behaviour, ethics, misinformation
and policy strategies
This rapid review of science of the behavioural aspects of vaccine uptake and
misinformation is from the Royal Society and the British Academy to assist in the
understanding of COVID-19.

This paper is a pre-print and has been subject to formal peer-review.

S U MM ARY K E Y P OIN TS

• A community-level vaccine coverage of 80+% will be required to protect the community from infection, dependent on
the vaccine efficacy and duration of protection.
• Public expectations urgently need to be managed to prepare for a longer-term transition where non-pharmaceutical
interventions remain in place.
• Behavioural factors underpinning vaccine uptake are: (1) complacency, (2) trust and confidence in efficacy and safety,
(3) convenience, (4) sources of information; and, (5) socio-demographic variation.
• COVID-19 vaccine deployment faces an unprecedented degree of uncertainty and complexity, which is difficult
to communicate, such as immune response, duration of immunity, repeated vaccination, transmission dynamics,
microbiological and clinical characteristics and multiple vaccines.
• Priority groups for vaccine deployment need transparent public debate to build support for ethical principles.
• Current seasonal flu uptake is low in certain groups, suggesting vaccination challenges, which include: high risk
groups under the age of 65 (40 - 50%), support staff in health care organisations (as low as 37%) and London and even
variation amongst key workers such as Doctors (40 - 100%).
• Deployment and tracking should build on existing immunisation programmes such as primary care by GPs to identify
comorbidities, track vaccinations and reminders for additional boosters.
• COVID-19 vaccine deployment faces an infodemic with misinformation often filling the knowledge void, characterised
by: (1) distrust of science and selective use of expert authority, (2) distrust in pharmaceutical companies and
government, (3) straightforward explanations, (4) use of emotion; and, (5) echo chambers.
• A narrow focus on misinformation disregards the fact that there are genuine knowledge voids, necessitating public
dialogue about vaccine concerns and hesitancy rather than providing passive one-way communication strategies.

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 1
Executive summary

• Vaccinations are the most successful public health measure • COVID-19 vaccine deployment faces high uncertainty
in history, saving millions of lives and preventing multiple and complexity over: immune responses following
diseases, with large societal and economic benefits. vaccination (e.g., fever), effectiveness, risks for various risk
groups (children, older adults, pregnant women, chronic
• The percentage of the population requiring vaccination
medical conditions, immunocompromised), duration of
depends on efficacy (i.e., probability of preventing infection),
immunity, repeated vaccination, transmission dynamics,
reproduction number (R0), immunity, infectiousness and
microbiological and clinical characteristics of the virus and
effectiveness of non-pharmaceutical interventions.
multiple vaccines.
• If we assume an R0 value of around 2.5 - 3.0, a community-
• COVID-19 infection and mortality has revealed structural
level vaccine coverage of 80+% for COVID-19 will be
inequalities by age, crowded settings, ethnicity, co-
required.
morbidities, sex, occupation and how these intersect.
• Public expectations must be urgently managed for a
• Deployment of a vaccine must follow ethical principles
longer-term transition period where non-pharmaceutical
of priority groups to: (1) maximise benefit, (2) equality,
interventions are still in place (i.e., face coverings, social
(3) promote and reward instrumental value; (4) prioritise
distancing) even after first vaccines are available.
the vulnerable and potentially consider (5) economic
• The UK has high levels of immunisation for most major consequences, and be publicly debated.
diseases, such as seasonal influenza (72%) and measles
• Vaccine deployment faces an infodemic (information mixed
(93%), with immunisation uptake varying internationally and
with fear and rumour) with the rise of misinformation that fills
over time.
knowledge voids under conditions of uncertainty.
• Vaccine confidence (importance, safety, effectiveness)
• The anti-vaccination group is heterogeneous, with
has increased over time with confidence damaged by late
misinformation characterised by: (1) distrust of science
announcements of adverse risks or lack of clarity of content
and selective use of expert authority, (2) distrust in
of vaccine or safety to certain groups (e.g., religion, children).
pharmaceutical companies and government, (3) simplistic
• Around 36% in the UK and 51% in the US report they explanations, (4) use of emotion and anecdotes to
are either uncertain or unlikely to be vaccinated against impact rational decision-making; and, (5) development of
COVID-19. information bubbles and echo chambers.

• Five central behavioural factors underpin vaccine uptake: • A narrow focus on misinformation and viewing individuals
(1) complacency (perception of risk, severity of disease), as easily influenced misses the fact that there are genuine
(2) trust and confidence (efficacy, safety), (3) convenience knowledge voids about vaccines, urgent need for open
(barriers, access), (4) sources of information; and, (5) socio- dialogue and public engagement rather than providing
demographic characteristics (e.g., education, sex, ethnicity, passive one-way communications.
religion, past vaccination behaviour).
• Valuable lessons can be learned from history and
international cases.

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 2
Conclusion and policy recommendations

• Transparent dialogue and community engagement with • Vaccine deployment should build on existing immunisation
the general public about vaccine deployment must begin programmes such as primary care by GPs on the weekend
immediately, respecting emotions and real concerns, as but also using GPs to identify comorbidities, log vaccinations
opposed to a one-way information supply. and reminders for additional boosters or intensive
vaccinations at polling stations. A model of centralised mass
• Public expectation management is crucial and urgently
sites and roving teams are likely ineffective.
needed to clarify that life will not immediately return to
normal and non-pharmaceutical interventions will remain • The public needs to be empowered to spot and report
in place during a transition period, with clarity over the timing misinformation, with more accountability for media
and scale of vaccination. companies to remove harmful information and legal
consequences for individuals or groups that spread
• Policies need to be coordinated and decentralised,
misinformation.
with tool kits developed to support local authorities and
aid with community engagement to support dialogue and • There are strong commonalities across history, past
reach diverse populations with tailored, appealing, visual pandemics and vaccine deployment; attention to history can
and multi-language messages to mobilise local communities. avoid repeating common mistakes in vaccine deployment.

• Phased vaccine deployment could go beyond age- and

comorbidity-based priority groups to adopt ethical principles
related to equity beyond non-health high-risk occupations
(e.g., teachers, bus drivers, retail workers) and priority to
vulnerable groups (e.g., homeless, prisons).

• Seasonal flu vaccination is very high in the over 65 age

group, suggesting that it will be an easier group to reach.
However, there is lower uptake in certain groups which
suggesting attention is required, including: under 65 and at
risk (40 - 50%), support staff in health care organisations (as
low as 37%) and in areas such as London. There is likewise
variation amongst key workers such as Doctors where it is
as low as 40% uptake to 100%.

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 3
 Contents
1. Introduction and motivation 5
2. Vaccinations save lives: Immunisation coverage and vaccine hesitancy 5
2.1 Vaccinations save lives and prevents disease 5
2.2 Herd immunity thresholds 6
2.3 Immunisation coverage for existing diseases: A cross-national comparison 6
2.4 Vaccine hesitancy: A cross-national comparison 8
3. Behavioural and socio-demographic factors underlying vaccine uptake 9
3.1 Complacency and threat appraisal 9
3.2 Trust: Efficacy and safety under conditions of uncertainty 9
3.2.1 Efficacy under conditions of uncertainty 9
3.2.2 Safety and speed of vaccine development and political interventions 9
3.2.3 Distrust and underrepresentation of key risk groups in vaccine trials 10
3.3 Convenience and Planning: Physical barriers and building on existing structures 10
3.4 Sources of information and knowledge deficits 11
3.5 Socio-demographic characteristics related to vaccine uptake 11
4. Ethics and Equity in the allocation of vaccinations 12
4.1 COVID-19 reveals structural inequalities 12
4.2 Ethical principles for scarce vaccine resources 13
4.3 Interim advice of priority groups for COVID-19 vaccination in the UK 13
4.4 An alternative phased approach considering equity and the vulnerable 14
4.5 Challenges of practical deployment in a phased approach 15
4.5.1 Practical challenges 15
4.5.2 Challenges of vaccine uptake across different groups 17
5. History repeated: from misinformation to public dialogue 17
5.1 Anti-vaccination movements in the Nineteenth Century 17
5.2 The contemporary anti-vaccination movement 18
5.3 Infodemic: Misinformation, anxieties and fear 18
5.4 Who creates COVID-19 misinformation and anti-vaccination material? 19
5.5 The anatomy of anti-vaccine misinformation 20
5.6 Dialogue and polarisation not misinformation: Knowledge voids and rumours 22
6. Conclusion and policy recommendations 22
6.1 Dialogue and community engagement 22
6.2 Inoculating the public against misinformation, accountability and enforcement 25

Appendix 1. Childhood DTP and Hepatitis B vaccination uptake, selected countries 2000 - 2019 27
Appendix 2. Data and Methods 28
Appendix 3. Main vaccine and COVID-19 misinformation and conspiracy theories 29
Appendix 4. Preparation of Report 30
References 31

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 4
1. Introduction and motivation understanding of how to ethically and equitably distribute
Vaccination is a ‘miracle of modern medicine’ and the
1 them both within countries and globally, and develop
most important contribution to public health in the past 100 policies and strategies for doing so is urgently required.
years2. From 1796 when Jenner first introduced vaccination
The current report extends our knowledge by first
to protect against smallpox, vaccines have been developed
emphasising the public health and economic benefits
to protect against pneumonia, measles, the human
of vaccinations. We then draw lessons from historical
papillomavirus (HPV) and countless other infections. The
vaccination efforts, reasons for variation in immunisation
value of vaccination has once again been emphasised with
coverage and vaccination hesitancy across countries
the outbreak of SARS-CoV-2 (hereafter COVID-19), with no
and over time. The behavioural and socio-demographic
scientific breakthrough ever more eagerly anticipated than
factors underlying vaccine uptake are then reviewed. This
this one. Considerable scientific resources and billions
is followed by a discussion of ethics and equity in vaccine
of pounds have been placed on producing an effective
allocation, considering ethical and equal allocation that
vaccine. Vaccination has been heralded as the solution to
also accounts for vulnerable populations. We then turn
the current pandemic crisis, to reduce morbidity, mortality
to the rise of misinformation, focussing on who produces
and transmission alongside non-pharmaceutical inventions.
the information, social networks and anatomy of the main
An assessment of return to investment found that every
strategies. The report concludes with concrete policy
dollar invested in vaccines over a decade is estimated to
recommendations including the shift from communication to
result in a return of 16 times the cost3.
dialogue to fill knowledge voids, address public concerns
Yet developing the vaccine is only one side of the challenge; and local community engagement.
it is vaccination not just the vaccine that saves lives, and
ensuring that enough individuals are vaccinated is crucial4. 2. Vaccinations save lives: Immunisation coverage and
A recent survey conducted in the UK found that around 36% vaccine hesitancy
of individuals are uncertain (27%) or very unlikely (9%) to be 2.1. Vaccinations save lives and prevents disease
vaccinated against COVID-195. In the US, 31% reported being Vaccinations have been the most successful and far
uncertain with 20% stating they will not obtain a vaccine reaching public health measure in history, reducing
when it becomes available6. Vaccine take up during the disease and millions of deaths. The gains from vaccines in
recent 2009 - 2010 H1N1 pandemic was very low7. False countering morbidity for multiple infectious diseases are
beliefs over vaccines can lead to the reduction of vaccine staggering. In the last 18 years, the measles vaccination
uptake, which has led to the resurgence of diseases such alone has been estimated to save more than 23 million
as measles8. Vaccination for influenza in the UK for those 65 lives12. Whereas at the start of the 20th Century, measles
and older, however, has been stable and high at over 70% resulted in around 530,217 deaths per year in the United
since 2005. As of 2019, in many nations between 90 - 95% States alone, as of 2016 it decreased to just 69 deaths per
of children are immunised for measles9. A recent report by year4. Although measles is a vaccine-preventable disease,
the Royal Society’s DELVE group examined the importance in 2018 more than 140,000 people died worldwide from
of determining the suitability of different vaccines, measles due to large outbreaks, with the majority of deaths
effectiveness and longevity of protection and levels of of infants under 5 years of age in sub-Saharan Africa.
immunity required10. It also looked at the colossal challenge Of those who survive, evidence shows that contracting
of manufacturing and prioritising recipients, the distribution measles can have long-term health effects which damage
and administration chain, need for global coordination and the immune system years after infection12. Vaccines have
equal access. virtually eradicated many serious diseases beyond only
measles such as mumps, rubella and pertussis (whooping
The aim of this report is to extend our knowledge by
cough). Before the vaccine for pertussis was introduced
focussing on the historical, ethical and socio-behavioural
in the 1950s in England, over 2,000 people died in some
factors related to vaccine uptake, barriers to and
years13, which dropped to just one death in 201914. Other
suggestions for deployment. We draw on scientific
vaccinations such as those for human papillomavirus (HPV)
evidence to aid policy makers in the UK and globally to plan
prevent a range of serious diseases such as cervical and
effective and equitable vaccine deployment, with a focus
mouth cancer. Cervical cancer is the most common cancer
on communication through dialogue and understanding
among young women 15 to 34 years old, with a considerable
rumours and misinformation. Given the global penetration
drop in HPV infections in England since the vaccination was
of the COVID-19 pandemic, some estimate that up to 60
introduced in 200815.
percent of the world’s population needs to be vaccinated11.
With vaccines soon to be deployed across the world, an

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 5
Vaccinations also have a considerable economic benefit. interventions (e.g., non-pharmaceutical interventions)20. As
An economic evaluation in the US found that routine noted in a previous SET-C review, it is possible to estimate
childhood vaccines for 13 preventable diseases in just one how many individuals the typical transmitter is capable of
birth cohort year prevented 40,000 deaths and 20 million infecting (if all were susceptible) using the R0, the basic
cases of disease, with net savings of $13.5 billion in direct reproduction number21.
and $68.8 billion in societal costs16. Another economic
evaluation of 10 vaccines across 94 low- and middle-income For COVID-19, if we assume an R0 value in the UK of
countries demonstrated that the investment of $34 billion in around 2.5 - 3.0, a community-level vaccine coverage of
immunisation resulted in savings of $586 billion to reduce around 80+% will be required to protect the community
the costs of illness and when taking into account broader from infection, which also depends on the efficacy of the
economic benefits, the number rose to $586 billion17. vaccine and the duration of protection (which will influence
the frequency of vaccination). Simple calculations suggest
Despite the immense benefits, it is often the case that that for an R0 of 3.5, a vaccine with an efficacy of 80% would
negative and safety concerns receive considerably require 90%+ vaccination coverage with a vaccine providing
more attention. A simple search on MEDLINE from 1950 long term immunity (many years) required, to eliminate viral
to October 2020 finds that ‘vaccine risks’ returns 37,751 transmission. This level of coverage must be uniform across
records whereas ‘vaccine benefits’ delivers a mere 13,692 the UK to avoid creating pockets of susceptibility.
records. Yet vaccines are safer than many therapeutic
medicines18. This focus on safety issues and examples can Our understanding of longer term immunity is limited at
have detrimental effects, such as the re-emergence of present. Herd immunity, as judged by serological surveys,
diseases such as pertussis, measles and polio, discussed is currently heterogeneous across the UK. A serological
later in this report. The ironic aspect is that vaccinations survey of London estimated that around 18% of the
have been so effective at eradicating serious diseases such population had antibodies, with other surveys reporting
as measles and polio, that the absence of these diseases substantially lower levels22. Seroprevalence surveys that
brings a false sense of complacency. measure antibodies are often used to estimate how many
people in a population have been infected by COVID-19,
2.2 Herd immunity thresholds with the assumption that they will carry some degree of
Effective disease prevention is contingent on achieved immunity. A recent pre-print on medRxiv finds that naturally
levels of vaccination compliance in populations. Vaccines acquired antibodies may drop after 2 - 3 months, which has
provide not only protection for the individual who is consequences for re-infection and vaccination23. A recent
vaccinated, but can also indirectly limit the spread of genomic study published October 12 2020 demonstrated
disease and protect the community. This means that a risk of re-infection, with the second infection more severe
vaccination not only has an individual benefit, but also acts than the first24. Work examining memory T cells suggests
as a protective shield for vulnerable community members. If that not only antibodies that play a role. T cells may offer
sufficient numbers are vaccinated and immune for a period some pre-existing immunological response and thus impact
post immunisation, the chain of infection can be broken the severity of the disease and future infection25. This was
within the population such that the basic reproductive the case for H1N1, for instance, where those with pre-existing
number R0 falls below unity in value (R0<1) ‘herd immunity’ reactive T cells had a less severe disease26.
is achieved4. As a rough approximation, the level of herd
2.3 Immunisation coverage for existing diseases:
immunity as a proportion of the population p required
A cross-national comparison
to block transmission is given by p>[1-1/R0 ]/f, where f is
vaccine efficacy as a proportion. If the duration of immunity For a general indication of the extent of immunisation in
is short, a more complex relation exists19. Although other the UK in comparison to other countries and over time,
approaches have been suggested to achieve herd immunity Figure 1 shows the percentage of individuals in the
by allowing COVID-19 to spread widely in the population, population 65 years of age and older who were vaccinated
vaccines are the safest way to reach the target level. The for seasonal influenza (top panel) and percentage of
percentage of the population that needs to be covered by children immunised for measles (bottom panel) from 2000 to
vaccination depends on vaccine efficacy (i.e., probability of 2019 (see Appendix 1 for Diphtheria, Tetanus and Pertussis
preventing infection), the natural reproduction number of and Hepatitis B). For influenza, we see considerable
the infection (R0), the proportion of the population already variation across countries. Hungary has low levels, similar
exposed before vaccination deployment, infectiousness of to some Eastern European neighbours9. Levels in the UK
asymptomatic individuals, and the effectiveness of parallel and US remained relatively high and stable at around 70%,

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 6
 with South Korea’s vaccination uptake gaining over time. 2.4 Vaccine hesitancy: A cross-national comparison
In contrast, countries such as Italy, France and Germany Despite the fact that vaccines represent one of the greatest
experienced a drop in uptake, particularly after 2014. public health achievements in the past century, a growing
body of research has examined vaccine confidence or
Vaccination levels for measles are likewise mixed, with
hesitancy, which refers to delay in acceptance or refusal
countries such as the UK, France and particularly Italy
despite availablity29,30. Vaccine hesitancy has been largely
making large gains in coverage over the last two decades.
attributed to: confidence, complacency and convenience,
Vaccination levels were very low in Italy the early 2000s.
as described shortly30. There is considerable research that
This resulted in a serious measles outbreak resulting in the
has focussed on detecting, monitoring and analysing public
introduction of compulsory vaccinations in Italy in 2017 to
confidence in vaccines, including systematic reviews29,
deal with the surge of the disease, which later included even
surveys31 and related policy reports such as from the WHO
more stringent measures such as banning unvaccinated
SAGE working group on vaccination30. A considerable
children from school27. Appendix 1 shows very low levels
share of the contemporary literature on vaccine hesitancy
of DTP and Hepatitis B in France which rose appreciably
focuses on parental attitudes regarding childhood
over time. Some attributed the low levels in France to
vaccination, largely surrounding MMR and HPV32. Other
public dissonance in reaction against what was perceived
areas concentrate on certain risk groups such as pregnant
as alarmist vaccination campaigns by public health officials,
women33 or Asian populations disproportionately affected by
which we return to in our policy recommendations28.
certain viruses such as the Hepatitis B Virus (HBV)34.

FIGU R E 1 .

Percentage of influenza vaccinations in the population aged 65 years and older (top) and percentage
children immunised for measles (bottom), selected countries, 2000 - 2019

100
% 65+ years old immunised for influenza

80

60 % children immunised for measles 90

40
80

2000 2005 2010 2015 2020 2000 2005 2

Year Y

100
% children immunised for measles

Country
France
90
Germany
Hungary
Italy
Korea
United Kingdom
United States
80

010 Source:2015
OECD (2020)9 2020 2000 2005 2010 2015 2020
ear Year

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 7
A recent study published in the Lancet from the Vaccine HPV vaccination in 2013. The fall in HPV uptake was
Confidence Project led by Larson examined vaccine staggering from 68 - 74% in the 1994-98 birth cohort to just
confidence across 149 countries between 2015 and 201931. 0 - 6% for those born in 200035. A similar drop was found
The authors found that confidence in the importance, safety in Indonesia when senior Muslim leaders warned against
and effectiveness of vaccines fell across certain areas of the vaccination, resulting in a sharp drop31,36.
world (e.g., Indonesia, the Philippines, Afghanistan, Pakistan,
South Korea). They also revealed significant increases in Conversely, confidence improved in many European
respondents who strongly disagreed that vaccines are safe member states such as Italy, France and Ireland. In Figure
in certain countries (e.g., as above but also Nigeria, Siberia). 2 we use data from the recent Lancet study31 to map
the percentage of respondents who strongly agree that
Widely published safety scares can have deep, long-lasting vaccines are safe, effective and important in 2018 for a
influence on vaccine confidence. The authors attributed global comparison. Here we see low confidence in the
the drop in vaccine confidence in nations such as the safety of vaccines in France and some Baltic (Estonia, Latvia,
Philippines and Indonesia to the announcement of the Lithuania) and Eastern European countries such as Poland.
vaccine manufacturer in 2017 that the newly introduced The UK also shows relatively lower levels of confidence in
dengue vaccine (Dengvaxia) posed a risk to those who had safety of vaccines compared to many African, Asian and
not previously been exposed to the virus. This resulted South American countries. The middle panel illustrates
in outrage and panic, where almost a million children had those who strongly agree that vaccines are effective,
already been vaccinated the previous year. This suggests mirroring roughly the same attitudes for vaccine safety. In
that widely rolling out a vaccine which may be followed by the bottom panel, however, we see considerably higher
announcements of adverse risks can damage confidence. global consensus that vaccines are important, with lower
Japan ranked the lowest in confidence likely due to the levels in countries in Europe (including the UK, France, the
human papillomavirus (HPV) safety controversy following Netherlands, Italy), Russia, China and the Philippines.
the government decision to stop proactively recommending

FIGU R E 2.

Percentage who strongly agree vaccinations are safe, effective, important, 2018

Source: Figure made using raw data from de Figueiredo et al. (2020)31

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 8
3. Behavioural and socio-demographic factors 3.2 Trust: Efficacy and safety under conditions of
underlying vaccine uptake uncertainty
Behavioural and socio-demographic factors are key drivers 3.2.1 Efficacy under conditions of uncertainty
of both vaccination intentions and uptake. This section The strongest predictors of intention and behaviour related
provides a brief overview of the main factors with study to vaccination is that the individuals need to understand
exemplars. and also believe that it is safe and effective. Studies with
individuals in South Korea43 and the UK in relation to H1N1
3.1 Complacency and threat appraisal
found that when individuals believed that the vaccine was
Perception of personal risk. A persistent finding is that effective, they were more likely to be vaccinated.40
individuals are complacent and perceive that if they are at a
low or no risk of contracting, becoming ill or dying from the What is unusual for COVID-19 compared to previous
virus, there will be little reason to vaccinate. As described vaccines is that dialogue and communications about
shortly, the individual risk of dying from COVID-19 has been the safety and efficacy of the various vaccines must be
disproportionality concentrated in older ages, those with developed under conditions of uncertainty. According to a
co-morbidities and particularly ethnic groups. A study COVID-19 Clinical trial tracker, over 100 vaccine candidates
in March 2020 in the US during the initial outbreak of are currently active44. As described in the recent DELVE
COVID-19 found that 25% were very worried about report, vaccines must go through various trials, with none
contracting the virus with around 13% not worried at all. of the current vaccines in the final stage of Phase III trials.
Those who rated the virus as less serious were younger It is at this stage where the vaccine is tested for potential
individuals, men, those living in lower socio-economic side-effects across various types of people. At the time
circumstances and Black participants37. In August 2020, of writing, there is still lack of clarity about the efficacy of
however, the Director of the WHO recognised what has different vaccines. Additional certainty is required regarding
been termed ‘long COVID’, which includes debilitating the length of protection and vaccination schedules or need
symptoms such as breathlessness and fatigue for those who for boosters10. Generally when vaccines are introduced
have recovered, predominantly concentrated in younger and communicated to the public there is already detailed
age groups38. The growing awareness of these long term information on immune responses following vaccination
health risks may increase awareness of personal risks. (e.g., fever), effectiveness, risks for various risk groups
(children, older adults, pregnant women, chronical medical
Multiple studies of H1N1 vaccine uptake amongst health conditions, immunocompromised), and also on the duration
professionals found that those who perceived that they of immunity and the need for repeated vaccination. Vaccines
were not at risk were less likely to be vaccinated39. are overwhelmingly safe, but do have some side effects for
Conversely, a study of pregnant women in the US found that particular individuals.
those more worried about the virus had a higher likelihood
to be vaccinated33. A study of H1N1 in the UK found that one 3.2.2 Safety and speed of vaccine development and political
of the strongest predictors of intentions not to vaccinate interventions
was the reason: “I cannot be bothered”40. This suggests A large volume of research lists fears of safety as one of
that considerable effort may be required to convince the largest deterrents of vaccine uptake29. Multiple media
certain groups of their own risks and of the low barrier to reports and individual scientists have discussed the speed
vaccination. at which the COVID-19 vaccine has been developed and
tested, raising safety concerns45,46. The timeline for vaccine
Perception of severity of pandemic or disease. Particularly
development for COVID-19 is unparalleled, with vaccine
relevant for COVID-19 are individual’s perceptions regarding
development which normally takes a decade compressed
the threat or severity of the disease or pandemic. As
into 1 to 2 years47. As discussed in the recent DELVE report,
with COVID-19, previous pandemics were initially met
vaccine candidates must complete clinical trials, be licensed
with scepticism and the belief that the virus was akin the
by regulatory boards and develop complex manufacturing
seasonal flu. Numerous studies of H1N1 found that when
and distribution programmes10. Although regulatory bodies
the public believed it was a mild disease they had lower
have in the past taken between one to two years, the UK
intentions to be vaccinated41,42.
Medicines and Healthcare products Regulatory Agency
(MHRA) has reported that it will fast-track it to take 70 days.

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 9
Some experts warn that vaccine development during 3.2.3 Distrust and underrepresentation of key risk groups
COVID-19 has also become entwined with political in vaccine trials
timetables, which they allege may jeopardise safety and There has also been the concern that COVID-19 clinical trials
efficacy. A prominent example is ‘Operation Warp Speed’ have underrepresented certain groups. One concern is the
in the US, for instance, which aims to have the vaccine lack of representation by minority groups, particularly by
ready before the presidential election in early November race and ethnicity53, yet these groups have the highest rates
202045. Experts point to some cautionary examples where of hospitalisation and mortality from the virus. This is often
the speed of vaccine deployment or development impacted related to high levels of distrust amongst certain groups.
safety, such as the 1955 Cutter incident discussed later in In the US for instance, the government’s Tuskegee syphilis
this report48. In 1976, when President Gerald Ford faced study from 1932 –72 carries a lasting negative memory54.
an election in the US, a vaccine for a swine flu strain was In this experiment, African Americans who had the disease
fast-tracked and given to 45 million Americans in fear of were told they were provided free health care and then
an impending epidemic49. Of those who were vaccinated, intentionally not provided treatment and were not informed
450 individuals developed Guillain-Barré syndrome and in order to study the progression of the disease. There are
there were 30 deaths. Although not exhaustive, the key also age-based concerns about the trials. Although the
lessons learned were that when large numbers of people vaccine will very likely be targeted first to those aged 65
are exposed to a vaccine, adverse reactions emerge and and older, the trials largely contain younger age groups but
children respond differently. It was also noted that public also exclude children.
explanation was necessary when coincidental deaths
occurred that were unrelated to the vaccine and what 3.3 Convenience and Planning: Physical barriers and
the relationship was with new and unrelated disease building on existing structures
(Legionnaires) that emerged. A well-planned distribution chain, convenience and building
on successful vaccination structures has been found as
Another example is the Pandemrix vaccine used during
crucial for vaccination uptake. Convenience of vaccination
the 2009 - 10 H1N1 (swine flu) epidemic, which had been
has been found in numerous studies as pivotal, including
allegedly given rapid approval by the European Medical
broad office hours, easy to reach by public transportation
Association (EMA)50. In the UK it was administered to six
and attention to the financial and time costs it would take
million high-risk groups including children. It is estimated
some individuals to receive the vaccination or take off work.
that of around the 30 million that were vaccinated in
Physician’s offices were the dominant location of H1N1
Europe around 1,300 children and adolescents developed
vaccinations, particularly among minorities. The CDC in the
narcolepsy, which was likely to be causal51. Recent attempts
US noted that vaccination levels were particularly high for
to eradicate polio in Africa, for instance, are referred to
H1N1 for children in states where vaccinations took place
where mass production began while the vaccine was still
at schools55. Given that vaccination levels for influenza and
in clinical trials with the aim to also faced serious setbacks
childhood vaccination are high in the UK, it is logical to
in 2019 when the live-virus vaccine was found to cause
build on those existing and trusted infrastructures, including
new infections52. Across 12 countries, 196 children were
pharmacies. Deterrents for vaccination were the need
paralysed by a strain derived from a live vaccine (vaccine-
to bring an immunisation card, a complicated or unclear
derived polio virus type 2) that in turn regained virulence
vaccination schedule, or poor communication. Some studies
and spread.
also mentioned concerns about the reliability of distribution
and supply, also highlighted in the recent DELVE report10,
These rapid approvals do not necessarily denote lower
and is a major hurdle in terms of late timing of vaccine
quality or vigilance but rather follow similar approval
delivery during H1N155.
procedures. This happened for instance during the
2014 - 16 West Ebola outbreak which had both high
transmission and case fatality rates. In that case, the risk of
receiving an experimental drug was deemed manageable
and was lower than the risks implicated by contracting the
virus. Other examples are in 2019, where mass production
began for vaccine for a new polio outbreak while the
vaccine was still in clinical trials, with plans to deploy it
for emergency use52.

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 10
3.4 Sources of information and knowledge deficits education is socio-economic status with those having lower
In the last section of this report we provide a more detailed incomes or the unemployed holding less positive views of
examination of information gaps and misinformation. vaccines29.
Sources of information are another factor related to vaccine
Age. Given that the majority of literature is on childhood
uptake. A study of parents during the H1N1 pandemic found
vaccination, the impact of age varies according to whether
that those who were more likely to vaccinate their children
it is a vaccine aimed at children or adults63. Age patterns
watched the national television news and pro-actively
generally show that younger people are less likely be
engaged in information-seeking behaviour56. Another
vaccine hesitant, particularly in relation to vaccinations for
study in the US found that individuals who received their
children and young adults29. The seasonal influenza and
information about H1N1 from a health-care provider or public
pandemic vaccination literature shows the opposite effect
health department were more likely to perceive the vaccine
of more intentions and vaccinations by the older population.
as safe57. A Greek study concluded that those who received
Given that recent pandemics (such as H1N1) and seasonal
information from the government were more likely to be
influenza are more detrimental to the older population64,
vaccinated than those who primarily received information
these differences are logical. A systematic review of H1N1
from the television and radio58. Effective communication
vaccination uptake found that those who had higher
and vaccine distribution strategies has been suggested as
intentions for vaccination were likely to be older, related to
particularly vital for minority communities59.
the age-related risks of that virus42.
As we discuss in more detail shortly, a growing strand of
Sex and parental status. Men are more likely to hold
literature claims that internet users are more likely to believe
anti-vaccine sentiments than women29, which is striking
that healthy individuals do not need to be vaccinated and
given that many of the anti-vaccine MMR parental activists
that it is harmful60. An experimental study examined the
and online forums are populated by women. Given that
impact of exposure to anti-vaccine conspiracy beliefs, a
the majority of the literature has focussed on children’s
group exposed to refuting anti-vaccine conspiracy theories
vaccinations and parental attitudes, studies often report
and a control group on vaccination intentions61. They found
mother’s attitudes and behaviour as opposed to parents
that those exposed to anti-vaccine beliefs showed a lower
in general62. Studies of H1N1 found, however, that men had
intention to have a vaccination compared to the supporting
higher intentions of vaccination than women42. Jennifer
and control group, with the effect mediated by the perceived
Reich who studied vaccination hesitancy of parents in
dangers of vaccines, perceptions of powerlessness and
relation to measles explores what defines good parenting
disillusionment and mistrust in authorities. This provides
in relation to vaccination32. She notes that relatively few
some evidence that exposure to anti-vaccine conspiracy
parents actually reject vaccines, but moreover harbour
theories can shape vaccine uptake and health behaviours.
concerns surrounding children’s safety and the pain
3.5 Socio-demographic characteristics related to vaccine of injections, suggesting the need for dialogue and
uptake communication in order to understand these concerns.
A wealth of studies and systematic reviews isolated key
Ethnicity. Ethnic minorities have been shown to have lower
socio-demographic characteristics related to vaccine
levels of vaccination, often related to issues of trust in the
hesitancy, and factors predicting vaccine intentions and
government or health care system, discussed previously,
uptake. It is notable that findings can be heterogeneous,
but also lack of health care insurance and convenience.
related to whether the vaccination is for children or adults,
A systematic review of H1N1 vaccination intentions and
with variation across countries and across whether survey
behaviour, however, found that in the UK, US and Australia,
participants were health care professionals or members of
individuals from ethnic minorities were more likely be
the general public.
vaccinated42. This was attributed to the fact that particularly
individuals from Asian ethnic minorities were more likely to
Education and socio-economic status. Findings are mixed
be hospitalised in the UK65. But also that for British children,
in relation to the educational levels related to vaccine
the H1N1 mortality rates were higher for Bangladeshi and
hesitancy with many studies finding that hesitancy is
Pakistani children, raising awareness in those communities66.
reduced with higher levels of education29. Online searches
A study of the H1N1 and seasonal influenza uptake in the
are said to have a stronger impact on the biases of
United States found a disparity in vaccine uptake of 13.8%
college-educated mothers than newspaper coverage, with
for Blacks versus 20.4% in the White and Hispanic groups59.
exposure to negative information strengthening their bias
via the mechanism of confirmation bias62. Closely related to

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 11
Religion. Clarity of messaging surrounding the safety of the 4. Ethics and Equity in the allocation of vaccinations
vaccines should also be sensitive and address concerns 4.1 COVID-19 reveals structural inequalities
across religious and cultural groups. The drop in confidence
COVID-19 has had disproportionate effects across different
of vaccines in Indonesia has been partially linked to key
social groups, exposing many of the structural inequalities
Muslim leaders questioning the safety of the MMR vaccine
in the UK and beyond. In the UK and similar nations, several
who issued a fatwa (religious ruling) that the vaccine was
core socio-demographic, regional and environmental factors
haram (containing ingredients derived from pigs, thus
have been attributed to an increased risk of certain groups
unacceptable for Muslims)36. A predominantly Muslim sample
to severe illness, hospitalisation and death from COVID-1969.
of respondents in Malaysia reported concerns that the
The current pandemic has likewise exposed structural
vaccine was not a Halal vaccine and were thereby less likely
inequalities in which many of these traits intersect. As of
to be vaccinated.67
October 2020, our understanding is that COVID-19 in the UK
disproportionately effects the following groups:
Social network. The proportion for and against vaccination
within an individual’s’ social circle has also been shown • People aged 65 and older, where the highest number of
to be relevant. Parents who chose not to vaccinate their deaths have been reported, with a considerably higher
children had a much higher percentage of individuals (70%) mortality rate in those 80 years and older64.
in their social networks with similar attitudes than those who
did vaccinate their children (13%)60. • Individuals living or working in crowded congregated
settings, particularly older adults living in senior care
Past health and vaccination behaviour. A systematic review homes70.
of H1N1 vaccination uptake found that one of the strongest
• Those with underlying health conditions and co-
predictors for vaccination was past behaviour. Those who
morbidities such as diabetes, severe asthma and obesity69
had previously been vaccinated against seasonal influenza
are more likely to become hospitalised and die.
were the most likely to opt for an pandemic vaccination42.
A study in the US, for example, found that those who • Ethnic minorities, termed BAME (Black, Asian and Minority
previously had influenza vaccinations were more likely to Ethnic) in the UK, have had an increased risk of death
consider the H1N1 pandemic as serious and were more particularly for Black African & Caribbean, Pakistani,
positive about the safety of vaccines57. A survey in the Bangladeshi and Indian ethnic groups, even after adjusting
UK of COVID-19 vaccine intentions likely found that past for multiple factors69,71.
vaccination behaviour was a key predictor. The researchers,
however, revealed potential confusion that may arise with • Men in the UK and elsewhere are more likely to have poorer
individuals who were vaccinated for seasonal influenza health outcomes die from COVID-1969, with nearly two-thirds
believing that it would aid in COVID-19 immunity5. of the deaths in England and Wales between 9 March and
25 May being male72.
Higher risk priority groups. Due to higher exposure to
• Occupation has also been shown to be an important risk
viruses and disease, a large volume of literature also
factor with the highest deaths in England and Wales. In fact,
focusses on vaccine uptake by occupations and in
examining deaths per 100,000 from March to the end of May
particular health care professionals. Doctors and health
2020 in England and Wales, compared to male doctors,
professionals have been shown to have higher vaccination
who had 30 deaths per 100,000, men in occupations with
intentions and rates in general and also during the H1N1
higher mortality levels were security guards (74), bus and
pandemic, which is logical since they are often designated
coach drivers (44) and van drivers (37). The highest deaths for
as priority groups42. The findings show that pregnant
women were amongst care home and home care workers
women who are also often a priority group are more likely to
(26) followed by those in local offices carrying out national
vaccinate, particularly when they have concerns about the
government administration (23) and sales and retail assistants
disease33. Other studies showed that as with other groups,
(15.7), which were all higher than female nurses (15.3)72.
pregnant women were also more likely to be vaccinated
if they believed it was effective68. Having a chronic illness • Intersectionality plays a key role in understanding these
or being the priority group for vaccination has also been differences, a term which refers to how the combination of
associated with greater intentions to vaccine, once again an individuals’ characteristics result in structural inequalities.
logical given the awareness and priority allocation28. For instance, the occupations in England and Wales with
the highest death rates also had statistically significantly
higher proportions of workers from Black and Asian minority
backgrounds72.

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 12
4.2 Ethical principles for scarce vaccine resources 4.3 Interim advice of priority groups for COVID-19
Four fundamental ethical principles have been suggested vaccination in the UK
with regards to the allocation of scarce resources during a Defining priority groups using an age-based system. On
pandemic: September 25 2020, the Joint Committee on Vaccination
and Immunisation (JCVI) of the Department of Health and
1. maximise benefit (save the greatest number of lives,
Social Care provided interim advice on the groups that
improving people’s length of life years by focussing on those
should be prioritised for COVID-19 vaccination when it is
with the best prognosis),
licensed in the UK75. The underlying principles that were
2. treat people equally (given that a first-come, first-served proposed were to:
system, or one offering vaccination to those who can pay is
1. reduce mortality,
not fair). If individuals have similar prognoses, vaccine access
should be randomised. Randomisation for vaccinations in a 2. improve population health by reducing serious illness; and,
‘vaccination lottery’ has been previously been conducted
3. protect the NHS (National Health Service) and social care
in response to shortages73. Another suggestion could be
system.
location or cluster-based randomisation targeted at inhibiting
transmission. Although articulated slightly differently, these ethical
principles are generally in line with those listed above,
3. promote and reward instrumental value (reward those such
namely, to maximise benefit (reduce mortality and serious
as health care or front-line workers who both put themselves
illness) and instrumental value (rewarding and protecting
at risk but also save others); and,
NHS). There is, however, a less explicit focus on treating
4. give priority to the vulnerable or worse off (those who will people equally and protecting vulnerable groups (beyond
become the most sick or die as a result of infection or to the age, co-morbidity, health care workers, care homes) in
young who will lose the most life years)74. addition to a stronger focus on protecting the health and
social care system. The emphasis on protecting the NHS
Although rarely introduced, some have argued that we need
resonates in the UK since it is a national symbol, with
to move beyond physical health to prioritise a fifth ethical
slogans in early April 2020 stating ‘Stay at home, protect
principal, which are the longer term economic benefits of
the NHS, save lives’, with weekly public displays thanking
keeping certain jobs or parts of the economy functioning.
these key workers. As with many health care systems during
Here the discussion is often linked to indirect effects such as
COVID-19, the NHS remains at risk of being overloaded,
excess mortality or the longer term effects of unemployment
particularly in certain geographical regions76.
or bankruptcy on stress and mental health.
The JCVI review indicated that their advice was based on a
Following these ethical principles, those deploying the
review of epidemiological data on the impact of COVID-19
vaccine also need to transparently articulate the general
to date, Phase I and II data on vaccines and mathematical
priorities that guide their decision making. This includes
modelling of the impact of various vaccination programmes.
core goals such as prioritising those most at risk of death
They note considerable unknowns, noted above such as
or severe morbidity if they acquire the virus, those at risk of
efficacy of the vaccine, safety across age and risk groups,
acquiring the virus, risks of negative societal and economic
effect on acquisition and transmission, transmission
impacts if some individuals become ill (e.g., school teachers)
dynamics, duration of protection and the epidemiological,
or a focus on vaccinating those who are more likely to
microbiological and clinical characteristics of COVID-19.
transmit the virus to others. These ethical values could also
be interpreted differently in relation to whether they are The committee takes a firm age-based approach, also with
based on benefits to health, social or economic purposes. an emphasis on frontline health and social care workers
and older adults living in residential care homes. The key
priority and message is that it is an age-based programme
for reasons of easier delivery and subsequently higher
uptake. They note that this age-based approach in many
ways overlaps with clinical risk factors. Frontline health and
social care workers were also considered as high priority
since they are at increased personal risk and will maintain
resilience in the NHS and social care systems. Care home
workers were likewise given a very high priority. Given
that older adults living in residential care homes were

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 13
disproportionately affected by COVID-19 with a higher She was quoted as saying that vaccinating everyone was
clinical risk of disease and mortality, this group also received “not going to happen” and that “We just need to vaccinate
one of the highest priorities for vaccination. everyone at risk”77. In this interview she noted that talking
about vaccinating the whole population was misguided
The committee noted that it was not possible to come to and clarified: “There’s going to be no vaccination of people
a firm position on priority groups, but produced an interim under 18. It’s an adult-only vaccine, for people over 50,
ranking combining an age-based approach with clinical risk focusing on health workers and care home workers and
stratification of 10 groups (i.e., older, high/moderate-risk, the vulnerable.” Other later media reports note that the
resident or worker in a care home and health workers), with NHS intend to be ready to vaccinate 75 to 100% of the
the priority to be determined for the 11th group, which is the population, sending highly mixed messages78.
rest of the population. The committee notes “early signals
have been identified of other potential risk factors, including 4.4 An alternative phased approach considering equity
deprivation and ethnicity” as well as for men. This interim and the vulnerable
approach that prioritises age, frontline health workers and Given our knowledge about the unequal impact of the
those in care homes is an important first phase but does not virus, another proposal for vaccine deployment could focus
consider broader equality ethical principles or prioritise the on rolling out the vaccine to more risk groups than listed
vulnerable in relation to known risk factors such as ethnicity, above. Building on the US’s recent National Academies
non-health high-risk occupations. Given that age is such a report11, previous experience of pandemic deployment79, a
dominant factor in the absolute risk of severity and mortality, similar phasing strategy could be adopted. For the purpose
it may however, override these risk factors even if the of illustration and fact that likely 80+% will need to be
relative risk is elevated for BAME or occupational groups. vaccinated, we adopt a higher level of coverage (95%) in
our illustration compared to the UK’s alleged less than 50%
Clarity and open engagement to manage expectations of
proposed coverage77.
the general public. There is also some confusion regarding
the percentage of the general population that will be As Figure 3 illustrates, vaccine deployment could stratify
vaccinated to reach herd immunity. On October 4 2020, groups into different phases to almost 95% coverage.
Kate Bingham, the head of the UK vaccine task force was Phase 1 includes those with the highest-priority to serve key
quoted as saying that around 30 million people, less than societal needs such as health care workers, emergency
half of the UK population could expect to be vaccinated. services but also the most vulnerable populations with

FIGU R E 3 .

A phased approach
A phased to vaccine
approach deployment
to vaccine and allocation
deployment for COVID-19
and allocation for COVID-19
95.0%
Front-line health All ages comorbid and Key Stage 0-5 teachers, 90.0%
workers, services underlying conditions at school staff, childcare
to health care significantly higher risk workers
All UK residents who
First responders 65+ living in congregated, Workers high-risk exposure have not had prior
80% crowded settings settings access
All ages comorbid and
underlying conditions at
moderately higher risk Young children
Occupations important
Population Coverage

60% to societal functioning,

increased risk exposure
50.0% not included in Phases 1-2

40%

Homeless shelters, group

homes, disabilities
Prisons, jails and similar
20% 15.0%
All older adults not included
in Phase 1
5.0%

Phase 1a Phase 1b Phase 2 Phase 3 Phase 4

Source: Adapted from Figure S2 (National Academies 2020)11

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 14
significantly higher co-morbidity risks, or those in care deprivation, age structure, ethnicity groups and population
homes. Phase 2 would include teachers, school staff and density76. Examining the concentration of individuals within
childcare workers but also those with less protection in high- the groups identified in each phase at the granular local
risk front-facing occupations such as transportation, also level would be an effective tool for more targeted vaccine
given that these have some of the highest mortality rates in deployment.
the UK72. During this early period, however, these groups
likely did not use multiple non-pharmaceutical interventions 4.5 Challenges of practical deployment in a phased
such as mandatory face coverings and had lower protection. approach
4.5.1 Practical challenges
A plan to protect the vulnerable might also include those
Although the previous phased proposal might at first
with moderate co-morbidity risks, the vulnerable in homeless
glance seem ethically appealing and even feasible,
shelters, group homes, prisons, with disabilities and older
similar approaches have failed. Given past experience
adults already not covered in phase 2. The US model
of immunisation, certain factors are essential to take into
argued that Phase 3 could then focus on young children,
account. First, it is necessary to define and locate those
additional occupations key to economic and societal
who have a priority status. Health care workers or those in
functioning (see report11 for detailed listing of all categories)
care homes are more easily defined. Those with underlying
with Phase 4 resulting the remaining UK residents. It
conditions, however, need to be classified and contacted.
remains a question, however, as to whether children would
GPs hold considerable data and could identify those most at
be a viable target group given that vaccine trials have not
risk to form an integral part of the vaccination deployment.
focused on this group.
Furthermore, although it is ethically desirable to give
priority to those in prisons and the homeless, previous
Equity is an intersectional or cross-cutting aspect with
experience has shown that this is very mobile group and it
certain groups also needs to be prioritised in different
may be difficult to achieve, track coverage and locate these
local and regional levels given large differences in social
individuals for a second immunisation. Although not defined

FIGU R E 4 .

Vaccine uptake in England, Seasonal flu vaccination by Clinical Commissioning Group (CCG),
2019 - 2020 by risk groups
Vaccine uptake in England
Seasonal flu vaccination by CCG, 2019−2020
<65, at risk 65+ years
80

NHS Stockport CCG

60
NHS Hammersmith
and Fulham CCG
40
% vaccinated

NHS Hammersmith
and Fulham CCG

Pregnant, at risk Pregnant, not at risk

80
NHS Stockport CCG
NHS Stockport CCG

60

40
NHS Dartford, Gravesham
and Swanley CCG NHS Isle of Wight CCG

Ea Lo Mi No No So So Ea Lo Mi No No So So
st nd dla r th r th uth uth st nd dla r th r th uth uth
of on nd Ea We Ea We of on nd E W E We
En s st s s st E n s a s e s a s st
gla an t t gla ta t t
nd dY nd nd
ork Yo
sh r ks
ire hir
e
Commissioning region

Source: PHE (2020)82

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 15
in detail here, the definition of occupations essential to clear rationale, there might be extensive negative debate
societal functioning need definition, which has been done for example, about why certain vulnerable populations
elsewhere11. in prisons or the homeless are prioritised before young
children or certain seemingly vital occupations.
Second, priority groups based on age can be difficult to
communicate. During the H1N1 influenza, age was chosen Third, although we present one stylised vaccination scheme,
as a priority, with children prioritised over older people there will likely be multiple vaccines deployed at different
since the virus disproportionately affected the young. times making communication highly complex and confusing.
Since older populations were often targeted in the past for Media reports suggest that Britain has purchased 400
seasonal influenza vaccines, however, they felt alienated million doses across six different vaccines, spreading the
that they were not included in the priority group, resulting risk78. This likely includes the Oxford/Astra Zeneca vaccine,
in considerable consternation80. Given that children are which started a fast-track review on October 1 and the Pfizer
often a focus for many vaccines, similar confusion could vaccine on October 6. The intricacies of and differences
also emerge if clear dialogue did not take place. When between these vaccinations and the second generation
planning a vaccination campaign with priority groups, it is ones that may follow will need to be expertly communicated
essential to develop a clear and transparent rationale to to the population.
explain why these target groups have been chosen and the
reasoning behind any ranking or phasing. Attention should A fourth aspect concerns infrastructure and distribution.
be placed not only on priority groups, but also the ‘excluded’ Although deployment plans are not publically available at
to clarify the reasoning behind allocation with clear and the time of writing, media reports suggest that the plans
targeted dialogue strategies. Although the prioritisation in will involve large NHS led ‘Nightingale Vaccination Centres’
Figure 3 is based on priority groups to limit harm, death and and the army to distribute the vaccine78. It appears that
virus transmission, without proper discussion and public existing systems for the influenza vaccination will be used
consolation a considerable backlash could arise. Without a in addition to a new hub-and-spoke model. Hubs will supply

FIGU R E 5.

Vaccine uptake amongst health care workers (HCWs) England, Seasonal flu vaccination by NHS Trust,
Vaccine uptake among English health care workers
2019 - 2020
Seasonal flu vaccination by NHS Trust, 2019−2020

100

75
% vaccinated

Salford Royal NHS

Pennine Care NHS Pennine Care NHS Foundation Trust
50 Foundation Trust East Suffolk and North Essex Foundation Trust
NHS Foundation Trust Pennine Care NHS
Foundation Trust
West London
Cornwall Partnership NHS NHS Trust West London NHS Trust Salford Royal NHS
Foundation Trust Foundation Trust
25

0
Frontline HCWs Doctors Qualified nurses Other qualified clinical staff Support staff

Source: PHE (2020)83

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 16
the vaccine given cold storage (likely at -60°C) needs and 5. History repeated: from misinformation to public
related equipment with spokes taking the form of: mass dialogue
Nightingale Vaccination Centres, mobile sites (potentially 5.1 Anti-vaccination movements in the Nineteenth
at polling stations) and roving teams. Reports suggest that Century
roving teams could cover 9 households a day and fixed
Public understanding and support for vaccination are pivotal,
sites 2,500. To avoid the disruption of care, another option
yet an enduring challenge. Although some argue that the
could be to carry out vaccinations during the weekend or
anti-vaccination or ‘anti-vaxxer’ movement emerged with
evenings at GP practices. This approach, however, it not
measles, the MMR scandal surrounding Andrew Wakefield
targeted at stopping or attempting to interrupt transmission
(discussed shortly) has multiple important parallels. In 1796,
in particular communities81.
Edward Jenner presented an article to the Royal Society
describing how cowpox could inoculate individuals against
Finally, we must consider how to actually track and trace
smallpox, coining the term ‘vaccine’ (from vacca, Latin for
those who received the vaccination to ensure coverage,
cow)84. The Vaccination Act of 1840 was introduced in
but also follow-up for a second immunisation. The vaccine
the UK followed by the Vaccination Act of 1853, making
developed by Oxford University, for instance, requires two
vaccination compulsory for all infants and parents liable to a
inoculations that are 28 days apart. Given challenges with
fine or imprisonment. This was extended in 1867 to the age
the track and trace system, considerable thought is required
of 14 and was one of the first acts that extended government
to achieve this goal, such as working with GPs and local
powers in the name of public health85. Resistance to these
communities.
laws grew with violent riots and demonstrations and the
4.5.2 Challenges of vaccine uptake across different groups founding of the Anti-Vaccination League, which focussed on
infringement of personality liberty and choice. What followed
As shown in a previous section, the UK currently has one
was the growth of a large number of anti-vaccination books
of the highest vaccination rates for seasonal flu in the world
and journals such as the Anti-Vaccinator85. After a large
for those 65 years of age and older. But vaccination uptake
demonstration in 1885, a Royal Commission heard testimony
differ across other age and risk groups, regions and type
(for seven years) and concluded in 1896 that vaccinations
of health care worker. Figure 4 shows vaccine uptake in
protected against smallpox but recommended to abolish
England for seasonal flu by Clinical Commissioning Group
penalties, thought to be a decision to appease the anti-
(CCG) in 2019 - 2020 by different risk groups82. The box
vaccine movement. This resulted in the amendment of
plots show that there is some variation by CCG, with the
the vaccination law in 1898 to allow parental exemptions
names of some of the outliers listed in the graph. Here we
based on conscience, which was when the concept of
see that there is broadly very high coverage of those 65
‘conscientious objector’ was introduced into English law84.
years and older, suggesting that COVID-19 will likely be
very effective in this group. However, we also see a striking
Opposition also grew in other parts of the world such as
finding that those under the age of 65 and in the ‘at risk’
in Sweden and particularly in Stockholm, opposition which
category show relatively low levels of uptake between 40-
emphasised an individuals’ right to choose given uncertainty
50%, suggesting that this group might be difficult to reach
surrounding the effectiveness of vaccines, with vaccination
for COVID-19 vaccinations. Areas such as London also have
rates subsequently falling to 40%. They quickly recovered,
lower overall uptake than others.
however, after a major smallpox epidemic in 1873 - 486.
In the United States, smallpox became an epidemic in the
Figure 5 shows vaccine uptake amongst health care
1870s, with states enforcing vaccination laws, and quickly
workers in England for seasonal flu vaccination in 2019-
passing new ones. Following the visit of leading British
2020, demonstrating considerable variation across
anti-vaccine campaigner William Tebb to New York in 1882,
occupation, but also NHS Trust83. The figure illustrates wide
the Anti-Compulsory Vaccination Society of America was
variation of uptake across NHS trust. Although doctors,
formed. This and related groups used pamphlets and legal
for instance, have high levels of seasonal flu vaccination
battles and to eventually overturn compulsory vaccination
it ranges from 40% in some of the smallest trusts to 100%
laws in various states (e.g, California, Minnesota, Utah)87.
coverage in others. There is also a wide range in vaccination
levels for support staff, as low as 37% in smaller trusts up to
100% in larger trusts such as Blackpool.

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 17
The opposition to vaccines in the late 1800s has striking the 12 co-authors in 199892, accompanied by an admission
parallels with contemporary movements, namely in the from the Lancet that the authors failed to disclose financial
ideas that: vaccines cause illness in children, immunity interests (Wakefield was funded by lawyers of parents suing
is temporary, vaccines are ineffective or poisonous, that vaccine-producing companies). This was followed by only a
medical science and government have created an alliance complete retraction by the journal only over 12 years later in
for profit, there is a cover up and move to totalitarianism 201093. A series of articles published in the British Medical
and infringement of basic rights and civil liberties and that Journal argued that the work was an ‘elaborate fraud’ which
healthy lifestyles or alternative medicine is a solution84,88. took place for financial gain94,95. This history has also been
described in detail by journalist Brian Deer96 with systematic
5.2 The contemporary anti-vaccination movement failures in the system documented elsewhere97.
Although social media and the internet have altered the
speed and manner in which anti-vaccination movements Just as British anti-vaccination campaigner William Tebb
operate, there are multiple parallels in the 20th and 21st travelled to the US in 1882, when removed from the UK,
Century89. Similar arguments to those posited in the 19th Wakefield found an alternate audience to perpetuate his
Century are not unique and perpetuate across time. Some beliefs. In addition to continuing his anti-vaccination activism,
attribute current vaccine hesitancy to the 1955 ‘Cutter he recently directed the propaganda film ‘VAXXED: From
incident’ where the US government vaccinated 200,000 Cover-up to Catastrophe’. The film, which was later removed
children using a new polio vaccine. One batch from Cutter from services such as Amazon, alleges to show that there
Laboratories accidently contained the live polio virus with has been a cover-up by the United States’ Centres for
40,000 children contracting polio, with 10 dying and several Disease Control (CDC) which in turn caused an increase
hundred paralysed48. The anti-vaccination movement against in autism. The film has interviews with purported parents,
pertussis (whooping cough) in the late 1960s for instance, journals and researchers who argue how governments and
in countries such as the UK, Sweden, Italy and former West the pharmaceutical industry cover up evidence against
Germany also had a detrimental impact on vaccination vaccination98.
uptake and epidemics90. This was in stark contrast with
5.3 Infodemic: Misinformation, anxieties and fear
countries that did not have vaccine resistance and had
virtually 93 - 100% vaccine coverage and thus low disease On February 15 2020, WHO Director-General Tedros
in that period (Portugal, Hungary, United States)90. In the UK, Adhanom Ghebreyesus announced at the Munich Security
a prominent health expert Dr Gordon Stewart claimed that Conference: “We’re not just fighting an epidemic; we’re
the protective effect of the pertussis vaccine was marginal, fighting an infodemic.” Infodemics are characterised by
coupled with a 1974 report about potential deleterious side an overabundance of information – both factual and
effects of the vaccine which was in turn widely covered misinformation – that occurs during a health emergency
in the media. Loss in confidence of the public resulted in such as COVID. It was first coined in 2003 by David
a sharp drop in coverage from 81% in England and Wales Rothkopf in relation to the SARS epidemic. It slightly differs
in the early 1960s to just 31% by the mid-1970s. This was from the WHO definition as “a few facts, mixed with fear,
followed by a pertussis epidemic90. The government reacted speculation and rumour,” amplified by technology to create
with a national reassessment of vaccine efficacy finding it a disproportionate reaction99. Infodemics spread even
had ‘outstanding value in preventing serious disease’91 in faster than the virus, and are characterised by an excessive
addition to financial incentives to doctors to achieve a target amount of information. This makes it difficult for both the
of vaccine coverage. The vaccine uptake soon rose to public, but also public authorities, to identify an actionable
93% with a dramatic decline in disease incidence, with just path to counter misinformation and rumours. They not only
1 death attributed to the disease in England in 201914. hamper public health responses, but generate confusion
and general distrust amongst the public100.
Although there are numerous examples throughout history,
the modern era of the anti-vaccination movement has Misinformation refers to misleading healthcare information,
been attributed to the now retracted 1998 Lancet study by dangerous hoaxes with false conspiracy theories, and
British ex-physician Andrew Wakefield and 12 colleagues fraud that endangers public health. Given that the advice
purporting a link between the MMR (measles-mumps- and information about the COVID-19 pandemic rapidly
rubella) vaccine and autism. Although the study had a small changes, it is an especially fertile ground which draws
sample size (n=12), an uncontrolled research design, and upon individuals’ anxieties and fear by those seeking to
speculative statistical conclusions, it received widespread promulgate anti-vaccination ideologies. Vaccine anxiety due
publicity and MMR vaccination rates sharply dropped. The to fear has been a constant when there is uncertainty and
retraction was a longer process, with a retraction from 10 of fear, which gives way to rumour101. The main contemporary

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 18
sources of the spread of misinformation occur on social coincided with a global measles outbreak, with anti-vaccine
media platforms such as Facebook, YouTube, Instagram, pages growing in this period by 500% compared to a 50%
Pinterest, Twitter, Tencent, TikTok or previously through growth of pro-vaccine pages.
Google searches. It is notable, however, that the traditional
mass media has also allegedly perpetuated this by Anti-vaxx messages have particularly surged in the last
covering misinformation100. Anti-vaxxers exploit shifts in 5 - 10 years helped by influencers on social media who
recommendations and knowledge as the political and largely focus on the false dangers of vaccines and offer
scientific establishment’s failures. Narratives are aloof, alternative healing methods for infectious diseases that have
unrepentant and aim at what they perceive as fallible effective vaccines (such as apple cider vinegar, or garlic),
medical and scientific experts. often for sale. Anti-vaccination Twitter messages linking
vaccines with autism have been widely re-tweeted by the
5.4 Who creates COVID-19 misinformation and anti- President of the United States Donald Trump107. There was
vaccination material? a marked shift in President Trump’s tweets, however, since
Conspiracy and anti-vaxx theories and misinformation early March 2020, with a positive focus on vaccines in
entice individuals by linking aspects that might seem to relation to COVID-19107. In the UK, the influential rapper M.I.A.
be correlated. The WHO provides a ‘mythbusters’ site said she would ‘choose death’ over a coronavirus vaccine.
collating the main misinformation coronavirus messages
A variety of studies have shown that negative attitudes
(see Appendix 3 for a short summary)102. The demographics,
towards science are correlated with right-wing
socio-economic position and political ideology of those
ideologies108,109 and that political conservatives are more
who spread and believe in anti-vaxx information is
likely to believe in vaccine conspiracies110. A survey of adults
heterogeneous. The anti-vaxx group has often been
in England (n=2,501) sampled by age, gender, income, and
characterised as being the polar opposite of the health
region found an appreciable endorsement of conspiracy
conscious or what Berman (2020) termed “hippies with
beliefs. Around 25% showed some degree of endorsement,
homeopathy” and conservative libertarians who see masks
15% a consistent pattern of endorsement, and 10% with
and vaccines as a sign of government oppression and an
very high levels111. Those with higher levels of endorsing
infringement of civil liberties103.
COVID-19 conspiracy theories reported to be less likely to
An analysis of six of the most popular anti-vaccination adhere to government guidelines, be tested, or vaccinated.
Facebook pages (from 2013 - 2016) examined the social They found that the groups who held general vaccination
network, core topics and demographics of these groups104. conspiracy beliefs also had a broader conspiracy mentality
This included the most popular sites, such as ‘Dr Tenpenny such as climate change conspiracy and a general distrust
on vaccines’, ‘RAGE against the vaccines’ and ‘Great in institutions. A recent comparative report found that there
mothers (and others) questioning vaccines’. They found was a recent surge in trust in some countries such as the
that the majority (72%) who participated were women. This US in the form of a ‘rally around the flag’ effect. A core
gender ratio is related to the focus of these groups largely finding, however, was the emergence of deep and polarised
on children’s vaccinations, such as Dr Sherri Tenpenny’s partisan divides112.
group or the ‘Great mothers’ who focus on vaccination
The majority of anti-vaccination ads on Facebook are
as a ‘mother’s question’. This echoes the anti-vaccination
funded by two organisations, The World Mercury Group (led
movement in England from 1853-1907, where mothers
by Robert Kennedy Jr.) and the Stop Mandatory Vaccination
were key in the resistance against childhood smallpox
group (run by Larry Cook who defines himself as a ‘healthy
vaccinations88. This phenomenon is global with drops in
lifestyle advocate’)113. Others have linked anti-vaccination
vaccination in South Korea attributed to an active on-line
movements to Russian-backed Twitter accounts, with anti-
anti-vaccination group called ANAKI (translated as ‘raising
vaccination messages found to target the US public114. In
children without medication’)105.
the Ukraine, for instance, vaccination rates went from 95%
An analysis published in Nature of more than 1,300 in 2008, to 31% in 2016. Some have partially attributed to
Facebook pages with nearly 100 million followers produced targeted anti-vaccination bots from Russian-backed Twitter
a network map of pro- and anti-vaccination pages106. They accounts115. A vital observation is that these targeted attacks
found 124 pro-vaccine pages with 6.9 million followers do not only focus on anti-vaccination material, but also on
and 317 anti-vaccine pages totalling 4.2 million followers. pro-vaccination messages, suggesting that their main goal is
Whereas the pro-vaccine pages were global or national, to generate polarisation and divide.
the anti-vaccination pages were both locally and globally
connected. Their study period of February to October 2019

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 19
5.5 The anatomy of anti-vaccine misinformation claim that data on the effectiveness (or serious negative
To develop effective communication strategies to counter side-effects) of vaccines are hidden or covered-up by the
misinformation, it is important to understand the main pharma companies and the government bribing scientists
strategies that are used. Our literature review found that the and those in power (see Appendix 3). These narratives
anti-vaccination and related conspiracy theory groups share often refer to fallacies such as a hidden link between
several common elements (see Appendix 2, 3). childhood vaccination for MMR and autism, regardless of
the fact that this has been firmly disproved and revealed as
Distrust of science and selective use of expert authority. fraudulent123. Since vaccines are manufactured by for-profit
Distrust in science has grown substantially in recent years, large pharmaceutical companies, often tied to scientists
with 55% of American adults in 2016 reporting that they and governments, it is a relatively easy issue for sceptics
trusted scientists ‘a lot’ about the risks of vaccines but to focus on. Since companies are driven by profit, there
only 39% on climate change116. A study of misinformation are real concerns from the general public that need to be
surrounding the Zika and yellow fever virus showed addressed. Many recall the recent opioid epidemic in the
that attempts to refute misinformation about the virus US that caused many deaths, which eroded trust since it
failed because they had developed a general distrust was related to drug companies compensating physicians. In
and reduction of confidence in the WHO’s epidemic 2015, a stunning 33,000 deaths in the US were attributed to
information117. The distrust in science and supranational opioid poisonings, a number rising to 43,000 in 2016 with
organisations such as the WHO reflects a general shift an increased mortality rate of 268% from 1999 to 2016124.
of individuals questioning the legitimacy of traditional Experts in the field of vaccine anxiety and hesitancy such
institutions and favouring their own interpretations over as Larson, Leach and Reich note that these concerns of
evidence-based facts104,118. Ironically, the use of authority and the public mistrust need to be addressed. As Reich states:
selective experts to bolster opinion is a common approach “some may dismiss these parental fears about vaccines
of this group. The organiser of the recent anti-vaccination as simply people who just don’t understand how vaccines
and anti-lockdown rally in London on September 19, 2020, work, it behoves us to take their concerns seriously” (p. 8)32.
for instance, was suspended Nurse Kate Shemirani, now
coined the ‘natural nurse’ who argues that vaccines are Straightforward, simplistic explanations that are difficult
poisonous and, related to 5G. She had a Facebook site with to distinguish from truth. A hallmark technique is to
14,000 followers, subsequently removed119. reduce complexity, often tied to mistrust and rejection in
science or alternative interpretations of scientific data125,126.
It also included Professor Dolores Cahill, of University A recent study of misinformation in relation to Zika and
College Dublin, and chair of the Irish Freedom Party who yellow fever concluded that it was difficult for individuals
was reported to have told the rally “We want freedom, truth to decipher complex information in a rapidly moving and
and love. I know that vaccines make people sick, you should chaotic environment where little concrete factual information
not trust the Government, the doctors and the media, they was available117. Another survey in the United States found
are lying about the Covid-19 vaccine”120. These groups often that almost two-thirds of Americans reported finding
leverage debates and updates on scientific knowledge, misinformation in the form of ‘fake news’ confusing and
public health officials or those in government as a sign around 25% reported that they themselves had shared fake
of doubt or significant disagreement, bolstering distrust news stories127.
in expertise. Another group of (previously respected but
discredited) scientists move from topic to topic in order to Use of emotion and individual anecdotes to impact
‘merchandise doubt’ with multiple examples chronicled by rational decision-making. Larson argues that emotion is
Oreskes and Conway, such as Frederik Seitz who moved one of the main drivers in the evocation of fear and anxiety
from successfully creating doubt for decades about the around vaccinations, and the perpetuation of rumours89. A
detriment of cigarettes to a denial of climate change121. hallmark of anti-vaccination information are individual and
emotional anecdotes which are used as a primary source of
Distrust of pharmaceutical companies and government. evidence128,129. For childhood vaccinations, this often includes
A central driver of anti-vaccination beliefs is not only safety, the story of one child that became ill, for instance, as told
but also a distrust in the commercial production of vaccines through the child’s parents. These parental testimonies are
and the regulatory agencies overseeing them32. A persistent often accompanied by visual pictures of children allegedly
and strong driver of vaccine conspiracy beliefs centres injured by vaccines, an approach that has been shown to
around the claim that both large pharmaceutical companies strongly impact intentions to vaccinate130.
and governments falsify vaccine data to further their own
objectives and for profit122. This is often coupled with the

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 20
The psychological literature has examined this use of Facebook pages, for instance, remove antagonist
emotions in impacting decision-making. When personal and opinions and bar dissenting voices from participation.
anecdotal information is presented in a vivid and powerful This communication within closed echo-chambers can
way, it is said to affect people’s general rational decision- exacerbate misunderstanding about scientific facts. The
making and reasoning131,132. This strand of research contends most common mode of participation on anti-vaccination
that vivid stories and anecdotes override rational thinking, Facebook pages is the sharing of material. A largescale
a potential factor leading to lower vaccine uptake. Another Facebook analysis found that anti-vaccination networks
mechanism is that these emotional experiences provoke were very large and active but had relatively sparse or
anxiety, with individuals more likely to use faster intuitive ‘loose’ connections and did not interact for a sustained
thinking than more deliberate information processing. period of time104.
Experts in this area are quick to add, however, that those
who are vaccine hesitant are not merely pawns to these An analysis of vaccine-related tweets in the Netherlands
tactics, but are rather driven by personal and legitimate fears in 2017 isolated several densely connected networks
and emotions that require conversation and dialogue32,89. that generally internally interacted with each other. These
were, in order of size: the Dutch media (e.g., main news
An experiment found that exposure to rude or uncivil platforms, broadcasters), the health community (e.g., nurses,
comments can polarise opinions and risk perceptions133. health services), writers and journalists, anti-establishment
In an experiment of 2,338 individuals, all subjects read the (e.g., patriotic, anti-Islam, pro-Trump), Belgian (Flemish)
same article on nanotechnology with one group reading media, farmers and veterinarians, and global vaccine
a series of negative and uncivil comments and the other advocates. They found several prominent narratives and
reading more polite comments. They found that the tone pathways of information. Scientific evidence and practical
of the reader comments made a substantial impact on vaccination information was for instance often reported
the way the readers interpreted what was in this case a by the mainstream media and then shared by the vaccine
particular technology. Anti-conspiracy arguments increased advocates and health community. Conversely, the anti-
the intention to vaccinate only if it was presented prior to establishment community shared information on natural
exposure to anti-vaccine conspiracy theories134. The effect medicine, theories related to Darwinian survival of the fittest
however, was reduced if individuals believed in anti-vaccine (i.e., vaccines weaken the human race), and the freedom
theories or perceived vaccines as dangerous. Importantly, and infringement of rights and conspiracy. They often
this study finds that once belief in anti-conspiracy theories referred to online documentaries, such as the now banned
are established, they are difficult to overturn. documentary VAXXED, discussed above.

Polarised communities: gatekeeping, information We know that online platforms tailor content feeds and
bubbles and echo chambers. Contemporary information adapt them to individual preferences. This means that
exchange depends on the media, social networks and individuals are increasingly in an information bubble that is
searchable web pages135, which is where individuals seek aligned with their own interests and beliefs138. This means
information125,136. The Internet is one of the most important that those with anti-vaxx views are automatically exposed
sources of health-related information seeking, yet finding to more material and rarely receive other perspectives
information on vaccines or facts related to anti-vaccination and those in favour of vaccines repeatedly ‘preach to the
claims is fragmented118. Few anti-vaxx sites are labelled as converted’ via a feedback loop. This results in what has
‘anti-vaccination’ but rather focus on ‘vaccine choice’118. been termed an ‘echo chamber’ where an individual’s pre-
These websites and Facebook groups are highly effective existing beliefs are persistently reinforced by likeminded
at engaging in social interaction to create a community of peers, which in turn reinforces polarised communities139.
believers in contrast to pro-vaccine websites that often
serve as a passive information repository with a complex
deluge of information137.

Vaccine deployment experts such as Larson argue that

we need to move to examining the individual, with a
focus on social networks89. Sites such as Facebook are
seen as particularly powerful platforms to seek and share
health information. This relies on community exchange
and facilitation of peer social support and networking.
Conversations on platforms and social media are often
tightly controlled by gatekeepers128. Gatekeepers of

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 21
5.6 Dialogue and polarisation not misinformation: 6. Conclusion and policy recommendations
Knowledge voids and rumours A recent DELVE report10 outlined the core factors related to
Social anthropologists who have studied vaccine anxieties vaccine development in addition to the production, supply
and uptake across multiple global contexts for decades chain, distribution and administrative issues, and they are
argue that the focus on misinformation is distracting. Or as therefore not discussed in detail here. We focus on what
Larson stated “A focus on misinformation is like cutting the we can learn from a social-behavioural response to vaccine
head off of a weed, missing the real underlying problems” deployment, with attention to learning from history, other
(personal communication). Leach and Fairhead (2007)101 vaccine deployment efforts and attention to misinformation
and Larson (2020)89 contend that public acceptance of and dialogue, in order to formulate policy recommendations.
vaccination is not the result of misinformation, but rather
an information and knowledge deficit or void. These 6.1 Dialogue and community engagement
researchers focus on how risk, trust and rumour underpin Perhaps one of the most important lessons that can be
vaccine anxieties and resistance. Importantly, this approach drawn from this literature is that a serious and well-funded
does not view parents or individuals as easily influenced COVID-19 community-based dialogue and engagement
by the ubiquitous anti-vaccination movement. Rather, strategy is essential for effective vaccine uptake.
they argue that individuals make decisions based on their
personal and local experiences and that their concerns are Open, transparent and immediate dialogue must begin
valid and need to be understood via dialogue. Leach and over vaccine deployment with the general public. The
Fairhead explain that parents make a decision about the promise of a vaccine in early or mid-2021 has brought
vaccination of their child not in relation to risk at a population high public expectations. Confusion, anger or distrust
level (as it is often presented in terms of X number of risks may emerge if expectations are not managed in relation
per 1,000 or other metrics), but rather of the health history to phasing of vaccination delivery and the timing of the
of the child, family and their personal experiences with vaccination rollout. The phasing of vaccination delivery as
institutions101. It is for this reason that personal anecdotes proposed in this report and elsewhere will only work if it is
and individual stories resonate. perceived as fair by the population. If the rationale is clear,
there is sufficient public debate, and if there is transparency
Vaccination can also take a political dimension when in decision-making and distribution, acceptance will be
international campaigns are disconnected from local and higher80.
national services, inviting suspicion101. The distrust and
boycott of polio vaccines in northern Nigeria in 2003 Debate also includes clarifying that we are operating
emerged from a longer contextual history related to the under conditions of uncertainty and what that means,
erosion of public trust and subsequent spread of rumours while developing an understanding of the percentage of
that lead to the rejection of vaccinations140. A recent election the population likely to be (and indeed required to be)
polarised the country, allowing rumours to quickly spread vaccinated is essential. Openly addressing uncertainties
that the vaccine was engineered by the West and contained about efficacy and safety, explaining which groups will
HIV, cancerous and sterilisation agents, particularly aimed have priority for which reasons must be a priority. Without
at Muslims. By January 2004 there was an alarming 30% transparently outlining the ethical principles and managing
increase in polio. The central policy recommendations expectations, vaccine deployment could be ineffective,
from this Nigerian experience were to understand first why generate distrust, and lack of adherence. Given that up to
people have concerns and fears about the vaccination 75% vaccine coverage would be required for a vaccine
and then to actively debate and discuss these concerns. with an efficacy of 80%, it is essential to manage public
Communication is therefore not passive, uni-directional, or expectations in order to clarify the fact that if vaccine
providing detailed information on a webpage, but rather a efficacy is lower or if coverage is hindered, a longer-term
dialogue that is participatory, iterative and sensitive to local hybrid situation will be required (e.g., test-trace and isolate
politics. They were also able to raise public awareness combined with face coverings, social distancing) while we
through something that was engaging by using well- live with the virus for longer period of time.
known and local musicians and in a language and type of
Enhance public debate, promote the ethical understanding
communication that resonated. They also demonstrated how
of prioritised risk groups, and provide clarity on the more
the exclusion of certain groups, such as prominent Muslim
realistic and longer time-scale of vaccination roll-out.
leaders, in the federal response to the boycott created
The promise of a vaccine in 2021 has brought high public
additional resistance. Particularly the sustained involvement
expectations. Confusion, anger or distrust may emerge
of local and community experts and leaders is essential.
if expectations are not managed in relation to phasing of

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 22
vaccination delivery and the timing of the vaccination rollout. • Work with diverse stakeholders to reach communities and
The phasing of vaccination delivery as proposed in this individuals with a history of vaccine hesitancy or exposure to
report and elsewhere will only work if it is perceived as fair misinformation
by the population. If the rationale is clear, if there is sufficient
• Messaging which is multi-language, visual and appealing
public debate, and if there is transparency in the decision-
making and distribution, acceptance will be higher.80 As • Take engagement to the places where people frequent (e.g.,
discussed previously, basic ethical principles must also be social media, religious groups) that counters well-known
upheld. The public has to agree that vaccine deployment is perceived and actual barriers to vaccination instead of
ethical and fair, which requires their engagement. They must expecting that they will only seek out official sources
also experience the transparency of any decision-making
processes in order to see how vaccine deployment is • Messaging around the timing of the supply and distribution
being developed, but also how it is adapted in response to are key, with the advice to ‘under-promise and over-deliver’
challenges or problems. Trust and confidence are enhanced being pivotal in the generation of public and political
by clarity in the form of communication of the best and most support79
up to date scientific information is deployed.
• Build on successful vaccination strategies (e.g., influenza,
childhood vaccination), of international organisations such
Dialogue and community engagement predicated on
as UNICEF or the Red Cross and Red Crescent Societies
scientific evidence, where the following elements are vital:
who have experience of communicating risk in emergency
• Balanced messaging about risks that match everyday situations
experience
We now elaborate on several of these points discussed in
• Time is required for transparent public debate to develop an the short summary below.
ethical understanding of prioritised risk groups and vaccine
Balanced messaging on personal and societal levels of
deployment
threat that match everyday experience. Individuals need
• An enhanced public understanding of the uncertainty of clear information on their personal and societal levels of
COVID-19 vaccinations, ethical principles, expected barriers, threat that is clear and balanced. A variety of countries
safety and efficacy, including expectation management have had mixed experiences with introducing mandatory
with regards to any potential changes in the response vaccinations, banning school children who have not been
due to new scientific knowledge, threats and public input, vaccinated or backlashes from public health vaccination
potential adverse effects, regularly reviewed by expert and campaigns from previous pandemics. A survey in France
independent scientists conducted around the peak of the H1N1 pandemic found
that the public rejected the mass vaccination campaign from
• Active monitoring of the public’s concerns, beliefs and
public health authorities28. The central reasons reported
debates through multiple channels
which were reported were perceived to regard over
• Active work on dialogue with the public, more than uni- alarming health messaging which aimed to increase an
directional communication and information, which is individual’s perception of the severity of risk. This danger
necessary to fill information gaps and counter misinformation and threat was not present in the individual’s daily and
transmitted via multiple channels personal experiences and thus the threat was not confirmed.
In addition to this, another central critique was that primary
• Management of expectations about the timing and roll out and local physicians were not involved in the campaign,
of the vaccine, anticipating potential supply and distribution which was pivotal in other related studies.
problems by ‘under-promising and over-delivering’ to
maintain public support Clarity on safety, efficacy and vaccination schedule.
Individuals need to know and understand that the
• Engagement in coordinated policies and communications
vaccination is effective, particularly across risk groups,
through all nations and local communities within the UK to
which remains unknown for some groups at the time of
avoid public confusion and avoidance of doubt
writing. Practical aspects such as the length of protection,
• Engagement not only in centralised government vaccination schedule, or the need for boosters must also be
communications, but also the provision of ‘tool kits’ to clear. Clarification on the safety of this vaccine is paramount
support and actively work with local authorities and given concerns and public debate surrounding rapid
communities by engaging with local stakeholders to reach development and the underrepresentation of certain groups
diverse populations in the trials47.

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 23
Move from global and national messaging to mobilising online strategies to counteract campaigns of mis- and
local communities. Previous pandemics such as H1N1 and disinformation are required. Science has been promoted
Ebola have taught us that it is essential to leverage and use in many countries as the most rational weapon against
existing structures and relationships such as local authorities, misleading information and irrational evidence. China, for
general practitioners, pharmacies and local groups89. A instance focussed on ending COVID misinformation through
recent analysis of pro- and anti-vaccination Facebook pages scientific information with the media slogan “rumours end
showed that the pro- and anti-vaccination groups operated with the wise”.
on different ‘battlefields’106. Whereas pro-vaccine groups and
pages were largely globally and nationally connected, the Government transparency and freedom of expression.
anti-vaccination pages were both globally but also locally Although it is important to counter and remove harmful
connected. Different groups also focus on different goals. misinformation, it is vital that this does not undermine
The main goal of pro-vaccine groups is to ensure that people transparency, freedom of expression and debate such as
get vaccinated, which is not engaging and rarely sufficiently challenges to the accountability of government, health
interesting to a general audience. In contrast, anti-vaccine authorities and scientists. This role remains important for
groups often focus on multiple seemingly urgent health the public but also contributes to vigorous debate and the
and safety topics which makes them more appealing to a necessary fact-checking by journalists and scientists to
large group of people who are undecided and are seeking the provision of balanced information to the public. When
information. They also engage directly with individual’s those arguing on the basis of misinformation are brought in
experiences, anxieties and daily life with anecdotal to media debates as supposed ‘balanced representation’
evidence101. In turn, this allows anti-vaccine groups to be more alongside mainstream scientists for sensation, this can
agile and responsive to diverse concerns. undermine accurate information and result in confusion. This
happened more recently in debates around herd immunity
Engage in conversation and dialogue, not reactive where a fringe group of scientists lacking evidence, a
challenges, respecting emotions. Messages that are publication track record or concrete policy advice, were
directly ‘reactive’ to a challenging a piece of propaganda given a substantial voice.
are often futile. This has the potential to create a backlash,
where a series of heavy informational and detailed Tailored dialogue. The review found that five central
exchanges are ineffective103,141. Others have argued that it is behavioural factors are related to vaccine uptake: (1)
important to take the concerns of individuals with vaccine complacency (perception of risk, severity of disease), (2)
hesitancy seriously and dispel misinformation103. In the case trust and confidence (efficacy, safety), (3) convenience
of childhood vaccinations the resistance stems from parents (barriers, access), (4) sources of information; and, (5) socio-
wishing to protect their children; legitimate concerns that demographic characteristics (e.g., education, sex, ethnicity,
need to heard and understood32. religion, past vaccination behaviour).

There are several key strategies used by the anti- Convenience: reducing barriers and leveraging existing
vaccination movement that are in stark contrast from stakeholders. It is vital to ensure that practical aspects are
neutral, rational and often complex scientific messaging. considered. This includes considerations of the multiple
A stronger approach is likely to adopt the methods used locations for vaccinations such as within local physicians’
by the anti-vaccination and conspiracy movement. This offices, schools, or pharmacies to counter inequalities in
is centring stories on anecdotes which are personal and access. This includes transportation and the ability to reach
often highly-emotional narratives. This could be in the form vaccination sites, or compensation or concessions for time
of an ‘uneventful’ vaccination where nothing happened to off of work. Documentation barriers need to be lowered,
provide security. A powerful and often used narrative is the with problems when a card is required. Covered elsewhere
‘conversion’ of an anti-vaxx to pro-vaccination ideology. in the DELVE report10 and recent National Academies report11
Examples of cases include previously anti-vaxx parents in the United States, is the issue of ensuring that the supply
whose child was saved from a tetanus shot after almost distribution is both timely and appropriate. Experiences from
dying128. Common suggestions are to use prominent H1N1 and other mass vaccination deployment shows that
influencers or local COVID-19 Vaccine Ambassadors who effective distribution systems are key for tracking distribution
can provide counselling. Finally, peer-to-peer contact and and that the supply is timely and the right amount. This
interaction has been shown to be very powerful. includes clear communication with those who produce
the vaccine, provide the inventory and monitoring and
Counteract misinformation and knowledge voids. As distribute it locally. Building upon existing infrastructures that
noted elsewhere, it is no longer enough for scientists and function well such as childhood or emergency vaccination
governments to merely clarify communication116. Active programmes or international efforts is key.

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 24
6.2 Inoculating the public against misinformation, Accountability by media companies for risks to public
accountability and enforcement health. Given that the majority of anti-vaccine misinformation
Beyond dialogue and building understanding this rapid is largely tolerated on social media and large platforms
review of the literature can also offer policy suggestions such as Facebook, Instagram and Twitter, a clear
related to misinformation. recommendation is that these companies take responsibility
by enforcing their own policies to avoid distributing COVID
Empowering the general public: spotting and reporting and health misinformation and hoaxes that endanger public
misinformation. An important practice is to promote health. One the early approaches from organisations such
media literacy and empower citizens to spot and report as the WHO was efforts to ensure that individuals were
misinformation. Governments such as Singapore and China directed to a reliable source such as the WHO, public health
not only engaged in legal and authoritative measures to or centre for disease control in their relevant country100.
stop misinformation, but called for social support from the In mid-March 2020, Google said it was committed to
community to stop rumours and battle misinformation. In removing misleading information about COVID-19 from
particular, vulnerable groups such as children or those with YouTube, Google Maps and its development platforms and
lower levels of media literacy are vital to reach. National in advertisements144.
governments and supra-national organisations have
attempted to counter infodemics by developing findable One of the strongest deterrents, however, seems to be a
platforms with correct information. The WHO Information boycott of social media companies by a powerful alliance
Network for Epidemics (EPI-WIN) was set up early in of major advertisers, such as Unilever and Mars, who
the COVID pandemic with the aim of using a series of boycotted all advertisements until Facebook and YouTube
amplifiers to share tailored information with specific target agreed to remove harmful content145. The companies had
groups100. The WHO also launched a chatbot on Facebook long protested their advertisements placed alongside
Messenger142 and a health alert on WhatsApp143. conspiracy, anti-vaxx and other harmful content. In early
April 2020, Twitter noted that it would check whether
Reliable COVID-19 sources include: accounts were credible sources of information and
monitor conversations to ensure that keyword searches for
• The COVID-19 Poynter Resources from the International
COVID-19 would lead to reliable information146.
Fact-Checking Network (IFCN) coordinated by
the United Nations: https://www.poynter.org/
Many conspiracy theories have been widely spread by
coronavirusfactsalliance/
the well-known QAnon, which has produced many viral
• WHO Mythbusters site: https://www.who.int/ conspiracy theories including Pizzagate147 and those
emergencies/diseases/novel-coronavirus-2019/advice- focussing on accusing liberal Hollywood actors and US
for-public/myth-busters Democratic politicians. Thousands of QAnon-affiliated
accounts were banned by Twitter in July 2020, who then
• Google COVID-19 warnings which includes general
allegedly changed the algorithm to reduce the spread of
information (if location services are not disabled, the
their messages148. Facebook also moved to restrict and
latest locally-optimised health information): https://www.
remove QAnon activity as part of its crackdown on extremist
google.com/covid19/
conspiracy theories in the summer of 2020, which included
• The province of Québec for instance prepared a site for millions of users spanning 790 groups and 300 hashtags
the public to use online fact-checking services called the across Facebook and Instagram149. Others such as YouTube
Détecteur de Rumeurs (Rumour Detector), http://www. and Amazon eventually removed conspiracy films such as
scientifique-en-chef.gouv.qc.ca/en/dossiers/chercheurs- Plandemic, but only after they were watched by millions98.
et-sphere-publique/detecteur-de-rumeurs/) Facebook is now also actively countering misinformation
• The WHO offers a site that contains the links of how about itself as an organisation in response to the Netflix
to report misinformation for the largest media sites; documentary ‘A Social Dilemma’, where it clarifies that they
https://www.who.int/campaigns/connecting-the-world-to- are taking steps to reduce content that drives polarisation
combat-coronavirus/how-to-report-misinformation-online and fight fake news, misinformation and harmful content.
They note that in the second quarter of 2020, they removed
over 94% of hate speech before it was reported150.

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 25
Bring in legislation and enforce criminal prosecutions Learning from history, international examples and past
for spreading misinformation. Several countries have pandemics. This review of the broad scientific literature
clearly defined information that is harmful and a threat to found several commonalties across history, past pandemics
public health. A study of the three Asian countries (China, and potentials to learn from other nations. Anti-vaccination
Singapore and South Korea), evaluating 5,000 news articles movements in the 19th Century share many communalities
and policy responses revealed several main strategies to with contemporary debates; anti-vaccination messages
counter COVID-19 misinformation151. A prominent strategy from experts, religious leaders, and key media sources
was clear legislation and punishment of those who since the 1960s (e.g., against pertussis, measles) have been
produced and disseminated false information. The actual associated with a drop in uptake and subsequent spread
prosecutions were then shared regularly and prominently of viruses. Uptake for the H1N1 2009 - 2010 vaccine was
with the public in addition to persistent reminders of laws markedly lower than anticipated, attributed to problems
that could be used to prosecute those guilty of spreading in the timing of supply and communications. Uptake was
misinformation. Singapore, for instance has the Protection higher when previously successful programmes were
from Online Falsehoods and Manipulation Act (POFMA), used, such as school vaccination clinics. Countries such
with four prominent cases within the first months of the as Singapore and South Korea have actively worked to
COVID-19 outbreak. POFMA also lifted any exemptions debunk rumours through coordinated action151. This included
for internet intermediaries which legally required social disseminating FAQs with experts, government officials and
media companies like Google, Facebook, Twitter and Baidu health authorities. In Singapore, five ministries joined to
to immediately correct cases of misinformation on their create correction of information and advisories via diverse
platforms151. platforms such as targeted digital advertisements at the local
level in neighbourhoods, and Facebook, Instagram pages
Monitoring nefarious misinformation spread by local belonging to government ministries and officials and push
and foreign actors. As many national governments, the channels in WhatsApp.
European Commission has adopted the monitoring of false
or misleading narratives by foreign actors. In their published
strategy to tacking coronavirus disinformation, they contend
that ‘foreign actors and certain third countries, in particular
Russia and China, have engaged in targeted influence
operations and disinformation campaigns in the EU, its
neighbourhood, and globally’152. As discussed previously,
others have linked anti-vaxx information to organised bots
and activities targeted at particular populations, which
remains an area of concern115.

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 26
Appendix 1. Childhood DTP and Hepatitis B vaccination uptake, selected countries 2000-2019

FIGU R E A1 .1 F IG UR E A1. 2

Percentage of children immunised for Diptheria, Percentage of children immunised for Hepatitis B,
Tetnus and Pertussis, Selected countries, 2000 - 2019 Selected countries, 2000 - 2019

100
100 100
100

% children immunised for Hepatitis B

% children immunised for Hepatitis B
% children immunised for DTP
% children immunised for DTP

Country
Country 8080
France
France Country
Country
9595
Germany
Germany France
France
Hungary
Hungary Germany
Germany
Italy
Italy 6060 Italy
Italy
Korea
Korea Korea
Korea
United
UnitedKingdom
Kingdom United
UnitedStates
States
9090 United
UnitedStates
States
4040

2000
2000 2005
2005 2010
2010 2015
2015 2020
2020 2000
2000 2005
2005 2010
2010 2015
2015 2020
2020
Year
Year Year
Year

Source: OECD (2020)9 Source: OECD (2020)9

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 27
Appendix 2. Data and methods

For the sections examining behavioural and socio- The literature reviewed here largely includes: systematic
demographic factors related to vaccine uptake and reviews, several quantitative attitudinal surveys, qualitative
hesitancy, there were sufficient systematic reviews and studies, historical accounts and analyses of social media.
information that could be collected and reviewed. This There is a large amount of literature in this area of research
was achieved using the main search terms in Table A2 that does not contain new research but rather editorials and
and limiting them to human studies. Given the lack of comments. These have been excluded from the current
systematic reviews on misinformation and conspiracies review. We first searched for these main search terms, paired
around vaccination, a more systematic review approach with one of each of the terms listed below in Table A2.
was adopted for that section. Using a custom-built library
which called various APIs, we included all studies that were
returned from the three leading bibliographic databases
(Scopus, PubMed and Web of Science). Due the rapid shifts
surrounding the currently COVID-19 pandemic, we also
included some pre-print and other material from prominent
databases (MedRxiv, PsyRxiv, bioRxiv, SocRiv) in addition to
some media reports and books on the topics. There was
no selection on language but the majority of the articles
are in English. We included all research designs and human
studies only.

TABLE A2

Search terms used in systematic review

Main search terms Paired by one by one with each of

'vaccine', 'vaccination', 'vaccinate', 'immunise', 'immunisation', 'attitude', 'perception', 'expectation', 'opinion', 'behav*',
'immunize', 'immunization', 'inoculate', 'inoculation', 'anti- 'misinformation', 'conspiracy'
vaccination', 'anti-vaccine', 'anti-vax', 'vaccine hesitancy',
'barriers', 'vaccine procurement', 'knowledge', 'attitude',
'perception', 'expectation', 'opinion', 'behav*', 'misinformation',
'conspiracy'

A flow diagram of the articles examined in this review including the screening, eligibility process will be provided with the
final peer-reviewed academic publication of this relevant portion of the report.

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 28
Appendix 3. Main vaccine and COVID-19 misinformation and conspiracy theories

There have been a variety of vaccine and COVID-19 related theories154 and selling bogus coronavirus cures155. These
conspiracy theories with the central ones summarised here, individuals monetise false preventative natural, traditional or
with a ‘mythbusters’ site collated by the WHO102. homeopathic treatments such as consuming large quantities
of their own medicine sold on their site, or a particular diet
No vaccine is needed since COVID-19 is a hoax. This (garlic, lemons, ginger, vitamin C, alkaline foods, a keto
theory poses that COVID-19 does not exist and is popular diet)156.
with professional conspiracy theorists such as David Icke
(notable for arguing that the world is controlled by reptilian Another common sub-narrative is that key scientists
elites) and InfoWars owner and host Alex Jones. A popular involved in advising governments stand to personally profit
film on YouTube that has been viewed millions of times is by from a COVID vaccine. One example is the alleged claim
Dr Annie Bukacek, a member of the Montana Health Board that Dr Anthony Fauci owned a protein patent that forms
who argues that COVID-19 death certificates are being part of SARS-CoV-2157. In September 2020 a claim alleged
manipulated153. that Sir Patrick Vallance, England’s Chief Scientific Advisor
who previously worked at pharmaceutical company GSK
Bill Gates and the vaccination plots. Multiple conspiracy (the company contracted to develop a COVID-19 vaccine),
theories have involved sub-plots around Bill Gates. A would profit from the COVID-19 due to shareholdings158. The
prominent video entitled ‘Plandemic’ on YouTube was government reported that this is not a conflict of interest
watched by millions of viewers before being removed by since he was not involved in the commercial decisions
YouTube and Facebook under their definition of dangerous regarding coronavirus vaccines.
misinformation. It focused on a 2015 Ted talk given by
Gates where he discussed the Ebola outbreak and warns This is in addition to a variety of other conspiracy theories
of a new pandemic which was used to claim that he knew such as that the virus is caused by 5G mobile phone
the pandemic was coming or purposely caused it. This is towers. This theory is not new and was previously alleged
linked to a supposed plot of Gates to vaccinate the world’s with other viruses and 2G-4G towers. Although it is
population. The other popular sub-narrative is that Gates biologically impossible for viruses to spread by waves or
uses vaccination programmes to implant digital microchips photons across the electromagnetic spectrum, this theory
to track and control people. This has been widely spread by did gain some traction. Within the UK the pandemic hit just
QAnon, a group discussed elsewhere within this report. as the government voiced security concerns and discussion
about the rolling out of 5G built by Chinese companies
COVID-19 vaccinations are a plot by big pharma and and became mixed with conspiracy theories about the
scientists to make money and, that natural medicine is virus. Several celebrities with very large followings (Woody
more effective. Here the focus is that evidence-based Harrelson, Anne-Marie) began sharing 5G conspiracy
conventional medicine does not work and is a plot by narratives. Other theories included that the virus could not
pharmaceutical companies and scientists to make people ill survive in hot weather, that taking hydrochloroquine has
for profit. Some of the large anti-vaxx and hoax influencers clinical benefits, or that the virus is part of a Chinese bio-
also appear to monetise their message in some cases. weapons programme.
Some sell miracle multi-purpose pills to cure or prevent
COVID (Alex Jones, Dr Marcola, NaturalNews). InfoWars
founder Alex Jones, for instance, was purported to become
very wealthy from spreading a variety of conspiracy

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 29
Appendix 4. Preparation of Report
Report prepared for the SET-C Group by Members of The Royal Society SET-C who contributed to
and commented on this report
Professor Melinda Mills FBA, MBE, University of Oxford,
Professor Peter Bruce FRS (Chair), The Royal Society
Leverhulme Centre for Demographic Science
Professor Sir Roy Anderson FMedSci FRS, Imperial College
Dr Charles Rahal (provision of API code), Dr David London
Brazel (graphics), Jiani Yan and Sofia Gieysztor (research
Professor Charles Bangham FMedSci FRS, Imperial College
assistance) University of Oxford, Leverhulme Centre for
London
Demographic Science
Professor Sir Richard Catlow FRS, The Royal Society
The committee is grateful for advice provided by experts
Professor Christopher Dye FMedSci FRS, University of
on a draft of this report including:
Oxford
Professor David Salisbury, Chatham House and Chair Professor Sir Marc Feldmann AC FAA FMedSci FRS,
of WHO Global Commission of Polio Eradication, former University of Oxford
Director of Immunisation, Department of Health
Professor Sir Colin Humphreys FREng FRS, Queen Mary
Advice provided by experts on a draft of this report during University of London
a joint British Academy, Social Science Research Council Professor Frank Kelly FRS, University of Cambridge
and the UK’s Science & Innovation Network in the USA
Professor Melinda Mills FBA, University of Oxford
Roundtable ‘Vaccination Engagement’ on 8 October 2020.
Professor Sir John Skehel FMedSci FRS, The Francis Crick
Melissa Leach (Institute of Development Studies) Institute
Heidi Larson (LSTHM) Professor Geoffrey Smith FMedSci FRS, University of
Linda Bauld (University of Edinburgh) Cambridge

Robert Breiman (Emory University) Professor Alain Townsend FRS, University of Oxford

Quassim Cassam (University of Warwick)

Maya J. Goldenberg (University of Guelph)
Sara Gorman (Critica)
Katherine Hawley (University of St. Andrews)
Will Jennings (University of Southampton)
Stephen John (University of Cambridge)
Shelley Lees (LSTHM)
Warren Pearce (University of Sheffield)
Ronit Prawer (SIN USA)
Jennifer Reich (University of Colorado Denver)
Vish Viswanath (Harvard University)
Laura Specker Sullivan (Fordham University)
Emily Vraga (University of Minnesota)

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 30
References
1. Anderson RM. 2016 The Impact of Vaccination on the Epidemiology 20. Plans-Rubió P. 2012 The vaccination coverage required to establish
of Infectious Diseases. In The Vaccine Book, pp. 3 - 31. Elsevier. herd immunity against influenza viruses. Preventive Medicine 55,
(doi:10.1016/b978-0-12-802174-3.00001-1) 72–77. (doi:10.1016/j.ypmed.2012.02.015)
2. Ehreth J. 2003 The value of vaccination: a global perspective. Vaccine 21. Anderson R et al. 2020 Reproduction number (R) and growth rate
21, 4105 - 4117. (doi:10.1016/s0264-410x(03)00377-3) (r) of the COVID-19 epidemic in the UK: methods of estimation, data
3. Ozawa S, Clark S, Portnoy A, Grewal S, Brenzel L, Walker DG. 2016 sources, causes of heterogeneity, and use as a guide in policy
Return On Investment From Childhood Immunization In Low- And formulation. Available from: https://royalsociety.org/-/media/policy/
Middle-Income Countries, 2011 - 20. Health Affairs 35, 199 - 207. projects/set-c/set-covid-19-R-estimates.pdf
(doi:10.1377/hlthaff.2015.1086) 22. Doshi P. 2020 Covid-19: Do many people have pre-existing immunity?
4. Orenstein WA, Ahmed R. 2017 Simply put: Vaccination saves lives. Proc BMJ , m3563. (doi:10.1136/bmj.m3563)
Natl Acad Sci USA 114, 4031 - 4033. (doi:10.1073/pnas.1704507114) 23. Seow J et al. 2020 Longitudinal evaluation and decline of antibody
5. Sherman SM et al. 2020 COVID-19 vaccination intention in the UK: responses in SARS-CoV-2 infection. medRxiv (doi:10.1101/2020.07.09.2
Results from the COVID-19 Vaccination Acceptability Study (CoVAccS), 0148429)
a nationally representative cross-sectional survey. (doi:10.1101/2020.08 24. Tillett RL et al. 2020 Genomic evidence for reinfection with SARS-
.13.20174045) CoV-2: a case study. The Lancet Infectious Diseases (doi:10.1016/s1473-
6. AP-NORC. 2020 Expectations for a COVID-19 Vaccine. Available from: 3099(20)30764-7)
https://apnorc.org/projects/expectations-for-a-covid-19-vaccine/. 25. Welsh RM, Selin LK. 2002 No one is naive: the significance of
7. Poland GA. 2010 The 2009 - 2010 influenza pandemic: effects on heterologous T-cell immunity. Nat Rev Immunol 2, 417 - 426.
pandemic and seasonal vaccine uptake and lessons learned for (doi:10.1038/nri820).
seasonal vaccination campaigns. Vaccine 28, D3 - D13. (doi:10.1016/j. 26. Greenbaum JA et al. 2009 Pre-existing immunity against swine-origin
vaccine.2010.08.024) H1N1 influenza viruses in the general human population. Proceedings
8. Poland GA, Jacobson RM. 2011 The Age-Old Struggle against of the National Academy of Sciences 106, 20365–20370. (doi:10.1073/
the Antivaccinationists. N Engl J Med 364, 97 - 99. (doi:10.1056/ pnas.0911580106)
nejmp1010594) 27. D’Ancona F, D’Amario C, Maraglino F, Rezza G, Iannazzo S. 2019
9. OECD Stat. 2020 Health Care Utilisation: Immunisation. Available The law on compulsory vaccination in Italy: an update 2 years
from: https://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT after the introduction. Eurosurveillance 24. (doi:10.2807/1560-7917.
(accessed: 29th September 2020) es.2019.24.26.1900371)

10. DELVE. 2020 SARS-CoV-2 vaccine development & implementation; 28. Schwarzinger M, Flicoteaux R, Cortarenoda S, Obadia Y, Moatti J-P.
scenarios, options, key decisions. Available from: https://rs-delve. 2010 Low Acceptability of A/H1N1 Pandemic Vaccination in French
github.io/reports/2020/10/01/covid19-vaccination-report.html Adult Population: Did Public Health Policy Fuel Public Dissonance?
PLoS ONE 5, e10199. (doi:10.1371/journal.pone.0010199)
11. 2020 Framework for Equitable Allocation of COVID-19 Vaccine.
National Academies Press. (doi:10.17226/25917) 29. Larson HJ, Jarrett C, Eckersberger E, Smith DMD, Paterson P. 2014
Understanding vaccine hesitancy around vaccines and vaccination
12. WHO. 2019 More than 140,000 die from measles as cases surge
from a global perspective: A systematic review of published literature,
worldwide. Available from: https://www.who.int/news/item/05-12-2019-
2007 - 2012. Vaccine 32, 2150 - 2159. (doi:10.1016/j.vaccine.2014.01.081)
more-than-140-000-die-from-measles-as-cases-surge-worldwide
30. WHO. 2014 Report on the SAGE working group on vaccine hesitancy.
13. Vaccine Knowledge Project. 2020 Pertussis (Whooping Cough).
Available from: https://www.who.int/immunization/sage/meetings/2014/
Available from: https://vk.ovg.ox.ac.uk/vk/pertussis-whooping-cough
october/1_Report_WORKING_GROUP_vaccine_hesitancy_final.pdf
(accessed: 12th October 2020)
31. de Figueiredo A, Simas C, Karafillakis E, Paterson P, Larson HJ. 2020
14. Public Health England. 2019 Laboratory confirmed cases of pertussis in
Mapping global trends in vaccine confidence and investigating barriers
England. Available from: https://www.gov.uk/government/publications/
to vaccine uptake: a large-scale retrospective temporal modelling
pertussis-laboratory-confirmed-cases-reported-in-england-2019
study. The Lancet 396, 898 - 908. (doi:10.1016/s0140-6736(20)31558-0)
15. Public Health England. 2015 Human Papillomavirus (HPV) Vaccine
32. Reich JA. Calling the Shots: Why Parents Reject Vaccines. New York
Coverage in England, 2008/09 to 2013/14: A review of the full six
University Press; 2016
years of the three-dose schedule. Available from: https://www.gov.uk/
government/publications/human-papillomavirus-hpv-immunisation- 33. Tucker Edmonds BM, Coleman J, Armstrong K, Shea JA. 2010 Risk
programme-review-2008-to-2014 Perceptions, Worry, or Distrust: What Drives Pregnant Women’s
Decisions to Accept the H1N1 Vaccine? Matern Child Health J 15,
16. Zhou F et al. 2014 Economic Evaluation of the Routine Childhood
1203 - 1209. (doi:10.1007/s10995-010-0693-5)
Immunization Program in the United States, 2009. PEDIATRICS 133,
577 - 585. (doi:10.1542/peds.2013-0698) 34. Li S, Sim S-C, Lee L, Pollack HJ, Wyatt LC, Trinh-Shevrin C, Pong P,
Kwon SC. 2017 Hepatitis B Screening & Vaccination Behaviors in a
17. Ozawa S, Clark S, Portnoy A, Grewal S, Brenzel L, Walker DG. 2016
Community-based Sample of Chinese & Korean Americans in New
Return On Investment From Childhood Immunization In Low- And
York City. am j health behav 41, 204 - 214. (doi:10.5993/ajhb.41.2.12)
Middle-Income Countries, 2011 - 20. Health Affairs 35, 199 - 207.
(doi:10.1377/hlthaff.2015.1086) 35. Hanley SJB, Yoshioka E, Ito Y, Kishi R. 2015 HPV vaccination crisis in
Japan. The Lancet 385, 2571. (doi:10.1016/s0140-6736(15)61152-7)
18. Andre FE et al. 2008 Vaccination greatly reduces disease, disability,
death and inequality worldwide. Bull. World Health Organ 86, 140 - 146. 36. Yufika A et al. 2020 Parents’ hesitancy towards vaccination in
Indonesia: A cross-sectional study in Indonesia. Vaccine 38,
19. Anderson RM, May RM. Infectious Diseases of Humans: Dynamics and
2592 - 2599. (doi:10.1016/j.vaccine.2020.01.072)
Control. Oxford University Press; 1991.

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 31
37. Wolf MS et al. 2020 Awareness, Attitudes, and Actions Related to 57. Maurer J, Uscher-Pines L, Harris KM. 2010 Perceived seriousness
COVID-19 Among Adults With Chronic Conditions at the Onset of the of seasonal and A(H1N1) influenzas, attitudes toward vaccination,
U.S. Outbreak. Annals of Internal Medicine 173, 100 - 109. (doi:10.7326/ and vaccine uptake among U.S. adults: Does the source of
m20-1239) information matter? Preventive Medicine 51, 185 - 187. (doi:10.1016/j.
38. 2020 Long COVID: let patients help define long-lasting COVID ypmed.2010.05.008)
symptoms. Nature 586, 170 - 170. (doi:10.1038/d41586-020-02796-2) 58. Rachiotis G, Mouchtouri VA, Kremastinou J, Gourgoulianis K,
39. Hidiroglu S, Ay P, Topuzoglu A, Kalafat C, Karavus M. 2010 Resistance Hadjichristodoulou C. 2010 Low acceptance of vaccination against
to vaccination: The attitudes and practices of primary healthcare the 2009 pandemic influenza A(H1N1) among healthcare workers in
workers confronting the H1N1 pandemic. Vaccine 28, 8120 - 8124. Greece. Euro Surveill. 15, 19486
(doi:10.1016/j.vaccine.2010.09.104) 59. Uscher-Pines L, Maurer J, Harris KM. 2011 Racial and Ethnic
40. Myers LB, Goodwin R. 2011 Determinants of adults’ intention Disparities in Uptake and Location of Vaccination for 2009 - H1N1 and
to vaccinate against pandemic swine flu. BMC Public Health 11. Seasonal Influenza. Am J Public Health 101, 1252 - 1255. (doi:10.2105/
(doi:10.1186/1471-2458-11-15) ajph.2011.300133)

41. Seale H, Heywood AE, McLaws M-L, Ward KF, Lowbridge CP, Van 60. Meleo-Erwin Z, Basch C, MacLean SA, Scheibner C, Cadorett V. 2017
D, MacIntyre CR. 2010 Why do I need it? I am not at risk! Public “To each his own”: Discussions of vaccine decision-making in top
perceptions towards the pandemic (H1N1) 2009 vaccine. BMC Infect parenting blogs. Human Vaccines & Immunotherapeutics 13,
Dis 10. (doi:10.1186/1471-2334-10-99) 1895 - 1901. (doi:10.1080/21645515.2017.1321182)

42. Bish A, Yardley L, Nicoll A, Michie S. 2011 Factors associated with 61. Jolley D, Douglas KM. 2014 The Effects of Anti-Vaccine Conspiracy
uptake of vaccination against pandemic influenza: A systematic review. Theories on Vaccination Intentions. PLoS ONE 9, e89177. (doi:10.1371/
Vaccine 29, 6472 - 6484. (doi:10.1016/j.vaccine.2011.06.107) journal.pone.0089177)

43. Kwon Y, Cho H-Y, Lee Y-K, Bae G-R, Lee S-G. 2010 Relationship 62. Qian M, Chou S-Y, Lai EK. 2020 Confirmatory bias in health decisions:
between intention of novel influenza A (H1N1) vaccination and Evidence from the MMR-autism controversy. Journal of Health
vaccination coverage rate. Vaccine 29, 161 - 165. (doi:10.1016/j. Economics 70, 102284. (doi:10.1016/j.jhealeco.2019.102284)
vaccine.2010.10.063) 63. Lovari A, Martino V, Righetti N. 2020 Blurred Shots: Investigating the
44. Thorlund K, Dron L, Park J, Hsu G, Forrest JI, Mills EJ. 2020 A real-time Information Crisis Around Vaccination in Italy. American Behavioral
dashboard of clinical trials for COVID-19. The Lancet Digital Health 2, Scientist, 000276422091024. (doi:10.1177/0002764220910245)
e286 - e287. (doi:10.1016/s2589-7500(20)30086-8) 64. Dowd JB, Andriano L, Brazel DM, Rotondi V, Block P, Ding X, Liu Y, Mills
45. Rigby J. 2020 Speed of coronavirus vaccine race ‘crazy’ and unsafe, MC. 2020 Demographic science aids in understanding the spread and
scientists warn. The Telegraph. Available from: https://www.telegraph. fatality rates of COVID-19. Proc Natl Acad Sci USA 117, 9696 - 9698.
co.uk/global-health/science-and-disease/speed-coronavirus-vaccine- (doi:10.1073/pnas.2004911117)
race-crazy-unsafe-scientists-warn/ 65. Nguyen-Van-Tam JS et al. 2010 Risk factors for hospitalisation and
46. Callaway E. 2020 Russia’s fast-track coronavirus vaccine draws poor outcome with pandemic A/H1N1 influenza: United Kingdom first
outrage over safety. Nature 584, 334 - 335. (doi:10.1038/d41586-020- wave (May-September 2009). Thorax 65, 645 - 651
02386-2) 66. Sachedina N, Donaldson LJ. 2010 Paediatric mortality related to
47. Graham BS. 2020 Rapid COVID-19 vaccine development. Science pandemic influenza A H1N1 infection in England: an observational
368, 945 - 946. (doi:10.1126/science.abb8923) population-based study. The Lancet 376, 1846 - 1852. (doi:10.1016/
s0140-6736(10)61195-6)
48. Offit PA. The Cutter Incident: How America’s First Polio Vaccine Led
to the Growing Vaccine Crisis. R.R. Donnelley & Sons; 2005 67. Wong LP, Sam I-C. 2010 Factors influencing the uptake of 2009
H1N1 influenza vaccine in a multiethnic Asian population. Vaccine 28,
49. Sencer DJ, Millar JD. 2006 Reflections on the 1976 Swine Flu
4499 - 4505. (doi:10.1016/j.vaccine.2010.04.043)
Vaccination Program. Emerg. Infect. Dis. 12, 23 - 28. (doi:10.3201/
eid1201.051007) 68. Fabry P, Gagneur A, Pasquier J-C. 2011 Determinants of A (H1N1)
vaccination: Cross-sectional study in a population of pregnant women
50. Doshi P. 2018 Pandemrix vaccine: why was the public not told of early
in Quebec. Vaccine 29, 1824 - 1829. (doi:10.1016/j.vaccine.2010.12.109)
warning signs? BMJ, k3948. (doi:10.1136/bmj.k3948)
69. Williamson EJ et al. 2020 Factors associated with COVID-19-related
51. Miller E, Andrews N, Stellitano L, Stowe J, Winstone AM, Shneerson
death using OpenSAFELY. Nature 584, 430 - 436. (doi:10.1038/s41586-
J, Verity C. 2013 Risk of narcolepsy in children and young people
020-2521-4)
receiving AS03 adjuvanted pandemic A/H1N1 2009 influenza vaccine:
retrospective analysis. BMJ 346, f794 - f794. (doi:10.1136/bmj.f794) 70. Oliver D. 2020 David Oliver: Let’s be open and honest about covid-19
deaths in care homes. BMJ, m2334. (doi:10.1136/bmj.m2334)
52. Roberts L. 2019 Polio eradication program faces hard choices as
endgame strategy falters. Science (doi:10.1126/science.aba7189) 71. Aldridge RW et al. 2020 Black, Asian and Minority Ethnic groups
in England are at increased risk of death from COVID-19: indirect
53. Chastain DB, Osae SP, Henao-Martínez AF, Franco-Paredes C,
standardisation of NHS mortality data. Wellcome Open Res 5, 88.
Chastain JS, Young HN. 2020 Racial Disproportionality in Covid
(doi:10.12688/wellcomeopenres.15922.2)
Clinical Trials. N Engl J Med 383, e59. (doi:10.1056/nejmp2021971)
72. ONS. 2020 Coronavirus (COVID-19) related deaths by
54. Washington HA. Medical Apartheid: The Dark History of Medical
occupation, England and Wales Coronavirus (COVID-19)
Experimentation on Black Americans from Colonial Times to the
related deaths by occupation, England and Wales: deaths
Present. Doubleday; 2007
registered between 9 March and 25 May 2020. Available
55. CDC. 2011 Final estimates for 2009 - 10 Seasonal Influenza and from: https://www.ons.gov.uk/peoplepopulationandcommunity/
Influenza A (H1N1) 2009 Monovalent Vaccination Coverage - United healthandsocialcare/causesofdeath/bulletins/
States, August 2009 through May, 2010. Available from: https://www. coronaviruscovid19relateddeathsbyoccupationenglandandwales/
cdc.gov/flu/fluvaxview/coverage_0910estimates.htm deathsregisteredbetween9marchand25may2020
56. Jung M, Lin L, Viswanath K. 2013 Associations between health 73. Mackay, B. 2003 And the winner of the vaccine is... CMAJ 169, 460
communication behaviors, neighborhood social capital, vaccine
knowledge, and parents’ H1N1 vaccination of their children. Vaccine 31,
4860 - 4866. (doi:10.1016/j.vaccine.2013.07.068)

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 32
74. Emanuel EJ et al. 2020 Fair Allocation of Scarce Medical Resources 93. Eggertson L. 2010 Lancet retracts 12-year-old article linking autism
in the Time of Covid-19. N Engl J Med 382, 2049 - 2055. (doi:10.1056/ to MMR vaccines. Canadian Medical Association Journal 182,
nejmsb2005114) E199 - E200. (doi:10.1503/cmaj.109-3179)
75. Department of Health & Social Care. 2020 Priority groups for 94. Godlee F. 2011 The fraud behind the MMR scare. BMJ 342, d22 - d22.
coronavirus (COVID-19) vaccination: advice from the JCVI, 25 (doi:10.1136/bmj.d22)
September 2020. Available from: https://www.gov.uk/government/ 95. Deer B. 2011 How the vaccine crisis was meant to make money. BMJ
publications/priority-groups-for-coronavirus-covid-19-vaccination- 342, c5258 - c5258. (doi:10.1136/bmj.c5258)
advice-from-the-jcvi-25-september-2020
96. Deer B. The Doctor Who Fooled the World: Science, Deception, and
76. Verhagen MD, Brazel DM, Dowd JB, Kashnitsky I, Mills MC. 2020 the War on Vaccines. Scribe Publications; 2020
Forecasting spatial, socioeconomic and demographic variation in
97. Opel DJ, Diekema DS, Marcuse EK. 2011 Assuring research integrity in
COVID-19 health care demand in England and Wales. BMC Med 18.
the wake of Wakefield. BMJ 342, d2 - d2. (doi:10.1136/bmj.d2)
(doi:10.1186/s12916-020-01646-2)
98. Brueck H. 2019 Amazon Has Removed a Misleading Documentary on
77. Gross A, Cameron-Chileshe J. 2020 Less than half UK population
Vaccines, And It’s About Time. ScienceAlert. Available from: https://
to receive coronavirus vaccine, says task force head. The Financial
www.sciencealert.com/amazon-just-removed-the-sham-science-
Times. Available from: https://www.ft.com/content/d2e00128-7889-
documentary-called-vaxxed
4d5d-84a3-43e51355a751
99. Rothkopf DJ. 2003 When the Buzz Bites Back. The Washington
78. The Economist. 2020 Vaccine programme: Ready, steady, jab.
Post. Available from: https://www.washingtonpost.com/archive/
The Economist 27. Available from: https://www.economist.com/
opinions/2003/05/11/when-the-buzz-bites-back/bc8cd84f-cab6-4648-
britain/2020/10/07/britain-prepares-to-roll-out-a-covid-19-vaccine
bf58-0277261af6cd/
79. US Government Accountability Office. 2011 Influenza Pandemic:
100. Zarocostas J. 2020 How to fight an infodemic. The Lancet 395, 676.
Lessons from the H1N1 pandemic should be incorporated into future
(doi:10.1016/s0140-6736(20)30461-x)
planning. Report to Congressional Requesters. Available from: https://
www.gao.gov/new.items/d11632.pdf 101. Leach M, Fairhead J. Vaccine anxieties: Global science, child healthy
and society. Earthscan; 2007
80. Insitute of Medicine. 2010 The 2009 H1N1 Influenza Vaccination
Campaign. National Academies Press. (doi:10.17226/12992) 102. WHO. 2020 Coronavirus disease (COVID-19) advice for the public:
Mythbusters. Advice for the Public. Available from: https://www.who.int/
81. Salisbury D. 2020 If you’re pinning your hopes on a Covid vaccine,
emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-
here’s a dose of realism. The Guardian. Available from: https://
busters (accessed: 28 September 2020)
www.theguardian.com/commentisfree/2020/oct/21/covid-vaccine-
immunisation-protection 103. Berman JM. Anti-vaxxers: How to challenge a misinformed movement.
The MIT Press; 2020.
82. Public Health England. 2020 Seasonal flu vaccine uptake in GP
patients: winter 2019 to 2020. Available from: https://www.gov.uk/ 104. Smith N, Graham T. 2017 Mapping the anti-vaccination movement on
government/statistics/seasonal-flu-vaccine-uptake-in-gp-patients- Facebook. Information, Communication & Society 22, 1310 - 1327. (doi:1
winter-2019-to-2020 0.1080/1369118x.2017.1418406)

83. Public Health England. 2020 Seasonal flu vaccine uptake in healthcare 105. Park B, Choi EJ, Park B, Han H, Cho SJ, Choi HJ, Lee S, Park H.
workers: winter 2019 to 2020. Available from: https://www.gov.uk/ 2018 Factors Influencing Vaccination in Korea: Findings From Focus
government/statistics/seasonal-flu-vaccine-uptake-in-healthcare- Group Interviews. J Prev Med Public Health 51, 173 - 180. (doi:10.3961/
workers-winter-2019-to-2020 jpmph.18.063)

84. Wolfe RM. 2002 Anti-vaccinationists past and present. BMJ 325, 106. Johnson NF et al. 2020 The online competition between pro- and
430 - 432. (doi:10.1136/bmj.325.7361.430) anti-vaccination views. Nature 582, 230 - 233. (doi:10.1038/s41586-
020-2281-1)
85. Porter D, Porter R. 1988 The politics of prevention: Anti-vaccinationism
and public health in nineteenth-century England. Med. Hist. 32, 107. Brown, B. 2020 Trump Twitter Archive. Website Archive. Available
231–252. (doi:10.1017/s0025727300048225) from: http://www.trumptwitterarchive.com/.

86. Nelson MC, Rogers J. 1992 The Right to Die? Anti-vaccination Activity 108. Gauchat G. 2012 Politicization of Science in the Public Sphere. Am
and the 1874 Smallpox Epidemic in Stockholm. Soc Hist Med 5, Sociol Rev 77, 167 - 187. (doi:10.1177/0003122412438225)
369–388. (doi:10.1093/shm/5.3.369) 109. Motta M, Callaghan T, Sylvester S. 2018 Knowing less but presuming
87. Kaufman M. 1967 The American anti-vaccinationists and their more: Dunning-Kruger effects and the endorsement of anti-vaccine
arguments. Bull. Hist. Med. 41, 463 - 78 policy attitudes. Social Science & Medicine 211, 274 - 281. (doi:10.1016/j.
socscimed.2018.06.032)
88. Durbach N. 2005 Bodily Matters. Duke University Press.
(doi:10.1215/9780822386506) 110. Featherstone JD, Bell RA, Ruiz JB. 2019 Relationship of people’s
sources of health information and political ideology with acceptance
89. Larson HJ. 20Stuck: How vaccine rumors start - and why they don’t go
of conspiratorial beliefs about vaccines. Vaccine 37, 2993 - 2997.
away. Oxford University Press; 2020
(doi:10.1016/j.vaccine.2019.04.063)
90. Gangarosa E, Galazka A, Wolfe C, Phillips L, Miller E, Chen R,
111. Freeman D et al. 2020 Coronavirus conspiracy beliefs, mistrust, and
Gangarosa R. 1998 Impact of anti-vaccine movements on pertussis
compliance with government guidelines in England. Psychol. Med. ,
control: the untold story. The Lancet 351, 356 - 361. (doi:10.1016/s0140-
1–13. (doi:10.1017/s0033291720001890)
6736(97)04334-1)
112. Jennings W et al. 2020 Political Trust and the COVID-19 Crisis.
91. PHLS. 1982 Efficacy of pertussis vaccination in England. Report from
Available from: https://www.ipsos.com/sites/default/files/ct/news/
the PHLS Epidemiological Research Laboratory and 21 area health
documents/2020-08/covid_and_trust.pdf
authorities. BMJ 285, 357 - 359. (doi:10.1136/bmj.285.6338.357)
113. Jamison AM, Broniatowski DA, Dredze M, Wood-Doughty Z, Khan
92. Murch SH et al. 2004 Retraction of an interpretation. The Lancet 363,
D, Quinn SC. 2020 Vaccine-related advertising in the Facebook Ad
750. (doi:10.1016/s0140-6736(04)15715-2)
Archive. Vaccine 38, 512 - 520. (doi:10.1016/j.vaccine.2019.10.066)

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 33
114. Walter D, Ophir Y, Jamieson KH. 2020 Russian Twitter Accounts and 132. Volz KG, Hertwig R. 2016 Emotions and Decisions. Perspect Psychol Sci
the Partisan Polarization of Vaccine Discourse, 2015 - 2017. Am J Public 11, 101 - 116. (doi:10.1177/1745691615619608)
Health 110, 718 - 724. (doi:10.2105/ajph.2019.305564) 133. Anderson AA, Brossard D, Scheufele DA, Xenos MA, Ladwig P. 2013
115. Broniatowski DA, Jamison AM, Qi S, AlKulaib L, Chen T, Benton A, The “Nasty Effect:” Online Incivility and Risk Perceptions of Emerging
Quinn SC, Dredze M. 2018 Weaponized Health Communication: Twitter Technologies. J Comput-Mediat Comm 19, 373 - 387. (doi:10.1111/
Bots and Russian Trolls Amplify the Vaccine Debate. Am J Public jcc4.12009)
Health 108, 1378 - 1384. (doi:10.2105/ajph.2018.304567) 134. Jolley D, Douglas KM. 2017 Prevention is better than cure: Addressing
116. Iyengar S, Massey DS. 2018 Scientific communication in a post- anti-vaccine conspiracy theories. J Appl Soc Psychol 47, 459 - 469.
truth society. Proc Natl Acad Sci USA 116, 7656 - 7661. (doi:10.1073/ (doi:10.1111/jasp.12453)
pnas.1805868115) 135. Wolfe RM. 2002 Content and Design Attributes of Antivaccination Web
117. Carey JM, Chi V, Flynn DJ, Nyhan B, Zeitzoff T. 2020 The effects Sites. JAMA 287, 3245. (doi:10.1001/jama.287.24.3245)
of corrective information about disease epidemics and outbreaks: 136. Dannetun E, Tegnell A, Hermansson G, Giesecke J. 2005 Parents’
Evidence from Zika and yellow fever in Brazil. Sci. Adv. 6, eaaw7449. reported reasons for avoiding MMR vaccination. Scandinavian Journal
(doi:10.1126/sciadv.aaw7449) of Primary Health Care 23, 149 - 153. (doi:10.1080/02813430510031306)
118. Kata A. 2012 Anti-vaccine activists, Web 2.0, and the postmodern 137. Grant L, Hausman BL, Cashion M, Lucchesi N, Patel K, Roberts J. 2015
paradigm – An overview of tactics and tropes used online by the Vaccination Persuasion Online: A Qualitative Study of Two Provaccine
anti-vaccination movement. Vaccine 30, 3778 - 3789. (doi:10.1016/j. and Two Vaccine-Skeptical Websites. J Med Internet Res 17, e133.
vaccine.2011.11.112) (doi:10.2196/jmir.4153)
119. Ellis R, Jennedy D. 2020 Kate Shemirani: antivax leader is banned 138. Pariser E. The filter bubble: how the new personalized web is changing
nurse who fears 5G network. The Times. Available from: https://www. what we read and how we think. Penguin Press; 2012
thetimes.co.uk/article/suspended-nurse-kate-shemirani-becomes-new-
139. Barberá P, Jost JT, Nagler J, Tucker JA, Bonneau R. 2015
face-of-anti-vax-movement-3dr27ftcw
Tweeting From Left to Right. Psychol Sci 26, 1531 - 1542.
120. Clifton, K. 2020 Trafalgar Square protest: Hundreds of anti-vaxxers (doi:10.1177/0956797615594620)
and coronavirus sceptics gather in central London. Evening Standard.
140. Jegede AS. 2007 What Led to the Nigerian Boycott of the Polio
Available from: https://www.standard.co.uk/news/london/trafalgar-
Vaccination Campaign? PLoS Med 4, e73. (doi:10.1371/journal.
square-protest-london-coronavirus-a4551266.html
pmed.0040073)
121. Oreskes N, Conway EM. Merchants of Doubt. How a handful of
141. Lutkenhaus RO, Jansz J, Bouman MPA. 2019 Mapping the Dutch
scientists obscured the truth on issues from tobacco smoke to global
vaccination debate on Twitter: Identifying communities, narratives, and
warming. Bloomsbury Press; 2010
interactions. Vaccine: X 1, 100019. (doi:10.1016/j.jvacx.2019.100019)
122. Jolley D, Douglas KM. 2014 The Effects of Anti-Vaccine Conspiracy
142. WHO. 2020 WHO launches a chatbot on Facebook Messenger to
Theories on Vaccination Intentions. PLoS ONE 9, e89177. (doi:10.1371/
combat COVID-19 misinformation. Available from: https://www.who.int/
journal.pone.0089177)
news-room/feature-stories/detail/who-launches-a-chatbot-powered-
123. Hviid A, Hansen JV, Frisch M, Melbye M. 2019 Measles, Mumps, facebook-messenger-to-combat-covid-19-misinformation
Rubella Vaccination and Autism. Ann Intern Med 170, 513. (doi:10.7326/
143. WhatsApp. 2020 The World Health Organization launches WHO Health
m18-2101)
Alert on WhatsApp. Available from: https://www.who.int/news-room/
124. Gaither JR, Shabanova V, Leventhal JM. 2018 US National Trends in feature-stories/detail/who-health-alert-brings-covid-19-facts-to-billions-
Pediatric Deaths From Prescription and Illicit Opioids, 1999-2016. JAMA via-whatsapp
Netw Open 1, e186558. (doi:10.1001/jamanetworkopen.2018.6558)
144. Google. 2020 COVID-19: How we’re continuing to help. Company
125. Bessi A, Coletto M, Davidescu GA, Scala A, Caldarelli G, Quattrociocchi Announcements. Available from: https://blog.google/inside-google/
W. 2015 Science vs Conspiracy: Collective Narratives in the Age company-announcements/covid-19-how-were-continuing-to-help/
of Misinformation. PLoS ONE 10, e0118093. (doi:10.1371/journal.
145. Barker A, Murphy H. 2020 Advertisers strike deal with Facebook and
pone.0118093)
YouTube on harmful content. The Financial Times. Available from:
126. Jacobson RM, Targonski PV, Poland GA. 2007 A taxonomy of ft.com/content/d7957f86-760b-468b-88ec-aead6a558902
reasoning flaws in the anti-vaccine movement. Vaccine 25, 3146 - 3152.
146. Twitter Inc. 2020 Coronavirus: Staying safe and informed on Twitter.
(doi:10.1016/j.vaccine.2007.01.046)
Available from: https://blog.twitter.com/en_us/topics/company/2020/
127. Schaeffer, K. 2020 Nearly three-in-ten Americans believe COVID-19 covid-19.html
was made in a lab. Pew Research Center. Available from: https://www.
147. Greenspan RE. 2020 QAnon conspiracy theorists have been linked
pewresearch.org/fact-tank/2020/04/08/nearly-three-in-ten-americans-
to a killing and multiple armed stand-offs. Here are the criminal
believe-covid-19-was-made-in-a-lab/
allegations connected to the movement and its followers. Insider.
128. Shelby A, Ernst K. 2013 Story and science. Human Vaccines & Available from: https://www.insider.com/qanon-violence-crime-
Immunotherapeutics 9, 1795 - 1801. (doi:10.4161/hv.24828) conspiracy-theory-us-allegation-arrest-killing-gun-2020-8
129. Tomljenovic H, Bubic A, Erceg N. 2019 It just doesn’t feel right – the 148. Conger K. 2020 Twitter Takedown Targets QAnon Accounts. New
relevance of emotions and intuition for parental vaccine conspiracy York Times. Available from: https://www.nytimes.com/2020/07/21/
beliefs and vaccination uptake. Psychology & Health 35, 538 - 554. (doi technology/twitter-bans-qanon-accounts.html
:10.1080/08870446.2019.1673894)
149. Seetharaman, D. 2020 Facebook removes QAnon groups as it
130. Betsch C, Renkewitz F, Betsch T, Ulshöfer C. 2010 The Influence of expands anti-violence policy. The Wall Street Journal. Available from:
Vaccine-critical Websites on Perceiving Vaccination Risks. J Health https://www.wsj.com/articles/facebook-removes-qanon-groups-as-it-
Psychol 15, 446 - 455. (doi:10.1177/1359105309353647) expands-anti-violence-policy-11597869178
131. Ubel PA, Jepson C, Baron J. 2001 The Inclusion of Patient Testimonials 150. Facebook. 2020 What ‘The Social Dilemma’ Gets Wrong. Available
in Decision Aids. Med Decis Making 21, 60 - 68. (doi:10.1177/027298 from: https://about.fb.com/wp-content/uploads/2020/10/What-The-
9x0102100108) Social-Dilemma-Gets-Wrong.pdf

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 34
151. Nekmat E, Yue A. 2020 How to fight the COVID-19 infodemic: lessons
from 3 Asian countries. World Economic Forum. Available from:
https://www.weforum.org/agenda/2020/05/how-to-fight-the-covid-19-
infodemic-lessons-from-3-asian-countries/
152. European Commission. 2020 Tackling COVID-19 disinformation:
Getting the facts right. Available from: https://ec.europa.eu/info/sites/
info/files/communication-tackling-covid-19-disinformation-getting-facts-
right_en.pdf
153. Dickson EJ. 2020 Anti-vax doctor promotes conspiracy theory that
death certificates falsely cite COVID-19. Rolling Stone. Available from:
https://www.rollingstone.com/culture/culture-features/anti-vax-doctor-
covid-19-death-certificates-984407/
154. Williamson E, Steel E. 2018 Conspiracy theories made Alex Jones very
rich. They may bring him down. New York Times. Available from: https://
www.nytimes.com/2018/09/07/us/politics/alex-jones-business-infowars-
conspiracy.html
155. Marantz A. Alex Jones’s bogus coronavirus cures. The New Yorker.
Available from: https://www.newyorker.com/magazine/2020/04/06/
alex-jones-bogus-coronavirus-cures
156. Ibitoye T. 2020 Coronavirus: there are no miracle foods or diets that
can prevent or cure COVID-19. The Conversation. Available from:
https://theconversation.com/coronavirus-there-are-no-miracle-foods-or-
diets-that-can-prevent-or-cure-covid-19-136666
157. Funke D. 2020 Conspiracy theorist spreads false claim about Fauci,
patents and COVID-19. PolitiFact. Available from: https://www.politifact.
com/factchecks/2020/may/12/jerome-corsi/conspiracy-theorist-
spreads-false-claim-about-fauc/
158. Hymas D, Walsh G. 2020 Revealed: Sir Patrick Vallance has £600,000
shareholding in firm contracted to develop vaccines. The Telegraph.
Available from: https://www.telegraph.co.uk/news/2020/09/23/
revealed-sir-patrick-vallance-has-600000-shareholding-firm-
contracted/

DISCLAIMER
This paper has drawn on the most recent evidence as of 21 October 2020 and has been subject to formal peer-review. Further evidence on this topic
is constantly published and the Royal Society and British Academy may return to this topic in the future. This independent overview of the science has
been provided in good faith by experts and the Royal Society and British Academy and paper authors who accept no legal liability for decisions made
based on this evidence.

THANKS
The Royal Society is grateful to the Leverhulme Trust for its support for the Society’s pandemic response work and for support to the Leverhulme Centre
for Demographic Science.

The text of this work is licensed under the terms of the Creative Commons Attribution License which permits unrestricted use, provided the original
author and source are credited. The license is available at: creativecommons.org/licenses/by/4.0
Issued: October 2020 DES7210 © The Royal Society

COVID-19 VACCINE DEPLOYMENT: BEHAVIOUR, ETHICS, MISINFORMATION AND POLICY STRATEGIES • 21 OCTOBER 2020 35
Yalçin et al. BMC Public Health (2020) 20:1087
https://doi.org/10.1186/s12889-020-09184-5

RESEARCH ARTICLE Open Access

Unvaccinated children as community

parasites in National Qualitative Study from
Turkey
Sıddıka Songül Yalçin1,2* , Ayça Gelgeç Bakacak3 and Osman Topaç4

Abstract
Background: This national qualitative study explores (1) the experiences, observations, and opinions of health care
workers (HCWs) about beliefs, socioeconomic, cultural, and environmental characteristics of parents refusing
vaccination and (2) regional differences in the identified risk factors; (3) recommended solutions to improve vaccine
acceptance in each of 12 regions in Turkey.
Methods: In total, we carried out 14 individual semi-structured in-depth interviews and 10 focus group discussions
with 163 HCWs from 36 provinces. A thematic analysis was performed to explore HCWs’ observations about the
parents’ decisions to reject vaccination and possible solutions for vaccine advocacy.
Results: Within the analyzed data framework, vaccine refusal statements could be defined as vaccine safety, the
necessity of vaccines, assumptions of freedom of choice, health workers’ vaccine hesitancy, lack of information
about national vaccination schedule and components, not trusting the health system, anti-vaccine publications in
social media and newspapers, and refugees. Suggestions based on the HCWs suggestions can be summarized as
interventions including (1) creating visual cards with scientific data on vaccine content and disease prevention and
using them in counseling patients, (2) writing the vaccine components in a way understandable to ordinary people,
(3) highlighting the national quality control and production in the vaccine box and labels, (4) conducting interviews
with community opinion leaders, (5) training anti-vaccine HCWs with insufficient scientific knowledge and (6)
reducing the tax of parents whose children are fully and punctually vaccinated.
Conclusions: The solution to vaccine rejection begins with the right approaches to vaccination during pregnancy.
Prepared written and visual information notes should present the information as “vaccination acceptance” rather
than “vaccination refusal”. Further studies on vaccine refusal rates should be carried out in various regions of the
world so that region-specific actions are implemented to decrease the anti-vaxxer movement and to prevent an
outbreak of infectious diseases.
Keywords: Vaccine refusal, Migrants, National vaccine schedule, Dunning-kruger effects, Qualitative

* Correspondence: [email protected]; [email protected]

1
Unit of Social Pediatrics, Department of Pediatrics, Faculty of Medicine,
Hacettepe University, Ankara, Turkey
2
Department of Vaccine Studies, Vaccine Institute, Hacettepe University,
Ankara, Turkey
Full list of author information is available at the end of the article

© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article's Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
Yalçin et al. BMC Public Health (2020) 20:1087 Page 2 of 17

Background specific causes of hesitation/rejection. Turkey is an area

Vaccination is the right of the child as well as a necessity connecting Asia and Europe and including Anatolia, an
for social life [1]. In recent years, outbreaks of vaccine- area with a high-density population with people of dif-
preventable diseases have been seen due to increased ferent ethnic backgrounds, including refugees. The per-
vaccine rejection and hesitation [2, 3]. The parental centages of children aged 24–35 months who did not
vaccination decision is known to be complex and multi- receive any childhood vaccination were 8% in Syrian ref-
dimensional, being influenced by past experiences, infor- ugees and 3.4% in Turkish nationals domestic people,
mation sources including peers/family, emotions, routine according to the TDHS-2018 [19, 20]. Declining
ways of thinking with risk perceptions, trusting the immunization uptake has been reported in many Euro-
health personnel, and decision-making processes [4–6]. pean countries [21, 22]. Identifying the reasons and bar-
Some factors leading to vaccine refusal may be the same riers for vaccine rejection in Anatolia will also help to
all over the world, such as lack of time, inappropriate create universal solution packages in Europe and the
behaviors of staff, poor awareness, and fear of adverse world. Qualitative studies are needed in order to show
events [4, 7–11]. Previous studies have proposed some show multifactorial interactions.
interventions to overcome vaccine hesitancy, such as Given the increasing refusal rates seen in the national
parental counseling, improving access to vaccines, im- childhood vaccination program in Turkey in recent
plementation of free vaccines, maximizing child health years, a qualitative study was carried out in health care
supervision, offering combination vaccines, using elec- workers (HCWs) (a) to find out the beliefs, socioeco-
tronic medical records, and reminder phone calls to nomic, cultural and environmental risk factors of parents
families [10, 11]. However, Turkey’s health care system having a role in vaccine refusal in all 12 NUTS (Nomen-
has some differences to those of other countries. Firstly, clature of Territorial Units for Statistics) regions in
the national vaccination calendar is applied free of Turkey; (b) to examine whether identified risk factors
charge to every child. Therefore, the cost of vaccination vary in different regions; (c) to compile the proposed so-
is not a reason for missing vaccination. Secondly, family lutions for the identified risks.
physicians (FP) and their midwives/nurses (family health
nurse, FHN) regularly call and remind the family who Method
does not attend the vaccination appointment on time An interview guide (Table 1) was prepared with a litera-
[12]. Thirdly, as most of the family health units are situ- ture review [22, 23]. The data collection began in Sep-
ated so that they are easily reachable by the families, tember 2017 and ended in June 2018. Ten focus group
there is no transportation problem. Moreover, the im- discussions (FGDs) with 163 HCWs and 14 individual
plementation of the national vaccination schedule for in- semi-structured in-depth interviews were performed.
fants is an important criterion that is considered when Overall, 36 from 81 provinces were enrolled for the
evaluating the FPs’ work performance, and in case of de- study.
layed vaccination, a deduction is made from the salary of
the FP [13]. In such cases, a missing/incomplete vaccin- Study team
ation report explaining the reasons for the vaccine rejec- The study team consisted of one social pediatrician
tion is prepared by the FP, signed by the parents, and (SSY), one sociologist (AGB), and the Head of the De-
notified to the Ministry of Health (MoH). The MoH partment of Vaccine-Preventable Diseases (OT). OT
Vaccination Department examines the report of vaccine identified the regions and family health units having vac-
rejection and tries to convince the family by phone. The cine rejection problems and provided the necessary ar-
salary deduction of the FP is reimbursed if there is no rangements for the participation of FPs and FHNs
negligence. Despite these implementations, an increase working in these units for FGDs. SSY and AGB were not
in cases of vaccine refusal has been observed in recent associated with the health care institutions where the
years in Turkey [14, 15]. The prevalence of unvaccinated study was conducted. SSY and AGB conducted all FGDs,
children aged 15–26 months increased from 1.6 to 2.9% together. Authority officials did not attend the meetings.
between the Turkish Demographic Health Surveys
(TDHS) of 2008 and 2013 [16, 17]. The ratio in the east Study participants
of Turkey increased from 2.8 to 3.8%; however, the ratio The study participants of FGDs were HCWs who were
in the western region went up from 1.6 to 4.7% during responsible for the vaccine applications, such as Vaccin-
the same period. ation Follow-up or Evaluation Officer at the Unit for
Previously, it has been stated that pro-vaccine activism Vaccine Programs of the Department of Public Health
should understand the views and behaviors of the par- Services in the Provincial Health Directorate (Provincial
ents who do not vaccinate their children [18]. Vaccine Vaccination Officers), in addition to FPs and FHNs. The
acceptance can be improved by identifying the region- board members of expert associations (infectious
Yalçin et al. BMC Public Health (2020) 20:1087 Page 3 of 17

Table 1 Outline of the interview and thematic queries

Topic Thematic Queries
Necessity of vaccine What do you think about the necessity for vaccination of children in terms of individual and
public health?
Causes of vaccine hesitancy What are your opinions on the main reasons for the hesitation/refusal of vaccine applications
within the national childhood vaccination schedule?
General characteristics of families who report What can you say about the general characteristics of families with vaccine hesitancy/refusal
vaccine hesitancy and the barriers to case management?
Freedom of choice Should the family have a choice to vaccinate? How can you evaluate this in the context of
child and public health? Why?
The National Health System Are there national health system-related problems in childhood vaccination? If so, what are
these? How can these problems be solved?
Suggestions about how to solve the problem How can family physicians and family health workers prevent cases of vaccine rejection?
What can be done to resolve vaccine rejection cases in your area?

diseases, family physicians, social pediatricians), aca- Survey periods

demics, and staff responsible for provincial vaccine ap- Phase 1
plications were attended to individual semi-structured In Ankara on September 21–22, 2017, two FGDs were
in-depth interviews. The purposeful sampling technique carried out with provincial vaccination officers who had
with intensity strategy [24], based on the refuser rate of high provincial vaccine refusal rates or those who had
the family health unit in the provinces, was applied. The limited vaccine refusal cases but wished to express their
study included family health units with at least five anti- opinions. We carried out two FGDs with 15 vaccination
vaxxer families or the highest rate in selected provinces officers from 12 provinces and 21 vaccination officers
and districts. FPs and FHNs from these family health from 16 provinces. Then, in-depth interviews were car-
units were invited for FGDs. ried out with three academics and six board members
The sample size was reached on the basis of thematic from associations of infectious diseases, and pediatri-
saturation when all the authors concluded that further cians or FPs from six provinces on September 23–30
interviews were unlikely to provide any new information (Fig. 1).
by evaluating the frequency of new codes with subse- These interviews revealed that most families who
quent interviews in each NUTS region. rejected the vaccination did not respond to the phone
calls from HCWs or other staff from the health care fa-
Ethics approval cility of the government. Also, such families did not con-
The study instrument and methodology were reviewed sent to one-to-one meetings with the professionals
and approved by the Ethical Board of Hacettepe Univer- designated to these families or even with professionals
sity and the Turkish Public Health Institute. not associated with their family health unit. Provincial
Before participating in the study, participants gave vaccination officers reported that these parents only
written informed consent after having been informed contacted the FPs and FHNs when their children be-
about the aim of the study, voluntary participation came ill. It was additionally reported that some families
without any imposed obligation, and using a tape to who were hesitant to vaccinate their children were open
record the interview. People who agreed to tke part to discussion, but they resisted vaccination because of
in the “In-depth Interviews” and FGDs were asked to the information they had received from the anti-
fill out a “Data Protection Form” confirming that vaccination groups. The FHN was generally found to
their data would be kept limited to the primary re- have the best insight into the structure and dynamics of
search only. Their personal information and experi- the families. In the light of obtained information, we
ence sharing would be anonymized and remain planned the next FGDs with both FPs and FHNs in se-
confidential. lected districts who had families with vaccine refusal,
The interviews were conducted in an open and non- seeking to identify their problematic families.
judgmental manner, akin to empathic neutrality. In face-
to-face interviews, participants were asked to give them- Phase II
selves a pseudonym containing the names of the districts We evaluated the most densely-populated provinces for
they came from (such as the blonde from Meram; the further interviews. Firstly, we carried out in-depth inter-
hard-working man from Mamak), and they expressed views with provincial vaccine officers in Ankara (Octo-
themselves under these pseudonyms during the ber 3, 2017), İstanbul (October 6, 2017), and Konya
interviews. (March 27, 2018). Later, we held two FGDs in each city.
Yalçin et al. BMC Public Health (2020) 20:1087 Page 4 of 17

Fig. 1 Survey design flowchart

One was performed with FPs and the other with FHNs. 2018). Then, two FGDs were conducted with central dis-
Thereby, we conducted two separate FGDs with 12 FPs tricts and nearby cities. We conducted the first FGD
and 15 FHNs from five districts (Pursaklar, Keçiören, with 15 FHNs working in six central districts of Diyarba-
Etimesgut, Yenimahalle, Sincan) in Ankara. We carried kır, including Sur, Silvan, Kayapınar, Yenişehir, Gaziler,
out two more separate FGDs with 18 FHNs and 13 FPs and Ergani. We carried out the second FGD with 20
from eight districts (Bağcılar, Sultangazi, Arnavutköy, FHNs from districts that had the most extensive vaccin-
Gazi Osman Paşa, Ümraniye, Küçükçekmece, Başakşehir ation problem in five provinces including Elazığ, Bat-
ve Fatih) in Istanbul. In Konya, 15 FHNs and 14 FPs man, Muş, Bingöl, Adıyaman (Fig. 1).
from three different districts, including Meram, Selçuklu,
and Karatay, joined the morning and afternoon sessions, Data analysis
respectively (Fig. 1). One author (AGB) audio-taped and transcribed the in-
terviews and FGDs verbatim. Then, two authors (AGB
Phase III and SSY) checked data quality. The data analysis was
We carried out two in-depth interviews with the Officer conducted using thematic analysis techniques on paper
of Vaccination Programs and public health specialists in [25]: First, data was organized by going back to the
the Provincial Health Directorate in Diyarbakır (June 4, interview guide, identifying the questions, and then
Yalçin et al. BMC Public Health (2020) 20:1087 Page 5 of 17

organizing the data in response to each research ques- believing some vaccines to be unnecessary because the
tion. The second step involved each of the authors inde- diseases they protect against have been eliminated
pendently analyzing the transcripts and the concepts (Table 3).
relating to each research question. Third, the concepts
were coded into categories. Finally, the categories identi- Vaccine safety
fied were grouped into overarching themes that an- Vaccine safety was mentioned as a reason for vaccine re-
swered the research objectives. The authors had fusal by 30 of 36 provinces; however, the reasons given
subsequent meetings to discuss and agree on the process for the lack of safety differed according to provinces and
of data analysis and the reporting of the final themes; regions (Table 3). HCWs mentioned that families object
that is, they followed a process of external validation of to multiple antigen loading, resulting in vaccine hesi-
the categories and themes. The analysis was guided by tancy. Concerns about the vaccine additives were
the SAGE Working Group on Vaccine Hesitancy report highlighted as a reason for vaccination rejection both in
and a comprehensive literature review [22, 23, 26], based educated families and in families adopting the Islamic
on The Vaccine Confidence Project. religion and sect lifestyles (Table 2). These data were
collected from HCWs in 11 NUTS regions (Table 3).
Results It was stated that some families in six NUTS regions
Among the participants of FGDs, 95% of FHNs, 30% of had no confidence in vaccination because of their belief
FPs, and 80% of provincial vaccination officers were fe- that vaccines might be the cause behind several diseases,
male, and between 26 and 52 years old. Eleven of 14 par- including autism and malignancy (Table 2). The age at
ticipants of the in-depth interviews were male. In both admission of a child with subacute sclerosing panence-
FGDs and in-depth interviews, the HCWs stated that phalitis (SPSS) coincided with measles vaccination at
“parents having vaccine refusal” have become a problem primary school age, prompting the family to believe that
in Turkey over the last 10 years. Almost all staff believed the vaccine caused this illness. On the other hand, it was
in the necessity of vaccination. thought that the risk of exposing health problems in
children who are vaccinated were greater than in chil-
“Unvaccinated children are ‘community parasites’ dren who are not vaccinated due to the substances in
and are protected by vaccinated children. But in an the vaccine. Additionally, it was suggested that the vac-
outbreak, they will get sick first.” (expert, Ankara). cine injected into the body makes children more suscep-
tible for many diseases in later years (Table 3).
“Unvaccinated child resemble a bomb: whenever it Families that particularly embrace the strict normative
explodes, epidemics occur, and it takes those who Islamic lifestyle or who are a dedicated follower of a cult
have immunodeficiency and chronic illness. As the in seven NUTS regions were reported to refuse vaccin-
numbers of vaccine refusals increase, so does their ation, stating that the vaccines come from abroad and
demolition power” (author, SSY). cause infertility and a change in the genetic codes of the
society (Table 2). Also, some stated that vaccines have
Within the analyzed data framework, vaccine refusal been claimed to reduce the intelligence capacity of
statements of HCWs are given in Table 2. children.
HCWs reported that some families rejected the re-
Necessity of vaccines vaccination of their children on the grounds of pur-
Of all HCWs, those from seven provinces reported that ported adverse events in connection with previous vacci-
vaccine refusals mostly occur in families that openly nations. Post-vaccination reactions including high fever,
stated that they regarded vaccines as unnecessary to pro- nausea, etc., in the immediate vicinity of the family often
tect the health of their children (Table 3). It was found resulted in rejection of vaccinations, even among the
that families with a traditional societal structure and ex- families of HCWs (Table 3).
tended family model often abstain from vaccination with
reference to their own childhood. HCWs reported that HCWs’ vaccine hesitancy and misinformation
the anti-vaxxer families asserted that being in an unvac- Another reason for families to refuse vaccination was a
cinated situation does not cause any problem, and that perceived negative approach of the health system and
illnesses help children to respond to viruses, so it makes some HCWs. Lack of scientific knowledge or misinfor-
the immune system robust (Table 2). Moreover, HCWs mation of HCWs on vaccine-preventable diseases are
in İstanbul and Mersin stated that some families do not mentioned in eight NUTS regions (Table 3). In 13 prov-
believe vaccines to have any protective qualities. In inces, the anti-vaccination attitude among some HCWs,
addition, HCWs mentioned that even some well- particularly obstetricians, is also reported to be influen-
educated families do not accept all types of vaccines, tial in causing families to refuse vaccination. During the
Table 2 Observations of the participants about the concerns of families with vaccine refusal
Topic Statements
Necessity of Vaccines
“Senior member of the family says that there was no vaccine in our youth. However, we have grown up as right as rain”.(Şanlıurfa)
“Disease is more “natural” than a vaccine.” (Şanlıurfa and Diyarbakır)
“Not all vaccines are necessary.” (Trabzon, Malatya provinces and Mediterranean region)
Vaccine Safety
Overload the immune system “Parents say the number of simultaneous vaccinations is too high and unnecessary. Therefore, the vaccine calendar must be
Yalçin et al. BMC Public Health

rearranged.”(Istanbul)
Vaccine additives “It is said that vaccines include monkey blood, mercury, and pig blood.” (Istanbul, Bolu, Düzce, Gümüşhane, Kütahya).
May make the child sick (SSPE, autism, cancer) and any adverse “Increased SSPE incidence in the region causes definite vaccine rejection in the affected families and also in other families in that
reaction after the previous vaccination region. The fact that SSPE cases are not related to vaccination is not fully explained; in 1990–2000, increased cases were linked to the
vaccine, the effects of which still continue.”(Diyarbakır)
“there is a teacher, his child got SSPE …, and he scares other teachers and families with erroneous non-scientific information, as a re-
(2020) 20:1087

sult of which both childhood and infancy vaccination rates in that district are reduced.”
“I have doubts about vaccination, too. In one family, there is a vaccinated child who has recently been diagnosed with leukemia; I
have hesitations for that reason. My child is vaccinated, but I have doubts about how much of a protective effect it has.”(nurse,
Diyarbakır)
Believing that vaccine changes genetic codes because of “As vaccines come from abroad, families think their children would be retarded if vaccinated, and they believe the countries that
additives produce vaccines do not vaccinate their own children who will take the country forward.” (Konya)
“It is said that there is pork blood in the vaccine; it’s therefore haram, and the most important fact is that it makes our children
infertile; they do not want to use any birth control either.” (Bingöl)
“It is said that you will sterilize us with the vaccines.” (Diyarbakır)
HCWs’ vaccine hesitancy and misinformation
Negative information of HCWs regarding vaccination “There’s a professor, a pediatrician, at the university. He says ‘do not vaccinate your child, a child should not be vaccinated for the first
two years of his/her life.’ Moms trust him, not me.” (İstanbul)
“In particular, negative attitudes of obstetricians to vaccines during pregnancy cause mothers to take a negative approach the
vaccination of their babies.” (Ankara)
“Obstetricians have an important role in vaccination refusal. Women safely commend themselves to doctors, and they believe that
doctors will not misdirect them. Therefore, in the light of the negative information given by obstetricians, women are not vaccinated
with tetanus diphtheria toxoids vaccine/tetanus diphtheria toxoids and acellular pertussis vaccine and even hesitate to vaccinate their
children.”(Karabük)
“Women report that their obstetricians say there is no need for vaccination and they perform all necessary initiatives during their
follow-up visits.”(İstanbul)
Self-refusal, anti-vaccine approaches among HCWs “The Ministry of Health sent an official document, saing that health workers born between 1980 and 1990 should be vaccinated. Of
them, 90% refused, I could not vaccinate them. In the case of the measles outbreak, health workers had refused vaccination. In our
field, we are aiming to achieve something in which he does not believe. The man is a health worker; however, he is not vaccinated,
and then he tells families ‘go and vaccinate your children’. Above all, those who do this work have to believe in their job.”.(Bayburt)
Distrust of some families regarding the National Health System or its components
Mistrust of government health authorities “In families who are members of some special religious orders, women avoid obstetric care, are not being given pregnancy
vaccinations, and some of them evade healthcare and vaccines by giving birth at home. Some religious groups have their own
television and radio channels, and members base their health behaviors on the information given in these channels.” (İstanbul)
“A remarkable proportion of dedicated followers of some religious orders do not trust state hospitals, they prefer to use small private
hospitals. These people are avoiding vaccination.” (Yalova)
“Local people do not trust state hospitals due to their ethnicity, and for that reason they refuse vaccination.” (Diyarbakır)
Page 6 of 17
Table 2 Observations of the participants about the concerns of families with vaccine refusal (Continued)
Topic Statements
Distrust of organized medicine and public health “Some remarkable groups are not vaccinated, and do not even benefit from any health services. They prefer alternative medicine,
giving birth at home with the help of district midwives or a labor coach. They hide their pregnancy, and they do not enter pregnancy
follow-up programs of the family health unit, because of distrust.” (Konya)
“Some families go to polyclinics belonging to their cults/groups instead of going to public health institutions; they do not trust state
programs and are not vaccinated.” (Ankara)
Distrust of foreign pharmaceutical companies “Families state that vaccines were developed by foreign states to make them infertile, so they refuse vaccines and … they do not trust
them.” (Bingöl)
Yalçin et al. BMC Public Health

“Refusal reasons indicated state that vaccines are foreign-originated, and there are unsuitable ingredients.” (Yalova, Konya)
“They refuse vaccines because vaccines are deployed as a biological weapon, and they come from abroad, so they have content which
causes genetic code change.” (Istanbul)
Insufficient control within the country “A family said … … .bring us the vaccine label, show the approval and control of Republic of Turkey … …. let the vaccine label write
the halal statement and commission approval; show me, then I will have my child vaccinated.” (Konya).
Ethical, moral or religious reasons
(2020) 20:1087

“Parents say … .. there are some substances which are not suitable for religion, administering a foreign substance to the body from
outside is not appropriate for religion, too.”(İstanbul, Bayburt, Konya)
“Parents state … … ..vaccination is a sin, forbidden by religion.”(Bolu, Trabzon)
“Families refusing vaccination mention … … .. the vaccine has been invented to disrupt the blood, and it is illicit.”(Gümüşhane,
Ankara, Bingöl)
“Cult leaders in the region do not permit their denominated families to vaccinate their children, and therefore give them anti-vaxxer
information.”(Diyarbakır, Bingöl, Konya, Ankara, İstanbul)
Social Media Consulting
“Anti-vaxxer groups share anti-vaccination conversations, stories, publications, broadcasts. Particularly, tweets sent by an eminent televi-
sion actress cause quite negative effects.”(Karabük)
“Especially media channels, bloggers, and brochures of anti-vaxxer groups cause insecurity regarding vaccine ingredients.”(Istanbul)
“There is a book that includes anti-vaxxer articles and is sold online; it is spreading fast, and information in this book popularize anti-
vaxxer views.”(İzmir)
“They read and learn something on their own and ask questions …. I could not refute their hypothesis - I could not even answer
them.” (HCWs, Ankara)
Freedom of Choice
Parents have the right to choose whether to immunize their child “It is accepted that vaccination is not mandatory due to the verdict confirming that parents have freedom of choice.” (Ankara)
“A decision of the Constitutional Court, ‘vaccine is an individual right, it does not affect public health,’ accelerated objections of
families.” (Amasya)
Refugees
“Some parents do not even know the birth date of their children, and children may be undernourished or born prematurely, so we
cannot even calculate their age.”
“We talk with parents with the help of an interpreter. We cannot get detailed histories of children, we cannot provide the necessary
information about the vaccine.”
Page 7 of 17
Table 3 Supposed Causes and Potential Solutions of Vaccine refusals by regions
Regions Supposed reasons for vaccine refusal Potential Solutions
Istanbul
Vaccine additives (pig blood and gelatin, monkey blood etc.) Initiatives to solve anti-vaccine politics of the sect or community leaders
Overload the immune system Imposing sanctions on non-vaccination families (financial penalties, inability to benefit from health dis-
Adverse reaction after previous vaccinations counts, premium punishment, inability to use family medicine system, etc.)
Vaccines do not work Prevention of anti-vaxx broadcasting through social media channels and media organs
Religious factors; specific religious lifestyle Preparation of pro-vaccination publications approved by the MoH, explaining the contents
Distrust of foreign pharmaceutical companies Training children for vaccine advocacy
Yalçin et al. BMC Public Health

Anti-vaccine groups in social media Creation of common working areas with the Presidency of Religious Affairs
Requirement for being fully vaccinated form at the school enrollment of children
West Marmara
Vaccine additives (thimerosal and aluminum) Prevention of anti-vaccine publications in the media
Possible adverse reaction after previous vaccinations Making public information spots
HCWs’ negative information about vaccination Increasing pro-vaccination campaigns and broadcast publications in social media channels
(2020) 20:1087

Anti-vaccine publications in social media and newspapers

East Marmara
Possible serious acute and long-term adverse reactions Preparing a strategy for the leaders of the congregation/cult structures, especially in the region
Specific religious lifestyle (sect); vaccine additives is harmful, forbidden by Establishment of vaccination centers to vaccinate and follow adverse events
religion Preparation of short films and public spots containing subliminal messages
Distrust of foreign pharmaceutical companies Development of an action plan with the Ministry of Education for school vaccination
Distrust of government health authorities
Anti-vaccine groups in social media
West Black Sea
Harmful vaccine additives Informing the public about the vaccination and vaccine content by written and visual publications
May make the child sick (autism, SSPE and cancer) Preventing non-scientific publications
Parental right to choose whether or not to immunize their child Specific Provision of legal regulations (inability to benefit from payments for Social Security Institution, no coverage
religious lifestyle and beliefs about vaccine and additives of health expenses, increasing premium payments)
Anti-vaccine groups in social media Raising awareness of mothers about vaccines; Use of message systems such as SMS, MMS and social
Problematic health literacy media tools such as twitter, instagram, facebook
Anti-vaccine publications in social media and newspapers Adding a training program on the management of vaccine refusal to the curricula of HCWs
To ensure the participation of the district imams in persuasion visits
East Black Sea
Vaccine additives (pig blood and gelatine) Bringing legal obligations to families who do not allow their children to be vaccinated
Belief that vaccine changes genetic code
Doubting the need for some vaccines
Anti-vaccination attitudes of some religions
Negative attitudes of obstetricians about vaccination
Anti-vaccine publications in social media and newspapers
Northeast Anatolia
May make the child sick (autism, SSPE and cancer) Collaboration with the Presidency of Religious Affairs in solving vaccination problems
Serious acute adverse reactions Ensuring the employment of health personnel who know the region and know their problems, reducing
Religious beliefs about vaccine additives short-term appointments
Lack of information among some health workers
Problems in the structure of the national health system
Distrust of HCWs
Page 8 of 17
Table 3 Supposed Causes and Potential Solutions of Vaccine refusals by regions (Continued)
Regions Supposed reasons for vaccine refusal Potential Solutions
Distrust of foreign pharmaceutical companies
Anti-vaccine publications in social media and newspapers
West Anatolia
Anti-vaccine opinions of sect leader: Vaccine additives are not appropriate to Providing counseling services for cases with vaccine adverse events and vaccine hesitancy and rejection
religion. Believing that vaccine changes genetic code and causes infertility Establishment of operational committees to assess families who refuse vaccination and to develop
Parental right to choose whether or not to immunize their child strategies to ensure persuasion,
Potential for long-term adverse events Providing postgraduate training to ensure consensus among physicians,
Yalçin et al. BMC Public Health

Belief that vaccines are unnecessary Health personnel should be fully informed about the vaccines they apply and should use standard
Lack of required information on vaccine efficacy and ingredients among HCWs informative brochures about the benefits of the vaccine,
Negative attitudes of obstetricians about vaccination Providing positive publications about vaccines in the national vaccination schedule on the media, using
Distrust of HCWs or government health authorities public spots,
Distrust of foreign pharmaceutical companies Labelling vaccine boxes to indicate that the vaccine has been controlled by MoH and is halal.
Anti-vaccine publications in social media
(2020) 20:1087

Central Anatolia
May make the child sick (autism, SSPE and cancer) Health personnel should be fully informed about the vaccines they apply,
Serious acute adverse reactions Public spots
Belief that vaccine changes genetic code or causes infertility because of vaccine
additives
Religious beliefs about immunization
Misinformation about vaccine by health workers
Distrust of foreign pharmaceutical companies
Central East Anatolia
Belief that vaccine changes genetic code or causes infertility Ensuring that all HCWs are properly informed about the vaccines and their contents,
Vaccine additives Revision of the curricula of pre-graduate education of health personnel,
Serious acute adverse reactions Use of correct communication techniques in the community (some rejections can be prevented through
May make the child sick (autism, SSPE and cancer) giving “fatwa” in the region)
Not all vaccines are necessary Giving vaccine information during pregnancy follow-up
Parental right to choose whether or not to immunize their child Information via mobile phones
Specific religious life (sect) and religious opinions More attention should be paid to the application of cold chains to the area
Some HCWs’ inadequate knowledge about vaccine Transition to oral vaccines instead of parenteral vaccines
Distrust of health workers or government health authorities Accelerating the production of domestic vaccines
Distrust of foreign pharmaceutical companies Explaining that the decrease in infant mortality rates in the region is related to vaccination
Anti-vaccine publications in social media
Southeast Anatolia
May make the child sick (autism, SSPE and cancer) Adding vaccine application to the positive performance criteria of family physicians
Belief that vaccine changes genetic code or causes infertility Publishing the scientific information to counteract false information
Serious acute adverse reactions Correct information about the causes of SSPE cases in the region
Vaccine additives Establishing vaccine information channel between obstetricians and family health workers.
Not believing that vaccine-preventable diseases can be serious. Development of legal measures against non-vaccination families; e.g., withdrawal of health insurance
Disease is more “natural” than vaccine cover, penal arrangements to be made in premium payments, direct fines, interruption of financial support
Specific religious life, religious beliefs; sin of individuals receiving conditional cash transfers,
Some HCWs’ misinformation about vaccine
Parental right to choose whether or not to immunize their child
Distrust of foreign pharmaceutical companies
Page 9 of 17
Table 3 Supposed Causes and Potential Solutions of Vaccine refusals by regions (Continued)
Regions Supposed reasons for vaccine refusal Potential Solutions
Mediterranean
Belief that vaccine changes genetic code or causes infertility Preparing cards, brochures, magazines and books about the vaccines and their contents for public use
Serious acute adverse reactions
Vaccines do not work
Vaccine-preventable diseases have disappeared
Anti-vaccine publications in social media
Aegean
Yalçin et al. BMC Public Health

Belief that vaccine changes genetic code or causes infertility Working with sociologists and social workers to determine a solution within the framework of regional
Vaccine additives considered not appropriate to religion features
Specific religious life (sect) Preparing cards, brochures, magazines and books about the vaccines and their contents for public use
Some HCWs’ misinformation about vaccines Blocking access to anti-vaccine websites
Distrust to health workers or government health authorities Legal regulations
Anti-vaccine publications in social media
(2020) 20:1087
Page 10 of 17
Yalçin et al. BMC Public Health (2020) 20:1087 Page 11 of 17

course of interviews, it was noted that some HCWs were opinions expressed on social media and the existence of
not vaccinated; therefore, families who discovered this anti-vaxxer groups and bloggers cause harmful effects
are not vaccinating their children (Table 2). on families (Table 3).

Distrust of some families in the National Health System or Freedom of choice

its components According to the statements of HCWs, most families
Another factor that led to the rejection of vaccines was a who refuse vaccination refer to their right to freedom of
lack of confidence in the functioning health system in a choice (Table 3). They expressed the opinion that
wide spectrum. Some families generally distrust the Na- HCWs have no right to vaccinate the child, on the basis
tional Health System, while others do not believe in the of personal rights and freedoms. Two main views from
necessity of modern medicine. They feel insecure about two different lifestyles are reported on this issue: (1)
the implemented health programs. Therefore, they give Some parents practising certain religious or sectarian
birth at home, consult with practitioners of alternative lifestyles say that parents know what is good for their
medicine, and even refuse the heel lance in some dis- children. (2) Some educated families argue that families
tricts (Table 2). HCWs in four NUTS regions reported have the right to choose whether or not to vaccinate
that parents who belong to certain ethnic groups or have their children (Table 2). Previously, a court decided that
a cult-lifestyle distrust not only vaccination but also any the national vaccine schedule could only be applied with
other programs implemented by the MoH (Table 3). the parents’ consent [27]. HCWs emphasize that parents
They also observed that such families prefer private hos- refuse vaccines by saying that they are the decision-
pitals or doctors with a similar cult-lifestyle. Further- making authority for their children under the court
more, HCWs stress that these families also distrust legal order.
public schools and other practices.
HCWs in seven NUTS regions reported vaccine re-
Refugees
fusals due to distrust of multinational pharmaceutical
HCWs have been reported that refugees rely on and
companies (Table 3). Based on the HCWs’ experience,
benefit from free vaccination and health services of
parents distrust vaccines produced abroad, and the fact
Turkey. However, their children may miss vaccines due
that there is no vaccine produced by the government is
to a lack of specific residential address. The high birth-
considered a reason for vaccine rejection.
rate in refugees and loss of the vaccination card by par-
It was also mentioned that families who think that vac-
ents may also reduce the possibility of the family
cines from abroad are unsafe also believe that vaccines
providing accurate health information about their chil-
are not controlled sufficiently by health service pro-
dren. Furthermore, the absence of a child identification
viders. Some families are reported to demand the control
number and birth certificate creates a problem in plan-
and approval of vaccine ingredients by national author-
ning and monitoring the vaccination of the child. Also,
ities. Some even want to see vaccine labels marked “cer-
they stress that different languages, communication
tified halal”.
problems and cultural characteristics are among the ob-
stacles to updating vaccinations in refugees (Table 2).
Ethical, moral or religious reasons
HCWs reported that some families in 20 provinces re-
fuse vaccination for religious reasons. There were reli- Health workers’ suggestions for solving the problem
gious concerns about vaccine ingredients in 11 NUTS Precautions suggested to manage the anti-vaccination
regions and refusals on the basis of discouragement from movement differed according to both refusal reasons
a cult-leader or due to a conservative-religious lifestyle and studied regions, as shown in Table 3.
in seven NUTS regions (Table 3). Most of these reasons
are categorized as faith-based (Table 2). Discussion
In line with previous studies [4, 6, 7, 28], vaccine refusal
Social media consulting reasons given by HCPs are summarized as vaccine safety,
All the FGDs revealed that many social media channels lack of necessity for vaccination, assumptions of freedom
include anti-vaxxer contents (Table 2). Some families of choice, health workers’ vaccine hesitancy and lack of
that have access to these channels were reported to state information about vaccination in the national vaccine
vaccine refusal. All interviews revealed that many nega- schedule, not trusting the national health system, and
tive experiences of allegedly vaccination-related symp- anti-vaccine publications in social media and newspa-
toms including convulsions, paralysis and allergies are pers. All these reasons can be rectified through vaccine
widely circulated through written and visual media, as literacy. Biasio [29] considered vaccine literacy as a tool
well as social media. Based on these interviews, negative mediating the transfer of information.
Yalçin et al. BMC Public Health (2020) 20:1087 Page 12 of 17

As documented in other societies [4, 7, 21, 30], the Wilson et al. also reported the importance of healthcare
concept of vaccine refusal and hesitancy is evident at dif- professionals’ views on maternal vaccination and the in-
ferent educational levels, within all socioeconomic clas- fluence of patient-health care professional relationships
ses and all ethnic origins, in our survey from Turkey. On on maternal vaccination acceptance [41]. It can be spec-
the other hand, factors affecting this emerging public ulated that a mother who is vaccinated during pregnancy
health issue vary according to the commonality. Per- will better follow her own child’s vaccination schedule.
ceived risks for vaccine-preventable disease and fear of Pre-graduate and post-graduate curricula should in-
vaccination-induced adverse events have also been found clude routine vaccination schedules with some add-
in other countries [31, 32]. In addition, vaccine distrust itional material regarding the importance and necessity
is not only an isolated issue but also associated with the of vaccines. Curriculum contents should also highlight
preference for alternative medicine and science rejection the drawbacks of not being vaccinated and its the impact
in other healthcare fields. Previous literature also men- on society. Emphasis on vaccine advocacy should be pro-
tioned adherence to complementary medicine, differ- found, stressing additionally the effects of vaccine refusal
ences in the usage of other medicines, and the on public health (Table 3). FPs and FHNs should also
application of topical fluoride, in association with vac- learn communication skills to manage problematic
cine hesitancy [33–35]. parents.
It is known that pregnant women often hesitate to vac-
cinate and want to discuss vaccine eligibility [36]. In line “Negative terminology results in confusion, it is bet-
with our survey, Danchin et al. [37] showed that vaccine ter to be positive. Vaccination acceptance should be
concerns and intentions came into existence during used instead of vaccination refusal.” (SSY)
pregnancy.
Our study revealed that most HCWs believe in the That fact is crucial in terms of demonstrating that vac-
safety and necessity of vaccines. Similar to a previous re- cine rejection is clearly not unique to ordinary families
view including midwives [38], only a minority of HCWs but also practiced by some HCWs [42]. Therefore, mis-
in Turkey were unsure and reported some physicians ex- information in HCWs should be checked and corrected
pressing doubt. on the basis of current scientific data.
HCWs report that due to frequently changing work-
Knowledge and advocacy of health care workers places, the doctors have reduced chances of recognizing
One critical factor creating parental distrust is the lack problematic families and taking appropriate measures.
of technical knowledge of some HCWs, making it diffi-
cult to answer queries and concerns about vaccination. Initiatives relating to families
A visual information file about vaccines in the national The MoH should provide a phone line valid 24/7 and a
vaccination schedule, the ingredients of the product, web page that includes current information on vaccin-
how vaccines prevent disease, possible adverse events, ation, vaccine ingredients and adverse events. Before the
and what the consequences may be if vaccination is child’s vaccination appointment, SMS messages about
abandoned, should be prepared for HCWs, especially the date of vaccination and the importance/necessity of
FHNs, to guide parents during vaccination. Similarly, vaccinations can be sent to the parents’ mobile phones.
vaccination education materials covering the topics of Providing current information to the parents weeks or
“how vaccines work, herd immunity, vaccine safety” were months before their visit can help to improve their
recommended to improve confidence and trust [39]. Un- knowledge, while also preventing them from paying at-
met information needs of parents can increase vaccine tention to false information on social media.
refusal, whereas by making them truly informed of their Centers to follow up post-vaccination adverse events
choices and the benefits of vaccination, vaccination is and to investigate the reasons for them and then to in-
advocated [21]. Increasing vaccination compliance and form families about the progress could be established.
vaccination rates of health personnel [40] will also affect Cases with suspected vaccine side effects should be
community vaccination. monitored closely. In addition, siblings of children suf-
Monitoring of the national maternal vaccination fering serious adverse events should also be vaccinated
schedule, primarily adult tetanus-diphtheria vaccination after being evaluated by skilled health personnel at the
in antenatal care, could be added to the performance cri- Provincial Vaccination Center.
teria of obstetricians, providing tax relief to the phys- It was shown that poor families who receive condi-
ician. This would increase the knowledge of tional cash transfers for a child’s health and education
obstetricians about vaccination, break down prejudices, generally have them fully immunized. Financial incen-
and play a role in increasing the acceptance of vaccin- tives, such as tax reductions, should be developed for
ation by both the doctor and the pregnant woman. families who have complete all childhood vaccinations
Yalçin et al. BMC Public Health (2020) 20:1087 Page 13 of 17

and health surveillance programs. Financial incentives institution, in pregnant women who fail to attend
could work better than financial penalties. In line with follow-up visits, and in those who reject heel blood
this, Helps et al. reported that financial penalties were screening. Since these families act in line with the opin-
not an effective policy measure for non-vaccinating fam- ion leaders, it is necessary to try to convince the leaders
ilies with an increased desire to maintain control over [50, 51]. The opinion and cult leaders should be given
health choices for their children [43]. In fact, these par- better information in order to change the negative atti-
ents were even found to accept income reductions by re- tudes on the subject, since the families in different sect-
moving children from early childhood learning and arian structures determine their own healthcare
accessing informal childcare arrangements. according to the advice of the leaders.
Mandatory vaccination can raise conflicting issues on
a parent’s right to choose what they consider is in the
Initiatives relating to refugees
best interest of their child. Effects of exercising these
A high rate of vaccine-preventable diseases has been re-
rights which should be discussed included the fact that
ported in Syrian refugees [52]. Despite non-payable pri-
the development of herd immunity in the community is
mary healthcare services and free childhood vaccinations
threatened and children cannot be protected against ser-
for refugees in Turkey, language barriers and high mo-
ious and preventable diseases [44–46]. Some HCWs rec-
bility among unregistered refugees were reported to limit
ommended the assessment of vaccination cards and
access to completion of the immunization schedule and
implementation of some limitations in school enrollment
lead to missed opportunities for health services [53].
for children with incomplete vaccination;
Previously, six FGDs with 33 mothers from Moroccan,
Turkish, and other ethnic backgrounds revealed that
“Children who are not vaccinated endanger the
parents perceived a language barrier in understanding
health of my child at school” (board member).
the provided information about the National
Immunization Program [54]. Preparing information
HCWs reported that some families rejecting vaccination
notes in their native language would help them under-
rely on complementary and alternative medicine. Similar
stand healthcare practices. On the other hand, cash
to our study, Attwell et al. observed that parents who re-
transfers are thought to play a significant role in redu-
fuse vaccination due to concerns regarding toxic and
cing health inequities and tackling the social determi-
contaminated materials viewed alternative medicine as
nants of health [55]. Transferring conditional cash to
harm-free, natural, and an effective protective strategy
refugees during childhood vaccination would be one way
for immune systems [47]. Given the epistemic basis of
to ensure that the family have their children vaccinated
some parents’ decisions, it is very important to increase
and keep their vaccination card safe. Similarly, China
confidence in vaccination using current scientific data.
employed three main health system strengthening strat-
HCWs should recognize and understand parent con-
egies to significantly improve immunization for the mi-
cerns to resolve vaccine refusal. Some HCWs suggested
grant population: first, through waivers of immunization
that “having flexibility in the vaccination schedule and
fees or immunization insurance, second, through good
more options or control over the timing of vaccinations”
management of immunization certificates, and third, by
might have encouraged families to participate in
paying extra attention to immunization for particular
decision-making and promote freedom of decision.
groups of children, including children of migrants [56].
Up-to-date and age-appropriate immunization rates for
Initiatives relating to groups that have different religious
migrant children were significantly improved by these
beliefs
strengthening strategies in the health system in China.
As discussed in previous reports [48, 49], Some muslim
parents in our survey believed vaccines are haram due to
blood or tissue contamination from pigs. Interestingly, Department of Vaccine-Preventable Diseases, MoH
the Halal Certificate for the Vaccine Industry is recom- Registration and data analysis with the national identifi-
mended by HCWs and their families. cation number of a child can prevent surveillance errors
Training sessions should be arranged especially for due to repeated rejection of vaccination for the same
personnel working in religious affairs and for Imams, in child. Follow-up of the number of cases with vaccination
order to highlight the importance of vaccines and their rejection in each family health unit can ensure early de-
impact on public health. This would help counteract tection of regional case clusters. Each year, 50–100 in-
false information regarding any non-religious substances fants were enrolled and followed up in a family health
in vaccines. unit in Turkey [12]. In this study, five cases of vaccine
It is not possible to solve the vaccination problem in rejection in a family health unit were defined as a “re-
families who do not receive any care from the health fusal outbreak”, and HCWs working at the center with
Yalçin et al. BMC Public Health (2020) 20:1087 Page 14 of 17

the refusal outbreak were selected to be called to unfounded claims and incorrect information on their
interview. social media blogs should be controlled (Table 3).
It was possible to establish “what-why” scientific data
specific to the regions of families where cases of sub- Ensuring cooperation between institutions
acute sclerosing panencephalitis (SSPE) are common. Legal regulations on childhood vaccination existed in
Vaccine packages and information notes should be Turkey until 2015. Non-vaccination was previously consid-
written so that they can be understood by the public. ered child neglect, and the MoH, the provincial
The box and inlay could indicate that the Turkish organization of the Ministry of Family, Labour and So-
MoH has inspected the vaccine and confirm that nei- cial Services, and the judicial system had worked as a team.
ther mercury nor porcine products are used as However, in 2015, a court verdict determined that the deci-
ingredients. sion for or against vaccination must be taken by the family
Families should be informed about the importance [27]. Currently, HCWs are left alone in dealing with anti-
of vaccination in all regions; however, risk manage- vaccination families, and vaccine hesitancy and refusal have
ment protocols should be created region-specifically both increased in Turkey. The joint work of the MoH, Min-
and implemented only in those regions (Table 3). istry of Education, and Ministry of Family, Labour and So-
Initiatives not related to the problems of the region cial Services should be ensured. Some legal arrangements
lead to confusion and may further increase vaccine may be required, depending on the percentage of vaccine
rejection. HCWs from the Aegean region recom- rejection and the reasons behind it. As reported previously
mend studies with sociologists and social workers to [11], immunization is a shared responsibility involving the
determine a solution within the framework of re- community, service providers, and policymakers.
gional features. West Anatolia HCWs recommend Importantly, since trust is a prerequisite for public ac-
the establishment of counseling services and senior ceptance of vaccines, mistrust of HCWs, governments,
committees for vaccination refusal management and institutions, and pharmaceutical companies emerged as
the development of strategies. Similarly, the Nigerian a significant theme, as reported previously [61]. Collab-
government has appointed consultants to provide orative studies might diminish this mistrust.
supportive supervision and technical assistance to
health facility staff for routine immunization, focus- Strengths and limitations
ing on trust building, advocacy, monitoring and This study is the first national report on vaccine refusal
evaluation [57]. in Turkey. Previous publications include surveys con-
ducted on families or doctors, covering only a few hospi-
Regulations relating to the prevention of infollution tals in one or two provinces [10, 14, 62]. Additionally,
(information pollution) on printed-visual media the populations of these studies included only families
Inadequate or problematic health literacy skills are asso- already receiving health care or presenting at hospital
ciated with increased vaccine refusal. Similarly, “over- because of a health problem. As a limitation of our
confidence”, as a type of Dunning-Kruger effect, showed study, the opinions of families about HCWs and vac-
that many individuals who lacked expertise failed to ap- cines were indirectly reported. Originally, we planned to
praise their knowledge accurately, got less support for do a study including FGDs with anti-vaxxer families.
mandatory vaccination policies, and viewed the role that Our initial interviews with experts and HCWs showed
medical professionals have in the policymaking process that families definitely rejecting vaccination do not re-
with skepticism [58]. spond to phone calls from vaccine representatives and
HCWs stress the issue of anti-vaccination posts in are not open to communication. Therefore, interviews
the media and its influence on patients. Tomeny with families on a voluntary basis would detect cases of
et al. studied trends in anti-vaccination beliefs on vaccine hesitation but would fail to show the exact fea-
Twitter for 6 years in the USA and documented anti- tures of vaccine rejection. For this reason, FPs and espe-
vaccine tweets [59]. Monitoring anti-vaccination be- cially FHNs who are responsible for the childhood
liefs on Twitter can be recommended for pediatricians national vaccination schedule and know the whole struc-
to refute anti-vaccine arguments. In line with previous ture of the families, formed our working collective. Sam-
studies [60], HCWs in our study advised the prepar- pling included family health units with a record of at
ation of public service advertisements and presenta- least five cases of vaccine rejection or those with the
tions based upon scientific publications about the highest number of vaccine rejections in that district. In
credibility and contents of childhood vaccinations. this way, the present study enabled us to observe the real
HCWs recommended legal penalties for those who reasons behind vaccine rejections. As a strength, our
publish “tabloid” news not based upon scientific arti- study examined families from different religions living in
cles. Also, they suggested that bloggers who post Turkey and the situation with regard to refugees.
Yalçin et al. BMC Public Health (2020) 20:1087 Page 15 of 17

In our study, we examined the acceptance of vaccines Authors’ contributions

provided to children free of charge as part of the na- SY, AGB provided input to the study design, undertook the data collection
and primary data analysis, supervised and refined data analysis, drafted the
tional vaccination calendar. However, payable vaccines manuscript and wrote the final manuscript. OT provided input to the study
(human papillomavirus, rotavirus, seasonal influenza) design, technical support, revised the manuscript. All authors have read and
were not included in the study. The results of our study approved the manuscript.

cannot, therefore, be generalized to private vaccination

Funding
protocols. The study focused only on childhood vaccin- This research received no specific grant from any funding agency in the
ation; however, some comments are made about preg- public, commercial or not-for-profit sectors. Transportation and accommoda-
nancy and HCW vaccination, and interrelations between tion expenses of FGDs in Konya, Diyarbakır and Istanbul were covered by
MoH. The FGD was held closed to the authorities in MoH conference halls.
them were also emphasized.
Availability of data and materials
The datasets used and/or analyzed during the current study are available
Conclusion from the corresponding author on reasonable request.
Vaccination refusal can take the form of different vac-
cination behaviors such as complete refusal, delaying Ethics approval and consent to participate
some or all of the vaccines, reducing the number of vac- Approved by the Ethical Board of Hacettepe University and the MoH Turkish
Public Health Institution. Written informed consent was obtained from all
cinations at one time, selective vaccination, or prolong- participants.
ing vaccination intervals. The findings of our study show
that the provision of sufficient information, use of cul- Consent for publication
Not applicable.
tural communication skills, trust building, and account-
ability of the HCWs can be considered the cornerstones Competing interests
to improving vaccine acceptance [6, 11, 63]. None.
Preventing vaccine rejection begins with the right ap-
Author details
proaches to vaccination during pregnancy. At least five 1
Unit of Social Pediatrics, Department of Pediatrics, Faculty of Medicine,
cases of vaccine rejection in a family health unit should be Hacettepe University, Ankara, Turkey. 2Department of Vaccine Studies,
considered a “vaccine rejection outbreak”, and thus trigger Vaccine Institute, Hacettepe University, Ankara, Turkey. 3Department of
Sociology, Hacettepe University, Ankara, Turkey. 4Ankara Health Directorate,
the evaluation of underlying reasons and initiation of re- Public Health Presidency, Ankara, Turkey.
gional measures. In the written and visual information
materials to be prepared, the focus should be always be on Received: 5 December 2019 Accepted: 30 June 2020
“vaccination acceptance” rather than “vaccination refusal”.
Key opinion-leading expert health professionals should References
highlight all the benefits of vaccines and the science behind 1. Engelhardt HT Jr. Beyond the best interests of children: four views of the
immunization on social media, blogs, and newspapers. family and of foundational disagreements regarding pediatric decision
making. J Med Philos. 2010;35(5):499–517. https://doi.org/10.1093/jmp/
Further studies on vaccine refusal rates and socio- jhq042..
cultural structures should be carried out in various re- 2. Bechini A, Boccalini S, Ninci A, Zanobini P, Sartor G, Bonaccorsi G, Grazzini
gions of the world to allow region-specific actions to be M, Bonanni P. Childhood vaccination coverage in Europe: impact of
different public health policies. Expert Rev Vaccines. 2019;18(7):693–701.
implemented, thus counteracting the anti-vaxxer move- https://doi.org/10.1080/14760584.2019.1639502.
ment and preventing disease outbreaks. 3. Blume S. Anti-vaccination movements and their interpretations. Soc Sci
Med. 2006;62(3):628–42. https://doi.org/10.1016/j.socscimed.2005.06.020.
4. Dube E, Gagnon D, MacDonald N, Bocquier A, Peretti-Watel P, Verger P.
Abbreviations
Underlying factors impacting vaccine hesitancy in high income countries: a
FGDs: Focus group discussions; FHN: Family health nurse; FP: Family
review of qualitative studies. Expert Rev Vaccines. 2018;17(11):989–1004.
physician; HCWs: Health care workers; MoH: Ministry of Health;
https://doi.org/10.1080/14760584.2018.1541406.
NUTS: Nomenclature of Territorial Units for Statistics; SSPE: Subacute
5. Berezin M, Eads A. Risk is for the rich? Childhood vaccination resistance and
sclerosing panencephalitis; TDHS: Turkish Demographic Health Survey
a culture of health. Soc Sci Med. 2016;165:233–45. https://doi.org/10.1016/j.
socscimed.2016.07.009.
Acknowledgements 6. MacDonald NE. Vaccine hesitancy: definition, scope and determinants.
We would like to acknowledge the valuable contribution of all the HCWs Vaccine. 2015;33(34):4161–4. https://doi.org/10.1016/j.vaccine.2015.04.036.
who participated in FGDs and in-depth interviews. We thank the following 7. Park B, Choi EJ, Park B, Han H, Cho SJ, Choi HJ, Lee S, Park H. Factors
individuals for assistance with fieldwork: Bekir Keskinkılıç, Hüseyin İlter, from influencing vaccination in Korea: findings from focus group interviews. J
General Directorate of Public Health, Ministry of Health; Rıfat Köse, Oğuzhan Prev Med Public Health. 2018;51(4):173–80. https://doi.org/10.3961/jpmph.
Özkan from General Directorate for Health Research, Republic of Turkey Min- 18.063.
istry of Health;Levent Kartal in Provincial Health Directorate of Konya; Serkan 8. Berry NJ, Henry A, Danchin M, Trevena LJ, Willaby HW, Leask J. When
Bütün, Zülfü Barış Şahin, Seyfettin Sarıbaş in Provincial Health Directorate of parents won't vaccinate their children: a qualitative investigation of
Diyarbakır; Asiye Çiğdem Şimşek, Emel İmren Taş in Provincial Health Direct- australian primary care providers' experiences. BMC Pediatr. 2017;17(1):19.
orate of Ankara; Abdullah Emre Güner, Esra Şahin, Önder Yel in Provincial https://doi.org/10.1186/s12887-017-0783-2.
Health Directorate of İstanbul; Pervin Özelçi, Sevtap Bostancı, Ayşe Gümüş 9. Harmsen IA, Mollema L, Ruiter RA, Paulussen TG, de Melker HE, Kok G. Why
from Department of Vaccine Preventable Diseases. The authors thank Janet parents refuse childhood vaccination: a qualitative study using online focus
Collins, iCCC Rhein-Main, Frankfurt am Main, Germany, for proofreading and groups. BMC Public Health. 2013;13:1183. https://doi.org/10.1186/1471-2458-
language correction of the manuscript. 13-1183.
Yalçin et al. BMC Public Health (2020) 20:1087 Page 16 of 17

10. Torun SD, Demir F, Hidiroglu S, Kalaca S. Measles vaccination coverage and 31. Wagner AL, Masters NB, Domek GJ, Mathew JL, Sun X, Asturias EJ, Ren J,
reasons for non-vaccination. Public Health. 2008;122(2):192–4. https://doi. Huang Z, Contreras-Roldan IL, Gebremeskel B, et al. Comparisons of Vaccine
org/10.1016/j.puhe.2007.06.004. Hesitancy across Five Low- and Middle-Income Countries. Vaccines (Basel).
11. Singh S, Sahu D, Agrawal A, Vashi MD. Barriers and opportunities for 2019:7(4). https://doi.org/10.3390/vaccines7040155.
improving childhood immunization coverage in slums: a qualitative study. 32. Guay M, Gosselin V, Petit G, Baron G, Gagneur A. Determinants of vaccine
Prev Med Rep. 2019;14:100858. https://doi.org/10.1016/j.pmedr.2019.100858. hesitancy in Quebec: a large population-based survey. Hum Vaccin
12. Ministry of Heath. Book of legislation [Mevzuat Kitabı. Halk Sağlığı Hizmetleri Immunother. 2019;15(11):2527–33. https://doi.org/10.1080/21645515.2019.
İzleme ve Değerlendirme Personeli için]. TC Sağlık Bakanlığı Halk Sağlığı 1603563.
Genel Müdürlüğü İzleme, Değerlendirme ve İstatistik Daire Başkanlığı. 2019. 33. Evans DR, Yemeke TT, Kiracho EE, Mutebi A, Apolot RR, Ssebagereka A,
https://hsgm.saglik.gov.tr/tr/izlemedegerlendirme-anasayfa. Ozawa S. Trust in vaccines and medicines in Uganda. Vaccine. 2019;37(40):
13. Ministry of Heath. Family medicine payment and contract regulations [Aile 6008–15. https://doi.org/10.1016/j.vaccine.2019.07.022.
hekimliği ödeme ve sözleşme yönetmeliği]. Resmi Gazete 2010; 27801. 34. Carpiano RM, Chi DL. Parents’ attitudes towards topical fluoride and
https://www.mevzuat.gov.tr/MevzuatMetin/3.5.20101237.pdf. vaccines for children: are these distinct or overlapping phenomena? Prev
14. Topcu S, Almis H, Baskan S, Turgut M, Orhon FS, Ulukol B. Evaluation of Med Rep. 2018;10:123–8. https://doi.org/10.1016/j.pmedr.2018.02.014.
childhood vaccine refusal and hesitancy intentions in Turkey. Indian J 35. Rozbroj T, Lyons A, Lucke J. Psychosocial and demographic characteristics
Pediatr. 2019;86(1):38–43. https://doi.org/10.1007/s12098-018-2714-0. relating to vaccine attitudes in Australia. Patient Educ Couns. 2019;102(1):
15. Gur E. Vaccine hesitancy - vaccine refusal. Turk Pediatri Ars. 2019;54(1):1–2. 172–9. https://doi.org/10.1016/j.pec.2018.08.027.
https://doi.org/10.14744/TurkPediatriArs.2019.79990. 36. Barnard JG, Dempsey AF, Brewer SE, Pyrzanowski J, Mazzoni SE, O’Leary ST.
16. Hacettepe University Institute of Population Studies (2014). 2013 Turkey Facilitators and barriers to the use of standing orders for vaccination in
demographic and health survey. In: Hacettepe University Institute of obstetrics and gynecology settings. Am J Obstet Gynecol. 2017;216(1):69.
population studies. Ankara: T.R. Ministry of Development and TÜBİTAK; 2014. e61–7. https://doi.org/10.1016/j.ajog.2016.09.096.
17. Hacettepe University Institute of Population Studies. Turkey Demographic 37. Danchin MH, Costa-Pinto J, Attwell K, Willaby H, Wiley K, Hoq M, Leask J,
and Health Survey, 2008. In: Hacettepe Üniversitesi Nüfus Etütleri Enstitüsü. Perrett KP, O'Keefe J, Giles ML, et al. Vaccine decision-making begins in
Ankara: Sağlık Bakanlığı Ana Çocuk Sağlığı ve Aile Planlaması Genel pregnancy: correlation between vaccine concerns, intentions and maternal
Müdürlüğü, Başbakanlık Devlet Planlama Teşkilatı Müsteşarlığı ve TÜBİTAK; vaccination with subsequent childhood vaccine uptake. Vaccine. 2018;
2009. 36(44):6473–9. https://doi.org/10.1016/j.vaccine.2017.08.003.
18. Vanderslott S. Exploring the meaning of pro-vaccine activism across two 38. Attwell K, Wiley KE, Waddington C, Leask J, Snelling T. Midwives’ attitudes,
countries. Soc Sci Med. 2019;222:59–66. https://doi.org/10.1016/j.socscimed. beliefs and concerns about childhood vaccination: a review of the global
2018.12.033. literature. Vaccine. 2018;36(44):6531–9. https://doi.org/10.1016/j.vaccine.2018.
19. Hacettepe University Institute of Population Studies. 2018 Turkey 02.028.
Demographic and Health Survey Syrian Migrant Sample. In: Hacettepe 39. Mendel-Van Alstyne JA, Nowak GJ, Aikin AL. What is ‘confidence’ and what
University Institute of Population Studies. Ankara: T.R. Presidency of Turkey could affect it?: a qualitative study of mothers who are hesitant about
Directorate of Strategy and Budget and TÜBİTAK; 2019. vaccines. Vaccine. 2018;36(44):6464–72. https://doi.org/10.1016/j.vaccine.
20. Hacettepe University Institute of Population Studies. 2018 Turkey 2017.09.007.
Demographic and Health Survey. In.: Hacettepe University Institute of 40. Ozisik L, Tanriover MD, Altinel S, Unal S. Vaccinating healthcare workers:
Population Studies, T.R. Presidency of Turkey Directorate of Strategy and level of implementation, barriers and proposal for evidence-based policies
Budget and TÜBİTAK, Ankara, Turkey; 2019. in Turkey. Hum Vaccin Immunother. 2017;13(5):1198–206. https://doi.org/10.
21. Gorman DR, Bielecki K, Willocks LJ, Pollock KG. A qualitative study of 1080/21645515.2016.1269992.
vaccination behaviour amongst female polish migrants in Edinburgh, 41. Wilson R, Paterson P, Larson HJ. Strategies to improve maternal vaccination
Scotland. Vaccine. 2019;37(20):2741–7. https://doi.org/10.1016/j.vaccine.2019. acceptance. BMC Public Health. 2019;19(1):342. https://doi.org/10.1186/
03.073. s12889-019-6655-y.
22. Lane S, MacDonald NE, Marti M, Dumolard L. Vaccine hesitancy around the 42. Dalma A, Karnaki P, Baka A, Raftopoulos V, Zota D, Veloudaki A, Garrison A,
globe: analysis of three years of WHO/UNICEF joint reporting form data- Ellis Montalban P, Dhanani Z, Linos A. Promotion of immunizations for
2015-2017. Vaccine. 2018;36(26):3861–7. https://doi.org/10.1016/j.vaccine. health professionals in Europe: a qualitative study in seven European
2018.03.063. member states. Hosp Top. 2018;96(1):18–27. https://doi.org/10.1080/
23. MacDonald NE, Butler R, Dube E. Addressing barriers to vaccine acceptance: 00185868.2017.1365571.
an overview. Hum Vaccin Immunother. 2018;14(1):218–24. https://doi.org/10. 43. Helps C, Leask J, Barclay L. “It just forces hardship”: impacts of government
1080/21645515.2017.1394533. financial penalties on non-vaccinating parents. J Public Health Policy. 2018;
24. Benoot C, Hannes K, Bilsen J. The use of purposeful sampling in a 39(2):156–69. https://doi.org/10.1057/s41271-017-0116-6.
qualitative evidence synthesis: a worked example on sexual adjustment to a 44. Heath Jeffery R. Vaccination and the law. Aust Fam Physician. 2015;44(11):
cancer trajectory. BMC Med Res Methodol. 2016;16:21. https://doi.org/10. 849–52.
1186/s12874-016-0114-6. 45. Mathieu P, Gautier A, Raude J, Goronflot T, Launay T, Debin M, Guerrisi C,
25. Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis: Turbelin C, Hanslik T, Jestin C, et al. Population perception of mandatory
implications for conducting a qualitative descriptive study. Nurs Health Sci. childhood vaccination programme before its implementation, France, 2017.
2013;15(3):398–405. https://doi.org/10.1111/nhs.12048. Euro Surveill. 2019;24(25). https://doi.org/10.2807/1560-7917.Es.2019.24.25.
26. Organization WH: Report of the SAGE working group on Vaccine Hesitancy. 1900053.
2014. Available on: http://www who int/immunization/sage/meetings/2014/ 46. Navin MC, Attwell K. Vaccine mandates, value pluralism, and policy diversity.
october/SAGE_working_group_revised_report_vaccine_hesitancy pdf [Last Bioethics. 2019;33(9):1042–9. https://doi.org/10.1111/bioe.12645.
accessed: 2017, Mar 21]: 2015; 2015. 47. Attwell K, Ward PR, Meyer SB, Rokkas PJ, Leask J. “do-it-yourself”: vaccine
27. Türkiye Cumhuriyeti Anayasa Mahkemesi Genel Kurul Kararı. In.; 24/12/2015– rejection and complementary and alternative medicine (CAM). Soc Sci Med.
29572. 2018;196:106–14. https://doi.org/10.1016/j.socscimed.2017.11.022.
28. Damnjanovic K, Graeber J, Ilic S, Lam WY, Lep Z, Morales S, Pulkkinen T, 48. Ahmed A, Lee KS, Bukhsh A, Al-Worafi YM, Sarker MMR, Ming LC, Khan TM.
Vingerhoets L. Parental decision-making on childhood vaccination. Front Outbreak of vaccine-preventable diseases in Muslim majority countries. J Infect
Psychol. 2018;9:735. https://doi.org/10.3389/fpsyg.2018.00735. Public Health. 2018;11(2):153–5. https://doi.org/10.1016/j.jiph.2017.09.007.
29. Biasio LR. Vaccine literacy is undervalued. Hum Vaccin Immunother. 2019; 49. Chan HK, Soelar SA, Md Ali SM, Ahmad F, Abu Hassan MR. Trends in
15(11):2552–3. https://doi.org/10.1080/21645515.2019.1609850. vaccination refusal in children under 2 years of age in Kedah, Malaysia: a 4-
30. Bocquier A, Fressard L, Cortaredona S, Zaytseva A, Ward J, Gautier A, Peretti- year review from 2013 to 2016. Asia Pac J Public Health. 2018;30(2):137–46.
Watel P, Verger P. Social differentiation of vaccine hesitancy among French https://doi.org/10.1177/1010539517751312.
parents and the mediating role of trust and commitment to health: a 50. Rockliffe L, Chorley AJ, Marlow LAV, Forster AS. It's hard to reach the "hard-
nationwide cross-sectional study. Vaccine. 2018;36(50):7666–73. https://doi. to-reach": the challenges of recruiting people who do not access
org/10.1016/j.vaccine.2018.10.085. preventative healthcare services into interview studies. Int J Qual Stud
Yalçin et al. BMC Public Health (2020) 20:1087 Page 17 of 17

Health Well-being. 2018;13(1):1479582. https://doi.org/10.1080/17482631.

2018.1479582.
51. Machekanyanga Z, Ndiaye S, Gerede R, Chindedza K, Chigodo C, Shibeshi
ME, Goodson J, Daniel F, Zimmerman L, Kaiser R. Qualitative assessment of
vaccination hesitancy among members of the apostolic Church of
Zimbabwe: a case study. J Relig Health. 2017;56(5):1683–91. https://doi.org/
10.1007/s10943-017-0428-7.
52. Terkawi AS, Bakri B, Alsadek AS, Al-Hasan AH, Alrahhal MS, Alsaleh FM,
Alsatouf FA, Arab MAI, Jnaid H, Hadid AA, et al. Child and adolescent health
in northwestern Syria: findings from healthy-Syria 2017 study. Avicenna J
Med. 2019;9(2):61–74. https://doi.org/10.4103/ajm AJM_184_18.
53. Godoy-Ramirez K, Bystrom E, Lindstrand A, Butler R, Ascher H, Kulane A.
Exploring childhood immunization among undocumented migrants in
Sweden - following qualitative study and the world health organizations
guide to tailoring immunization Programmes (TIP). Public Health. 2019;171:
97–105. https://doi.org/10.1016/j.puhe.2019.04.008.
54. Harmsen IA, Bos H, Ruiter RA, Paulussen TG, Kok G, de Melker HE, Mollema
L. Vaccination decision-making of immigrant parents in the Netherlands; a
focus group study. BMC Public Health. 2015;15:1229. https://doi.org/10.1186/
s12889-015-2572-x.
55. Owusu-Addo E, Renzaho AMN, Smith BJ. Cash transfers and the social
determinants of health: a conceptual framework. Health Promot Int. 2019;
34(6):e106–18. https://doi.org/10.1093/heapro/day079.
56. Fang H, Yang L, Zhang H, Li C, Wen L, Sun L, Hanson K, Meng Q.
Strengthening health system to improve immunization for migrants in
China. Int J Equity Health. 2017;16(1):19. https://doi.org/10.1186/s12939-016-
0504-8.
57. O'Connell M, Wonodi C. Routine immunization consultant program in
Nigeria: a qualitative review of a country-driven management approach for
health systems strengthening. Glob Health Sci Pract. 2016;4(1):29–42.
https://doi.org/10.9745/GHSP-D-15-00209.
58. Motta M, Callaghan T, Sylvester S. Knowing less but presuming more:
dunning-Kruger effects and the endorsement of anti-vaccine policy
attitudes. Soc Sci Med. 2018;211:274–81. https://doi.org/10.1016/j.socscimed.
2018.06.032.
59. Tomeny TS, Vargo CJ, El-Toukhy S. Geographic and demographic correlates
of autism-related anti-vaccine beliefs on twitter, 2009-15. Soc Sci Med. 2017;
191:168–75. https://doi.org/10.1016/j.socscimed.2017.08.041.
60. Getman R, Helmi M, Roberts H, Yansane A, Cutler D, Seymour B. Vaccine
hesitancy and online information: the influence of digital networks. Health
Educ Behav. 2018;45(4):599–606. https://doi.org/10.1177/1090198117739673.
61. Jamison AM, Quinn SC, Freimuth VS. “You don’t trust a government
vaccine”: narratives of institutional trust and influenza vaccination among
African American and white adults. Soc Sci Med. 2019;221:87–94. https://doi.
org/10.1016/j.socscimed.2018.12.020.
62. Akis S, Velipasaoglu S, Camurdan AD, Beyazova U, Sahn F. Factors associated
with parental acceptance and refusal of pandemic influenza a/H1N1 vaccine
in Turkey. Eur J Pediatr. 2011;170(9):1165–72. https://doi.org/10.1007/s00431-
011-1425-6.
63. Facciola A, Visalli G, Orlando A, Bertuccio MP, Spataro P, Squeri R, Picerno I,
Di Pietro A. Vaccine hesitancy: an overview on parents' opinions about
vaccination and possible reasons of vaccine refusal. J Public Health Res.
2019;8(1):1436. https://doi.org/10.4081/jphr.2019.1436.

Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Article
Experiences with Testing, Self-Isolation and Vaccination in
North East England during the COVID Pandemic
Richard Harris

Department of Economics & Finance, Durham University, Durham DH1 3LB, UK; [email protected]

Abstract: This study was based on a (population weighted) sample of some 4533 responses to a
household survey conducted in March 2021 that looked at the impact of COVID-19 on residents
in most of the local authorities covering the North East of England. It considered the outcomes
relating to needing a COVID test, self-isolating, whether residents agreed that UK government and
NHS-approved vaccines were ‘very safe’, and whether they had enough information in order to
make an informed decision about whether or not to get vaccinated. Modelling these outcomes
using multivariate regression produced a range of results that showed that all of the following were
important: the impact of age, living in deprived areas, ethnicity, religious affiliation, disability, indus-
try, occupation, economic status, changes in household income, sexual orientation, and household
composition. Thus, the results showed that there are complex socioeconomic factors associated with
the willingness to get a test, self-isolate, and the levels of vaccine hesitancy, such that, in future
ensuring that (re-)vaccination and ‘track and trace’ programmes are successful, may need to be better
nuanced by references to such factors rather than adopting programmes that mostly just rely on age
as the criteria for roll-outs.






Keywords: vaccine hesitancy; COVID-19; ethnicity; multivariate regression
Citation: Harris, R. Experiences with
Testing, Self-Isolation and Vaccination
in North East England during the
COVID Pandemic. Vaccines 2021, 9,
1. Introduction
759. https://doi.org/10.3390/
vaccines9070759 The COVID-19 pandemic (hereafter, C19) has had an unprecedented impact on people
and economies since it began to spread globally at the beginning of 2020. It is generally
Academic Editor: Ralph accepted now in mid-2021 that the optimal way to tackle C19 in terms of mitigating
J. DiClemente its socioeconomic and health impact is through (i) establishing ‘herd immunity’ that
will significantly reduce the spread of the disease, and this principally means ensuring
Received: 19 May 2021 somewhere between 67% and 80% of the population of the UK is (re-)vaccinated, and
Accepted: 6 July 2021 (ii) ensuring an effective containment of outbreaks (especially any new variants) through
Published: 7 July 2021 ‘track-and-trace’, and this is reliant on people being willing and able to both test for the
disease and then self-isolate if testing produces a positive result.
Publisher’s Note: MDPI stays neutral There has been considerable discussion of the extent to which vaccine uptake is lower
with regard to jurisdictional claims in in more deprived areas [1,2] and, especially, whether those from non-White ethnic groups
published maps and institutional affil-
place less trust in the health system more generally and are therefore less likely to engage
iations.
with, especially, the vaccination programme. Specifically, a recent study [3] surveyed 9390
respondents in late November 2020 to statistically identify those mostly likely to exhibit
vaccine hesitancy [4], along with the reasons for such hesitancy. Noting that respondents
were asked for information ex ante, since vaccine roll-out did not begin in the UK until
Copyright: © 2021 by the author. early December 2020, overall, for the UK, some 53.5% of participants stated they were very
Licensee MDPI, Basel, Switzerland. likely to be vaccinated, with a further 28.5% saying they were likely, leaving 18% classified
This article is an open access article as vaccine-hesitant. When disaggregated into subgroups, the study showed higher vaccine
distributed under the terms and
hesitancy for females (log odds of 1.68 higher compared to males); younger people (i.e.,
conditions of the Creative Commons
1.64 higher for those aged 25–34 vs. 45–54 year olds, the reference group); and certain ethnic
Attribution (CC BY) license (https://
groups (led by Black/Black British with a 12.96 higher ratio, then Pakistani/Bangladeshi at
creativecommons.org/licenses/by/
2.31, followed by mixed ethnicity at 2.24). The main reasons for vaccine hesitancy were
4.0/).

Vaccines 2021, 9, 759. https://doi.org/10.3390/vaccines9070759 https://www.mdpi.com/journal/vaccines

Vaccines 2021, 9, 759 2 of 15

concerns over unknown future effects (42.7% stating this as the main reason), although
for Black/Black British, the main reasons were unknown future effects (30%) and a lack
of trust in vaccines (29%); for Pakistani/Bangladeshi, the most important reasons were
concerns about side effects (36%) and unknown future effects (35%). Ex post NHS England
data discussed in reference [5], based on reference [6], showed substantially lower rates of
vaccinations among those over 80 in ethnic minority subgroups and deprived communities,
e.g., between 8 December 2020 and 17 March 2021, 94.7% of patients aged ≥ 80 not in a
care home received a vaccine (with substantial variations such as: White, 96.2% vaccinated
and Black, 68.3% and least-deprived, 96.6% and most-deprived, 90.7%).
Other research [7] has shown that non-White ethnic groups have experienced higher
infection rates from C19, hospitalisation, and death, and this is explained by (inter alia)
their being “ . . . more likely to live in crowded and multi-generational households where
self-isolation and social distancing may prove to be difficult . . . individuals living in
deprived areas have higher diagnosis and death rates . . . (and) social distancing was
effective and possible in higher socioeconomic level households” (p. 1). It was also noted
that ethnic minorities were also more likely to work in certain industries with a higher
risk of exposure, such as food retail, health and social care, and transport. These groups
experience a lower uptake of vaccines because of a lack of trust resulting from prior “ . . .
cultural and structural racism, low confidence in the safety and efficacy of the vaccine . . .
moreover, physical barriers including lack of vaccines, transport access and inconvenient
appointments can also hinder vaccine uptake in these communities” ([8], p. 2).
A major survey undertaken to understand vaccine hesitancy is the Oxford Coronavirus
Explanations, Attitudes, and Narrative Survey [9], which obtained responses from 5114 UK
adults between 24 September and 17 October 2020. It found some 28.3% of the population
could be labelled as vaccine-hesitant. The major task was to explain the reasons for this
hesitancy, finding that the major reasons were that respondents thought vaccine data are
fabricated (20% of the sample), while 25% did not know whether such fraud is occurring
or not. Importantly, the study found that mistrust was evident across the entire population
and only “ . . . slightly higher in young people, women, those on lower income, and people
of Black ethnicity” ([10], p. 2). In contrast, reference [11] found that during weeks 9–12 of
the first national lockdown (May to June 2020) some 26% of Scottish participants (based
on a sample of 3436) could be grouped as vaccine-hesitant (by August 2020, this fell to
22.5% for the 2016 respondents who stated they remained hesitant when completing a
follow-up survey). Based on a multivariate analysis of the pooled samples that included
age, ethnicity, education, household income, and those at high risk/shielding, the study
found that gender and age were not statistically significant as a predictor of vaccine uptake,
but those of White ethnicity were almost three times as likely to get vaccinated as Black,
Asian, and minority ethnic (BAME) groups (high income and highest education subgroups
were also more likely to accept future vaccinations, as were those shielding).
Lastly, polling data in December 2020 [12] found the vaccine hesitancy in the UK
population at around 24%, although this rose to 43% for those from ethnic minority
backgrounds and 30% for low-income earners (women had a slightly higher level of
hesitancy compared to the overall population at 27%). Data reported in reference [13] in
February also showed that, when comparing the NHS vaccination data with Public Health
England’s deprivation scores, “ . . . that six of the most deprived areas in England were in
the bottom 10 local areas for vaccine uptake among the over-80 s and those aged over 75”.
Based on the same data sources, reference [14] reported on similar differences across rich
and poorer localities.
This paper makes a contribution by looking at the extent to which a wide range of
personal characteristics and locations are associated with the C19 questions asked in the
North East Covid Survey undertaken in March 2021 to provide information relevant to
how to run the most effective vaccination and ‘track-and-trace’ programmes.
Vaccines 2021, 9, 759 3 of 15

2. Materials and Methods

An online survey was conducted by the Gateshead Council from 8 to 28 March 2021
resulting in 5556 responses and a sample size of 4533 available for a subsequent analysis
(when nonresponses to key variables like age, ethnicity, economic status, and gender are
taken into account). It included 8 other local authorities in the North East administrative
region of England (see Figure SA.1 in a longer version of this paper [15]), and jointly
through their Directors of Public Health, they promoted the survey via various (resident)
groups and other email lists available to these councils. In addition, all employers with
50 or more employees operating in the area were identified using the Orbis company
database, and these were contacted and asked to promote the survey to their employees.
The first question in the survey itself asked which local authority did the respondent live
in, and, together with a question on their postcode, this was used to filter out a very small
number of noneligible returns. Data from the Quarterly Labour Survey conducted by the
ONS [16] was used to construct weights to ensure the survey was representative of the
underlying population. Details on the distribution of respondents by the local authority,
and the other subgroupings of the data used to construct weights, is available in Appendix
2 of reference [15].
The focus of the survey was the impact of C19 on how it affected people, their families,
employment situations, and incomes, as well as views about a post-pandemic future.
However, the focus in this paper was on a set of questions relevant to the NHS obtained
from reference [17] that were also included during testing for C19, self-isolation, and
vaccines; these questions are reproduced in Appendix A. A range of questions on personal
and household characteristics (such as age, gender, ethnicity, religious affiliation, disability,
sexual orientation, household composition, economic status, industry and occupation
subgroups, and location) were included to consider the extent to which the outcomes
were correlated with these characteristics. Table 1 provides the (weighted) means and
standard deviations for these ‘explanatory’ variables, noting that cross-sectional modelling
as undertaken here cannot establish causal relationships but only correlations.

Table 1. Weighted means and standard deviations of the explanatory variables.

Variable Means St. Dev. Minimum Maximum

Age of respondent 52.08 14.24 16 92
Male gender 0.48 0.50 0 1
Index of deprivation score in postcode lived (source: [18]) a 22.84 15.75 1.53 78.01
White ethnic subgroup 0.97 0.17 0 1
Impact of C19 on household finances
Negative impact on household finances 0.30 0.46 0 1
No impact on household finances b 0.48 0.50 0 1
Positive impact on household finances 0.22 0.42 0 1
Religious affiliation
Buddhist 0.00 0.05 0 1
Christian 0.53 0.50 0 1
Hindu 0.00 0.03 0 1
Jewish 0.00 0.05 0 1
Muslim 0.01 0.10 0 1
No faith/religion 0.44 0.50 0 1
Sikh 0.00 0.02 0 1
Other 0.02 0.14 0 1
Disability
No 0.73 0.45 0 1
Yes, limited a little 0.20 0.40 0 1
Yes, limited a lot 0.07 0.26 0 1
Vaccines 2021, 9, 759 4 of 15

Table 1. Cont.

Variable Means St. Dev. Minimum Maximum

Industry subgroups
Nonretired, n.a. 0.21 0.41 0 1
Agriculture, Forestry and Fishing 0.00 0.05 0 1
Mining and Quarrying 0.00 0.03 0 1
Manufacturing 0.05 0.21 0 1
Electricity, Gas, Water supply 0.02 0.12 0 1
Construction 0.02 0.14 0 1
Wholesale distribution 0.01 0.07 0 1
Retail distribution 0.03 0.18 0 1
Transportation 0.01 0.12 0 1
Accommodation and Food Service Activities 0.02 0.12 0 1
Information and Communication 0.03 0.18 0 1
Financial and Insurance Activities 0.03 0.17 0 1
Professional, Scientific, and Technical 0.05 0.22 0 1
Administrative and Support Service Activities 0.05 0.22 0 1
Employment, Travel, Security 0.01 0.10 0 1
Public administration and defence; social security 0.08 0.27 0 1
Human Health and Social Work Activities 0.24 0.42 0 1
Arts, Entertainment and Recreation 0.03 0.16 0 1
Other Services 0.12 0.32 0 1
Occupation subgroups
None-retired, n.a. 0.20 0.40 0 1
Managers, directors, senior officials 0.10 0.30 0 1
Professionals 0.27 0.45 0 1
Associate profession and technical 0.06 0.23 0 1
Admin and secretarial 0.16 0.37 0 1
Skilled trades 0.04 0.20 0 1
Caring, leisure, other services 0.08 0.27 0 1
Sales and customer services 0.05 0.21 0 1
Process, plant, and machine operatives 0.02 0.13 0 1
Elementary occupations 0.02 0.16 0 1
Economic status
Full-time employed 0.44 0.50 0 1
Part-time employed 0.15 0.36 0 1
Unemployed/not active 0.16 0.37 0 1
Retired 0.25 0.43 0 1
Change in employment status during pandemic 0.24 0.43 0 1
Sexual orientation
Heterosexual 0.94 0.24 0 1
Bisexual 0.02 0.13 0 1
Gay or Lesbian 0.03 0.19 0 1
Other (not straight/heterosexual) 0.01 0.08 0 1
Household size
No. of adults 1.97 0.80 0 5
Children present in household 0.37 0.48 0 1
Household composition
Couple 0.41 0.49 0 1
Couple with child/children 0.26 0.44 0 1
Other 0.02 0.15 0 1
Single parent 0.03 0.16 0 1
Single person 0.18 0.38 0 1
Single person or couple living with parents 0.03 0.18 0 1
Single person or couple with adult children 0.06 0.24 0 1
Local authority lived in
Vaccines 2021, 9, 759 5 of 15

Table 1. Cont.

Variable Means St. Dev. Minimum Maximum

County Durham 0.26 0.44 0 1
Darlington 0.05 0.23 0 1
Gateshead 0.11 0.31 0 1
Middlesbrough 0.05 0.22 0 1
Newcastle 0.13 0.34 0 1
N Tyneside 0.11 0.31 0 1
Redcar and Cleveland 0.07 0.25 0 1
S Tyneside 0.07 0.26 0 1
Sunderland 0.14 0.35 0 1
Observations 4533
a See Figure S1 in reference [15]. b Variables in bold are omitted as the benchmark subgroup in the estimated regression models.

Table 1 shows that the analysis reported in the next section was based on residents
with an average age of just over 52 years old, some 48% were male, only 3.1% were of
non-White ethnicity, and there was a very wide range in deprivation levels across the areas
in which people lived.
Some 30% of the respondents stated C19 had a negative impact on the household
finances, and 24% stated that the pandemic resulted in a change in their employment
status. As to religious affiliation, the largest subgroup reported as being Christian (some
53%) followed by ‘no faith/religion’ (44%). Some 27% stated they had a disability (mostly
limiting mobility ‘a little’), and the most important industry sector was human health
and social work activities, followed by other services. Some 27% of respondents stated
they were part of the ‘professional’ socioeconomic subgroup, with administration and
secretarial occupations the next most important. Some 7% of respondents reported as non-
heterosexual. The average number of adults in a household was close to 2, and some 37%
reported children in the household. The dominant household composition was couples
(some 41% with no children and a further 26% with children), followed by around 18%
of households comprising single occupants. Durham County had the largest share of
residents (26%), with Middlesbrough and Darlington both accounting for about 5% of the
16+ resident population.

3. Results
A longer version of this paper [15] contains a set of results based on univariate analyses
that showed that there were statistically significant differences, in terms of the impact of
C19, across various subgroups (e.g., ethnicity, age, whether there were children in the
household; see Section 3 of reference [15]). However, as Table 2 shows, many of these
differences do not remain statistically significant when other covariates (cf. Table 1) are
introduced into multivariate models that seek to determine which factors have the strongest
associations with the outcomes.

Table 2. (Weighted) marginal effects (∂ p̂/∂x) from the regression models.

UK Govt- NHS Make

Challenge
Needed Needed Had Approved Approved Informed Challenge Challenge
Variable Getting
Testing a Isolation a Vaccine a Vaccine Very Vaccine Very Vaccine Testing a Isolating a
Vaccine a
Safe b,c Safe b,c Decision b,c
Age of
−0.003 *** −0.002 0.013 *** 0.001 −0.001 0.001 −0.001 * −0.002 * −0.004 ***
respondent
Male 0.036 0.060 ** −0.001 0.037 * 0.039 * −0.017 0.025 0.049 ** −0.007
Index of
deprivation −0.000 0.001 −0.000 −0.001 ** −0.001 ** −0.000 0.001 * 0.000 0.001
score in area
White ethnic
−0.126 ** 0.032 0.037 0.028 0.078 0.055 −0.107 ** −0.024 −0.119 **
subgroup
Vaccines 2021, 9, 759 6 of 15

Table 2. Cont.

UK Govt- NHS Make

Challenge
Needed Needed Had Approved Approved Informed Challenge Challenge
Variable Getting
Testing a Isolation a Vaccine a Vaccine Very Vaccine Very Vaccine Testing a Isolating a
Vaccine a
Safe b,c Safe b,c Decision b,c
Religious
affiliation
Buddhist 0.396 ** −0.008 −0.011 −0.413 ** −0.339 −0.012 0.092 0.052 0.103
Christian 0.068 *** 0.037 * 0.014 0.040 * 0.011 0.002 −0.016 0.026 0.001
Jewish −0.061 0.035 −0.032 −0.360 ** −0.231 −0.212 −0.049 −0.054 0.005
Muslim −0.088 0.106 0.119 −0.147 −0.203 ** −0.196 * −0.151 * −0.001 −0.068
Other 0.090 0.057 −0.183 *** 0.018 0.007 −0.032 0.007 0.028 0.018
Disability
Yes, limited a
0.057 ** 0.140 *** 0.106 *** −0.056 ** −0.059 ** −0.047 * 0.093 *** 0.135 *** 0.091 ***
little
Yes, limited a
0.131 *** 0.219 *** 0.139 *** −0.085 ** −0.019 −0.084 ** 0.110 *** 0.236 *** 0.126 ***
lot
Industry
subgroups
Agriculture,
Forestry and −0.195 0.389 ** 0.140 0.597 *** 0.451 ** 0.492 ** −0.225 0.262 * 0.000
Fishing
Mining and
0.470 ** −0.192 −0.286 * 0.623 ** 0.581 ** 0.261 0.316 ** −0.345 0.000
Quarrying
Manufacturing 0.067 0.037 −0.022 0.069 −0.030 −0.134 ** −0.065 −0.043 −0.026
Electricity, Gas,
−0.003 0.107 −0.201 ** 0.077 0.022 −0.063 −0.188 0.021 0.040
Water supply
Construction 0.121 0.080 −0.059 0.068 −0.052 −0.078 −0.076 −0.022 −0.125
Wholesale
−0.308 ** 0.001 −0.050 0.315 ** 0.003 0.077 −0.092 0.055 −0.093
distribution
Retail
−0.046 0.103 −0.134 * −0.051 −0.169 * −0.079 −0.072 0.028 −0.083
distribution
Transportation 0.289 ** 0.091 0.046 0.018 −0.125 −0.085 −0.027 −0.128 −0.214 **
Accommodation
and Food −0.047 −0.058 −0.014 0.042 −0.053 0.014 −0.096 −0.107 −0.005
Services
Information
and Communi- 0.125 0.090 −0.062 −0.056 −0.072 −0.161 * 0.045 0.051 −0.066
cation
Financial and
Insurance 0.019 0.134 * −0.118 * −0.013 −0.069 −0.111 −0.089 −0.029 0.012
Activities
Professional,
Scientific, and 0.038 0.087 −0.112 −0.009 −0.014 −0.066 0.039 −0.014 0.011
technical
Administrative
and Support 0.072 0.117 * 0.010 −0.009 −0.078 −0.064 −0.033 0.033 0.032
Service
Employment,
Travel, 0.179 0.163 0.065 0.131 0.066 0.050 −0.166 * 0.079 −0.199 *
Security
Public admin
and defence, 0.026 0.079 −0.095 0.052 −0.014 −0.015 −0.078 0.024 −0.043
etc.
Human Health
and Social 0.005 0.081 0.061 0.050 0.011 −0.014 −0.025 0.038 −0.044
Work
Arts,
Entertainment, −0.051 0.024 −0.016 0.105 0.109 * 0.115* −0.061 0.042 −0.044
and Recreation
Other services 0.006 0.100 * −0.020 0.001 −0.042 −0.048 0.003 0.088 0.003
Vaccines 2021, 9, 759 7 of 15

Table 2. Cont.

UK Govt- NHS Make

Challenge
Needed Needed Had Approved Approved Informed Challenge Challenge
Variable Getting
Testing a Isolation a Vaccine a Vaccine Very Vaccine Very Vaccine Testing a Isolating a
Vaccine a
Safe b,c Safe b,c Decision b,c
Occupation
subgroups
Managers,
directors, 0.005 −0.009 −0.019 −0.006 0.020 0.048 0.082 * −0.045 0.006
senior officials
Professionals 0.004 −0.018 −0.013 −0.009 −0.009 0.044 0.080 * −0.015 0.012
Associate
profession and −0.106 −0.121 * −0.042 0.043 0.029 0.019 0.043 −0.058 0.059
technical
Admin and
−0.101 * −0.125 ** −0.030 −0.061 −0.041 −0.026 0.037 −0.078 0.024
secretarial
Skilled trades −0.028 0.035 −0.053 −0.179 ** −0.188 ** −0.080 0.165 ** 0.117 0.048
Caring, leisure,
−0.012 −0.008 0.150 ** −0.094 ** −0.048 −0.078 0.081 −0.007 0.047
other service
Sales and
customer −0.058 0.054 0.008 −0.023 −0.017 0.022 0.090 0.054 0.002
services
Process, plant,
and machine −0.072 −0.036 −0.059 −0.211 ** −0.196 ** 0.033 0.096 0.070 0.003
operatives
Elementary
0.119 0.037 0.014 0.018 −0.029 −0.071 0.119 * −0.048 0.074
occupations
Economic
status
Full−time
0.061 −0.040 −0.133 *** −0.090 ** −0.077 ** −0.013 −0.022 −0.035 0.021
employed
Part−time
0.057 −0.057 −0.111 *** −0.063 * −0.061 −0.021 −0.008 −0.042 0.032
employed
Unemployed/not
−0.034 0.045 −0.149 *** −0.120 *** −0.117 ** −0.009 −0.084 ** 0.047 0.056
active
Change in
employment 0.083 *** 0.037 −0.030 −0.026 −0.035 −0.025 0.093 *** 0.015 0.049 **
status
Negative
impact on −0.004 0.039 −0.049 ** −0.094 *** −0.052 ** −0.051 ** 0.036 * 0.099 *** 0.107 ***
finances
Positive impact
0.007 −0.014 −0.026 0.059 ** 0.109 *** 0.065 *** −0.023 −0.006 −0.002
on finances
Sexual
orientation
Bisexual 0.041 −0.058 0.012 −0.042 −0.060 −0.093 0.010 −0.016 0.031
Gay or Lesbian −0.033 0.055 0.118 ** 0.121 ** 0.110 * 0.067 0.008 0.026 −0.092
Other (not
straight/ 0.012 −0.050 0.028 −0.088 −0.172 −0.086 0.099 −0.011 0.158 *
heterosexual)
Household
size
No. of adults 0.006 −0.010 0.006 0.005 0.001 −0.005 0.006 0.026 * −0.008
Children
present in 0.155 * 0.156 0.077 0.010 −0.049 0.086 0.096 0.091 0.103
household
Household
composition
Couple with
−0.005 −0.019 −0.057 −0.054 −0.007 −0.161 * −0.035 −0.017 −0.077
child/children
Other 0.096 0.169 ** 0.034 0.091 0.050 −0.057 0.046 0.079 −0.141 **
Single parent 0.027 0.078 −0.136 −0.136 −0.109 −0.230 ** −0.031 0.131 −0.061
Vaccines 2021, 9, 759 8 of 15

Table 2. Cont.

UK Govt- NHS Make

Challenge
Needed Needed Had Approved Approved Informed Challenge Challenge
Variable Getting
Testing a Isolation a Vaccine a Vaccine Very Vaccine Very Vaccine Testing a Isolating a
Vaccine a
Safe b,c Safe b,c Decision b,c
Single person −0.058 * −0.006 0.019 −0.042 −0.014 −0.031 −0.000 0.003 0.048
Single
person/couple 0.041 0.024 0.058 −0.106 * −0.072 −0.026 0.057 0.003 0.078
with parents
Single
person/couple
−0.028 −0.030 −0.035 −0.050 0.013 −0.206 ** −0.038 −0.054 −0.079
with adult
child
Local authority
lived in
Darlington 0.122 *** −0.020 −0.027 0.042 0.012 0.029 0.006 −0.041 −0.023
Gateshead 0.042 0.043 −0.084 *** 0.007 −0.009 0.006 −0.023 −0.001 0.029
Middlesbrough 0.165 *** 0.052 0.070 0.004 0.024 0.026 0.045 0.055 0.118 **
Newcastle 0.039 −0.045 −0.050 0.067 * 0.074 * 0.062 * 0.034 −0.052 −0.035
N. Tyneside 0.014 −0.018 −0.047 * −0.010 0.032 0.041 −0.042 * −0.026 0.013
Redcar and
0.088 * −0.012 −0.031 −0.018 −0.036 −0.005 −0.068* −0.090 ** 0.060
Cleveland
S Tyneside −0.033 0.075 0.092 ** 0.015 −0.048 0.060 −0.036 0.012 0.058
Sunderland 0.034 0.055 −0.062 ** −0.004 −0.011 0.031 0.000 0.019 −0.004

Observations 4385 4395 4418 4435 4435 4435 4385 4395 4419
pseudo−R2 0.084 0.068 0.274 0.051 0.053 0.030 0.092 −0.017 0.092

*/**/*** represent significance at the 10%/5%/1% levels (based on robust standard errors). Tables A1–A5 in Appendix A set out the actual
survey questions asked for each model estimated. a Estimated using the probit regression model. b Estimated using the ordered probit
regression model. c Only marginal effects for ‘strongly agreed’ reported.

The outcomes that were subjected to multivariate testing considered which covariates
were more strongly associated with:
• The 55% of residents who needed a COVID test;
• The 47% of residents who needed to self-isolate;
• The just over 55% (by March 2021) who had received at least one dose of a vaccine;
• The 18% who stated they faced a challenge getting a test;
• The nearly 31% who faced challenges when self-isolating;
• The 48% (57%) stating they strongly agreed that the UK government (NHS)-approved
vaccine was very safe; and
• The 51% who stated they strongly agreed they could make an informed decision about
being vaccinated or not.
It is worth noting that, with respect to whether residents disagreed (or were neutral)
about the statements underlying the last two bullet points, overall, the percentage who
disagreed (including and/or excluding those who neither agreed or disagreed) with these
three statements was relatively small; including those who disagreed and/or were neutral,
it was 17%, 13.5%, and 19.5% for the UK government-approved vaccine, NHS-approved
vaccine, and the ability to make an informed decision. Excluding the neutral answers, these
percentages fall to 4.3%, 2.9%, and 6.2%, respectively. This suggests that, when compared
to the ex ante information reported in early studies using the pre-roll-out 2020 data, vaccine
hesitancy may have substantially declined (assuming the North East is representative of
other areas and the UK as a whole).
A multivariate regression analysis was undertaken; and for dependent variables that
were dichotomous (no/yes coded as 0/1), (weighted) probit regression was used. When the
dependent variable (e.g., whether the UK government-approved vaccine is very safe) had more
than a 0/1 outcome, ordered probit regression was used. The results obtained are provided in
Table 2; note, for the ordered probit models, only the results for the largest subgroup (i.e., those
Vaccines 2021, 9, 759 9 of 15

who strongly agreed) are reported (full results are provided in reference [15], Tables SA2.9–11).
Marginal effects are provided; for discrete (0/1) explanatory variables (cf. Table 1), these indicate
the increase in the probability of the outcome (e.g., needed testing) from switching someone
from 0 to 1 (e.g., moving from a non-White to White ethnic status). For continuous variables (age
and the index of multiple deprivation), the marginal effect shows the increase in the probability
of the outcome for a unit change in the explanatory variable (e.g., the effect of increase from
being 25 to 26 years old).
To aid interpretation, the first column of results in Table 2 are presented variable-by-
variable: as the age of the respondent increases, the need for testing declines. As shown
diagrammatically in Figure S3 in reference [15], for those aged 20 years, the probability
of needing a test is 0.66—or 66%—and this declines to 0.46—or 46%—for those aged
80 years. Thus, the marginal effect of moving from 20 to 80 years is a ceteris paribus (cet.
par.) decline in the probability of needing a test of 0.20 (or 20%). Those belonging to the
White ethnic subgroup were some 12.6% less likely (vs. other ethnic groups) to need a
test. Those of the Buddhist faith had a much (nearly 40%) higher probability of needing to
test, while, for Christians, there was a 6.8% higher probability (compared to those with no
faith/religion). Having a major disability increased the (cet. par.) need for testing by over
13% compared to those without disabilities. Those working in the mining and quarrying
and transportation sectors were more likely to need testing (47% and nearly 29% more
likely, respectively), while those working in wholesale distribution were nearly 31% less
likely to need testing. The skilled trades occupation subgroup was associated with around
a 10% less need for testing, and those who experienced a change in their employment
status during the pandemic were over 8% more likely to need testing. Having children in
the household increased (cet. par.) by over 15% the likelihood of a need to test for C19,
while households with only single-person occupancies were some 6% less likely to need
testing. Lastly, those resident in Darlington, Middlesbrough, and Redcar and Cleveland
(areas where the transmission rates were known to be higher) were between 9% and 17%
more likely to need a COVID test.
Rather than go through the results in Table 2 column by column, the alternative used
here is to summarise the impact of each of the determinants on the range of outcomes
considered. Starting with age, this was significantly and negatively related to needing a
test, challenges to testing, to isolating, and to getting a vaccine, and increases in age was
positively associated with having had at least one vaccination dose by March 2021. Moving
from someone aged 20–80 years reduced (the probability of) the need for testing, facing
a challenge getting a test, and isolating or getting a vaccine by 20%, 9%, 13%, and 27%,
respectively. In contrast, the likelihood of receiving a vaccine increased by 78% over this
age range. This was after having controlled for family characteristics, religious affiliation,
sexual orientation, ethnicity, and other socioeconomic characteristics, including where
people lived. There was no statistically significant age effect on being able to make an
informed decision on whether to vaccinate, and overall, the results presented here showed
a much smaller level of vaccine-hesitant attitudes associated with age when compared
to reference [3]; instead, the results were more in line with those found in reference [9].
Still, younger people have generally had poorer experiences with C19 relative to older
generations and not just because the vaccination roll-out has been targeted in an inverse
relationship with age.
Gender as an influence is statistically important in less than half of the models es-
timated, and generally, the impacts are small, i.e., males had a 6% higher probability of
needing to self-isolate and were nearly 5% more likely to face a challenge with isolating and
were (about 4%) more likely than women to believe the UK- and NHS-approved vaccines
are very safe. Additionally, living in an area with greater levels of socioeconomic depri-
vation was not a statistically significant factor across many of the outcomes considered,
although it was negatively correlated with attitudes on whether the UK government and
NHS-approved vaccines are deemed very safe, i.e., moving from a IMD score of 2 to 80
reduced the probability of believing vaccines are very safe by around 11% to 12%. Being in
Vaccines 2021, 9, 759 10 of 15

a high deprivation area was also associated with a higher likelihood of facing challenges
accessing COVID testing (8% higher moving from the lowest to highest deprivation scores).
Certain univariate results (reported in Section 3 of reference [15]) that showed that the
non-White ethnic subgroup was less likely to have been vaccinated, were less likely to agree
that vaccines were very safe, or were less likely to be able to make an informed decision on
whether to vaccinate—all taken as indicators of vaccine hesitancy—were not confirmed
by the multivariate model results. After controlling for other factors (principally age), the
non-White subgroup only had a (statistically significant) higher probability of needing
to test (nearly 13% higher), challenges in accessing testing (11% higher), and challenges
getting vaccinated (12% higher relative to the White ethnic population). Thus, these results
for the North East of England did not seem to indicate, ex post, that vaccine-hesitant
attitudes are (cet. par.) more of an issue with the non-White ethnic population per se. The
results presented here therefore do not seem to support the earlier analyses reported in
references [3,5,7,11], but it is in accord with reference [9]. However, this was (at least in
part) because of the inclusion of religious affiliation, which is considered next.
When the impact of religious affiliation is considered, and given that Muslims in
particular almost all classified themselves as non-White, the results show that a higher
vaccine hesitancy (associated with the safety of vaccines and making an informed decision
about vaccination) is indeed prevalent in the North East of England but represents itself via
its Muslim (and, to a lesser extent, Buddhist and Jewish) community. For example, those
of a Buddhist faith were over 40% less likely to strongly agree that the UK government-
approved vaccine is very safe (the result for NHS approval was weaker—a parameter
estimate of −0.339 was only significant at the 12% level, while the result for making an
informed decision on getting vaccinated was close to 0). As with Buddhists, those from the
Jewish community were more sceptical of the safety of a UK government-approved vaccine
(there is weaker evidence that they were also sceptical with regard to NHS approval or
making an informed decision on getting vaccinated, with both estimates significant at
the 11% level). Muslims were nearly 15% less likely to trust a UK government-approved
vaccine (although this result was only significant at the 11% level) and even more hesitant
about one approved by the NHS (they were 20% less likely to agree that the latter was
very safe), and they were 20% less likely to strongly agree they could make an informed
decision on getting vaccinated. Thus, taking together ethnicity and religious affiliation
associated with ethnicity, there is robust evidence in favour of suggesting vaccine hesitancy
is higher in the non-White population, as well as this subgroup having had a greater need
to test for C19, and higher for the challenges associated with testing and getting a vaccine.
Those with a disability (especially the greater the incapacity) were more negatively
affected by the pandemic. They were more likely to need to test for COVID and to self-
isolate (especially those where the disability added more limits, who were 13% and 22%
more likely to need a test and self-isolate, respectively). Disabled residents were (cet. par.)
some 11–14% more likely to have received a vaccine, but they were more hesitant about
endorsing the safety of the approved vaccines and had a lower probability of strongly
agreeing they could make an informed decision about vaccination (for those with a greater
disability, there was an 8% lower likelihood of strongly agreeing they could make an
informed decision). The disabled faced more of a challenge with testing for C19, self-
isolating, and getting a vaccine. The more disabled were, respectively, 11%, 24%, and 13%
more likely to face such challenges.
The industry and occupation in which someone worked often mattered—e.g., in
mining and quarrying, there were some large impacts: a 47% greater likelihood of needing
to test, alongside a 32% higher probability of facing a challenge with testing, and a nearly
29% lower level of vaccination, together with a strong agreement (at around the 58–62%
level) that vaccines were very safe. In other industry sectors, there were fewer impacts
across the range of outcomes covered; some of the more striking results included a 31%
lower likelihood of needing testing (cet. par.) for wholesale distribution, while those in
transportation were 29% more likely to need testing. Notable occupation effects included a
Vaccines 2021, 9, 759 11 of 15

lower need to test or self-isolate for those in the admin and secretarial subgroup and greater
challenges associated with testing for C19 for managers, professionals, skilled trades, and
elementary occupations. Those less likely to be able to work from home in skilled trades;
caring, leisure, and other service occupations; and process, plant, and machine operatives
were also less likely to strongly agree that the approved vaccines were very safe. Compared
to other occupation subgroups, (cet. par.), those in the caring, leisure, and other service
subgroup were some 15% more likely to have received a vaccine.
When compared to the retired, the employed and unemployed/not economically
active were less likely (cet. par.) to have received a vaccination by March 2021, and these
groups were also more likely to show signs of vaccine hesitancy (i.e., they were less likely
to agree that the approved vaccines were very safe). Those that experienced a change in
their employment status during the pandemic were over 8% more likely to need testing and
over 9% more likely to experience challenges when so doing. As to the impact of changes
in household finances associated with the pandemic, for those experiencing declining
incomes (poorer households), they were less likely to have been vaccinated and were
less likely to strongly agree that the approved vaccines were very safe (including being
some 5% less likely to strongly agree they could make an informed decision about being
vaccinated). This group also faced more challenges with testing, self-isolating, and getting
a vaccine. In contrast, households experiencing a positive effect on their finances (e.g.,
through lower outgoings leading to higher savings), all had higher levels of endorsement
of the safety of the approved vaccines (as well as 7% stronger agreement that they could
make an informed decision).
The sexual orientation of residents showed that gay and lesbian residents were some
12% more likely (cet. par.) to have received a vaccine, and they were also more likely
to strongly agree that the approved vaccines were very safe. Those non-heterosexuals
identifying as ‘other’ (not gay/lesbian/bisexual) were nearly 16% more likely to face a
challenge in getting a vaccine. Household size had (cet. par.) few impacts; more adults were
associated with a small (nearly 3%) increased challenge in self-isolating, while children
in the household increased the need for testing by around 15.5%. Turning to household
compositions, those with a couple and children, single parents, and those with adult
children living with their parent(s) all had a lower probability of strongly agreeing that they
could make an informed decision about the vaccinations (between 16% and 23% lower). In
addition, those living with their parents were nearly 11% less likely to strongly agree that
UK government-approved vaccines were very safe. Single-person households were (some
6%) less likely to need to test. Thus, overall, when compared to households comprising a
couple (with no other residents), other types of households showed a greater propensity
towards being vaccine-hesitant.
Lastly, there were some different outcomes depending on the local authority of the
resident, e.g., those living in Darlington, Middlesbrough, and Redcar and Cleveland were
more likely to need testing for COVID-19 (where the infection rates were relatively high),
but it was only in Redcar and Cleveland that residents also had a greater challenge in testing
and/or self-isolating. Middlesbrough had a nearly 12% higher likelihood of experiencing
challenges linked to getting a vaccine.

4. Discussion
Given the major impact C19 has had on the economy, health, and the way people live
their lives [19], tackling the pandemic continues to be a worldwide priority. At the time of
writing, this means, in the UK, relying on the roll-out of vaccines to effectively immunise
the population in order to reduce the transmission of the disease, hospitalisation levels,
and deaths. The second major ‘plank’ in the ongoing control of COVID-19 is to ensure
an effective means of testing and (self-)isolation of those infected, especially where new
variants are concerned.
This paper makes a contribution by looking at the extent to which a wide range of
personal characteristics and location are associated with the C19 questions asked in the
Vaccines 2021, 9, 759 12 of 15

North East Covid Survey to provide information relevant on how to run the most effective
vaccination and ‘track-and-trace’ programmes. Issues such as the current approach to
vaccination by priority groups (with precedence mostly age-related, with some inclusion of
those deemed extremely vulnerable or, lower in the rankings, in particular, at-risk groups
linked to prior medical conditions—see reference [20]) and whether this is optimal or needs
amending to take account of other factors, such as ethnicity and/or location, are relevant
policy questions needing examination. In this study, it was found that who needed to
test or self-isolate, with their associated challenges, and those who received a vaccine
and the challenges they faced, as well as which factors were the most associated with
vaccine hesitancy, were not simply linked to the ages of the resident population. There are
a range of other factors that are important, and the present study confirmed that ethnicity
is important (especially when connected with religious affiliation), while another (linked to
the more vulnerable and at risk) is disability. In contrast, the level of social deprivation of
the area in which a resident lives seems less important (although whether the household
is relatively poor is significant). Overall, these results showed that there are complex
socioeconomic factors associated with the willingness to get a test, self-isolate, and the
levels of vaccine hesitancy, such that, in the future, ensuring that (re-)vaccination and ‘track
and trace’ programmes are successful may need to be better nuanced by references to
such factors rather than adopting vaccination programmes that mostly just rely on age as
the criteria for roll-outs. This also relates to the extent to which the government needs to
combat health inequalities and, especially, the “anti-vaxxer” movement [21,22] through
the better understanding of what makes certain people hesitant about undertaking C19
tests, self-isolating, and taking a vaccine. Hence, the results presented here lead to similar
conclusions as in reference [11], who stated “ . . . Our findings suggest, for example, that a
“one size fits all” approach to mass media interventions represents, at best, a partial solution
to increasing vaccination uptake and, at worst, a solution that backfires, amplifying existing
inequalities. These findings suggest that future interventions need to be targeted to a range
of sub-populations and diverse communities” (p. 6).
The major strengths of this study included its large sample size, representative of
the population covered after weighting; the range of outcomes considered (rather than
ex ante questions about the likelihood of whether residents are likely to get vaccinated);
and the range of covariates (including religious faith, sexual orientation, and the indus-
try/occupation of the respondent where relevant). A major caveat was the low level of rep-
resentation of ethnic minorities in the North East region (some 4.6% of those aged 16+ years,
when such minorities are classified as everyone except White British/Irish/Gypsy/Other
White); moreover, when restricting the sample to those with full data on a range of char-
acteristics (cf. Table 1), the weighted percentage for non-Whites fell to 3.1%. Thus, there
is some evidence that ethnic minorities are relatively more reluctant to provide full infor-
mation to this type of survey, and in any case, the North East (for this dimension) is not
representative of other areas such as London, the Midlands, or even the North West [23].

Funding: This research received no external funding.

Institutional Review Board Statement: Ethical review and approval were not applicable for this
study, as the household survey was conducted by Gateshead Council, and the secondary data analysis
did not require further approval at Durham University.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the
study by the Gateshead Council when conducting the survey.
Data Availability Statement: The SPSS and STATA code that cleaned the data and produced the
results reported here are available on request. Those wanting to use the dataset should contact the
Director of Public Health, Gateshead Council.
Acknowledgments: The author wishes to thank the Gateshead Council for permission to use the data
from their survey. None of the results presented here represent the views of any other third party.
Conflicts of Interest: The author declares no conflict of interest.
Vaccines 2021, 9, 759 13 of 15

Appendix A
The questions used to produce the outcome variables analysed in Table 2 are as follows:

Table A1. What challenges have you faced in accessing Coronavirus (COVID-19) testing? (please
tick all that apply).

Not applicable–my household have not needed to access testing No challenges faced
Not knowing where to get a test Distance to test sight
Lack of transport to the test site Lack of time to take the test
Cost of accessing test (e.g., transport/time off work) Childcare/Care responsibilities
Desire not to test positive due to
Desire not to test positive due to impact on social life
impact on employment
Rather not know my result Other
Note, all other responses other than ‘not applicable’ were coded 1 for the variable ‘needed testing’ in Table 2.
Other responses than ‘not applicable’ and ‘no challenges faced’ were coded 1 for the variable ‘challenge testing’.
Further details on the responses to this question are provided in Table S3 in reference [15].

Table A2. What challenges have you faced in completing self-isolation for the Coronavirus (COVID-19)?
(please tick all that apply).

Not applicable–my household have not needed

No challenges faced
to self-isolate
Not knowing who to ask
Lack of clarity around the rules for self-isolation
for advice
Accessing essentials like groceries
Childcare/Care responsibilities
and medications
Pressure from friends or family
Lost income
not to self-isolate
Pressure from work or employment not to self-isolate Mental health impacts
Other
Note, all other responses other than ‘not applicable’ were coded 1 for the variable ‘needed isolation’ in Table 2.
Other responses than ‘not applicable’ and ‘no challenges faced’ were coded 1 for the variable ‘challenge isolating’.
Further details on the responses to this question are provided in Table S4 in reference [15].

Table A3. Have you been vaccinated for the Coronavirus (COVID-19)? (please select one option only).

No Yes, I’ve had 1 dose Yes, I’ve had 2 doses

Table A4. To what extent do you agree or disagree with the following statements about vaccines?
(please select one option only in each row).

Neither
Strongly Tend to Tend to Strongly Don’t
Agree nor
Agree Agree Disagree Disagree Know
Disagree
I believe that a Coronavirus vaccine
a
approved by a UK Government a a a a a
a
body will be very safe
I believe that a Coronavirus vaccine
a
approved by the NHS will be a a a a a
a
very safe
I know enough about the safety of
a Coronavirus vaccine to make an
a
informed decision about whether a a a a a
a
or not to get vaccinated
for Coronavirus
Note, for the analysis carried out in Table 2, the ‘don’t know’ category was assigned to ‘Neither agree nor disagree’.
Vaccines 2021, 9, 759 14 of 15

Table A5. What are the practical challenges you face, or have faced, getting vaccinated for the
Coronavirus (COVID-19)? (please tick all that apply).

I don’t feel that I need it as I’ve already

None
had Coronavirus
I don’t feel that I need it as I’m not in a
I’d rather wait to see how safe it is
high-risk group
Childcare/Care responsibilities Worried it will make me unwell
Cost of accessing test (e.g., transport/time Pressure from friends or family not to get
off work) the vaccine
Pressure from work or employment not to get
Fear of needles
the vaccine
Other
Note, all other responses other than ‘none’ were coded 1 for the variable ‘challenge getting vaccine’ in Table 2.
Further details on the responses to this question are provided in Table S5 in reference [15].

References
1. Mangtani, P.; Breeze, E.; Kovats, S.; Ng, E.S.W.; Roberts, J.A.; Fletcher, A. Inequalities in influenza vaccine uptake among people
aged over 74 years in Britain. J. Epidemiol. Community Health 2005, 74, 964. [CrossRef] [PubMed]
2. Jain, A.; van Hoek, A.J.; Boccia, D.; Thomas, S.L. Lower vaccine uptake amongst older individuals living alone: A systemic review
and mete-analysis of social determinants of vaccine uptake. Vaccine 2017, 35, 2315–2328. [CrossRef] [PubMed]
3. Robertson, E.; Reeve, K.S.; Niedzwiedz, C.L.; Moore, J.; Blake, M.; Green, M.; Katikireddi, S.V.; Benzeval, M.J. Predictors of
COVID-19 vaccine hesitancy in the UK household longitudinal study. Brain Behav. Immun. 2021, 94, 41–50. [CrossRef] [PubMed]
4. World Health Organisation. Report of the SAGE Working Group on Vaccine Hesitancy. 2014. Available online: https://www.
who.int/immunization/sage/meetings/2014/october/1_Report_WORKING_GROUP_vaccine_hesitancy_final.pdf (accessed on
7 July 2021).
5. Razai, M.S.; Osama, T.; McKechnie, D.G.J.; Majeed, A. COVID-19 vaccine hesitancy among ethnic minority groups. BMJ 2021,
372, n513. [CrossRef] [PubMed]
6. OpenSAFELY. Collaborative Trends, Regional Variation, and Clinical Characteristics of COVID-19 Vaccine Recipients: A Retro-
spective Cohort Study in 23.4 Million Patients Using OpenSAFELY. 2021. Available online: https://www.medrxiv.org/content/
10.1101/2021.01.25.21250356v1 (accessed on 7 July 2021).
7. Osama, T.; Razai, M.S.; Majeed, A. COVID-19 vaccine allocation: Addressing the United Kingdom’s colour-blind strategy. J. R.
Soc. Med. 2021, 114, 240–243. [CrossRef] [PubMed]
8. SAGE. Factors Influencing COVID-19 Vaccine Uptake Among Minority Ethnic Groups. 2021. Available online: https:
//www.gov.uk/government/publications/factors-influencing-covid-19-vaccine-uptake-among-minority-ethnic-groups-17
-december-2020 (accessed on 7 July 2021).
9. Freeman, D.; Loe, B.S.; Chadwick, A.; Vaccari, C.; Waite, F.; Rosebrock, L.; Jenner, L.; Petit, A.; Lewandowsky, S.; Vanderslott,
S.; et al. COVID-19 vaccine hesitancy in the UK: The Oxford coronavirus explanations, attitudes, and narratives survey (Oceans)
II. Psychol. Med. 2020, 1–15. [CrossRef]
10. Freeman, D. COVID-19 Vaccine Hesitancy in the UK. Oxford Science Blog. 2020. Available online: https://www.ox.ac.uk/news/
science-blog/covid-19-vaccine-hesitancy-uk (accessed on 7 July 2021).
11. Williams, L.; Flowers, P.; McLeod, J.; Young, D.; Rollins, L. The CATALYST Project Team The CATALYST Project Team Social
Patterning and Stability of Intention to Accept a COVID-19 Vaccine in Scotland: Will Those Most at Risk Accept a Vaccine?
Vaccines 2021, 9, 17. [CrossRef] [PubMed]
12. Royal Society for Public Health. New Poll Finds Ethnic Minority Groups Less Likely to Want COVID Vaccine. 2020. Available on-
line: https://www.rsph.org.uk/about-us/news/new-poll-finds-bame-groups-less-likely-to-want-covid-vaccine.html (accessed
on 7 July 2021).
13. Idependent. Poorer Areas Falling Behind on Vaccination Against Coronavirus. 2021. Available online: https://www.independent.
co.uk/news/health/coronavirus-vaccination-deprivation-nhs-b1803021.html (accessed on 7 July 2021).
14. BBC News. Is Covid at Risk of Becoming a Disease of the Poor? Available online: https://www.bbc.co.uk/news/health-56162075
(accessed on 7 July 2021).
15. Harris, R. Experiences with Testing, Self-isolation and Vaccination in North East England during the COVID Pandemic. 2021.
Available online: https://www.dropbox.com/s/b9m4rkgdvivxo60/NHS%20analysis%20updated%2019.5.21.pdf?dl=0 (accessed
on 7 July 2021).
16. ONS. Quarterly Labour Force Survey, 1992–2020: Secure Access; 22nd Edition. 2021a. UK Data Service. SN: 6727. Available
online: https://beta.ukdataservice.ac.uk/datacatalogue/doi/?id=6727#!#22 (accessed on 7 July 2021).
Vaccines 2021, 9, 759 15 of 15

17. NIHR. Factors Associated with Vaccine Intervention in Adults Living in England Who Either do not Want or Have not Yet Decided Whether to
Be Vaccinated against COVID-19; Policy Brief; Policy Research Unit in Behaviour Science, NIHR, Newcastle University: Newcastle,
UK, 2020. Available online: https://research.ncl.ac.uk/behscipru/ourresearch/covid-19responsivework/vaccineintentions/
(accessed on 7 July 2021).
18. HCLG. English Indices of Social Deprivation. 2019. Available online: https://www.gov.uk/government/statistics/english-
indices-of-deprivation-2019 (accessed on 7 July 2021).
19. BBC News. Coronavirus: How the Pandemic has changed the World Economy. 24th January 2021b. Available online: https:
//www.bbc.co.uk/news/business-51706225 (accessed on 7 July 2021).
20. UK Government. COVID-19 Vaccination First Phase Priority Groups. 2021. Available online: https://www.gov.uk/government/
publications/covid-19-vaccination-care-home-and-healthcare-settings-posters/covid-19-vaccination-first-phase-priority-
groups (accessed on 7 July 2021).
21. Smith, T.C.; Reiss, D.R. Digging the rabbit hole, COVID-19 edition: Anti-vaccine themes and the discourse around COVID-19.
Microbes Infect. 2020, 22, 608–610. [CrossRef] [PubMed]
22. Orsini, M. Quit Mocking “Anti-Vaxxers” and Understand Roots of Vaccine Hesitancy; Institute for Science, Society and People,
University of Ottawa: Ottawa, ON, Canada, 2021; Available online: https://issp.uottawa.ca/en/news/quit-mocking-anti-
vaxxers-and-understand-roots-vaccine-hesitancy (accessed on 7 July 2021).
23. ONS. Regional Ethnic Diversity. 2018. Available online: https://www.ethnicity-facts-figures.service.gov.uk/uk-population-by-
ethnicity/national-and-regional-populations/regional-ethnic-diversity/latest (accessed on 7 July 2021).
Perspective
Oppose the right-wing campaign against
vaccination!
Statement of the WSWS Editorial Board
29 July 2021
The campaign being carried out against mass vaccination
is thoroughly right-wing and must be opposed by workers
throughout the world. Under conditions of the global
pandemic of a lethal virus, which has killed more than
four million people, according to official figures (in
reality, far more than 10 million), mass vaccination is an
elementary requirement of public health and the self-
defense of the working class.
Even the presentation of the issue as one of “vaccine
mandates” is false to the core, since it treats the issue of
vaccination as if it is some sort of infringement on
“personal liberty.” In fact, no individual has the “right” to
infect others and endanger their lives.
A health worker administers a dose of Janssen Johnson &
Johnson COVID-19 vaccine. (AP Photo/Leo Correa)
The safeguarding of public health in a mass society
depends on a whole host of regulations: the wearing of
seatbelts and speed limits, proscriptions against drunk
driving and smoking in public places, maximum
occupancies for buildings, rules for handicapped parking
and many other measures. Then there are the
achievements won through bitter struggle by the working
class (and everywhere under attack) like the eight-hour
day and the prohibition of child labor.
It is always the most right-wing forces that oppose the
protection of social rights by raising the banner of
“individual rights,” the most notorious of which is the
“right of profit.”
As for vaccinations, this is now a routine requirement for
foreign travel, frequently to protect travelers against
diseases in the countries they are visiting, to which they
may lack native immunity, but also against widespread
diseases like tuberculosis and malaria. These are
protections against death and severe illness, not
infringements on “personal liberty.”
It is, likewise, commonplace that children are required to
“have their shots” before attending school, including
against MMR, polio and other illnesses, despite the
criminally irresponsible efforts of “anti-vaxxer” groups.
Once a version of the COVID-19 vaccine is developed
that is effective and safe for children, which hopefully is
only months away, that should become a compulsory
requirement for school attendance as well.
There is nothing in the least progressive about the
campaign against “vaccine mandates.” It is based on
appeals to ignorance, fear and anti-scientific prejudice.
Those who are campaigning against vaccinations by
claiming they are an intolerable violation of personal
liberty are peddling anarchism and libertarianism, which
has nothing in common with the interests of the working
class.
It should come as no surprise that the trade unions, which
have done nothing to protect workers against the
pandemic, have joined in the campaign. The Service
Employees International Union, which refused to fight the
wave of infections and deaths in nursing homes last year,
called a demonstration last week in New York City
against mandatory vaccination of health care workers.
There, Randi Weingarten of the American Federation of
Teachers, who has demanded the reopening of all schools
for in-person instruction regardless of the pandemic,
mouthed phrases against vaccine requirements because of
the need “for everyone to feel safe and welcome in their
workplaces.”
Given the fact that the consequences of an infected person
working in a crowded workplace, school or hospital can
be catastrophic, the requirement that he or she be
vaccinated is entirely legitimate and necessary.
It is unavoidable that anyone who has access to a vaccine
but refuses to get it cannot be allowed to work beside
others. In such cases, the individual should be placed on
furlough, which can be brought to an end as soon as he is
vaccinated. This must be combined with a systematic
public education campaign, led by medical experts and
health care workers, to explain the benefits and
insignificant risks of being protected against COVID-19.
To pose the problem as one of individual negligence,
however, is fundamentally wrong. It is not workers who
are responsible for the catastrophic spread of COVID-19,
but the ruling class. A genuine change in public attitudes
involving millions of people is possible only under
conditions in which there is an industrial and political
movement of the working class against the entire policy
of the financial oligarchy in response to the pandemic.
The campaign against “vaccine mandates” is the latest
stage in the opposition of the ruling class to all necessary
measures to stop the spread of the pandemic. It is truly
tragic that many of those who have been entrapped by this
campaign, by failing to take a vaccination are placing
their own lives and the lives of family members and co-
workers at grave risk.
Not only has there been no mass education campaign to
promote vaccination, but there has been a systematic
miseducation campaign from the ruling class throughout
the pandemic, combined with the longer-term promotion
of reactionary anti-scientific conceptions.
The entire response of the ruling class to the pandemic
has been shot through with deceit and criminality: from
the initial downplaying of the danger, to the efforts to
force workers back to work even as the pandemic was still
spreading, to the lying claim that it was China that was
responsible for mass death and not the capitalist oligarchy
that refused to take the necessary measures to stop it.
The policies of the Biden administration, building on
those of the Trump administration, seem almost
deliberately calculated to fuel public skepticism. Trump
and his fascistic followers denounced all public health
measures from the beginning, attacking lockdowns and
pledging to “liberate Michigan” and other states with even
limited restrictions. Republican-ruled states now have the
noxious combination of low vaccination percentages and
accelerating infection rates as the Delta variant runs wild.
Alabama Governor Kay Ivey now blames the soaring
coronavirus toll on the unvaccinated, but it was her own
party that led the campaign against taking the threat of the
pandemic seriously.
The Biden administration set as its top priority the
reopening of in-person education, regardless of the impact
on teachers and students, so that parents could be sent
back to work in factories and offices. The Centers for
Disease Control and Prevention ended its regulations on
mask mandates following the Biden administration’s
claim that the pandemic was effectively over. It has been
compelled to partially backtrack and advocate mask-
wearing for the vaccinated under limited circumstances
only because the explosive growth of the Delta variant
made some change unavoidable.
Mass vaccination is only one component of what must be
a global effort to eradicate the virus, through masking,
social distancing, mass testing and the shutdown of
nonessential production until the entire population of the
world has been made safe. Such an effort, to be paid for
by the trillions accumulated by the super-rich, requires the
political intervention of the working class against the
policies of the capitalist ruling elite, which at every point
prioritizes profits over human life and the interests of
rival nation-states over the collective needs of humanity.
On a global scale, the vast majority of humanity has as yet
no access to vaccines at all, as the vaccine-producing
countries in the industrialized world have hoarded
virtually the entire supply. Barely one percent of the
population of Africa have been fully vaccinated. The rates
in South and Southeast Asia are not much better. And the
vast social polarization in every capitalist country means
that the wealthy and the upper-middle class may have
easy access to vaccination, but the poor have virtually
none.
This is true in the wealthy countries as well. A major
obstacle to vaccination in the United States is poverty,
both for those living in urban slums and those in rural
isolation. One recent study found that, according to
Census Bureau data, more than half of unvaccinated
Americans live in households with incomes of less than
$50,000 annually. The study’s authors remarked that in
explaining the failure to get an inoculation, despite an
ample supply of vaccines, “juggling work schedules and
child care could be bigger factors than politics.”
The policy of the working class must combine political
intransigence and patient explanation. The development
of a class-conscious labor movement, through the
organization of rank-and-file safety committees in every
workplace, would enable workers, particularly those in
health care, to become advocates in a political campaign
to require vaccination and protect their class from the
deadly danger of the pandemic.
The fight against the pandemic is not simply a medical
issue. It requires a political struggle of the working class
against the capitalist system. The response to the
pandemic in the interests of public health requires a
global plan and global coordination, which is possible
only through the building of an international
revolutionary leadership and the taking of power by the
working class.
https://www.wsws.org/en/articles/2021/07/29/pers-j29.html
 News

The online anti-vaccine movement in the age of COVID-19

A new report by the Centre for they had seen “a lot or a great deal of YouTube removed advertisements

Numstocker/Shutterstock.com
Countering Digital Hate (CCDH) has false or misleading” information about from anti-vaccine videos, meaning
lambasted social media com­panies for COVID-19 on social media during the the account holders would not make
allowing the anti-vaccine movement to previous week. money, and Twitter ensured that the
remain on their plat­forms. The report’s “Attention grabbing headlines with National Health Service or Department
authors noted that social media sensationalist content can attract of Health and Human Services would
accounts held by so-called anti-vaxxers even the savviest internet users and appear as the first result for anyone For more on the report by the
have increased their following by at studies have shown they tend to searching for vaccine-related topics in CCDH on the anti-vaxx industry
see https://252f2edd-1c8b-49f5-
least 7·8 million people since 2019. generate more user engagement”, the UK and USA, respectively. 9bb2-cb57bb47e4ba.filesusr.
“The decision to continue hosting warned the Organisation for Economic In August, 2020, Facebook deleted com/ugd/f4d9b9_7aa1bf981990
known misinformation content and Cooperation and Development, a video posted by the US President, 4295a0493a013b285a6b.pdf

actors left online anti-vaxxers ready to in July, 2020. “As a result, content Donald J Trump, in which he suggested For publicly available data on
Facebook generated revenues
pounce on the opportunity presented personalisation algorithms can that children were “almost immune” see https://s21.q4cdn.com/
by coronavirus”, stated the report. The repeatedly expose people to the same to SARS-CoV-2, on the grounds 399680738/files/doc_news/
CCDH warned that the growing anti- or similar content and ads even on the that it contained “harmful COVID Facebook-Reports-Fourth-
Quarter-and-Full-Year-2019-
vaccine movement could undermine basis of disinformation.” misinformation”. Twitter suspended Results-2020.pdf
the roll-out of any future vaccine The CCDH report divided the online Trump’s campaign account, which For more on the survey about
against COVID-19. anti-vaccine movement into four posted the same video. “The platforms social media and COVID-19 see
The report noted that 31 million (sometimes overlapping) groups. First, genuinely want to tackle this problem”, https://f4d9b9d3-3d32-4f3a-
afa6-49f8bf05279a.usrfiles.com/
people follow anti-vaccine groups campaigners work full-time to foment explained Heidi Larson, director of ugd/f4d9b9_87e35c162490470
on Facebook, with 17 million people distrust in vaccines, but they only reach the Vaccine Confidence Project at the 9a8c81b6a93bdee47.pdf
subscribing to similar accounts 12% of the total audience that follows London School of Hygiene and Tropical For more on the survey by the
on YouTube. The CCDH calculated the anti-vaccine movement. Second, Medicine. “Facebook have hired a Reuters Institute for the Study
of Journalism on the Infodemic
that the anti-vaccine movement entrepreneurs reach around half of lot of people to work on this and
and COVID-19 see https://
could realise US$1 billion in annual the anti-vaccine following, exposing they are genuinely motivated to find reutersinstitute.politics.ox.ac.uk/
revenues for social media firms. As them to advertisements for products answers. You often find that the staff sites/default/files/2020-04/
much as $989 million could accrue purporting to have health benefits. in the social media firms are putting Navigating%20the%20
Coronavirus%20Infodemic%20
to Facebook and Instagram alone, The CCDH report accuses Facebook pressure on management to get FINAL.pdf
largely from advertising targeting the of being a “shopfront for anti-vaxx things right—people want to feel good For more on the OECD guidance
38·7 million followers of anti-vaccine products”, directing customers to about where they work.” Facebook to tackle COVID-19
accounts. Huge sums indeed, but it is online marketplaces where these uses fact-checkers to identify and label disinformation see http://www.
oecd.org/coronavirus/policy-
worth noting that, in 2019, Facebook products can be purchased. Imran false information about COVID-19. responses/combatting-covid-19-
generated revenue of $70·7 billion. Ahmed, founder and chief executive Twitter has similar policies. Alongside disinformation-on-online-
A survey commissioned by the officer of CCDH, advocates prosecuting Facebook, it has also offered free platforms-d854ec48/#section-
d1e139
CCDH and released alongside their vendors who make false claims advertising space to WHO and national
For more on the report by the
report found that around one in about their products. “Going after a health authorities. CCDH entitled Failure to Act see
six British people were unlikely to few high-profile hucksters who are The CCDH is unconvinced. Their https://252f2edd-1c8b-49f5-
agree to being vaccinated against exploiting and encouraging anti- latest report, entitled Failure to Act, 9bb2-cb57bb47e4ba.filesusr.
com/ugd/f4d9b9_8d23c70f0a01
severe acute respiratory syndrome vaccine sentiment to make money describes how out of 912 posts
4b3c9e2cfc334d4472dc.pdf
coronavirus 2 (SARS-CoV-2), and a would be a powerful disincentive to containing misinformation about
For the paper published in
similar proportion had yet to make up anyone else considering choosing COVID-19, fewer than one in 20 were Nature analysing online views
their mind. The survey, which polled the same path”, he said. Conspiracy dealt with by social media companies. on vaccination see Nature 2020;
582: 230–33
1663 people, found that individuals theorists constitute the third category. Ahmed argues for a far sterner
who relied on social media for Finally, there are the communities, response: removing the anti-vaccine
information on the pandemic were which have a relatively small following movement from the platforms.
more hesitant about the potential and are mainly to be found on “The first step is to de-platform”,
vaccine. WHO has warned of an Facebook. he said. “Shutting down spaces and
infodemic of false information about In 2019, several social media firms de-platforming individuals is the single
COVID-19 spreading online. Around a pledged to act against the anti-vaccine most effective tool for dealing with
third of respondents to a six-country movement. Facebook announced that these sorts of malign actors.” Ahmed
survey by the Reuters Institute for it would not recommend content that cites studies from counterterrorism,
the Study of Journalism reported that contained misinformation on vaccines. in which de-platforming was found

www.thelancet.com/digital-health Vol 2 October 2020 e504

 News

to cause networks to fragment. “It is then there is a strong incentive for “I want to reduce the R0, rather than
the one thing that absolutely works. It the platforms to remove it; we have treat the disease.”
cripples the networks and it is the best seen plenty of examples of advertisers Public attitudes towards vaccination
way to stop the anti-vaxx infection refusing to be associated with can be split into three categories.
from spreading”, he stated. particular material”, he explained. First, there are people who have been
Vish Viswanath, Professor of Health Instead of de-platforming, Viswanath persuaded of the merits of vaccination.
Communication in the Department advises that vaccine advocates should In the UK and USA, this group consti­
of Social and Behavioral Sciences at be putting their energy into rebutting tutes somewhere between 70% and
the Harvard T H Chan School of Public anti-vaccine arguments. “Groups 90% of the population. Second, there
Health, disagrees. “De-platforming such as the CCDH deserve a great deal are dogmatic anti-vaxxers. “These
makes me nervous”, he said. “This of credit for calling attention to this are people on the fringes”, explains
is an issue of freedom of speech. issue, and adopting such a combative Viswanath. “They are not going to
Unless you have a situation where attitude”, he said. “For much too change their views.” Between the
there is blatant misinformation that long, the pro-vaccine groups have two groups lies a third comprising
is directly causing harm, you have been reactive and reticent; they have people who are undecided. “These
to ask ‘where do you draw the line?’ assumed that science can speak people have legitimate questions”,
You might have actors whose anti- for itself. That has not worked. We said Viswanath. “They want to do the
vaxx activities are not taking place on need to throw light on these malign right thing, but they have doubts. This
their social media channel, are they actors, refute their arguments very is where we need to be focusing our
also to be removed?” Shutting down aggressively and proactively.” attention.”
conspiracy theorists and campaigners Viswanath believes that the The anti-vaccine movement look as
risks making them into martyrs and platforms are still not acting quickly if they have already figured this out.
could even lend credence to their enough. “They are making some A paper published in Nature earlier
arguments that they are speaking tentative steps, but it is insufficient. this year mapped online views on
truth to power. “You cannot just take It is not adequate to simply flag vaccination. The authors concluded
away the stage, and assume these inappropriate posts; people will still that “although smaller in overall size,
people are going to go away”, adds read them and we know that even if anti-vaccination clusters manage
Larson. “We are talking about very a falsehood is labelled as such, people to become highly entangled with
deep-rooted beliefs; they will simply will still remember it, and some people undecided clusters in the main online
find another stage.” will believe it”, he said. “Our response network, whereas pro-vaccination
The CCDH-commissioned survey has to draw on the science of how clusters are more peripheral”. They
found strong public support for people develop these beliefs and then warned that in a decade the anti-
sanctions such as financial penalties we can take up strategies to call the vaccination movement could over­
and advertising boycotts against anti-vaxxers on their misinformation, whelm pro-vaccination voices online.
social media companies that declined rather than completely eliminate their If that came to pass, the consequences
to remove “material designed to voices.” Ahmed counters that there would stretch far beyond COVID-19.
spread fake news or misinformation is limited evidence on the efficacy
on vaccines”. Ahmed points out that of rebuttal. “The best way to stop Talha Burki
98% of Facebook’s revenues come someone from becoming an anti- Copyright © 2020 The Author(s). Published by
from advertising. “If advertisers are vaxxer is to stop them from becoming Elsevier Ltd. This is an Open Access article under
the CC BY 4.0 license.
scared off by the content on a site, infected in the first place”, he stated.

e505 www.thelancet.com/digital-health Vol 2 October 2020

862949
article-commentary2019
GPHXXX10.1177/2333794X19862949Global Pediatric HealthBenecke and DeYoung

Humanitarian and Crisis Research- Commentary

Global Pediatric Health

Anti-Vaccine Decision-Making Volume 6: 1­–5 

© The Author(s) 2019
Article reuse guidelines:
and Measles Resurgence in sagepub.com/journals-permissions
DOI: 10.1177/2333794X19862949
https://doi.org/10.1177/2333794X19862949

the United States journals.sagepub.com/home/gph

Olivia Benecke, BA1 and Sarah Elizabeth DeYoung, PhD2

Keywords
vaccination; pediatrics; health behavior; health communication

Received May 10, 2019. Received revised June 4, 2019. Accepted for publication June 13, 2019.

Introduction Historical Context

Measles outbreaks in 2019 reached emergency levels in In the United States, fear of vaccines emerged in the
the United States, in addition to other countries such as 18th century. Religious figureheads often referred to
the Philippines, Ukraine, Venezuela, Brazil, Italy, France, them as “the devil’s work” and actively spoke against
and Japan.1 The aim of our article is to provide an over- them.4,5 In the 19th century, the movement became
view of the major social, psychological, and technologi- increasingly politically motivated as passage of laws in
cal factors that led to these outbreaks in the United States. Britain made it mandatory for parents to vaccinate
We also explore the policy landscape and potential solu- their children. In response, anti-vaccine activists
tions for public health researchers. Specifically, we formed the Anti-Vaccination League in London,
address the social and contextual factors can provide emphasizing their mission to protect individual liber-
health professionals with tools to develop an effective ties that were being “invaded” by government.5 These
pro-vaccine response campaign for this highly conta- movements expanded to Britain in the 1970s and 1980s
gious, preventable disease. when parents increasingly refused to vaccinate their
children against pertussis in response to a report that
Epicenter of the Outbreak attributed 36 negative neurological reactions to the
pertussis vaccine. This caused a decrease in the pertus-
During January 2019, a measles outbreak in Clark sis vaccine uptake in the United Kingdom from 81% in
County, Washington, in the United States infected 72 1974 to 31% in 1980, eventually resulting in a pertus-
people, 53 of whom were children aged between 1 and sis outbreak in the United Kingdom.5
10 years. This prompted the governor to declare a state of However, the anti-vaccination sentiments in recent
emergency.2 Though once eliminated, measles outbreaks decades were also fomented by the 1998 publication of a
are becoming increasingly common. Since 2014, public series of articles in The Lancet by a former British doc-
health officials have observed an increase in vaccine tor, Andrew Wakefield. Wakefield suggested a connec-
opposition throughout the United States, primarily con- tion between the measles, mumps, and rubella (MMR)
centrated in major metropolitan areas. Seventeen states vaccine and development of autism in young children.
allow for nonmedical vaccination exemptions. This dan- Despite flawed research methodology, and conflict of
gerous trend renders multiple populous cities vulnerable interest in funding, the MMR vaccine rates continued to
to vaccine-preventable diseases.3 Recent resurgences of drop dramatically. Members of the anti-vaccine
measles, mumps, and pertussis and increased mortality
from vaccine-preventable diseases prompt an in-depth
exploration of the social and behavioral factors that influ- 1
University of Georgia, Athens, GA, USA
ence the “anti-vaxx” movement. Understanding these 2
University of Delaware, Newark, DE, USA
social and behavioral factors can prevent these behav-
Corresponding Author:
ioral trends from gaining additional traction throughout Sarah Elizabeth DeYoung, University of Delaware, 166 Graham Hall,
the United States and beyond, protecting an increasingly 111 Academy Street, Newark, DE 19716, USA.
connected world from preventable illnesses. Email: [email protected]

Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons
Attribution-NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-
commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified
on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
2 Global Pediatric Health

movement still cite his research as a talking point in anti-vaccination.5 Skeptics also use online platforms to
refuting vaccinations. advocate vaccine refusal; as many as 50% of tweets
There is an inverse association between nonmedical about vaccination contain anti-vaccine beliefs.10
exemption rates and MMR vaccine coverage of kinder- Research suggests that it only takes 5 to 10 minutes on
garteners in the 17 states that allow for vaccination an anti-vaccine site to increase perceptions of vaccina-
exemptions.3 States with higher overall nonmedical tion risks and decrease perceptions of the risks of vac-
exemption rates have lower MMR vaccine coverage, cine omission.5
demonstrating the dangerous and lasting influence of Among these social media influencers are parents
Wakefield’s publication. who attribute the deaths of their children or illnesses
The anti-vaxx movement may also be situated within they contract to “vaccine injury,” and they often take to
economic and social movements in the United States. the Internet to discuss their experiences and warn other
Sociological research on parental perception about vac- parents. Indeed, a substantial part of the vaccine discus-
cination decision-making reveals that gender, resources, sion takes place on anti-vaccine website discussion
and norms influence medical decision-making.6,7 As boards such as Age of Autism, Say No to Vaccines, and
Reich6 points out, ideas about neoliberalism and skewed Naturalnews.com.12 Even on mainstream social media
perceptions of feminist concepts of bodily autonomy sites like Facebook and Twitter, anti-vaccine discussions
and parental decision-making trumps medical expertise. are flourishing as these groups have closed their forums
Reich’s data and findings suggest that upper-class to anyone who describes themselves as “pro-vaccine.”
women may adopt anti-vaxx sentiments as a means for According to Shelby and Ernst,12 these parents and other
expressing independence—while tragically undermin- anti-vaccine activists “have relied on the profound
ing the value and science behind herd immunity. The power of storytelling to infect an entire generation of
landscape of vaccination is complex. Lack of access to parents with fear and doubt”.
regular healthcare— for low-income families, can Perhaps the most common trope told by this group is
reduce vaccination compliance (Chen et al., 2018).8 the “overnight autism” narrative, in which a parent
takes their child in to get the MMR vaccine only to
The Role of Social Media in the watch them digress cognitively almost immediately
after.12 In the anti-vaccine community, these stories
Anti-Vaxx Movement
serve as cautionary tales that vaccines are dangerous
Persuasion from entertainment and pop culture figures without accurate information to refute their claims.
can influence health behavior and decision-making Additionally, the widespread involvement of bots and
about vaccinations (eg, Tiedje et al10). Celebrities such malware promoted by foreign powers in online public
as Jenny McCarthy, Alicia Silverstone, Rob Schneider, health discourse is skewing discussions about vaccina-
and Robert De Niro used fear-based messaging to influ- tion. In 2015, DARPA’s (the US Defense Advanced
ence parents to avoid vaccination, particularly in claim- Research Projects Agency) Bot Challenge asked
ing a false link between vaccinations and autism.5 researchers to identify “influence bots” on Twitter in a
Political leaders also play a role in spreading misinfor- stream of vaccine-related tweets, focusing heavily on
mation. Donald Trump shared anti-vaxx messages on the actors behind the content.11 Researchers studied
social media,9 although in recent months he encouraged #VaccinateUS, a Twitter hashtag linked directly to
vaccinations. More recently, vocal representative Russian troll accounts connected to the Internet
Jonathan Strickland in Texas described vaccinations as Research Agency—a company backed by the Russian
“sorcery.” government that specializes in online influence proj-
Another reason skepticism has begun to flourish over ects.11 One of the primary tactics used by these influ-
vaccinations is due to the spread of misinformation on ence bots is to use the vaccine debate to target
social media.20 Medical knowledge that was once held socioeconomic tensions that are unique to the United
exclusively by medical professionals is now accessible States. For example, anti-vaccine tweets from this
to anyone and can be shared in posts that become “viral.” source will often blame elite groups for forcing vaccine
According to an analysis of YouTube videos about on low-income people. In addition, it was determined
immunization, 32% opposed vaccination.5 Perhaps more that “93% of tweets about vaccines are generated by
concerning, these videos had higher ratings and more accounts whose provenance can be verified as neither
views than pro-vaccine videos. In addition, a study that bots nor human users yet who exhibit malicious behav-
explored the content of the first 100 anti-vaccination iors.”11 This amplifies the misinformation that parents
sites found after typing “vaccination” and “immuniza- are exposed to, and it fuels the belief that the science
tion” into Google revealed that 43% of websites were behind vaccine efficacy and safety is still debatable.
Benecke and DeYoung 3

Psychological Factors and Beliefs Education and Anti-Vaxx

In tandem with access to information, components of Movements
social psychology play a key role in understanding the Effectively countering the anti-vaccine movement
escalation of the anti-vaccine movement. After surveying should be addressed through understanding mechanisms
1000 parents of children younger than 13 years of age for increasing trust between the medical community and
who were living in the United States, researchers found parents. Issues of mistrust began with the way in which
that the morals of purity and liberty were most associated the measles vaccine campaign was introduced in the
with vaccine hesitancy.14 Those who place high value on United States in 1967. Concerned by the relationship
liberty are most concerned with individual freedom, between socioeconomic disparities and infectious dis-
resenting government mandates that demand parents vac- ease incidence, the Johnson administration made federal
cinate their children. Similarly, those who value purity funds for measles vaccination available starting in 1965.
disapprove “of acts that are deemed ‘disgusting’ or A mass measles eradication began in 1967, which did
‘unnatural,’” which they associate with vaccination.14 not allow popular confidence around the vaccine to take
Indeed, anti-vaccination websites and other propaganda hold.4 In addition, early side effects left some parents
often claim that vaccines contain “contaminants.” skeptical.
According to epidemiologist Amin,14 this finding is sig- In Great Britain, public health officials and policy-
nificant because many pro-vaccine arguments and cam- makers cautiously established a large-scale clinical trial
paigns are grounded on the values of harm and fairness. to distinguish the relative benefits of the different avail-
For example, they usually strive to remind parents that able vaccines and possible immunization schedules.4
getting immunized helps prevent outbreaks, or they frame Through this, the goal was to convince parents about
it as an obligation to protect those who cannot be vacci- vaccination efficacy from a disease they previously
nated.14 Understanding the sociobehavioral variables that thought to be inevitable.4 This method of transparency
influence vaccine-hesitant parents is critical because it was a success, and mass evacuations were accepted by
will allow the public health community to develop a more the public when they were introduced in 1968.4 The dis-
targeted and effective response campaign that will pre- parities in these cases highlight the importance of the
vent this dangerous movement from growing. responsibility held by doctors and public health officials
in keeping the science behind vaccines transparent and
Mitigation Against Misinformation parents informed. This allows confidence and trust
around the practice to take hold.
Sites like Facebook, Twitter, and Instagram are all home In the United States, most of the Centers for Disease
to flourishing anti-vaccine communities. In 2017, Control and Prevention Vaccine Information
Pinterest blocked all searches for the term “vaccines,” Statements parents receive before vaccination dedi-
as a part of the company’s enforcement of a broader cate almost half of their information to detailing risks
policy against health misinformation.15 Soon after, of the vaccines and providing information to parents
YouTube announced that anti-vaccine channels and on how to report negative vaccine reactions to the
videos on its platform would no longer be able to adver- National Vaccine Injury Compensation Program.12
tise or receive money from viewers. In addition, in This does little to reassure parents who may feel fear-
March of 2019, Facebook said it will no longer recom- ful or skeptical. Information in these statements should
mend groups and pages that spread hoaxes about vac- also contain content about the benefits of vaccina-
cines, and that it will also reject ads that do this.15 tions. Outreach efforts should also focus on communi-
Instagram also recently announced that it would block ties and marginalized group that may have higher
anti-vaccine hashtags, such as #vaccinescauseautism levels of mistrust in government-based medical ser-
and #vaccinesarepoison.16 vices. It is also important to acknowledge the harm
Despite these strides, groups are still finding ways caused to racial minorities by government trials such
to spread misinformation. For example, one can still as the Tuskegee Study in the United States (Reverby,
find anti-vaccine content on Pinterest by instead 2017).13 Eroded trust can still be a factor today in
searching for “measles vaccine.” While Facebook’s medical decision-making, and this historical context
new policies are making it more difficult for a lay per- should be considered when working with communities
son to come across anti-vaccine propaganda, the plat- for vaccination promotion.
form is not banning the groups altogether.15 Twitter has In addition, public health officials should use social
yet to make any formal announcements regarding science and behavioral research to develop pro-vaccine
action against anti-vaccine related content.16 narratives. Indeed, emerging evidence suggests that one
4 Global Pediatric Health

of the most persuasive and effective means of communi- parents about vaccines that includes outreach for vul-
cating vaccine information to some parents is through nerable communities. Finally, K-12 policies on vac-
sharing anecdotes.12 Doctors and public health organiza- cines and common loopholes should be addressed
tions should publish stories online or in pamphlets of through policy change.
successful vaccine appointments and preventable dis- These longterm programs should be carried out
ease horror stories. Some parents who feel strongly through collaborative efforts. Research by sociologists,
about the importance behind vaccines may serve as psychologists, public health researchers, and other
“vaccine ambassadors.”12 These parents can volunteer scholars should be integrated with strategies launched
to provide their e-mail addresses or phone numbers to by nonprofits, state-level health initiative, and commu-
the clinic to hand to vaccine-hesitant parent, allowing nity health promotion efforts.
peer-to-peer communication to serve as interventions.17
Author Contributions
Policy Implications Both authors contributed to the writing for this article. The
first author (Benecke) wrote initial drafts of the content and the
The anti-vaccine movement poses several implications second author (DeYoung) provided guidance on revisions and
for the future direction of public health policy. Developing organization of content.
public policy that closes vaccine loopholes is critical.
Despite all 50 states having legislation requiring vaccines Declaration of Conflicting Interests
for students, almost every state allows exemptions for The author(s) declared no potential conflicts of interest with
people with religious beliefs against immunizations. respect to the research, authorship, and/or publication of this
Specifically, 17 states grant philosophical exemptions for article.
those opposed to vaccines because of personal or moral
beliefs, and 45 permit “conditional entrance” on the Ethical Approval and Informed Consent
promise that children will be vaccinated. Rarely do
Ethical approval or informed consent was not needed for this
schools follow-up.16 Indeed, lifetime exemption is as easy article because human subject data were not gathered for this
as obtaining a notarized letter. research.
Exemptions cluster geographically—these are
places at greater risk as herd immunity disappears. In Funding
order to counter these loopholes, the Centers for
Disease Control and Prevention recommends that The author(s) received no financial support for the research,
authorship, and/or publication of this article.
states begin by implementing vaccination require-
ments that reach more children through a broad range
of facilities, that have more requirements for receiving ORCID iD
an exemption, that require parental documentation of Sarah Elizabeth DeYoung https://orcid.org/0000-0001
exemption requests, and that are implemented with -8420-8762
strong enforcement and monitoring.18 Indeed, with the
recent measles outbreaks that occurred this past win- References
ter, 8 states are considering removing personal exemp- 1. Wamsley L. Measles is spiking around the globe. How
tions for the measles vaccine.19 As of right now, only 3 worried should we be? https://www.npr.org/sections/
states—Mississippi, West Virginia, and California— goatsandsoda/2019/03/12/697928724/measles-is-spiking-
prohibit nearly all vaccine exemptions. This number is around-the-globe-how-worried-should-we-be. Published
expected to grow as bills to restrict exemptions are March 12, 2019. Accessed April 13, 2019.
now pending in a growing number of states.19 2. WashingtonStateDepartmentofHealth.Measles2019.https://
www.doh.wa.gov/YouandYourFamily/IllnessandDisease/
Measles/MeaslesOutbreak. Accessed March 17, 2019.
Long-Term Solutions 3. Olive JK, Hotez PJ, Damania A, Nolan MS. The state of
the antivaccine movement in the United States: a focused
To address the root causes of the measles outbreak,
examination of nonmedical exemptions in states and
social science can inform community-based interven- counties. PLoS Med. 2018;15:e1002578. doi:10.1371/
tions and policies. journal.pmed.1002578
Additionally, social media platforms should play an 4. Hendriks J, Blume S. Measles vaccination: before the mea-
active role in monitoring and banning false informa- sles-mumps-rubella vaccine. American Journal of Public
tion. Second, medical and public health professionals Health. 2013;103:1393-1401. doi:10.2105/AJPH.2012
must take a different approach in informing skeptical .301075
Benecke and DeYoung 5

5. Hussain A, Ali S, Ahmed M, Hussain S. The anti-vaccina- of Public Health, 107(1), 14-15. https://doi-org.proxy-
tion movement: a regression in modern medicine. Cureus. remote.galib.uga.edu/10.2105/AJPH.2016.303554
2018;10:e2919. doi:10.7759/cureus.2919 14. Amin AB, Bednarczyk RA, Ray CE, et al. Association
6. Reich JA. Neoliberal mothering and vaccine refusal: of moral values with vaccine hesitancy. Nat Hum Behav.
imagined gated communities and the privilege of choice. 2017;1:873-880.
Gender Soc. 2014;28:679-704. 15. Ortutay B. How social media is trying to contain misin-
7. Reich JA. Of natural bodies and antibodies: parents’ vac- formation over vaccines. https://www.pbs.org/newshour/
cine refusal and the dichotomies of natural and artificial. health/how-social-media-is-trying-to-contain-the-spread-
Soc Sci Med. 2016;157:103-110. of-misinformation-over-vaccines. Published April 5,
8. Chen, W., Elam-Evans, L. D., Hill, H. A., & Yankey, 2019. Accessed April 13, 2019.
D. (2018). Employment and Socioeconomic Factors 16. Belluz J. Instagram, Facebook, and YouTube are crack-
Associated With Children’s Up-to-Date Vaccination ing down on fake vaccine news. https://www.vox.
Status. Clinical Pediatrics, 56(4), 348–356. https:// com/2019/3/1/18244384/measles-outbreak-vaccine
doi-org.proxy-remote.galib.uga.edu/10.1177/ -washington. Updated March 22, 2019. Accessed April
0009922816660540 13, 2019.
9. Schwartz JL. Vaccines and the Trump administra- 17. Krisberg K. Study: training parents as immunization advo-
tion—reasons for optimism amid uncertainty. Am cates a promising approach to vaccine hesitancy. http://
J Public Health. 2017;107:1892-1893. doi:0.2105/ www.thepumphandle.org/2017/05/01/study-training-par
AJPH.2017.304111 ents-as-immunization-advocates-a-promising-approach-
10. Tiedje K, Shippee ND, Johnson AM, et al. “They leave to-vaccine-hesitancy/#.XRMMv-gzbIU. Published May
at least believing they had a part in the ­ discussion”: 1, 2017. Accessed June 26, 2019.
­
understanding decision aid use and ­ patient–clinician 18. Centers for Disease Control and Prevention. State vacci-
­decision-making through qualitative research. Patient Educ nation requirements. https://www.cdc.gov/vaccines/imz-
Counsel. 2013;93:86-94. doi:10.1016/j.pec.2013.03.013 managers/laws/state-reqs.html. Accessed April 13, 2019.
11. Broniatowski DA, Jamison AM, Qi S, et al. Weaponized 19. Neighmond P. States move to restrict parents’ refusal to
health communication: Twitter bots and Russian vaccinate their kids. https://www.npr.org/sections/health-
trolls amplify the vaccine debate. Am J Public Health. shots/2019/02/28/698606894/states-move-to-restrict-par-
2018;108:1378-1384. ents-refusal-to-vaccinate-their-kids. Published February
12. Shelby A, Ernst K. Story and science: how providers and 28, 2019. Accessed April 13, 2019.
parents can utilize storytelling to combat anti-vaccine 20. Wong JC. How Facebook and YouTube help spread

misinformation. Hum Vaccin Immunother. 2013;9:1795- anti-vaxxer propaganda. https://www.theguardian.com/
1801. doi:10.4161/hv.24828 media/2019/feb/01/facebook-youtube-anti-vaccination-
13.
Reverby, S. M. (2017). Historical Misfeasance: misinformation-social-media. Published February 1,
Immorality to Justice in Public Health. American Journal 2019. Accessed April 13, 2019.
Journal of Law and the Biosciences, 229–249
doi:10.1093/jlb/lsx017
Advance Access Publication 20 June 2017
Original Article

Injecting doubt: responding to the

naturopathic anti-vaccination rhetoric
Timothy Caulfield∗ , Alessandro R Marcon and Blake Murdoch

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

Health Law Institute, Faculty of Law, University of Alberta, Edmonton, AB T6G 2H5, Canada
∗
Corresponding author. E-mail: [email protected]

A B ST R A CT
There is growing controversy about vaccination rates in Canada. A signifi-
cant percentage of the population is uncertain about the science of vaccines,
and in some areas ‘herd immunity’ is being threatened. Hesitancy to vacci-
nate is a complex phenomenon, but there is little doubt that complemen-
tary and alternative medicine (CAM) providers have played a role. In this
study, our first objective was to examine websites of naturopathic clinics and
practitioners in the provinces of British Columbia and Alberta, looking for
(1) the presence of discourse that may contribute to vaccine hesitancy, and
(2) recommendations for ‘alternatives’ to vaccines or flu shots. Of the 330
naturopath websites we analysed, 40 included vaccine hesitancy discourse
and 26 offered vaccine or flu shot alternatives. Using these data, we explored
the potential impact such statements could have on the phenomenon of vac-
cine hesitancy. Our second objective was to consider these misrepresenta-
tions in the context of Canadian law and policy, and to outline various le-
gal methods of addressing them. We concluded that tightening advertising
law, reducing CAM practitioners’ ability to self-regulate, and improving en-
forcement of existing common and criminal law standards would help limit
naturopaths’ ability to spread inaccurate and science-free anti-vaccination
and vaccine-hesitant perspectives.

K E Y W O R D S: anti-vaccination, alternative medicine, naturopath, regula-

tion, vaccines, websites

INTRODUCTION
There is growing controversy about vaccination rates in Canada.1 While a strong ma-
jority of Canadians support vaccination, public health authorities note that vaccination
1 See, for example, Colin Busby & Nicholas Chesterley, A Shot in the Arm: How to Improve Vaccination Policy in
Canada, 421C.D. HOWE INSTITUTE, Mar. 2015, at 1: ‘Most Canadian provinces fail to meet national immu-
nization targets for key diseases, and coverage ratios among children in a few provinces, where data are well

C The Author 2017. Published by Oxford University Press on behalf of Duke University School of Law,

Harvard Law School, Oxford University Press, and Stanford Law School. This is an Open Access arti-
cle distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence
(http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distri-
bution of the work, in any medium, provided the original work is not altered or transformed in any way, and that
the work is properly cited. For commercial re-use, please contact [email protected]
230 r Responding to naturopathic anti-vaccination rhetoric

rates are still below ideal levels.2 This is occurring in part because numerous vaccination
myths are being circulated throughout popular culture. The ongoing and unfounded
connection made between vaccines and autism,3 for example, leads to inaccurate per-
ceptions about risk, and in turn, a greater number of Canadians becoming hesitant
about vaccinating. A 2015 survey found that one in four Canadian parents either be-
lieves vaccines are associated with autism and other mental health issues or is uncertain
about the issue.4 Other research has found that, on average, 39% of Canadians believe
that the science on vaccines is not clear.5 This is not to say that a large portion of Cana-
dians harbor strident anti-vaccination beliefs. But a growing percentage has doubts and

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

concerns that seem to be fueled by the misleading rhetoric around vaccination safety.
Indeed, recent outbreaks of measles and other vaccine preventable diseases have
been attributed, at least in part, to the vaccine hesitancy phenomenon6 and to efforts
by those in the anti-vaccination community to create doubt about the effectiveness and

kept and up-to-date are falling over time. If immunization coverage continues to fall, more vulnerable popu-
lations, such as children, the elderly, and people with medical conditions that may prevent them from being
immunized, will be put at risk’. Also see David W. Scheifele, Scott A. Halperin & Julie A. Bettinger, Childhood
Immunization Rates in Canada are too low: UNICEF, 19 PAEDIATR CHILD HEALTH 237, 237 (2014), which,
summarizing a UNICEF study states, ‘Canada fared poorly in comparison with other affluent countries, rank-
ing 28th among 29 countries. The immunization coverage rate cited for Canada was 84%, compared with
rates of 96% in the United Kingdom, and 93% in the United States and Australia. Canada was one of only
three countries with rates <90%’.
2 Madeline Smith & Elizabeth Church, Canada’s High Vaccination Rates Still Need Improvement,
Study Finds, THE GLOBE AND MAIL, July 21, 2015, http://www.theglobeandmail.com/news/
national/most-canadian-toddlers-vaccinated-against-key-childhood-diseases-statscan/article25601789/
(accessed Jan. 16, 2017).
3 Central to the vaccine-causing autism claims was a paper by Andrew Wakefield initially published in the
influential The Lancet journal in 1998. This paper postulated that after eight children received the MMR
vaccine, they developed intestinal inflammation leading to usually non-permeable peptides translocating
first to the bloodstream, then the brain, where development was affected. This paper was later retracted
by The Lancet. Much has been written about this retraction, and the vaccination scare which it produced.
See for example, http://www.bmj.com/content/342/bmj.c7452 (accessed Jan. 16, 2017). Claims made by
Wakefield as well as other anti-vaccination authors have been assessed and discredited. See for example,
http://cid.oxfordjournals.org/content/48/4/456.full.pdf+html (accessed Jan. 16, 2017), where it reads in
the conclusion, ‘Twenty epidemiologic studies have shown that neither thimerosal nor MMR vaccine causes
autism. These studies have been performed in several countries by many different investigators who have em-
ployed a multitude of epidemiologic and statistical methods. The large size of the studied populations has
afforded a level of statistical power sufficient to detect even rare associations. These studies, in concert with
the biological implausibility that vaccines overwhelm a child’s immune system, have effectively dismissed the
notion that vaccines cause autism. Further studies on the cause or causes of autism should focus on more-
promising leads’. Andrew Wakefield continues to propagate anti-vaccination views in the current day. His
2016 film, ‘Vaxxed: From Cover-up to Catastrophe’, was screened in cinemas across North America.
4 Elizabeth Payne, Survey Raises Concern About Vaccine ‘Hesitancy’ Among Canadian Parents, Shows
Some Harbour Misinformation, THE NATIONAL POST, Dec. 18, 2015, http://news.nationalpost.com/
news/canada/survey-raises-concern-about-vaccine-hesitancy-among-canadian-parents-shows-some-
harbour-misinformation (accessed Jan. 16, 2017).
5 Arik Motskin & Zack Gallinger, Canadians Are Surprisingly Skeptical of Vaccines, THE 10 AND 3, Sept. 28, 2016,
http://www.the10and3.com/canadians-are-surprisingly-skeptical-of-vaccines/ (accessed Jan. 16, 2017).
6 See, for example, Peter J Hotez, Texas and Its Measles Epidemics, 13 PLOS MED. e1002153 (2016),
where it is noted that a rapidly growing Anti-Vaxxer movement in the state appears to be con-
tributing to the increase in vaccine exemptions. See also, Steven Salzberg, Anti-Vax Movement To
Blame For Quadrupling Of Mumps Cases This Year, FORBES, Dec. 20, 2016, http://www.forbes.com/
sites/stevensalzberg/2016/12/20/anti-vax-movement-to-blame-for-quadrupling-of-mumps-cases-this-year
/#d56c28f28d2b (accessed Jan. 16, 2017); See also Susan Scutti, Washing State Mumps Outbreak:
 Responding to naturopathic anti-vaccination rhetoric r 231

safety of vaccination.7 A recent study found that in some areas of Vancouver the vacci-
nation rates have declined to the point where the benefits of ‘herd immunity’ have been
lost.8 Less than ideal vaccination rates can also have an economic impact. A 2016 study
estimates that, in the USA alone, the economic burden of vaccine preventable diseases
is approximately $9 billion.9
The reasons for the existence and spread of vaccination hesitancy are complex, nu-
merous, and interrelated.10 Still, there seems little doubt that complementary and al-
ternative medicine (CAM) practitioners play a role.11 While not all CAM practitioners
are overtly anti-vaccination, there is an association between CAM use and not vaccinat-

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

ing children.12 In addition, studies have found that training in CAM is associated with

278 Cases Reported in 5 Counties, CNN, Jan. 27, 2017, http://www.cnn.com/2017/01/26/health/

mumps-outbreak-washington-disease/ (accessed Jan. 31, 2017).
7 See, for example, Jon Woodward, B.C. Vaccination Rates Drop Amid ’Misinformation’ Campaign, CTV NEWS,
Mar. 24, 2014, http://bc.ctvnews.ca/b-c-vaccination-rates-drop-amid-misinformation-campaign-1.1744379
(accessed Jan. 16, 2017); and Steven Salzberg, Anti-Vaccine Movement Causes Worst Measles Epidemic In
20 Years, FORBES, Feb. 1, 2015, http://www.forbes.com/sites/stevensalzberg/2015/02/01/anti-vaccine-
movement-causes-worst-measles-epidemic-in-20-years/#28efab767ef9 (accessed Jan. 16, 2017).
8 See Lisa Johnson, Vaccination Rates too Low for ’Herd Immunity’ in Most Vancouver-Area Schools, Study Finds,
CBC NEWS, Nov. 15, 2016; Also see additional reporting in Richard M. Carpiano & Julie A. Bettinger, Vaccine
Coverage for Kindergarteners: Factors Associated with School and Area Variation in Vancouver, British Columbia,
6 VACCINE REP. 50 (2016); and CBCNews, Lack of Herd Immunity Could Cause Mumps to Spread, Says
Province, CBC NEWS, Oct. 20, 2016, where it is reported that 70% in the province of Manitoba are vaccinated
for mumps.
9 The authors estimate that 80% of that cost is attributable to unvaccinated individuals. See Sachiko Ozawa et
al., Modeling The Economic Burden Of Adult VaccinePreventable Diseases In The United States, 35 HEALTH AFF.
2124 (2016).
10 There is a rich literature on this topic that has explored the impact of trust, conspiracy theories, cognitive
biases, social media, and parental experience with healthcare providers, to name but a few relevant factors.
See, for example, Mariana Voinson, Sylvain Billiard & Alexandra Alvergne, Beyond Rational Decision-Making:
Modelling the Influence of Cognitive Biases on the Dynamics of Vaccination Coverage, 10 PLOS ONE e0167842
(2015); Linda M. Niccolai & Melinda M. Pettigrew, The Role of Cognitive Bias in Suboptimal HPV Vaccine
Uptake, 138 PEDIATRICS e20161537 (2016); Cornelia Betsch et al., The Influence of Vaccine-critical Websites
on Perceiving Vaccination Risks, 15 J. HEALTH PSYCHOL. 446 (2010); Vanessa Wamsley, The Psychology of Anti-
Vaxers: How Story Trumps Science, THE ATLANTIC, Oct. 19, 2014; Eve Dubé et al., Understanding Vaccine
Hesitancy in Canada: Results of a Consultation Study by the Canadian Immunization Research Network, 11 PLOS
ONE e0156118 (2016); Eve Dubéet al., Parental Vaccine Hesitancy in Quebec (Canada), 8 PLOS CURR. (2016);
and, for a study on the impact of parental experience with providers, see Douglas J. Opelet al., The Influence
of Provider Communication Behaviors on Parental Vaccine Acceptance and Visit Experience, 105 AM. J. PUBLIC
HEALTH 1998–2004 (2015).
11 CAM is a complex term to define, but as written on the Canadian Bioethics society, ‘At the heart
of all definitions of CAM is the fundamental distinction between therapies that are taken in com-
plement with western medicine and those which are pursued as an alternative to the offerings of
western medicine’. (https://www.bioethics.ca/blog.html?Step=2&MB=283) (accessed Jan. 16, 2017).
A similar definition is provided on the NIH’s National Centre for Complementary and Integrative
Health, which defines ‘complementary’ as ‘a non-mainstream practice is used together with conventional
medicine’, and ‘alternative’ as ‘a non-mainstream practice is used in place of conventional medicine’
(https://nccih.nih.gov/health/integrative-health) (accessed Jan. 16, 2017). Common examples of CAM in-
clude acupuncture, homeopathy, chiropractic, spinal manipulation therapy, reiki, etc.
12 William K. Bleser et al., Complementary and Alternative Medicine and Influenza Vaccine Uptake in US Children,
138 PEDIATRICSe20154664 (2016). Also, people who are prone to being anti-vaccination or to having vaccine-
hesitant attitudes may be more attracted to CAM professions. Regardless, there is a relationship between the
use and practice of CAM and anti-vaccination attitudes. See also Tycho Jan. Zuzak et al., Attitudes Towards
Vaccination: Users of Complementary and Alternative Medicine Versus Non-Users, 138 SWISS MED. WKLY 713,
232 r Responding to naturopathic anti-vaccination rhetoric

increased anti-vaccination attitudes,13 and a 2004 study of Canadian Naturopathic stu-

dents found that only 12.8% would advise full vaccination.14 As such, in Canada, there
has been concern about how the naturopathic community and other alternative practi-
tioners represent the health benefits and risks associated with vaccination.15
In this paper, we will shed light on vaccination-hesitant16 discourse used by the
naturopathic community on clinic websites as well as those of individual naturopaths.
An exploration of how naturopaths represent the risks and benefits of vaccination will
inform what policies should be used to correct the spread of misinformation about vac-
cination. Furthermore, it will serve to highlight the degree to which naturopaths are en-

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

gaged in the distribution of scientifically questionable vaccination-hesitant discourse.17

at abstract (2008): ‘Refusal to follow the basic vaccination schemata was more frequent among CAM-users
than non-users and reflected in most cases parental wishes rather than physicians’ recommendations’. And,
of course, naturopaths aren’t the only CAM providers that have been associated with a tendency toward
anti-vaccination views. See, for example, Emily A Medd & Margaret L Russell, Personal and Professional
Immunization Behavior Among Alberta Chiropractors: A Secondary Analysis of Cross-Sectional Survey Data,
32:6 J. MANIPULATIVE PHYSIOL. THER. 448, at abstract (2009), where it is noted that ‘only 35.7% [of Alberta
chiropractors] would accept immunization for themselves in the future’; and Linda Lombroso, Some Chiro-
practors Turn Their Backs on Vaccines, USA TODAY, Feb. 17, 2015, http://www.usatoday.com/story/news/
nation/2015/02/17/some-chiropractors-turn-their-backs-on-vaccines/23582549/ (accessed Jan. 16,
2017); and also Bruce Y Lee, Are Chiropractors Backing the Anti-Vaccine Movement?, FORBES, Dec. 10,
2016, http://www.forbes.com/sites/brucelee/2016/12/10/are-chiropractors-backing-the-anti-vaccine-
movement/#3bd3e3f15db6 (accessed Jan. 16, 2017).
13 Jason W. Busse et al., Attitudes Towards Vaccination Among Chiropractic and Naturopathic Students, 26 VAC-
CINE 6237 (2008). In this study, it was found that naturopathic and chiropractic students in the later years of
training were more likely to hold anti-vaccination views.
14 Kumanan Wilson et al., A Survey of Attitudes Towards Paediatric Vaccinations Amongst Canadian Naturopathic
Students, 22 VACCINE 329, at abstract (2004). It was also noted that ‘both willingness to advise full vacci-
nation and trust in public health and conventional medicine decreased in students in the later years of the
programme’. See also Ali Atheret al., Vaccination Attitudes and Education in Naturopathic Medicine Students,
20 J. ALTERN. COMPLEMENT MED. A115, at abstract (2014): About 40% reported a healthy diet and lifestyle
was more important for prevention of infectious diseases than vaccines.
15 See, for example, CBC NEWS, Anti-vaccine Message From Some Naturopaths Raises Concerns, Apr. 14, 2014,
http://www.cbc.ca/news/canada/calgary/anti-vaccine-message-from-some-naturopaths-raises-concerns-
1.2609717 (accessed Jan. 16, 2017); Carly Weeks, Regulating Alternative Medicine Adds False Legiti-
macy to Anti-vaccine Claims, THE GLOBE AND MAIL, Nov. 26, 2015, http://www.theglobeandmail.com/
life/health-and-fitness/health/regulating-alternative-medicine-adds-false-legitimacy-to-anti-vaccine-claims/
article27497447/ (accessed Jan. 16, 2017); Joanna Frketich, Anti-vaccination Attitudes High
Among Alternative Health Care Providers, THE HAMILTON SPECTATOR, Feb. 27, 2015,
http://www.thespec.com/news-story/5452950-anti-vaccination-attitudes-high-among-alternative-health-
care-providers/ (accessed Jan. 16, 2017); Jesse Ferreras, Measles In Alberta: Naturopaths,
Chiropractors Promoting Anti-Vaccine Messages, HUFFINGTON POST CANADA, Feb. 5, 2014,
http://www.huffingtonpost.ca/2014/05/02/measles-alberta-naturopaths-anti-vaccine n 5150252.html
(accessed Jan. 16, 2017); and see Bill Graveland, Trial of Woman Who Treated Son With Holis-
tic Medicine Will Reignite Debate Over Alternative Treatments, THE NATIONAL POST, Nov. 27, 2016,
http://news.nationalpost.com/news/canada/trial-of-woman-who-treated-son-with-holistic-medicine-will-
reignite-debate-over-alternative-treatments (accessed Jan. 16, 2017).
16 By ‘vaccination hesitant’, we mean discourse which (1) explicitly denounces vaccination; (2) raises issues of
harms and risks of vaccines; (3) offers alternative vaccination services such as alternatives to the flu shot.
17 Previous research has found that much of what is advertised on the websites for naturopath clinics is not
supported by a solid foundation of science. For example, see Timothy Caulfield & Christen Rachul, Supported
by Science?: What Canadian Naturopaths Advertise to the Public, 7 ALLERGY, ASTHMA & CLIN. IMMUNOL.14
(2011), ‘A review of the therapies advertised on the websites of clinics offering naturopathic treatments does
not support the proposition that naturopathic medicine is a science and evidence-based practice’.
 Responding to naturopathic anti-vaccination rhetoric r 233

VACCINE EFFECTIVENESS AND SAFET Y

The development of vaccines has been characterized as one of civilization’s greatest
health achievements.18 It has been estimated that, worldwide, vaccination prevents
two to three millions deaths every year.19 It has been noted that if people stop vacci-
nating their children, vaccine preventable disease can and will come back.20 Indeed,
measles—a vaccine preventable disease—remains one of the leading causes of death
for young children.21 While almost all health interventions are associated with some
risks,22 the vaccines that are currently recommended have a strong and well-known
safety profile.23 Also, there is no credible evidence that the preservatives used in vac-

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

cines, such as thermasol, are associated with the development of any disease or ailment,
including autism.24 Indeed, there is absolutely no credible evidence to support the myth
that vaccines cause autism.25 The concern that children can’t handle multiple vaccines
at once is also without foundation.26 In fact, the immune system can handle thousands
of different challenges. Every day children are exposed to multiple foreign substances
that create an immune response. So while new vaccines require rigorous testing and we
should continue to monitor the safety and effectiveness of existing vaccines, there is a
large body of literature that has established not only their safety but the vital role that
vaccines play in maintaining a healthy population.

CONTINUUM OF DOUBT
We sought to provide a snapshot of the vaccination-hesitant discourse present on natur-
opath websites in the provinces of British Columbia and Alberta. This is not meant to
be a comprehensive analysis of all the potentially problematic language available on

18 See World Health Organization, 10 Facts on Immunization (May 2014) http://www.who.int/

features/factfiles/immunization/en/ (accessed Jan. 16, 2017).
19 Id.
20 CDC, ‘What Would Happen If We Stopped Vaccinations?’ http://www.cdc.gov/vaccines/vac-gen/
whatifstop.htm (accessed Jan. 16, 2017).
21 See World Health Organization, Fact Sheet: Measles (Nov. 2016) http://www.who.int/
mediacentre/factsheets/fs286/en/ (accessed Jan. 16, 2017). In 2015, there were over 130,000 measles
deaths globally. Vaccination resulted in 79% reduction in deaths between 2000 and 2015 worldwide.
22 There are risks associated with vaccination, but the adverse events are very infrequent and generally relatively
mild (eg reaction at the injection site). More serious adverse events (eg allergic reactions) are extremely rare.
23 See, for example, CDC–Understanding MMR Vaccination Safety http://www.cdc.gov/vaccines/hcp/
conversations/downloads/vacsafe-mmr-color-office.pdf (accessed Jan. 16, 2017); and Public health Agency
of Canada, Vaccine Safety http://www.phac-aspc.gc.ca/im/safety-securite-eng.php (accessed Jan. 16, 2017);
and Public Health Agency of Canada, Canadian Adverse Events Following Immunization Surveillance System
(CAEFISS) (2015), http://www.phac-aspc.gc.ca/im/vs-sv/index-eng.php (accessed Jan. 16, 2017).
24 CDC, Understanding Thermasol, Mercury and Vaccine Safety (Feb. 2013) https://www.
cdc.gov/vaccines/hcp/patient-ed/conversations/downloads/vacsafe-thimerosal-color-office.pdf (accessed
Jan. 16, 2017).
25 Stehr-Green P et al., Autism and Thimerosal-Containing Vaccines: Lack of Consistent Evidence for an Association,
25 AM. J. PREVENTIVE MED. 101 (2003); See Mady Hornig et al., Lack of Association Between Measles Virus
Vaccine and Autism with Enteropathy: A Case-Control Study, 3 PLOS ONE e3140 (2008); and CDC, Vaccines
Do Not Cause Autism http://www.cdc.gov/vaccinesafety/concerns/autism.html (accessed Jan. 16, 2017).
26 Institute of Medicine, The Childhood Immunization Schedule and Safety: Stakeholder Concerns, Scientific
Evidence, and Future Studies (National Academy of Sciences, 2013), http://nationalacademies.org/hmd/
∼/media/Files/Report%20Files/2013/Childhood-Immunization-Schedule/ChildhoodImmunization
ScheduleandSafety RB.pdf (accessed Jan. 16, 2017), complete study at https://www.ncbi.
nlm.nih.gov/books/NBK206940/ (accessed Jan. 16, 2017).
234 r Responding to naturopathic anti-vaccination rhetoric

naturopath websites. Rather, the goal is to highlight examples of the type of rhetoric
used by naturopaths in this context.
First, we identified naturopaths in each province using the website
www.findanaturopath.com, which has over 1850 naturopaths listed in Canada
(157 in Alberta and 388 in British Columbia), and captured all available websites
for the listed naturopaths in the two provinces (221 in British Columbia, 105 in
Alberta).27 We then used Google to search for the appearance of the following words
in each website: vaccine, vaccination, flu, immune, immunization.28 In the case of any
search words appearing on the website, we looked for the following: (1) discourse of

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

vaccine hesitancy (text or links to text which demonstrate explicit anti-vaccination
views or which raise issues surrounding the harms/risks of vaccination) and (2)
services offered or text descriptions of alternatives to vaccinations or the flu shot.
While there is an abundance of websites offering natural solutions to ‘boost immunity’
or to prepare one for the flu season,29 these websites were not included in our analysis
as they did not explicitly address vaccination or flu shots.30
After reviewing just over 330 websites, we found 40 websites with vaccine hesitancy
discourse, and 26 websites offering vaccine or flu shot alternatives. Thirteen websites
had both. In total, 53 had either vaccine-hesitant language, suggested a vaccine alterna-
tive or had both. Text examples of vaccine hesitancy discourse can be found in Table 1,
and text examples of vaccine or flu shot alternatives in Table 2.
As evident in Table 1, the vaccination hesitancy information on the naturopath web-
sites falls on a continuum, from those that are overtly anti-vaccination to those that
subtly undermine the relevant science. For example, it is common on websites with
vaccine hesitancy discourse to make a link between mercury (thimerosal) and vac-
cines, and to then discuss the related risks and harms (see examples 1 and 2 in Ta-
ble 1). There is no credible evidence that the mercury-based preservative used in vac-
cines, thimerosal, is linked to illnesses in children.31 Furthermore, almost all vaccines in

27 Additional websites (approximately 10) were added when found URLs didn’t work but others matching the
same listed naturopath or same clinic appeared in Google searches.
28 The search query was the following: search word + site: URL. So, in the case of the search word
‘vaccine’ and the website www.naturopathicfundamentals.com, the search was as followed: vaccine
site:www.naturopathicfundamentals.com and vaccine site:naturopathicfundamentals.com
29 For example, the clinic www.backtowellness.ca (accessed Nov. 14, 2016) offers ‘Joy of the Mountains
Oregano Oil’, which is ‘absolutely’ proven ‘to boost your immune system’. The site www.askdoctorbill.com
(accessed Nov. 14, 2016) suggests numerous ‘suppliments [sic] to boost your immune system’ includ-
ing vitamin D3 and Astragalus. The clinic www.woodgrovepinesclinic.com (accessed Nov. 14, 2016) offers
acupuncture for flu prevention. A large number of sites such as www.drarelmajian.ca, www.drhabert.com,
www.drkarenmcgee.com, www.crossroadsnaturopathic.com (accessed Nov. 16, 2016) (to name just a few)
offer an ‘IV therapy’ service, among others, for flu prevention. Other sites such as www.pointgreywellness.com
(accessed Nov. 16, 2016) offer intravenous vitamin therapy not in the context of preventing the flu, but as
a means to ‘manage stress, boost your immune system, increase energy levels, balance hormones’, etc. Of
course, these claims and services are also not supported by science. See, for example, Timothy Caulfield, The
IV Therapy Myth, NATIONAL POST, July 11, 2016; and Timothy Caulfield, Immune Boost Bunk, HEALTH NEWS
REVIEWS, Oct. 15, 2015.
30 It is worth noting, however, that while these websites did not explicitly suggest that vaccination is not required,
there is an implication that these ‘natural’ approaches are an effective way to deal with ‘boosting’ your immune
system, which may also contribute to vaccination hesitant thinking by contributing to the belief that there are
alternatives to vaccination.
31 CDC, supra note 24, at 1–2.
 Responding to naturopathic anti-vaccination rhetoric r 235

Table 1. Examples of vaccine hesitancy discourse (all websites accessed in November

2016)
1) ‘...children are now being given increasing numbers of vaccinations containing
potentially harmful derivatives and substances such as mercury, thimerisol [sic],
aluminum and formaldehydes. These harmful derivatives can become trapped in our
tissues, clogging our filters and diminishing one’s ability of further toxins
out.’—www.evolvenaturopathic.com
2) ‘Vaccines given to children and adults contain mercury and aluminum. Babies are

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

especially susceptible to small amounts of mercury injected directly into their tiny bodies.
It is now suspected that the increase in autism and Asperger Syndrome is related to the
mercury in childhood vaccinations.’—www.vancouvernaturopathicclinic.com
3) ‘The conventional Flu Shot is a mixture of 3 strains of flu viruses mixed with a number
of chemical preservatives and these strains are based on a prediction of what flu viruses
some medical experts think will be the most problematic this season. This is really an
impossible prediction to make when we have thousands of different strains of viruses that
are continuously mutating.’—www.advancednaturopathic.com
4) ‘A [sic] epidemiologist researcher from British Columbia, Dr. Danuta Skowronski,
published a study earlier this year showing that people who were vaccinated consecutively
in 2012, 2013 and 2014 appeared to have a higher risk of being infected with new strains of
the flu.’—www.drtas.ca
5) ‘Increasing evidence suggests that injecting a child with nearly three dozen doses of 10
different viral and bacterial vaccines before the age of five, while the immune system is still
developing, can cause chronic immune dysfunction. The most that vaccines can do is lead
to an increase in antibodies to a specific disease.’—www.evolvevitality.com
6) ‘The bugs in question (on the Canadian Vaccine List) can enter our systems and
depending on our bodies, our histories, and mostly the bugs’ propensity, they can cause
serious harm. There are certainly questionable ingredients in vaccines that have the
potential to do the same.’—www.tharavayali.ca

Canada are made without thimerosal. Regardless, there is no evidence that the amount
of thimerosal used in vaccines is harmful. Another common vaccination-hesitancy sen-
timent revolves around either questioning the efficacy of vaccines to prevent symptoms
(see example 3 in Table 1) and/or suggesting that vaccination can lead to higher de-
grees of risk (see examples 4 and 5 in Table 1). The risks associated with vaccination
are not only relatively mild but also very infrequent.32 And more serious occasions, for
example, an allergic reaction, are very rare.33 Notably, very few naturopath websites
were explicitly supportive of vaccinations.

32 Id.; Public health Agency of Canada, Vaccine Safety, http://www.phac-aspc.gc.ca/im/safety-securite-eng.php

(accessed Jan. 16, 2017); and Public Health Agency of Canada, Canadian Adverse Events Following Immuniza-
tion Surveillance System (CAEFISS) (2015) http://www.phac-aspc.gc.ca/im/vs-sv/index-eng.php (accessed
Jan. 16, 2017).
33 Id.
236 r Responding to naturopathic anti-vaccination rhetoric

Table 2. Examples of vaccine or flu shot alternatives [all websites accessed in

November, 2016]
1) ‘Get a homeopathic prophylactic immune injection—As an alternative to the flu shot,
you can choose a homeopathic prophylactic injection instead. These have been
scientifically shown to increase white blood cell activity by over 30%. This injection is safe
and without side effects.’—www.drattema.com
2) ‘Book a 30 minute visit with our naturopathic doctor for: Homeopathic Flu Injection:
safe and effective alternative to the regular flu shot. It is a combination of homeopathic

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

remedies, Heel’s Engystol and Gripp to stimulate body’s own health defense
system.’—www.revivenaturopathic.com
3) ‘There are alternatives to the standard vaccines, and these work on boosting your
immune response naturally through diet, supplements and with standardized plant
extracts that stimulate and strengthen the immune response without any added
toxins.’—www.fishcreek.ca
4) ‘Unfortunately the flu vaccine includes adjuvants (additives) that are poorly tolerated
and can be difficult to process (including many patients suffering from auto-immune
diseases, that often suffer major relapses after receiving a flu shot). Its [sic] also based on
last year’s virus, which has mutated considerably by this year, hence rendering the
vaccine’s effectiveness questionable to this year’s newly mutated virus. Dosing a
homeopathic preparation based on the last 100 years of flu pandemics encompasses the
many genetic variants that occur with flu viruses. It is free of adjuvants, and will not
interfere with any other medications or cause the immune dysregulation that is seen in
auto-immune diseases.’—www.daiseykentnd.com
5) ‘It’s that time again, the dreaded cold and flu season! Many people opt to get a flu shot.
This year, there is concerns [sic] the flu vaccine may not be effective against all virus
strains. Fortunately, our body has excellent defense mechanisms to protect us from these
harmful viruses and bacteria. It’s time to start boosting your immune system....
Naturally!!! Many of the suggestions I have listed are herbs or botanicals you can find in
your kitchen cupboard. Let’s start with the basics, as these really do
work.’—www.vitaliahealthcare.ca
6) ‘Immune Boosting Homeopathics: You may be more familiar with the conventional flu
shot, which provides vaccination from predicted influenza virus strains; not necessarily
what people are actually exposed to this season. Homeopathic immune boosters can be
delivered by injection or orally, and do not have the side effects commonly seen with flu
shots, such as malaise, fever, and lethargy. They are great for prevention and treatment of
colds and give your immune system an extra punch to naturally knock out those bugs and
viruses throughout the year.’—www.drsafiakassam.com

In terms of alternatives to vaccines or flu shots, again a continuum is present as

some suggest complete replacement while others suggest supporting flu shots with nat-
ural measures. Although naturopaths recommend a wide range of vaccination alterna-
tives including plant extracts, ‘biopuncture’, ultraviolet blood irradiation, acupuncture,
Vitamin C & D, herbs, ‘immune booster shots’, etc., the most commonly mentioned
 Responding to naturopathic anti-vaccination rhetoric r 237

alternatives are described as some form of homeopathy.34 Of course, there is no sci-

entific evidence supporting the efficacy of homeopathy for treating any health condi-
tion.35 The idea that homeopathic vaccines could work is scientifically absurd.36 Addi-
tionally, as recently as November of this year, the American Federal Trade Commission
(FTC) echoed this statement, stating that there is no scientific basis supporting the ef-
ficacy claims made by homeopathic products.37 Our analysis is, of course, confined to
what is disclosed on the websites. We do not know what may or may not be disclosed by
naturopaths to patients during clinical encounters. Regardless, our data provide a sense
of the kind of anti-vaccination rhetoric that exists within the naturopathic community

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

in Alberta and British Columbia.
THE IMPACT
As noted, there is evidence that suggests that CAM providers play a role in parental atti-
tudes and vaccination intentions.38 The relationship is complex, however, as those who
are more likely to be attracted to CAM are also the ones most likely to hold negative
attitudes toward vaccination.39 Still, there seems little doubt that healthcare providers
can play an important role in how parents and patients approach vaccination.40 This
seems particularly true if naturopaths are involved. A 2011 study found that ‘endorsing
a naturopathic physician’ as the ‘most trusted source of information regarding vacci-
nation’ was ‘associated with greater odds of having a partially vaccinated or unvacci-
nated child’.41 In addition, because the information is available to anyone searching for

34 Of the 26 websites offering vaccination or flu shot alternatives, 16 (approximately 62%) were described as
‘homeopathic’. This included alternatives such as ‘homeopathic and vitamin injection’, ‘homeopathic reme-
dies’, ‘herbal and homeopathic medicines’, ‘homeopathic preparation of WHO influenza vaccine’, ‘homeo-
pathic prophylaxis’, ‘homeopathic prophylactic immune injection’, etc.
35 See, for example, Australian Government, National Health and Medical Research Council, NHMRC
Statement: Statement on Homeopathy (Australia: NHMRC, ref #CAM02, 2015), which offers the following
summary: ‘Based on the assessment of the evidence of effectiveness of homeopathy, NHMRC concludes
that there are no health conditions for which there is reliable evidence that homeopathy is effective’. https://
www.nhmrc.gov.au/ files nhmrc/publications/attachments/cam02 nhmrc statement homeopathy.pdf
(accessed Jan. 16, 2017).
36 Edzard Ernst, There is No Scientific Case for Homeopathy: the Debate Is Over, THE GUARDIAN, Mar. 12, 2015,
https://www.theguardian.com/commentisfree/2015/mar/12/no-scientific-case-homeopathy-remedies-
pharmacists-placebos (accessed Jan. 16, 2017).
37 United States Government, Federal Trade Commission, Staff Report on the Homeopathic
Medicine & Advertising Workshop (United States of America: FTC, 2016) https://www.
ftc.gov/system/files/documents/reports/federal-trade-commission-staff-report-homeopathic-medicine-
advertising-workshop/p114505 otc homeopathic medicine and advertising workshop report.pdf (ac-
cessed Jan. 16, 2017).
38 Michelle J. Mergler et al., Association of Vaccine-Related Attitudes and Beliefs Between Parents and Health Care
Providers, 31 VACCINE 4591 (2013).
39 Mathew Browneet al., Going Against the Herd: Psychological and Cultural Factors Underlying the ‘Vaccination
Confidence Gap’, 10 PLOS ONE e0132562 (2015).
40 See, for example, Deborah Gust et al., Parental Attitudes Toward Immunizations and Health
Care Providers, 29 AM. J. PREVENTIVE MED. 105 (2005), https://www.researchgate.net/
profile/Glen Nowak/publication/7738358 Parent Attitudes Toward Immunizations and Healthcare
Providers/links/00b7d51b5e5084fd09000000.pdf (accessed Jan. 16, 2017) as well as (in the Amer-
ican context), Philip J. Smith et al., Associations Between Health Care Providers’ Influence on Parents
Who Have Concerns About Vaccine Safety and Vaccination Coverage, 118 PEDIATRICS 2197 (2006),
http://pediatrics.aappublications.org/content/118/5/e1287.short (accessed Jan. 16, 2017).
41 Jason W Busse, Rishma Walji & Kumanan Wilson, Parents’ Experiences Discussing Pediatric Vaccination With
Healthcare Providers: A Survey of Canadian Naturopathic Patients, 6 PLOS ONE e22737 (2011).
238 r Responding to naturopathic anti-vaccination rhetoric

information on vaccination and it appears on the websites of healthcare providers, it

may facilitate the spread of misinformation to the public more broadly. This seems par-
ticularly worrisome given that many provincial jurisdictions have explicitly legitimized
naturopaths via legislative action.42
Furthermore, research tells us that mere exposure to anti-vaccination
rhetoric—whether in the form of conspiracy theories43 or falsely balanced stories in the
media44 —can also impact attitudes and can play a role in the intention to vaccinate. It
is not the case, of course, that people make decisions about vaccination based solely on
rational, evidenced-based, scientific perspectives.45 Individuals are situated in diverse

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

contexts and are informed and influenced by a range of different individuals and social
entities when it comes to making decisions about vaccinations.46 Once a particular
perspective is established, we all have a natural tendency, known as the confirmation
bias, to seek information that corresponds with and validates our existing view.47 As
such, for those who are already hesitant or hold anti-vaccination views, the existence of
anti-vaccination or vaccination-hesitant rhetoric on naturopathic websites could serve
as a source of validation. This seems particularly so because of the heightened status
of naturopaths, at least in some jurisdictions, as a government regulated healthcare
profession.
To be fair, the number of naturopathic websites with explicitly anti-vaccination
rhetoric was relatively small (53 out of the 330 that we reviewed). Still, the ease
with which this information can be accessed online increases the significance of the

42 In 2012, the Albertan provincial government gave naturopaths full status as medical professionals. Josh
Wingrove, Alberta Gives Naturopaths Full Status as Medical Professionals, THE GLOBE AND MAIL, July 25, 2012,
http://www.theglobeandmail.com/news/national/alberta-gives-naturopaths-full-status-as-medical-
professionals/article4441076/ (accessed Jan. 16, 2017). Full provincial document provided here:
http://www.qp.alberta.ca/documents/Regs/2012 126.pdf (accessed Jan. 16, 2017). In 2009,
the B.C. Ministry of health recognized naturopathic doctors as primary health-care providers,
granting the ability of prescription authority in addition to other additional privileges. See:
http://www.cnpbc.bc.ca/wp-content/uploads/Scope-of-Practice-for-Naturopathic-Physicians-Standards-
Limits-and-Conditions-for-Prescribing-Dispensing-and-Compounding-Drugs.pdf (accessed Jan. 16, 2017).
43 See, for example, Daniel Jolley & Karen M Douglas, The Effects of Anti-Vaccine Conspiracy Theories on Vaccina-
tion Intentions, 9 PLOS ONE e89177 (2014); and Ted Goertzel, Conspiracy Theories in Science, 11 EMBO REP.
493 (2010).
44 Graham Dixon & Christopher Clarke, The Effect of Falsely Balanced Reporting of the Autism–Vaccine Contro-
versy on Vaccine Safety Perceptions and Behavioral Intentions, 28 HEALTH EDUC. RES. 352 (2013); and Graham
Dixon & Christopher Clarke, Heightening Uncertainty Around Certain Science Media Coverage, False Balance,
and the Autism-Vaccine Controversy, 35 SCI. COMMUN. 358 (2013).
45 See Julie Leask, Target the Fence-sitters: Past Waves of Vaccine Rejection in Industrialized Nations Have a Lot to
Teach us About Preventing Futures Ones, 473 NATURE 443 (2011); Voinson et al., supra note 10; and Sherry L.
Seethaler, Shades of Grey in Vaccination Decision Making Tradeoffs, Heuristics, and Implications, 38 SCI. COM-
MUN. 261 (2016).
46 MELISSA LEACH & JAMES FAIRHEAD, VACCINE ANXIETIES: GLOBAL SCIENCE, CHILD HEALTH
AND SOCIETY (2007). See also Mathew C. Nisbet & Ezra Markowitz, American Associa-
tion for the Advancement of Science, American’s Attitudes About Science and Technology: The
Social Context for Public Communication (Commissioned Review) (2016), http://www.aaas.
org/sites/default/files/content files/NisbetMarkowitz ScienceAttitudesReview AAAS Final March10.pdf
(accessed Jan. 16, 2017) and http://pus.sagepub.com/content/early/2016/07/23/0963662516661090.full.
pdf+html (accessed Jan. 16, 2017).
47 Hart William et al., Feeling Validated Versus Being Correct: A Meta-analysis of Selective Exposure to Information,
135 PSYCHOL. BULL. 555 (2009). For the impact of confirmation bias in the context of vaccination see, for
example, Voinson et al., supra note 10.
 Responding to naturopathic anti-vaccination rhetoric r 239

confirmation bias issue and the potential sway of the naturopath websites. The num-
ber of people going online for health information continues to increase48 and social
media use is also popular.49 Studies have found that social media can facilitate the cre-
ation of online echo chambers,50 or online confirmation bubbles,51 whereby individuals
are more often exposed to information which confirms rather than questions their per-
spectives.52 Coupled with a fairly significant presence of anti-vaccination sentiment on
the internet,53 a social media environment continually confirming and supporting one’s
views might play a substantial role in not only reinforcing anti-vaccination perspectives
but also in heightening skepticism among those with doubts.54

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

CHANGING PUBLIC REPRESENTATIONS
Once an individual has formed an opinion about vaccination, it can be a challenge to
alter that perspective. Studies have shown that the effect of providing more information
about the evidence supporting vaccination may not, at least in some situations, have an
effect on intention to vaccinate.55 In addition, providing individuals with ‘the facts’ can,
paradoxically, cause individuals to entrench further into their original position of oppo-
sition.56 As such, changing perspectives in order to increase vaccination rates will not
be easy. That said, the circulation of misleading rhetoric can only make the task more
difficult, as it undermines the production of a consistent and accurate message, which

48 Statistics Canada website. 2009 Canadian Internet Use Survey. Ottawa, ON: Government of
Canada; 2011, www.statcan.gc.ca/daily-quotidien/100510/dq100510a-eng.htm (accessed Jan. 16,
2017); See also, Bradford W. Hesse, Richard P. Moser & Lila J. Rutten, Surveys of Physicians and Electronic
Health Information, 362 NEW ENG. J. MED. 859 (2010).
49 In a 2015 poll conducted by Forum Research, nearly 60% of Canadians use Facebook,
30% use LinkedIn, 25% use Twitter, and 16% use Instagram. (http://poll.forumresearch.
com/post/213/facebook-leads-in-penetration-linkedin-shows-most-growth) (accessed Jan. 16, 2017).
In the USA, PEW research shows social media growing among all age categories (http://www.pewinternet.
org/2015/10/08/social-networking-usage-2005-2015/) (accessed Jan. 16, 2017).
50 See, for example, Michela D. Vicario et al., Echo Chambers in the Age of Misinformation (2015)
arXiv:1509.00189; also Loren Jasny, Joseph Waggle & Dana R Fisher, An Empirical Examination of Echo
Chambers in US Climate Policy Networks, 5 NAT. CLIM. CHANGE 782 (2015); and Hywel T.P. Williamset al.,
Network Analysis Reveals Open Forums and Echo Chambers in Social Media Discussions of Climate Change, 32
GLOBAL ENVIRON. CHANGE 126 (2015).
51 Giordano Pérez Gaxiola & Badenoch D., Online Filter Bubbles and Confirmation Bias in Health Care:
Narrative of a Vaccine Skeptic, In:Evidence-Informed Publich Health: Opportunities and Challenges. Ab-
stracts of the 22nd Cochrane Colloquium; 2014 21-26 Sep; Hyderabad, India. John Wiley & Sons;
2014; and Tanushree Mitra et al., Understanding Anti-Vaccination Attitudes in Social Media (2016),
http://comp.social.gatech.edu/papers/icwsm16.vaccine.mitra.pdf (accessed Jan. 16, 2017).
52 Id.
53 See, for example, Richard K. Zimmerman et al., Vaccine Criticism on the World Wide Web, 7 J. MED. INTERNET
RES. e17 (2005).
54 The impact of misinformation on those that are hesitant, rather than fully anti-vaccination, is the cre-
ation of doubt: CD Howe, Why Vaccination Rates Are Below Targets across Canada and What To Do About
It (Mar. 2015), https://www.cdhowe.org/media-release/why-vaccination-rates-are-below-targets-across-
canada-and-what-do-about-it (accessed Jan. 16, 2017). Also, Cornelia et al., supra note 10, at 446–455.
55 Lynn B Myers & Robin Goodwin, Determinants of Adults’ Intention to Vaccinate Against Pandemic Swine Flu,
11 BMC PUBLIC HEALTH 15 (2011); contrarily, see Olivier Chanel et al, Impact of Information on Intentions to
Vaccinate in a Potential Epidemic: Swine-Origin Influenza A (H1N1), 72 SOC. SCI. & MED. 142 (2011).
56 Brendan Nyhan & Jason Reifler, Does Correcting Myths About the Flu Vaccine Work? An Experimental Evalu-
ation of the Effects of Corrective Information, 33 VACCINE 459 (2015); see also Corey L. Guenther & Mark D.
Alicke, Self-Enhancement and Belief Perseverance, 44 J. EXP. SOC. PSYCHOL. 706 (2008).
240 r Responding to naturopathic anti-vaccination rhetoric

studies show can, over the long term, have an impact on vaccination intentions.57 So,
there are certainly many reasons for seeking to correct online misinformation, includ-
ing the fact that the misleading or false information proffered by naturopaths and other
alternative practitioners conflicts with various statutory regulations, common law rules,
and ethical standards. We detail breaches of this nature below, and consider the poten-
tial roles of law and policy in eliminating them.

1. Truth in advertising

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

The Competition Bureau enforces the Competition Act and regulates Canadian truth
in advertising. Section 52(1) of the Competition Act states that ‘No person shall, for the
purpose of promoting, directly or indirectly, the supply or use of a product or for the
purpose of promoting, directly or indirectly, any business interest, by any means what-
ever, knowingly or recklessly make a representation to the public that is false or mislead-
ing in a material respect’.58 This is an offence punishable by fine or imprisonment.59 The
Bureau’s standards define materiality in the context of ‘false and misleading in a material
respect’ as when the ‘literal meaning or general impression conveyed could influence
the ordinary consumer to buy or use the advertised product or service’.60 Performance
claims must be supported by an ‘adequate and proper test’.61 This involves objectively
establishing that the product or service has an effect beyond chance, but does not re-
quire methodological rigor equivalent to that of a scholarly publication.62 The omission
of a requirement of methodological rigor enables the use of unscientific research and
biased information to justify products and services.63
Special civil remedies also exist under the Competition Act. Section 36 (1) states that
‘any person who has suffered loss or damage as a result of conduct that is contrary to any
provision of Part VI [which includes s.52] [...] may, in any court of competent jurisdic-
tion, sue for and recover from the person who engaged in the conduct or failed to com-
ply with the order [...]’. The Competition Tribunal is a specialized adjudicative body
that handles most matters relating to advertising misrepresentation. However, there is
precedent for handling such matters in the courts. In Maritime Travel Inc. v Go Travel
Direct.Com Inc., the Nova Scotia Supreme Court, in a decision later upheld by the Nova

57 See, for example, Alina Sadaf et al, A Systematic Review of Interventions for Reducing Parental Vaccine Refusal and
Vaccine Hesitancy, 31 VACCINE 4293 (2013); Sander L. van der Linden et al., Highlighting Consensus Among
Medical Scientists Increases Public Support for Vaccines: Evidence From a Randomized Experiment, 15 BMC PUB-
LIC HEALTH 1207 (2015).
58 Competition Act, RSC 1985, c C-34.
59 Id.
60 Competition Bureau, False and Misleading Representations and Deceptive Marketing Practices under the Com-
petition Act, Nov. 3, 2011, http://www.competitionbureau.gc.ca/eic/site/cb-bc.nsf/eng/03133.html (ac-
cessed Jan. 31, 2017).
61 Id.
62 Canada (Commissioner of Competition) v. Chatr Wireless Inc, 2013 ONSC 5315 at para 295,
http://www.canlii.org/en/on/onsc/doc/2013/2013onsc5315/2013onsc5315.html (accessed Jan. 31,
2017).
63 An entirely new series of publications has been developed over decades to grant legitimacy to what is
often methodologically poor research on alternative medicine interventions. See, for example, a list of
naturopathic journals here: Naturopathic Peer-Reviewed Journals, The WORLD NATUROPATHIC FEDERATION,
http://worldnaturopathicfederation.org/naturopathic-peer-reviewed-journals/? (accessed Jan. 31, 2017).
 Responding to naturopathic anti-vaccination rhetoric r 241

Scotia Court of Appeal, held that a plaintiff travel agency had suffered compensable loss
due to a second travel agency’s advertisements comparing its price to a misrepresenta-
tion of the plaintiff’s.64 The same principle of loss found in s.36 would logically apply to
misrepresentations made by health care providers or health care product companies,
online or otherwise, to patients/consumers who subsequently experience harm or loss,
though case law in this vein is currently lacking.65
Health Canada has a mandate to approve or deny proposed natural health prod-
ucts, to determine labeling requirements for them, and to regulate advertising relating
to them. Specific changes to the federal Natural Health Product Regulations in 2015

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

now require homeopathy vaccines (also referred to as nosodes) to include on their la-
bels the statement that ‘[t]his product is neither a vaccine nor an alternative to vaccina-
tion. This product has not been proven to prevent infection. Health Canada does not
recommend its use in children and advises that your child receive all routine vaccina-
tions’.66 The press release for these changes also indicated that Health Canada will no
longer approve ‘specific health claims on homeopathic remedies for cough, cold and flu
for children 12 or under’,unless the claims are backed by scientific evidence.67 This is
an important first step in curbing inaccurate representations, though tighter regulation
involving bans on unproven claims in all contexts would be beneficial. A 2016 proposal
from Health Canada, currently in the consultation stage, would change the standard for
natural health products to one that only allows claims that are supported with scientific
proof.68 The adoption of this standard would finally require de facto truth in advertis-
ing among natural health products in Canada. However, the proposal is being strongly
opposed by the Canadian Health Food Association, and its future is uncertain.69
Better regulation of product claims will help establish science-based norms that will
likely reduce, in the long term, the number of false claims found on Canadian websites.
Yet, Health Canada has limited power to directly regulate the claims made on the web-
sites we studied. The Food and Drugs Act and Regulations only apply to advertisements
64 Maritime Travel Inc. v. Go Travel Direct.Com Inc., 2008 NSSC 163 (CanLII).
65 Recently, the B.C. Supreme Court rejected an application to certify a class-action lawsuit against Valeant Phar-
maceuticals and subsidiary Afexa Life Sciences relating to false advertising of efficacy for cold and flu remedy
Cold-FX. However, an individual lawsuit appears to be moving forward: see Harrison v. Afexa Life Sciences
Inc., 2016 BCSC 2123 (CanLII); see also Harrison v. Afexa Life Sciences Inc., 2016 BCSC 83 (CanLII);
see also The Canadian Press, Judge Rejects B.C. Man’s Class Action Suit Against Cold-FX Makers, CBC NEWS,
Nov. 17, 2016, http://www.cbc.ca/news/business/cold-fx-class-action-lawsuit-1.3854944 (accessed Jan. 31,
2017).
66 Government of Canada, Statement From the Minister of Health on Labelling Changes for Certain Homeopathic
Products, [Health Canada Labeling], July 31, 2015, http://news.gc.ca/web/article-en.do?nid=1014019 (ac-
cessed Jan. 31, 2017).
67 Id.
68 Government of Canada, Consulting Canadians on the Regulation of Self-Care Products in Canada, Nov. 25, 2016,
http://healthycanadians.gc.ca/health-system-systeme-sante/consultations/selfcare-autosoins/document-
eng.php (accessed Jan. 31, 2017); see also Carly Weeks, Health Canada to Change Standards for Nat-
ural Health Products, THE GLOBE AND MAIL, Sept. 9, 2016, http://www.theglobeandmail.com/
news/national/health-canada-to-change-standards-for-natural-health-products/article31810843/ (ac-
cessed Jan. 31, 2017).
69 Canadian Health Food Association, Save Our Supplements, https://chfa.ca/en/natural-health-products/
nhps-not-drugs/index.html (accessed Jan. 31, 2017); see also Regulatory Affairs Professionals So-
ciety, Health Canada Looks to Raise the Bar for Regulating Natural Health Products, Oct. 4, 2016,
http://www.raps.org/Regulatory-Focus/News/2016/10/04/25942/Health-Canada-Looks-to-Raise-the-
Bar-for-Regulating-Natural-Health-Products/ (accessed Jan. 31, 2017).
242 r Responding to naturopathic anti-vaccination rhetoric

that promote ‘directly or indirectly the sale or disposal of any food, drug, cosmetic or
device’.70 Thus, Health Canada does not regulate advertisements for health services like
acupuncture, nor does it control general anti-vaccination claims like those we noted on
40 of the websites we analysed. However, it could enforce its standards in relation to
the 26 websites we noted that put forth vaccination alternatives.
Abroad, the USA has recently undertaken a truth-in-advertising approach to deal
with unproven remedies. On November 15, 2016, the FTC, which is responsible for
marketing regulation in the USA, released an ‘Enforcement Policy Statement on Mar-
keting Claims for Over-the-Counter (OTC) Homeopathic Drugs’ that changes the

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

national marketing landscape.71 Under this new policy, the FTC prohibits claims of
efficacy and safety for OTC homeopathic drugs that are not supported by ‘competent
and reliable’ scientific evidence, unless the promotion also clearly communicates that
there is ‘no scientific evidence that the product works’ and that the product’s claims are
‘based only on theories of homeopathy from the 1700s that are not accepted by most
modern medical experts’.72 These statements must stand out on the product and must
be featured in close proximity to the claim of efficacy.73
There are many other examples where regulatory bodies in other jurisdictions have
used truth-in-advertising policies to curb the proliferation of unproven claims and
therapies.74 This approach seems likely to help create an expectation for a more
70 Health Canada, The Distinction Between Advertising and Other Activities, Aug. 2005,
http://www.hc-sc.gc.ca/dhp-mps/advert-publicit/pol/actv promo vs info-eng.php (accessed Jan. 31,
2017).
71 United States of America Federal Trade Commission, Enforcement Policy Statement on Mar-
keting Claims for OTC Homeopathic Drugs, https://www.ftc.gov/system/files/documents/
public statements/996984/p114505 otc homeopathic drug enforcement policy statement.pdf (accessed
Jan. 31, 2017).
72 Id.; see also Federal Trade Commission, FTC Issues Enforcement Policy Statement Regarding Mar-
keting Claims for Over-the-Counter Homeopathic Drugs, Nov. 15, 2016, https://www.ftc.gov/news-
events/press-releases/2016/11/ftc-issues-enforcement-policy-statement-regarding-marketing (accessed
Jan. 31, 2017).
73 Id.
74 For example, the Philippines directly regulates unproven stem cell claims: Philippines Depart-
ment of Health, Administrative Order No. 2013-0012 – Rules and Regulations Governing the Ac-
creditation of Health Facilities Engaging in Human Stem Cell and Cell-Based or Cellular Thera-
pies in the Philippines, Mar. 18, 2013, http://www.fda.gov.ph/attachments/article/38686/STEM
CELL AO.pdf (accessed Jan. 31, 2017); see also new rules for manufacturers of traditional
medicinal products in India: Sumi Sukanya Dutta, Crackdown on Magic Cure Ad–Govt to Write
to States After Ministry Push, THE TELEGRAPH (Calcutta, India)Dec. 12, 2016, http://www.
telegraphindia.com/1161212/jsp/nation/story 124265.jsp#.WFHOmqIrI5k (accessed Jan. 31, 2017);
in Australia, resources have been devoted to multiple investigations to address dangerous and unsub-
stantiated claims made by chiropractors—see Natalie MacGregor, Crackdown on ‘Dangerous’ Claims
Made by Rogue Chiropractors in Victoria, ABC NEWS, May 6, 2016, http://www.abc.net.au/news/2016-
05-06/chiropractors-rogue-victoria-dangerous-health/7389484 (accessed Jan. 31, 2017);
see also recent notice from the UK Advertising Standards Authority to homeopaths,
which demands they stop making false claims of efficacy: Advertising Standards Au-
thority, Advertising Standards for Homeopathy, [UK Ad Standards 1], Sept. 29, 2016,
https://www.asa.org.uk/News-resources/Media-Centre/2016/Advertising-standards-for-homeopathy.
aspx#.V-0HOYWcHIV (accessed Jan. 31, 2017); these notices were necessary due to the UK Society
of Homeopaths’ failure to enforce advertising standards that were clarified in a 2013 decision: Adver-
tising Standards Authority, ASA Ruling on Society of Homeopaths, [UK Ad Standards 2] July 3, 2013,
https://www.asa.org.uk/Rulings/Adjudications/2013/7/Society-of-Homeopaths/SHP ADJ 157043.
aspx (accessed Jan. 31, 2017).
 Responding to naturopathic anti-vaccination rhetoric r 243

science-informed approach to marketing in this context. Still, merely creating adver-

tising policy and enforcing it upon receipt of a complaint is unlikely to result in im-
mediate widespread compliance, especially since the accused parties sometimes sub-
sequently refuse to comply.75 Therefore, Health Canada and the Competition Bureau
should adopt proactive enforcement methods that actively identify and eliminate false
and misleading claims and practices, using successes in other jurisdictions as a template.

2. Self-regulation

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

Naturopaths present themselves as evidence-based, and governments have echoed
this position.76 The provincial health professional and naturopathy statutes and
regulations by which naturopaths are granted self-regulation (as is the case in British
Columbia, Alberta, Saskatchewan, Manitoba, and Ontario) create provincial colleges
of naturopathy that are typically responsible for setting standards of practice and for
enforcing them among members.77 The Ontario Naturopathy Act’s Professional Mis-
conduct Regulation, for example, states that it is an act of professional misconduct to
recommend or provide a treatment ‘the member knows or ought to know is unneces-
sary or ineffective’.78 Further listed acts of professional misconduct include ‘making a
claim respecting a drug, substance, remedy, treatment, device or procedure other than
a claim that can be supported as reasonable professional opinion’, and ‘permitting the
advertising of the member or his or her practice in a manner that is false or misleading
or that includes statements that are not factual or verifiable’.79
Based on these regulations, it would be logically consistent to take disciplinary ac-
tion against members who give their clients false information about vaccines and who
suggest unproven or disproven alternatives. Yet, there is little evidence that appropriate
enforcement takes place. Indeed, a national journalist recently reviewed the websites of
approximately 300 active naturopaths in Toronto, and found that almost half of them
breached the advertising rules of the College of Naturopaths of Ontario.80 Moreover,

75 Sasha Hall & Tiana Moutafis, Whacking Moles, a Pharmacist and the TGS, AUSTRALIAN JOURNAL OF PHAR-
MACY, Dec. 14, 2016, https://ajp.com.au/columns/opinion/whacking-moles-pharmacist-tga/ (accessed Jan.
31, 2017).
76 College of Naturopathic Physicians of British Columbia, Scope of Practice for Naturopathic Physicians:
Standards, Limits and Conditions for Prescribing, Dispensing and Compounding Drugs, Sept. 23, 2010,
http://www.cnpbc.bc.ca/wp-content/uploads/Scope-of-Practice-for-Naturopathic-Physicians-Standards-
Limits-and-Conditions-for-Prescribing-Dispensing-and-Compounding-Drugs.pdf (accessed Jan.
31, 2017); Jen Gerson, Alberta Creates College to Oversee Naturopathic Doctors, Stops Short of En-
dorsing Treatments, NATIONAL POST, July 26, 2012, http://news.nationalpost.com/news/canada/
alberta-creates-college-to-oversee-naturopathic-doctors-stops-short-of-endorsing-treatments (accessed
Jan. 31, 2017).
77 Alberta Health Professions Act, RSA 2000, c H-7; BC Health Professions Act, RSBC 1996, c 183; Naturopa-
thy Act, RSS 1978, c N-4; Naturopathy Act, SO 2007, c10, Sch P; Professional Misconduct, O Reg 17/14
[Ont Reg].
78 Ont Reg, supra note 77, at s.1.7.
79 Id., at ss.1.26-1.27.
80 Carly Weeks, Are We Being Served by the Regulation of Naturopaths? Not
if Patients Are Still Being Misled, THE GLOBE AND MAIL, Apr. 28, 2016,
http://www.theglobeandmail.com/life/health-and-fitness/health/canadian-naturopaths-need-to-follow-
the-rules-if-they-want-regulation/article29785140/ (accessed Jan. 31, 2017); The College
of Naturopaths of Ontario, Standards of Practice, Practice Guideline, Professional Policies,
244 r Responding to naturopathic anti-vaccination rhetoric

since Alberta legislated self-regulation in 2012, the provincial college has engaged in
only one investigation of misconduct by a member, in the context of the highly pub-
licized death of child Ezekiel Stephan.81 A similar lack of policy enforcement by self-
regulating bodies of alternative practitioners has been observed in other jurisdictions,
including Australia and New Zealand.82
The regulatory bodies that govern and represent the profession have, to date, largely
been silent or have taken remarkably soft positions on vaccination. For example, of all
the naturopath college websites in Canada, only the College of Naturopaths of Ontario
site contains content that speaks directly to homeopathic vaccines and vaccines in a

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

way that restricts allowable claims to those that are scientifically proven.83 In this case,
Health Canada’s position is merely reiterated.84
Conversely, the British Columbia Naturopathic Association has published a posi-
tion paper on vaccination that supports a vaccine-hesitant approach.85 The document
is an excellent example of the ambiguous attitude of the naturopathic community to
vaccines. It purports to explain the advantages and disadvantages of vaccination, at one
point implying that the risks are equivalent to the benefits. The document notes that
vaccine preventable ‘diseases can cause injury or death in a less than robustly healthy
infant or child’, then states that ‘[i]t’s of equal importance to note that all of the vaccines
for these diseases can also cause injury or death in a less than robustly healthy infant or
child, and this is where most of the parental concerns arise’.86 It contains a list of unsub-
stantiated concerns such as the alleged presence of toxic preservatives and the unnat-
ural route of entry of vaccines.87 The document suggests that vaccines are helpful only
because without them ‘parents run the risk of their child encountering a virile disease
agent at a time when their child’s immune system may be compromised by stressors
such as injury and poor nutrition’.88 The implication seems to be that one can build up

http://www.collegeofnaturopaths.on.ca/CONO/Resources/Professional Standards Policies and

Guidelines/CONO/Resources/Professional Standards Policies and Guidelines/Professional Standards.
aspx?hkey=930bfc83-1add-466d-be0f-8cb95ed002ca (accessed Jan. 31, 2017).
81 Wendy Stueck, Child’s Death Becomes Lightning Rod: Regulations for Naturopaths Vary Widely Across
Canada—and Few Have Faced Disciplinary Sanctions, Reports Wendy Stueck, THE GLOBE AND MAIL, June
25, 2016, http://www.theglobeandmail.com/news/alberta/ab-bc-naturopaths/article30616727/ (accessed
Jan. 31, 2017).
82 See, for example, Mark Hanna & Mark Honeychurch, Chronic Misleading Online Advertising by Chiropractors,
129 N Z MED. J. 91 (2016); see also similar issues among self-regulating chiropractors in Australia: Melissa
Davey, Chiropractors Using ‘Unacceptable’ False Advertising, Says Board, THE GUARDIAN, Mar. 7, 2016,
https://www.theguardian.com/australia-news/2016/mar/07/chiropractors-using-unacceptable-false-
advertising-says-board (accessed Jan. 31, 2017); see also UK Ad Standards 1, supra note 74 and UL Ad
Standards 2, supra note 74.
83 Mary-Ellen McKenna, Regulatory Guidance: Nosodes and Homeopathic Labelling, THE COL -
LEGE OF NATUROPATHS OF ONTARIO, Oct. 14, 2015, http://www.collegeofnaturopaths.
on.ca/CONO/Members/Professional Practice/Practice Advice/Nosodes and Homeopathic Labelling/
CONO/Members/Professional Practice/Practice Advice/Nosodes and Homeopathic Labelling.aspx?
hkey=11cb689e-77fd-4b22-ae9b-a992d4f6fcfc (accessed Jan. 31, 2017).
84 Health Canada Labeling, supra note 66.
85 British Columbia Naturopathic Association, Vaccination Position Paper, http://www.bcna.ca/about-
bcna/articles/bcna-vaccination-position-paper/ (accessed Jan. 31, 2017).
86 Id.
87 Id.
88 Id.
 Responding to naturopathic anti-vaccination rhetoric r 245

the immune system ‘naturally’ to prevent serious vaccine-preventable diseases, which

is scientifically inaccurate.
Moreover, though it is not a self-regulating body, the Canadian Association of
Naturopathic Doctors indicates on its website that, at its most recent 2015 biennial
conference held for the purpose of educating its naturopath membership, it featured a
presentation in which the speaker claimed that ‘vaccines do not confer immunity’,that
homeopathic vaccines can ‘help treat miasms created by vaccinations’, and that ‘acute
diseases can improve the constitution’.89
Documents and claims of this nature are clearly contradictions of claims made by

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

naturopathic institutions that the practice is evidence-based. Along with the noted
lack of enforcement of self-proclaimed standards by colleges, it is reasonable to con-
clude that self-regulation is, at best, ineffective, and, at worst, a podium upon which
naturopaths can legitimize scientifically inaccurate perspectives.90 As such, increased
regulatory restrictions, a related reduction in powers of self-regulation, and third party
oversight of disciplinary functions could all contribute to curbing the harmful represen-
tations made by naturopaths about vaccination.

3. Common law disclosure requirements

Informed consent has many components, but importantly requires the disclosure of
information about the proposed intervention, including any material, special and un-
usual risks, and potential treatment alternatives.91 Indeed, disclosure must include any-
thing a reasonable person in the patient’s position would want to consider before giving
consent.92 The standard of disclosure is the same regardless of whether the treatment
is conventional or alternative in nature.
Naturopaths are increasingly positioning themselves as primary care providers.93
As health care providers, they are legally responsible to uphold existing common law
standards of informed consent.94 The fact that they are not physicians does not exempt
them from this responsibility. Indeed, the courts have applied the duty of disclosure to

89 Ingrid Pincott, 03 May Health Fusion 2015 Conference Review, CANADIAN ASSOCIATION OF NATUROPATHIC
DOCTORS http://www.cand.ca/health-fusion-2015-conference-review/ (accessed Nov. 25, 2016). After we
publicized these comments, the CAND removed this content from their website.
90 As we have written about in the past, we do not support the creation of self-regulating colleges for comple-
mentary and alternative practitioners whose interventions are not evidence based. See Blake Murdoch, Robyn
Hyde-Lay & Timothy Caulfield, Commentary: An Examination of the Public Justifications for the Expansion of
Canadian Naturopaths’ Scope of Practice, 19HEALTH L. J. 215 (2011).
91 Reibl v. Hughes, [1980] 2 S.C.R. 880, 1980 CanLII 23 (SCC); Hopp v. Lepp, [1980] 2 S.C.R. 192, 1980 Can-
LII 14 (SCC); see also Timothy Caulfield, Commentary: The Law, Unproven CAM and the Two-Hats Fallacy:
Guest Editorial, 17 FOCUS ALTERNATIVE & COMPLEMENTARY THERAPIES 4 (2012), [Two Hats Fallacy].
92 Hopp v. Lepp, supra note 91, at 206 (citing Halushka v. University of Saskatchewan (1965), 53 D.L.R. (2d)
436).
93 Ontario Association of Naturopathic Doctors, FAQs, http://oand.org/naturopathic-medicine/faqs/ (ac-
cessed Jan. 31, 2017); see also Canadian Association of Naturopathic Doctors, What is Naturopathic
Medicine?, http://www.cand.ca/about-naturopathic-medicine/ (accessed Jan. 31, 2017).
94 ELLEN PICARD & GERALD ROBERTSON, LEGAL LIABILITY OF DOCTORS AND HOSPITALS IN CANADA (4th ed.
2007); Patricia Peppin, Informed consent, in CANADIAN HEALTH LAW AND POLICY (Jocelyn Downie, Timothy
Caulfield & Colleen Flood, 4th ed. 2011).
246 r Responding to naturopathic anti-vaccination rhetoric

other practitioners such as nurses, chiropractors, and even veterinarians.95 As such, if a

naturopath wishes to recommend a homeopathic vaccine instead of a real vaccine, he
or she has a legal obligation to disclose existing evidence (known to him/her) that the
homeopathic vaccine does not work, and that there is a highly efficacious alternative
in the form of a vaccine. Where a naturopath does not make these disclosures, he or
she may be guilty of negligence. Deception or lack of disclosure is not legally justified
by the potential benefits of the placebo effect.96 It should be noted that medical doc-
tors likely have a similar obligation if they wish to refer to unproven practitioners like
naturopaths.97

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

The law is quite settled in this area, but policing of those who breach these legal stan-
dards appears to be scarce in the context of complementary and alternative medicine.
So while the existing consent law is likely not a tool that can be easily used to police
the misleading claims on websites, it can be used to enforce a science-based standard of
disclosure that may help to counter the misinformation.98 In addition, if this standard
becomes more well known, it may help to promote a more science-informed approach,
and aggrieved patients may be more likely to pursue remedies.
The common law can potentially provide remedies, in parallel with s.36 of the Com-
petition Act, to patients and consumers who act on misleading advertising to their detri-
ment. The torts of deceit and fraudulent misrepresentation can be used to obtain reme-
dies for loss resulting from misleading advertising. Indeed, an ongoing lawsuit in the
B.C. Supreme Court about alleged misrepresentation by a cold and flu remedy manu-
facturer includes a claim under the Act as well as in tort.99 While there is no Canadian
case law directly on point, it seems reasonable to conclude that this law would apply to
statements made on practitioner websites and, therefore, could serve as a potential reg-
ulatory tool in the fight against the spread of misinformation. The tort of negligent mis-
representation requires proof of five elements. First, there must be a duty of care based
on a ‘special relationship’ between the representor and representee. Second, the mis-
representation must be untrue, inaccurate, or misleading. Third, the representor must
have acted negligently in making the misrepresentation. Fourth, the representee must
have relied in a reasonable manner on the negligent misrepresentation. Fifth, the re-
liance must have been detrimental to the representee.100 Fraudulent representation is
different and requires proof of a specific intent to deceive.101 Given the lack of scien-
tific evidence for recommending against vaccination and for recommending homeo-
pathic vaccination, it is likely that naturopaths making such suggestions are engaging in

95 Robertson, supra note 94, at 172; Mason v. Forgie, 1986 CanLII 3928 (NB C.A.); Heughan v. Sheppard,
[2000] O.J. No 2188 (S.C.J.); Southwhite Stables Inc. v. Ingram Veterinary Services Ltd. (1984), 26 A.C.W.S.
(2d) 159 (Q.B); More v. Haines, [1995] O.J. No. 1357 (Gen. Div.); Melnychuk v. Ronaghan (1999), [1999]
A.J. No. 660, 1999 CarswellAlta 469 (C.A.).
96 Caulfield, Two-Hats Fallacy, supra note 91, at 5.
97 Timothy Caulfield, Ubaka Ogbogu & Gerald Robertson, Commentary: The Law, Unproven CAM and the Re-
ferral Challenge, 18 FOCUS ALTERNATIVE & COMPLEMENTARY THERAPIES 1 (2013).
98 As with the regulatory bodies for physicians, one would hope that this standard would also be adopted by
naturopath regulatory entities.
99 See supra note 65.
100 Enercare v. Energy Canada, 2016 ONSC 5804 (CanLII); see also EnerWorks Inc. v. Glenbarra Energy Solu-
tions Inc., 2012 ONSC 414 (CanLII).
101 See Queen v. Cognos Inc., [1993] 1 S.C.R. 87, 1993 CanLII 146 (S.C.C.).
 Responding to naturopathic anti-vaccination rhetoric r 247

negligent misrepresentation—though, to date, we are unaware of any negligent mis-

representation jurisprudence in Canada focused on representations by a naturopath.

4. Potential criminal implications

A naturopath who recommends homeopathic vaccines or who counsels against

conventional vaccination could potentially be criminally negligent. Section 219 of the
Criminal Code of Canada [Code] states that ‘[e]very one is criminally negligent who,

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

in doing anything, or in omitting to do anything that it is his duty to do, shows wan-
ton or reckless disregard for the lives or safety of other persons’.102 Subsection (2) goes
on to state that, for the purposes of criminal negligence, ‘duty’ means a duty imposed
by law;103 a legal duty in this context is one arising from statute or from the common
law.104 The Code creates a legal duty for anyone ‘who undertakes to administer surgical
or medical treatment to another person or to do any other lawful act that may endanger
the life of another person’ to ‘have and to use reasonable knowledge, skill and care in
so doing’.105 This duty is a uniform standard, meaning the requirement of reasonable
knowledge, care, and skill is based on the treatment or lawful act in question, not on
the level of experience of the person administering it.106 As such, naturopaths offering
services similar to medical doctors will be held to the same standards under the Code.
Criminal negligence occurs due to the ‘failure to direct the mind to a risk of harm
which [a] reasonable person would have appreciated’.107 Fault is premised on the
wrongful act involved, rather than the guilty mind of the perpetrator.108 Naturopaths
counseling patients against vaccination are arguably undertaking a lawful act that en-
dangers the life of another person (especially in the case of a young child, elderly indi-
vidual, or immunocompromised person), breaching s.216 of the Code.109 In addition,
since relevant legal duties include those arising through the common law,110 natur-
opaths could alternatively be criminally negligent for failing to satisfy the aforemen-
tioned duty of reasonable disclosure inherent to standard of care in tort. In the context
of a community with diminished vaccination rates, either failure could be considered
wanton or reckless, as it may greatly and needlessly endanger the patient. However,
under the standard for criminal negligence, the trier of fact must ‘assess whether the ac-
cused’s conduct, in view of his or her perception of the facts, constituted a marked and
substantial departure from what would be reasonable in the circumstances’.111 This is
similar to the standard of gross negligence, so ultimately a finding of criminal negligence
would require meeting a rather onerous threshold.112

102 Criminal Code, R.S.C. 1985, c C-46, s.219 [Code].

103 Id. at s.219(2).
104 R v. Thornton, 1991 CanLII 7212 (ON C.A.), aff’d [1993] 2 S.C.R. 445.
105 Code, supra note 102, at s.216.
106 R v. Creighton, 1993 CanLII 61 (S.C.C.), [1993] 3 S.C.R. 3 [Creighton].
107 Id.
108 R v. J.F., [2008] 3 S.C.R. 215, 2008 S.C.C. 60 (CanLII).
109 Code, supra note 102, at s.216.
110 Thornton, supra note 104.
111 MORRIS MANNING & PETER SANKOFF, CRIMINAL LAW 1004 (5th ed. 2015).
112 Id. at 1005.
248 r Responding to naturopathic anti-vaccination rhetoric

CONCLUSION
There is reason for concern over the decrease in vaccination rates in Canada. While
numerous factors coalesce to cause this complex phenomenon, negative or hesitation-
inducing representations of vaccines by naturopaths and other alternative practitioners
seem likely to play an important role. Our survey of naturopath websites in Alberta and
B.C. demonstrates the not-uncommon presence of misleading positions on vaccines.
The information presented here exists on a continuum. On one end are examples of
websites subtly raising issues over vaccine safety and effectiveness. On the other are
explicit anti-vaccination perspectives raising suspicions and fears. Vaccination alterna-

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

tives offered by these naturopathic websites are, without exception, unproven or dis-
proven, and reliance on these products in lieu of vaccines creates a false sense of immu-
nity while exposing both the individual and the surrounding community to potential
harm.
It is essential that we combat these dangerous misrepresentations. Various legal
and policy approaches could be taken to address this issue. The Competition Bureau
and Health Canada could modify advertising standards to prohibit all clearly unsub-
stantiated treatment and performance claims online, and the latter could even act
to prevent entirely the sale of demonstrably ineffective natural health products like
homeopathic vaccines. After all, these products need not be intrinsically harmful to ulti-
mately cause harm. Provincial regulation has helped to legitimize naturopaths, making
their claims more persuasive.113 It would be wise to roll back the scope of naturopath
self-regulation, and to establish third party oversight and management of disciplinary
bodies.114 If naturopaths were truly an evidence-based profession and held to a science-
informed standard, one would expect the relevant regulatory bodies to take action on
the misleading advertising. Naturopaths genuinely interested in the science of health
care would logically also be open and welcoming to such changes. The scope of offerings
available for naturopaths to advertise would certainly be diminished, and these changes
would likely entail a ban on naturopaths providing any advice or service relating to vac-
cination, other than a referral to an appropriate, science-informed, healthcare provider.
As a result, we could expect an improvement in the accuracy of representations made
to Canadians trying to make difficult health care decisions. Misrepresentations relating
to vaccination can be matters of life and death. As such, it is essential to employ the
various legal tools that could be used to help address this dangerous social trend.

113 Naturopaths regularly reference the fact that they are government regulated when advertising their legiti-
macy. For example, ‘Naturopathic physicians are licensed primary care providers; they are the equivalent of
a GP in the realm of alternative medicine. They are regulated just as MDs, nurses and other health profes-
sionals are licensed and regulated’. Anita Komonski, Frequently Asked Questions, NATUROPATHIC PHYSICIAN
http://www.drkomonski.com/faq (accessed Jan. 31, 2017).
114 While describing the exact nature of this oversight mechanism is beyond the scope of this paper, this could
be a government-created entity that monitors claims made by alternative providers. Given that it seems im-
possible for science-free providers to self-regulate in a manner that would impose a science-informed stan-
dard, an independent third party seems a logical way forward. To be clear, we are not endorsing the exis-
tence of these regulatory bodies. Indeed, Caulfield has argued that their creation was a mistake. See, for exam-
ple, http://news.nationalpost.com/full-comment/timothy-caulfield-dont-legitimize-the-witch-doctors (ac-
cessed Jan. 31, 2017).
 Responding to naturopathic anti-vaccination rhetoric r 249

ACKNOWLEDGE MENT
We would like to thank the Allergy, Genes and Environment Network (AllerGen) NCE and the
Trudeau Foundation for funding support as well as the HLI’s executive director Robyn Hyde-Lay for
continual assistance with all projects. In addition, we would like to thank Ubaka Ogbogu for assisting
with the manuscript and Erin Nelson and Steven Penney for their input.
The Health Law Institute (HLI) is a research team at the University of Alberta that is focused on
health and science policy issues. The HLI is engaged in interdisciplinary research on a broad range of
topics, including, inter alia, stem cell research, genetics, precision medicine, transplantation, comple-
mentary and alternative medicine, and health promotion.

Downloaded from https://academic.oup.com/jlb/article/4/2/229/3871793 by guest on 31 October 2021

 International Journal of
Environmental Research
and Public Health

Article
Applying Machine Learning to Identify Anti-Vaccination
Tweets during the COVID-19 Pandemic
Quyen G. To 1, * , Kien G. To 2 , Van-Anh N. Huynh 2 , Nhung T. Q. Nguyen 3 , Diep T. N. Ngo 2 ,
Stephanie J. Alley 1 , Anh N. Q. Tran 2 , Anh N. P. Tran 2 , Ngan T. T. Pham 2 , Thanh X. Bui 2
and Corneel Vandelanotte 1

1 Physical Activity Research Group, Appleton Institute, Central Queensland University,

Rockhampton, QLD 4701, Australia; [email protected] (S.J.A.); [email protected] (C.V.)
2 Public Health Faculty, University of Medicine and Pharmacy at Ho Chi Minh City,
Ho Chi Minh City 700000, Vietnam; [email protected] (K.G.T.);
[email protected] (V.-A.N.H.); [email protected] (D.T.N.N.);
[email protected] (A.N.Q.T.); [email protected] (A.N.P.T.);
[email protected] (N.T.T.P.); [email protected] (T.X.B.)
3 Trung Vuong Hospital, Ho Chi Minh City 700000, Vietnam; [email protected]
* Correspondence: [email protected]; Tel.: +61-7-4930-6456

Abstract: Anti-vaccination attitudes have been an issue since the development of the first vaccines.



The increasing use of social media as a source of health information may contribute to vaccine

 hesitancy due to anti-vaccination content widely available on social media, including Twitter. Being
Citation: To, Q.G.; To, K.G.; Huynh, able to identify anti-vaccination tweets could provide useful information for formulating strategies
V.-A.N.; Nguyen, N.T.Q.; Ngo, D.T.N.; to reduce anti-vaccination sentiments among different groups. This study aims to evaluate the
Alley, S.J.; Tran, A.N.Q.; Tran, A.N.P.; performance of different natural language processing models to identify anti-vaccination tweets
Pham, N.T.T.; Bui, T.X.; et al. that were published during the COVID-19 pandemic. We compared the performance of the bidi-
Applying Machine Learning to rectional encoder representations from transformers (BERT) and the bidirectional long short-term
Identify Anti-Vaccination Tweets
memory networks with pre-trained GLoVe embeddings (Bi-LSTM) with classic machine learning
during the COVID-19 Pandemic. Int.
methods including support vector machine (SVM) and naïve Bayes (NB). The results show that per-
J. Environ. Res. Public Health 2021, 18,
formance on the test set of the BERT model was: accuracy = 91.6%, precision = 93.4%, recall = 97.6%,
4069. https://doi.org/10.3390/
F1 score = 95.5%, and AUC = 84.7%. Bi-LSTM model performance showed: accuracy = 89.8%,
ijerph18084069
precision = 44.0%, recall = 47.2%, F1 score = 45.5%, and AUC = 85.8%. SVM with linear kernel per-
Academic Editors: Paul formed at: accuracy = 92.3%, Precision = 19.5%, Recall = 78.6%, F1 score = 31.2%, and AUC = 85.6%.
B. Tchounwou and Quyen G. To Complement NB demonstrated: accuracy = 88.8%, precision = 23.0%, recall = 32.8%, F1 score = 27.1%,
and AUC = 62.7%. In conclusion, the BERT models outperformed the Bi-LSTM, SVM, and NB models
Received: 21 March 2021 in this task. Moreover, the BERT model achieved excellent performance and can be used to identify
Accepted: 8 April 2021 anti-vaccination tweets in future studies.
Published: 12 April 2021

Keywords: deep learning; neural network; LSTM; BERT; transformer; stance analysis; vaccine
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
published maps and institutional affil-
iations. 1. Introduction
Vaccination is one of the most important public health achievements that save millions
of lives annually and helps reduce the incidence of many infectious diseases, including
eradicating smallpox [1]. However, anti-vaccination attitudes still exist in the population.
Copyright: © 2021 by the authors.
A study by the American Academy of Pediatrics showed that 74% of pediatricians encoun-
Licensee MDPI, Basel, Switzerland.
tered a parent who declined or postponed at least one vaccine in a 12-month period [2]. In
This article is an open access article
addition, the prevalence of non-medical vaccination exemption has increased in the last
distributed under the terms and
two decades, especially in states with less strict exemption criteria in the U.S. [3]. Vaccine
conditions of the Creative Commons
hesitancy was also named as one of the top ten threats to global health by the World Health
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
Organisation in 2019 [4]. During the COVID pandemic, resulting in more than 120 million
4.0/).
infections, 2.66 million deaths (as of 17 March 2021), and the development of safe and

Int. J. Environ. Res. Public Health 2021, 18, 4069. https://doi.org/10.3390/ijerph18084069 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 4069 2 of 9

effective vaccines, it is expected that most people would be willing to vaccinate. However,
a study in New York showed that only 59% reported that they would get a vaccine and 53%
would give it to their children [5]. Other surveys in Australia showed a higher willingness
to vaccinate, about 85% [6] and 75% [7].
The increasing use of social media as a source of health information may contribute to
vaccine hesitancy due to anti-vaccination content being widely available on social media [8].
A report found that about 31 million people were following Facebook accounts of ‘anti-
vaxxers’ in 2019, and about 17 million people were subscribing to similar accounts on
YouTube [9]. Since then, the number of people following anti-vaxxer accounts on social
media has increased by at least 7.8 million people [9]. The report also pointed out that
those who received information on the COVID pandemic from social media were more
likely to be more hesitant about the vaccine [9]. Another study found that uptake of
influenza vaccine was inversely associated with the use of Twitter and Facebook for health
information [10].
Research that can make use of the huge amount of rich data generated from social
media, such as Twitter, will be able to provide useful information for formulating strategies
that could help reduce anti-vaccination sentiments among different groups. One of the
first tasks in this context is to develop a text classification method that can identify anti-
vaccination tweets on Twitter. However, given the text-based format and the large amount
of data, it is quite a challenging task to handle. An effective approach that was adopted
in several Twitter studies on anti-vaccination was to use machine learning techniques.
However, most of these studies used traditional machine learning techniques such as
support vector machine (SVM), naïve Bayes (NB), and decision tree [11–16]. A few other
studies did not describe what machine learning techniques they used [17,18] whereas one
study used hashtag scores instead of a machine learning technique [19]. Although these
methods may generate comparable results in some machine learning tasks compared to
deep learning (or deep neural network) [20,21]. Deep learning has been shown to produce
state-of-the-art results in many natural language processing tasks [22]. However, only two
studies applied deep learning to identify tweets against HPV vaccines [23,24].
Therefore, this study aims to evaluate the performance of different natural language
processing models to identify anti-vaccination tweets that were published during the
COVID-19 pandemic with the main focus on the bidirectional long short-term memory
networks with GLoVe embeddings [25] (Bi-LSTM) and bidirectional encoder representa-
tions from transformers (BERT). We also compared the performance of these models with
those of classic machine learning methods including SVM and NB. The finding from this
study provides useful information to determine an appropriate model for use to identify
anti-vaccination tweets in future studies.

2. Related Work
Zhou et al. (2015) [15] used a random sample of 884 tweets to develop a supervised
classifier that could identify anti-vaccine tweets. Particularly, the SVM method with a
radial basis function kernel was used. Forward selection and backward elimination were
used to select features that were most likely to discriminate between the two classes. Using
only the content of the tweet, the top performer achieved an accuracy of 89.8%.
Mitra et al. (2016) [14] also developed a vaccination stance classifier by training an
SVM with 8000 tweets. However, they only used tweets with the same ratings by all three
raters as well as only retained tweets with a predicted probability greater than 90%. The
accuracy of this classifier was 84.7%.
Another study using SVM was conducted by Shapiro et al. (2017) [13]. However,
the classification was implemented in two stages. First, they used 1000 manually labeled
tweets to develop a binary classifier that could identify tweets expressing concerns or no
concerns about vaccines. This classifier achieved an F1-score of 93% for concern and 81%
for non-concern. Then they used another 1000 manually labeled tweets to build another
classifier that could identify tweets with specific types of concerns. The performance of
Int. J. Environ. Res. Public Health 2021, 18, 4069 3 of 9

this classifier was widely different with F1 scores ranging from 0.22 to 0.92 for each type
of concern.
Kunneman et al. (2020) [16] used multinomial naïve Bayes and SVM with a linear
kernel to develop a vaccine stance classifier. The classifier was trained on 8259 labeled
tweets. The results suggested that SVM as a binary classifier outperformed NB for the task
with the highest F1-score of 34% for SVM and 27% for NB. The highest AUC was 63% for
SVM and 58% for NB.
Du et al. (2017) [26] also found that SVM outperformed NB and random forest on
the ability to identify negative tweets against HPV vaccines. The SVM models used a
radial basis function kernel and were trained with 6000 labeled tweets. Compared with the
standard SVM model (a micro-averaging F1 score of 67.32%), the hierarchical classification
SVM model achieved a micro-averaging F1 score of 72.08%.
For the purpose of identifying anti-vaccination tweets, we found two studies that
developed deep learning models with the use of transfer learning. Du et al. (2020) [23]
compared the performance of extremely randomized trees (a classic machine learning
method) with deep-learning-based methods including Attention-based RNN, Attention-
based ELMo, and BERT. The models were developed using 6000 labeled HPV-related tweets.
The results showed that top performers were deep-learning-based models with the mean
F1 score between 70% and 81%. The other study was conducted by Zhang et al. (2020) [24].
This study used deep learning models with three transfer learning approaches. The first
was to use static embeddings (Word2Vec, GloVe, and FastText) [27] and embeddings from
language models (ELMo) [28] processed by the bidirectional gated recurrent unit with
attention. The other two were to fine-tune generative pre-training (GPT) and BERT models.
6000 tweets relating to HPV were used for the experiments. The results showed that the
BERT model was the top performer with a micro-average F1 score of 76.9%.

3. Methods
3.1. Data Source
Twitter is a social networking platform where users post messages and respond
to messages from other users. These messages are known as tweets. A tweet has an
original length of 140 characters but since November 2017, the length was doubled to
280 characters [29]. A Twitter dataset collected by Banda et al. 2020 was used [30]. Details
of the dataset (version 24) were published elsewhere [30]. In brief, tweets were collected
between 1 January and 23 August 2020 using a Twitter Stream API which allows public
access to a one percent sample of the daily stream of Twitter. Although the dataset includes
635,059,608 tweets and retweets in the full version, the clean version (no retweets) with
150,657,465 tweets was used. After removing tweets not in English, 75,797,822 tweets
were hydrated using the Tweepy library in Python 3 (https://www.tweepy.org, accessed
on 10 April 2021). A total of 1,651,687 tweets containing “vaccin”, “vaxx”, or “inocul”
were extracted.

3.2. Data Processing and Labeling

Texts were changed to lowercase. Twitter handles, URLs, hyphens, hashtags (with at-
tached words), numbers, and special characters were removed. A list of English stop words
(e.g., is, that, has, a, do, etc.) from the NLTK library (https://www.nltk.org, accessed on 10
April 2021) were used to remove stop words from the tweets (negations including “not”
and “no” were not removed given the purpose was to identify anti-vaccination tweets).
Lemmatization, a process of generating the canonical form of a word, was implemented
for words in all tweets. Tweets with no content after being processed were removed. A
total of 1,474,276 remained.
A systematic random sampling method was used to select 20,854 tweets from 1,474,276
tweets for labeling. This sampling method ensures that tweets across the different times
during the pandemic were selected. Tweets were labeled as either “anti-vaccination” or
“other” (i.e., neutral, news, or ambiguous) as the model was aimed to use for stance analysis.
Int. J. Environ. Res. Public Health 2021, 18, 4069 4 of 9

In stance analysis, a tweet is determined to be in favor or against a target [31]. This is

different from sentiment analysis in which a tweet is classified as positive or negative.
A negative tweet may not mean anti-vaccine while a positive tweet may not mean pro-
vaccine. Ten researchers worked in pairs to label the tweets. Differences in labeling were
checked and decided by a third researcher. The average agreement between the two raters
was 91.04% ranging between 85.90% and 94.48% (Supplementary file). The percentage of
anti-vaccine tweets was 9.1%. The data were then split into three parts: training set (70%),
development set (15%), and test set (15%). The training and development sets were used to
build the model, the performance of which was evaluated on the test set.

3.3. Bidirectional Long Short-Term Memory Networks (Bi-LSTM)

Recurrent neural networks (RNN) have been used in many natural language process-
ing tasks due to their ability to handle sequential data with various lengths. However,
standard RNNs have limitations. First, as the inputs are processed in order, the outputs are
mostly based on only previous context (i.e., words) [32]. The second issue is referred to
as difficulty in learning long-term dependencies when the sentences are too long [32,33].
For the first problem, a solution is to use bidirectional RNN [32,34]. Bidirectional RNNs
combine two unidirectional RNNs that process data in two opposite directions. As such, at
every time step, the bidirectional RNN has all information before and after it [34]. For the
second problem, LSTM units can be used. An LSTM unit is comprised of a cell that can
remember information over time intervals, and a set of gates (i.e., input, forget, and output
gates) that are used to control which information flows into and out of the cell [32,35]. Ad-
ditionally, word embeddings from pre-trained models were used to increase performance.
Specifically, we used the GloVe model, pre-trained with 2 billion tweets, 27 billion tokens,
and 200 dimensions [25].
The RNN with one bidirectional LSTM layer was used as increasing the network size
did not improve the performance. We used a dropout rate of 0.1, Adam with weight decay
(AdamW) optimizer, and binary cross-entropy loss function. We also experimented with
a learning rate = (0.00003, 0.0001, 0.001), the number of units of the bidirectional LSTM
layer = (256, 128, 64), and the number of epochs = (10, 20, 30, 40, 50, 60, 70, 80). Class
weights were also calculated and used in the training.

3.4. Bidirectional Encoder Representations from Transformers (BERT)

Although static word embedding methods such as GloVe and word2vec have obtained
great achievement in many natural language processing tasks, it does not take into account
the order of words in the sentence. Also, the same word may have different meanings
depending on the context of the sentence. This problem is addressed with dynamic
embedding methods such as BERT [36] that produce vector representations for words
conditional on the sentence context. BERT has been shown to achieve new state-of-the-art
results on natural language processing tasks [36]. In this study, we used the BERT pre-
trained uncased model with 12 hidden layers (transformer blocks), a hidden size of 768, and
12 attention heads (https://tfhub.dev/tensorflow/bert_en_uncased_L-12_H-768_A-12/3,
accessed on 10 April 2021). We also experimented with different learning rate = (0.0003,
0.0001) and number of epochs = (1, 2, 3, 4, 5).

3.5. Support Vector Machine (SVM) and Naïve Bayes (NB) Classifier
SVM [37] and NB [38] are traditional machine learning methods that have been used
in text classification tasks [13–15]. Some studies showed that the performance of SVM
and NB is comparable to neural networks [20,21] while the opposite results were found
in the other studies [39,40]. In this study, we used the term frequency-inverse document
frequency method to vectorize the text data. In addition, we experimented with four SVM
kernels = [linear, poly, radial basis function, and sigmoid] but used default values (as
reported in c-support vector classification, the Scikit-learn package) for other parameters.
For NB, we used the complement NB and multinomial NB.
Int. J. Environ. Res. Public Health 2021, 18, 4069 5 of 9

3.6. Metrics for Evaluating Performance

We reported the following metrics for evaluating the performance of all machine
learning models. Accuracy is the proportion of tweets correctly predicted by the model
over all of the tweets. Precision (also named positive predictive value) is the proportion of
anti-vaccination tweets that are correctly predicted by the model over all anti-vaccination
predictions. Recall (also named sensitivity) is the proportion of anti-vaccination tweets
that are correctly predicted by the model over all anti-vaccination tweets. As the data are
imbalanced (i.e., the percentage of anti-vaccination tweets is small), accuracy may not be a
good metric. Therefore, we used the F1 score as the primary metric. We also reported the
area under the receiver operating characteristic curve (AUC) which is drawn based on true
positive and false-positive rates.

Precision × Recall
F1 score = 2 × (1)
Precision + Recall
True positive + true negative
Accuracy = (2)
Total number o f predictions
True positive
Precision = (3)
True positive + f alse positive
True positive
Recall = (4)
True positive + f alse negative

4. Results
Table 1 shows the performance of the Bi-LSTM models on the development set. We
only reported results for Bi-LSTM models with 128 units as these outperformed those
with 64 and 256 units. In general, the performance of these 128-unit models was not very
different across learning rates and epochs. The top performer was the Bi-LSTM-128 model
that used a learning rate of 0.0001 and was trained for 60 epochs. For this model, the F1
score was 51.7%. AUC was also quite high (87.9%).
Table 2 shows the performance of the BERT models on the development set. In general,
all BERT models performed very well. F1 scores for all models were above 95%. Although
AUC was also high, the models seem to overfit after three epochs. The top performer based
on the F1 score was the model which was trained with a learning rate of 0.0001 and for
3 epochs.
Table 3 shows the performance of the SVM and NB models on the development set.
The SVM model with linear kernel outperformed the other SVM models with an F1 score
of 32.2% and AUC of 83.9%. The complement NB model, which achieved an F1 score of
30.5% and AUC of 65.2%, outperformed the multinomial NB model. Although F1 scores
were similar between the SVM model with linear kernel and the complement NB (32.2%
vs. 30.5%, respectively), the SVM model with linear kernel achieved much higher AUC
compared to the complement NB (83.9% vs. 65.2%, respectively).
Table 4 shows the performance of the top Bi-LSTM, BERT, SVM, and NB models that
were evaluated on the test set. The BERT model outperformed the other models with an F1
score of 95.5% which is more than two times higher than the Bi-LSTM model (45.5%) and
three times higher than the SVM with the linear kernel (31.2%) and the complement NB
(27.1%) models. However, the performance of AUC for the BERT model was lower when
evaluating with the test set (84.7%) compared to the development set (90.8%). AUC for the
complement NB model was also low at 62.7%.
Int. J. Environ. Res. Public Health 2021, 18, 4069 6 of 9

Table 1. Performance of the Bi-LSTM-128 models on the development set.

Learning Rate Epoch Accuracy Precision Recall F1 Score AUC

10 77.2% 26.2% 74.9% 38.9% 84.2%
20 78.7% 28.1% 76.9% 41.1% 85.1%
30 79.8% 28.7% 73.3% 41.2% 86.3%
40 82.3% 31.2% 68.6% 42.9% 87.1%
0.00003
50 82.3% 31.3% 69.3% 43.2% 87.6%
60 82.7% 31.8% 68.6% 43.4% 87.7%
70 81.3% 30.1% 70.6% 42.2% 87.6%
80 82.5% 31.9% 71.3% 44.0% 88.0%
10 80.7% 29.9% 73.9% 42.6% 87.2%
20 80.5% 29.9% 75.6% 42.8% 88.3%
30 80.8% 30.1% 74.9% 43.0% 88.0%
40 85.8% 37.0% 66.3% 47.5% 88.2%
0.0001
50 89.7% 47.2% 53.1% 50.0% 86.2%
60 88.4% 43.2% 64.4% 51.7% 87.9%
70 86.1% 37.4% 64.0% 47.2% 87.3%
80 88.8% 43.9% 54.1% 48.4% 85.0%
10 84.5% 35.2% 71.3% 47.1% 88.1%
20 84.7% 35.1% 68.0% 46.3% 86.9%
30 90.0% 47.9% 41.6% 44.5% 83.8%
40 89.1% 44.6% 52.1% 48.1% 80.4%
0.001
50 90.7% 53.3% 34.3% 41.8% 74.5%
60 89.6% 46.2% 42.6% 44.3% 78.3%
70 88.6% 42.1% 47.2% 44.5% 79.4%
80 88.7% 42.5% 46.5% 44.4% 77.5%

Table 2. Performance of the BERT models on the development set.

Learning Rate Epoch Accuracy Precision Recall F1 Score AUC

1 91.7% 92.5% 98.8% 95.5% 90.7%
2 91.8% 94.3% 96.8% 95.5% 91.5%
0.00003 3 92.2% 94.6% 96.8% 95.7% 86.5%
4 92.1% 94.5% 96.9% 95.7% 83.7%
5 91.7% 94.5% 96.4% 95.4% 79.8%
1 92.1% 93.5% 98.0% 95.7% 91.0%
2 92.0% 94.1% 97.2% 95.6% 91.4%
0.0001 3 92.5% 94.5% 97.3% 95.9% 90.8%
4 92.1% 94.5% 96.9% 95.7% 84.6%
5 92.0% 94.4% 96.9% 95.6% 82.1%

Table 3. Performance of the SVM and NB models on the development set.

Accuracy Precision Recall F1 Score AUC

SVM-linear 91.7% 20.5% 75.6% 32.2% 83.9%
SVM-poly 90.8% 9.2% 66.7% 16.2% 78.9%
SVM-rbf 91.1% 12.5% 74.5% 21.5% 83.0%
SVM-sigmoid 91.5% 17.5% 75.7% 28.4% 83.8%
Complement NB 88.8% 25.4% 38.1% 30.5% 65.2%
Multinomial NB 90.6% 5.6% 68.0% 10.4% 79.4%
Int. J. Environ. Res. Public Health 2021, 18, 4069 7 of 9

Table 4. Performance among Bi-LSTM, BERT, SVM, and NB on the test set.

Accuracy Precision Recall F1 Score AUC

Bi-LSTM-128, learning
89.8% 44.0% 47.2% 45.5% 85.8%
rate = 0.0001, epoch = 50
BERT, learning rate = 0.0001,
91.6% 93.4% 97.6% 95.5% 84.7%
epoch = 3
SVM-linear 92.3% 19.5% 78.6% 31.2% 85.6%
Complement NB 88.8% 23.0% 32.8% 27.1% 62.7%

5. Discussion
This study aimed to evaluate the performance of machine learning models on iden-
tifying anti-vaccination tweets that were obtained during the COVID-19 pandemic. The
findings showed that BERT models outperformed the Bi-LSTM, SVM, and NB models
across all performance metrics (i.e., accuracy, precision, recall, F1 score, and AUC). The next
top performer was the Bi-LSTM deep learning models. Classic machine learning models
including SVM and NB models did not perform as well on this task of identifying the
anti-vaccination tweets compared to the BERT and Bi-LSTM models.
The BERT models did very well on this text classification task with four of five metrics
being above 90% and an AUC of 84.7%. This is higher than the performance of systems
using the classic SVM method (accuracy less than 90%) [14,15,18]. Our finding is consistent
with other studies that deep learning-based models outperformed classic machine learning
methods on this task [23,24]. Moreover, the finding that BERT models outperformed other
deep learning models is consistent with that by Zhang et al. (2020) [24]. The BERT model
also achieved an F1 score higher than the deep learning models by Du et al. (2020) (mean
F1 scores from 70% to 81%) [23] and Zhang et al. (2020) (F1 score 76.9%) [24]. These
results show that the BERT models were extremely good at identifying anti-vaccination
tweets even in the case that the data are imbalanced (i.e., anti-vaccination tweets were
a small percentage of all vaccination tweets). With a basic BERT model, we have been
able to achieve an F1 score higher than F1 scores achieved by a more complex static word
embedding system, which was the top performer (average F1 score of 67.8%) among the
19 submissions to a supervised stance analysis task [41]. We suggest that the BERT model
should be considered as a method of choice for stance analysis on large Twitter datasets.
This finding is not surprising given that the BERT model has been shown to outperform
other state-of-the art natural language processing systems and even human performance
on eleven natural language processing tasks [36].
In this study, the average agreement rate between coders (91.04%) was comparable to
that in other studies which were 85.1% by Du et al., 2020 [23], 95% by Zhou et al., 2015 [15],
and 100% by Tomeny et al., 2017 [18]. However, the number of tweets used in this study
(20,854 tweets) was larger than those used in other studies such as 884 tweets by Zhou et al.,
2015 [15], 2000 tweets by Tomeny et al., 2017 [18], 6000 tweets by Du et al., 2020 [23], and
8000 tweets by Mitra et al., 2016 [14] which is a strength of this study.
This study has some limitations. As public access to tweets is limited due to rules
imposed by Twitter, the tweets used in this study accounted for only one percent of daily
tweets and therefore, may not be representative for all of the tweets. In addition, due to lack
of time and resources needed for training, model fine-tuning was limited to a few learning
rates and the number of epochs, other parameters were not tuned. The performance of
these models might have been improved further if the tuning had been conducted more
widely. However, we consider that the performance of BERT models in this study was
excellent and good enough for use to identify anti-vaccination tweets in future studies.
Int. J. Environ. Res. Public Health 2021, 18, 4069 8 of 9

6. Conclusions
The BERT models outperformed the Bi-LSTM, SVM, and NB models on this task.
Moreover, the BERT model achieved excellent performance and can be used to identify
anti-vaccination tweets in future studies.

Supplementary Materials: The following are available online at https://www.mdpi.com/article/10

.3390/ijerph18084069/s1, Confusion Matrix Tables, and Examples of Prediction.
Author Contributions: Conceptualization, Q.G.T. and C.V.; data curation, Q.G.T., N.T.Q.N., D.T.N.N.,
S.J.A., A.N.Q.T., A.N.P.T., N.T.T.P., and T.X.B.; formal analysis, Q.G.T.; investigation, Q.G.T., K.G.T.,
V.-A.N.H., N.T.Q.N., D.T.N.N., S.J.A., A.N.Q.T., A.N.P.T., N.T.T.P., and T.X.B.; methodology, Q.G.T.;
project administration, Q.G.T., K.G.T., and V.-A.N.H.; resources, K.G.T., V.-A.N.H., and C.V.; supervi-
sion, Q.G.T., K.G.T., V.-A.N.H., and C.V.; validation, N.T.Q.N., D.T.N.N., S.J.A., A.N.Q.T., A.N.Q.T.,
N.T.T.P., and T.X.B.; writing—original draft, Q.G.T.; writing—review & editing, K.G.T., V.-A.N.H.,
N.T.Q.N., D.T.N.N., S.J.A., A.N.Q.T., A.N.P.T., N.T.T.P., T.X.B., and C.V. All authors have read and
agreed to the published version of the manuscript.
Funding: The research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Acknowledgments: We thank Nguyen Le Quoc Vuong for participating in tweet labeling.
Conflicts of Interest: The authors declare no conflict of interest.

Abbreviations

AUC Area under the receiver operating characteristic curve

BERT Bidirectional encoder representations from transformers
Bi-LSTM Bidirectional long short-term memory networks
ELMo Embeddings from language models
GPT Generative pre-training
NB Naïve Bayes
RNN Recurrent neural networks
SVM Support vector machine

References
1. Doherty, M.; Buchy, P.; Standaert, B.; Giaquinto, C.; Prado-Cohrs, D. Vaccine impact: Benefits for human health. Vaccine 2016,
34, 6707–6714. [CrossRef]
2. American Academy of Pediatrics. Documenting Parental Refusal to Have Their Children Vaccinated. Available online: https:
//www.aap.org/en-us/documents/immunization_refusaltovaccinate.pdf (accessed on 30 November 2020).
3. Bednarczyk, R.A.; King, A.R.; Lahijani, A.; Omer, S.B. Current landscape of nonmedical vaccination exemptions in the United
States: Impact of policy changes. Expert Rev. Vaccines 2019, 18, 175–190. [CrossRef]
4. World Health Organization. Ten Threats to Global Health in 2019. Available online: https://www.who.int/news-room/spotlight/
ten-threats-to-global-health-in-2019 (accessed on 30 November 2020).
5. Megget, K. Even covid-19 can’t kill the anti-vaccination movement. BMJ 2020, 369, m2184. [CrossRef]
6. Alley, S.J.; Stanton, R.; Browne, M.; To, Q.G.; Khalesi, S.; Williams, S.L.; Thwaite, T.L.; Fenning, A.S.; Vandelanotte, C. As the
Pandemic Progresses, How Does Willingness to Vaccinate against COVID-19 Evolve? Int. J. Environ. Res. Public Health 2021,
18, 797. [CrossRef]
7. Rhodes, A.; Hoq, M.; Measey, M.-A.; Danchin, M. Intention to vaccinate against COVID-19 in Australia. Lancet Infect. Dis. 2020.
Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489926/ (accessed on 10 April 2020). [CrossRef]
8. Puri, N.; Coomes, E.A.; Haghbayan, H.; Gunaratne, K. Social media and vaccine hesitancy: New updates for the era of COVID-19
and globalized infectious diseases. Hum. Vaccines Immunother. 2020, 16, 2586–2593. [CrossRef]
9. Burki, T. The online anti-vaccine movement in the age of COVID-19. Lancet Digit. Health 2020, 2, e504–e505. [CrossRef]
10. Ahmed, N.; Quinn, S.C.; Hancock, G.R.; Freimuth, V.S.; Jamison, A. Social media use and influenza vaccine uptake among White
and African American adults. Vaccine 2018, 36, 7556–7561. [CrossRef] [PubMed]
11. Dunn, A.G.; Leask, J.; Zhou, X.; Mandl, K.D.; Coiera, E. Associations between exposure to and expression of negative opinions
about human papillomavirus vaccines on social media: An observational study. J. Med. Internet Res. 2015, 17, e144. [CrossRef]
[PubMed]
Int. J. Environ. Res. Public Health 2021, 18, 4069 9 of 9

12. Massey, P.M.; Leader, A.; Yom-Tov, E.; Budenz, A.; Fisher, K.; Klassen, A.C. Applying multiple data collection tools to quantify
human papillomavirus vaccine communication on Twitter. J. Med. Internet Res. 2016, 18, e318. [CrossRef]
13. Shapiro, G.K.; Surian, D.; Dunn, A.G.; Perry, R.; Kelaher, M. Comparing human papillomavirus vaccine concerns on Twitter: A
cross-sectional study of users in Australia, Canada and the UK. BMJ Open 2017, 7, e016869. [CrossRef]
14. Mitra, T.; Counts, S.; Pennebaker, J.W. Understanding anti-vaccination attitudes in social media. In Proceedings of the Tenth
International AAAI Conference on Web and Social Media, Cologne, Germany, 17–20 May 2016.
15. Zhou, X.; Coiera, E.; Tsafnat, G.; Arachi, D.; Ong, M.-S.; Dunn, A.G. Using social connection information to improve opinion
mining: Identifying negative sentiment about HPV vaccines on Twitter. Stud. Health Technol. Inform. 2015, 216, 761–765.
16. Kunneman, F.; Lambooij, M.; Wong, A.; Bosch, A.V.D.; Mollema, L. Monitoring stance towards vaccination in twitter messages.
BMC Med. Inform. Decis. Mak. 2020, 20, 33. [CrossRef]
17. Deiner, M.S.; Fathy, C.; Kim, J.; Niemeyer, K.; Ramirez, D.; Ackley, S.F.; Liu, F.; Lietman, T.M.; Porco, T.C. Facebook and Twitter
vaccine sentiment in response to measles outbreaks. Health Inform. J. 2019, 25, 1116–1132. [CrossRef] [PubMed]
18. Tomeny, T.S.; Vargo, C.J.; El-Toukhy, S. Geographic and demographic correlates of autism-related anti-vaccine beliefs on Twitter,
2009–2015. Soc. Sci. Med. 2017, 191, 168–175. [CrossRef]
19. Gunaratne, K.; Coomes, E.A.; Haghbayan, H. Temporal trends in anti-vaccine discourse on twitter. Vaccine 2019, 37, 4867–4871.
[CrossRef] [PubMed]
20. Hartmann, J.; Huppertz, J.; Schamp, C.; Heitmann, M. Comparing automated text classification methods. Int. J. Res. Mark. 2019,
36, 20–38. [CrossRef]
21. Al-Smadi, M.; Qawasmeh, O.; Al-Ayyoub, M.; Jararweh, Y.; Gupta, B. Deep Recurrent neural network vs. support vector machine
for aspect-based sentiment analysis of Arabic hotels’ reviews. J. Comput. Sci. 2018, 27, 386–393. [CrossRef]
22. Zhang, L.; Wang, S.; Liu, B. Deep learning for sentiment analysis: A survey. Wires Data Min. Knowl. Discov. 2018, 8, e1253.
[CrossRef]
23. Du, J.; Luo, C.; Shegog, R.; Bian, J.; Cunningham, R.M.; Boom, J.A.; Poland, G.A.; Chen, Y.; Tao, C. Use of Deep Learning to
Analyze Social Media Discussions About the Human Papillomavirus Vaccine. JAMA Netw. Open 2020, 3, e2022025. [CrossRef]
24. Zhang, L.; Fan, H.; Peng, C.; Rao, G.; Cong, Q. Sentiment Analysis Methods for HPV Vaccines Related Tweets Based on Transfer
Learning. Healthcare 2020, 8, 307. [CrossRef] [PubMed]
25. Pennington, J.; Socher, R.; Manning, C.D. (Eds.) Glove: Global vectors for word representation. In Proceedings of the 2014
Conference on Empirical Methods in Natural Language Processing (EMNLP), Doha, Qatar, 25–29 October 2014.
26. Du, J.; Xu, J.; Song, H.; Liu, X.; Tao, C. Optimization on machine learning based approaches for sentiment analysis on HPV
vaccines related tweets. J. Biomed. Semant. 2017, 8, 9. [CrossRef] [PubMed]
27. Joulin, A.; Grave, E.; Bojanowski, P.; Mikolov, T. Bag of tricks for efficient text classification. arXiv 2016, arXiv:160701759.
28. Peters, M.E.; Neumann, M.; Iyyer, M.; Gardner, M.; Clark, C.; Lee, K.; Zettlemoyer, L. Deep contextualized word representations.
arXiv 2018, arXiv:180205365.
29. Wikipedia. Twitter. Available online: https://en.wikipedia.org/wiki/Twitter#cite_note-15 (accessed on 1 April 2021).
30. Banda, J.M.; Tekumalla, R.; Wang, G.; Yu, J.; Liu, T.; Ding, Y.; Chowell, G. A large-scale COVID-19 Twitter chatter dataset for open
scientific research—An international collaboration. arXiv 2020, arXiv:2004.03688v03681.
31. Mohammad, S.; Kiritchenko, S.; Sobhani, P.; Zhu, X.; Cherry, C. Semeval-2016 task 6: Detecting stance in tweets. In Proceedings
of the 10th International Workshop on Semantic Evaluation (SemEval-2016), San Diego, CA, USA, 16–17 June 2016; pp. 31–41.
32. Graves, A.; Schmidhuber, J. Framewise phoneme classification with bidirectional LSTM and other neural network architectures.
Neural Netw. 2005, 18, 602–610. [CrossRef] [PubMed]
33. Bengio, Y.; Simard, P.; Frasconi, P. Learning long-term dependencies with gradient descent is difficult. IEEE Trans. Neural Netw.
1994, 5, 157–166. [CrossRef]
34. Schuster, M.; Paliwal, K.K. Bidirectional recurrent neural networks. IEEE Trans. Signal Process. 1997, 45, 2673–2681. [CrossRef]
35. Hochreiter, S.; Schmidhuber, J. Long short-term memory. Neural Comput. 1997, 9, 1735. [CrossRef]
36. Devlin, J.; Chang, M.-W.; Lee, K.; Toutanova, K. Bert: Pre-training of deep bidirectional transformers for language understanding.
arXiv 2018, arXiv:1810.04805.
37. Cortes, C.; Vapnik, V. Support-vector networks. Mach. Learn. 1995, 20, 273–297. [CrossRef]
38. McCallum, A.; Nigam, K. A comparison of event models for naive bayes text classification. In Proceedings of the AAAI-98
Workshop on Learning for Text Categorization, Madison, WI, USA, 26–27 July 1998; pp. 41–48.
39. Kamath, C.N.; Bukhari, S.S.; Dengel, A. Comparative study between traditional machine learning and deep learning approaches
for text classification. In Proceedings of the ACM Symposium on Document Engineering 2018, Halifax, NS, Canada, 28–31
August 2018; pp. 1–11.
40. Mariel, W.C.F.; Mariyah, S.; Pramana, S. Sentiment analysis: A comparison of deep learning neural network algorithm with SVM
and naive Bayes for Indonesian text. In Journal of Physics: Conference Series; IOP Publishing: Bristol, UK, 2018; p. 012049.
41. Zarrella, G.; Marsh, A. Mitre at semeval-2016 task 6: Transfer learning for stance detection. arXiv 2016, arXiv:1606.03784.
anti-vaxxer
See also: antivaxxer

Contents
English
Alternative forms
Etymology
Pronunciation
Noun
Related terms
Translations

English

Alternative forms
anti-vaxer, antivaxer, antivaxxer

Etymology

From anti-vax + -er or anti- + vax + -er. Equivalent to anti- + vaxxer.

Pronunciation
Audio (AU) (file)

Noun

anti-vaxxer (plural anti-vaxxers)

 1. (informal) A person who opposes vaccination, as for its purported dangerous effects. [from c.
2000]

Synonym: anti-vaccinationist
Antonyms: (informal) pro-vaxxer, (informal) vaxxer

2012, Amanda Marcotte, "Measles Outbreak Traced to Super Bowl, Anti-Vaccination

Fanatics (http://www.slate.com/blogs/xx_factor/2012/02/24/the_super_bowl_outbreak_d
emonstrates_the_dangers_of_anti_vaccination_advocacy_.html)", Slate, 24 February
2012:

Janice D'Arcy reports at the Washington Post on the latest measles outbreak
traced back to anti-vaccination fanatics, but this time, instead of an outbreak being
traced back to a Whole Foods or a nursery school---the usual places where the
kids of yuppie anti-vaxxers have a chance to expose and be exposed---the trail for
this one leads back to the Super Bowl.

2020 November 18, Nigel Harris, “Comment: Of ministers and messaging”, in Rail, page
3:

Like everyone else (other than anti-vaxxers, I guess), I was delighted to see the
good news about the Pfizer vaccine hopefully being rolled out before Christmas.

2020 November 21, Mark Hilliard, “Health officials working on strategy to overcome
vaccine scepticism”, in The Irish Times[1] (https://www.irishtimes.com/news/health/health-officials-
working-on-strategy-to-overcome-vaccine-scepticism-1.4415922):

She acknowledged the existence of a “cohort of anti-vaxers”, as well as “valid”

scepticism among other parts of society given the speed at which the vaccine has
been developed. But the bigger issue, she said, will be how they manage a drip
feed in supply.

For more quotations using this term, see Citations:anti-vaxxer.

Related terms
anti-vaccination anti-vax vaxx
anti-vaccine anti-vaxxing

Translations
person who opposes vaccination

French: antivax (fr) m or f Macedonian: антиваксер m (antivakser)

German: Impfgegner (de) m, Norwegian:
Impfgegnerin (de) f
Bokmål: antivaksinist m

Polish: antyszczepionkowiec (pl) m

Spanish: antivacunas (es) m or f

Retrieved from "https://en.wiktionary.org/w/index.php?title=anti-vaxxer&oldid=64450294"

This page was last edited on 27 October 2021, at 23:11.

Text is available under the Creative Commons Attribution-ShareAlike License; additional terms may apply. By using
this site, you agree to the Terms of Use and Privacy Policy.
Vaccine hesitancy
Vaccine hesitancy is a delay in acceptance, or refusal of vaccines despite the availability of vaccine
services. The term covers outright refusals to vaccinate, delaying vaccines, accepting vaccines but
remaining uncertain about their use, or using certain vaccines but not others.[1][2][3][4] "Anti-
vaccinationism" refers to total opposition to vaccination; in more recent years, anti-vaccinationists have
been known as "anti-vaxxers" or "anti-vax".[5] Vaccine hesitancy is complex and context-specific,
varying across time, place and vaccines.[6] It can influenced by factors such lack of proper scientifically-
based knowledge and understanding about how vaccines are made or how vaccines work, complacency,
convenience, or even fear of needles.[2]

There is an overwhelming scientific consensus that vaccines are generally safe and effective.[7][8][9][10]
Vaccine hesitancy often results in disease outbreaks and deaths from vaccine-preventable
diseases.[11][12][13][14][15][16] Therefore, the World Health Organization characterizes vaccine hesitancy as
one of the top ten global health threats.[17][18]

Hesitancy primarily results from public debates around the medical, ethical, and legal issues related to
vaccines. Vaccine hesitancy stems from multiple key factors including a person's lack of confidence
(mistrust of the vaccine and/or healthcare provider), complacency (the person does not see a need for the
vaccine or does not see the value of the vaccine), and convenience (access to vaccines).[3] It has existed
since the invention of vaccination and pre-dates the coining of the terms "vaccine" and "vaccination" by
nearly eighty years. The specific hypotheses raised by anti-vaccination advocates have been found to
change over time.[19]

Proposed laws that would mandate vaccination, such as California Senate Bill 277 and Australia's No Jab
No Pay, have been opposed by anti-vaccination activists and organizations.[20][21][22] Opposition to
mandatory vaccination may be based on anti-vaccine sentiment, concern that it violates civil liberties or
reduces public trust in vaccination, or suspicion of profiteering by the pharmaceutical
industry.[13][23][24][25][26]

Contents
Effectiveness
Population health
Cost-effectiveness
Necessity
Safety concerns
Thiomersal
MMR vaccine
Vaccine overload
Prenatal infection
Ingredient concerns
Sudden infant death syndrome
Anthrax vaccines
 Swine flu vaccine
Other safety concerns
Fear of needles
Malpractice and fraud
CIA fake vaccination clinic
Fake COVID-19 vaccines
Medical racism
Vaccine myths
Autism
Vaccination during illness
Natural infection
HPV vaccine
Vaccine schedule
Events following reductions in vaccination
Stockholm, smallpox (1873–74)
UK, pertussis (1970s–80s)
Sweden, pertussis (1979–96)
Netherlands, measles (1999–2000)
UK and Ireland, measles (2000)
Nigeria, polio, measles, diphtheria (2001–)
United States, measles (2005–)
Wales, measles (2013–)
United States, tetanus
Romania, measles (2016–present)
Samoa, measles (2019)
2019–2020 measles outbreaks
Countermeasures
Providing information
Communication strategies
Provider presumption and persistence
Pain mitigation for children
Cultural sensitivity
Avoiding online misinformation
Incentive programs
Vaccine mandates
History
Variolation
Smallpox vaccination
Later vaccines and antitoxins
Geographical distribution
Policy implications
Individual liberty
Children's rights
Religion
Alternative medicine
Chiropractic
Homeopathy
Financial motives
War
Spanish–American War
Vietnam War
Information warfare
See also
References
Further reading
External links

Effectiveness
Scientific evidence for the effectiveness of large-
scale vaccination campaigns is well
established.[27] Two to three million deaths are
prevented each year worldwide by vaccination,
and an additional 1.5 million deaths could be
prevented each year if all recommended vaccines
were used.[28] Vaccination campaigns helped
eradicate smallpox, which once killed as many as
one in seven children in Europe,[29] and have
nearly eradicated polio.[30] As a more modest
example, infections caused by Haemophilus
influenzae (Hib), a major cause of bacterial Rates of measles fell sharply when universal
meningitis and other serious diseases in children, immunization was introduced.
have decreased by over 99% in the US since the
introduction of a vaccine in 1988.[31] It is
estimated that full vaccination, from birth to adolescence, of all US children born in a given year would
save 33,000 lives and prevent 14 million infections.[32]

There is anti-vaccine literature that argues that reductions in infectious disease result from improved
sanitation and hygiene (rather than vaccination) or that these diseases were already in decline before the
introduction of specific vaccines. These claims are not supported by scientific data; the incidence of
vaccine-preventable diseases tended to fluctuate over time until the introduction of specific vaccines, at
which point the incidence dropped to near zero. A Centers for Disease Control and Prevention website
aimed at countering common misconceptions about vaccines argued, "Are we expected to believe that
better sanitation caused the incidence of each disease to drop, just at the time a vaccine for that disease was
introduced?"[33]

Another rallying cry of the anti-vaccine movement is to call for randomized clinical trials in which an
experimental group of children are vaccinated while a control group are unvaccinated. Such a study would
never be approved because it would require deliberately denying children standard medical care, rendering
the study unethical. Studies have been done that compare vaccinated to unvaccinated people, but the
studies are not randomized. Moreover, a literature already exists that prove the safety of vaccine using other
experimental methods.[34]

Other critics argue that the immunity granted by vaccines is only temporary and requires boosters, whereas
those who survive the disease become permanently immune.[13] As discussed below, the philosophies of
some alternative medicine practitioners are incompatible with the idea that vaccines are effective.[35]

Population health

Incomplete vaccine coverage increases the risk of disease for the

entire population, including those who have been vaccinated,
because it reduces herd immunity. For example, the measles
vaccine is given to children 9–12 months old, and the short
window between the disappearance of maternal antibody (before
which the vaccine often fails to seroconvert) and natural infection
means that vaccinated children are frequently still vulnerable. Herd
immunity lessens this vulnerability if all the children are
vaccinated. Increasing herd immunity during an outbreak or the
risk of an outbreak is perhaps the most widely accepted
justification for mass vaccination. When a new vaccine is
introduced mass vaccination helps increase coverage rapidly.[39]
Charlotte Cleverley-Bisman, is a
If enough of a population is vaccinated, herd immunity takes child known as the face of a New
effect, decreasing risk to people who cannot receive vaccines Zealand campaign to encourage
because they are too young or old, immunocompromised, or have vaccination against meningococcal
severe allergies to the ingredients in the vaccine.[40] The outcome disease after contracting and
for people with compromised immune systems who get infected is surviving severe meningococcal
often worse than that of the general population.[41] sepsis.[36] She had all four limbs
partially amputated at age seven
months due to meningococcal
Cost-effectiveness disease,[37] which is preventable in
children too young to vaccinate
Commonly used vaccines are a cost-effective and preventive way through widespread population
of promoting health, compared to the treatment of acute or chronic vaccination sufficient to develop herd
disease. In the US during 2001, routine childhood immunizations immunity.[38]
against seven diseases were estimated to save over $40 billion per
birth-year cohort in overall social costs, including $10 billion in
direct health costs, and the societal benefit-cost ratio for these vaccinations was estimated to be 16.5.[42]

Necessity

When a vaccination program successfully reduces the disease threat, it may reduce the perceived risk of
disease as cultural memories of the effects of that disease fade. At this point, parents may feel they have
nothing to lose by not vaccinating their children.[43] If enough people hope to become free-riders, gaining
the benefits of herd immunity without vaccination, vaccination levels may drop to a level where herd
immunity is ineffective.[44] According to Jennifer Reich, those parents who believe vaccination to be quite
effective but might prefer their children to remain unvaccinated, are those who are the most likely to be
convinced to change their mind, as long as they are approached properly.[45]
Safety concerns
While some anti-vaccinationists openly deny the improvements vaccination has made to public health or
believe in conspiracy theories,[13] it is much more common to cite concerns about safety.[46] As with any
medical treatment, there is a potential for vaccines to cause serious complications, such as severe allergic
reactions,[47] but unlike most other medical interventions, vaccines are given to healthy people and so a
higher standard of safety is demanded.[48] While serious complications from vaccinations are possible, they
are extremely rare and much less common than similar risks from the diseases they prevent.[33] As the
success of immunization programs increases and the incidence of disease decreases, public attention shifts
away from the risks of disease to the risk of vaccination,[49] and it becomes challenging for health
authorities to preserve public support for vaccination programs.[50]

The overwhelming success of certain vaccinations has made certain diseases rare, and, consequently, has
led to incorrect heuristic thinking in weighing risks against benefits among people who are vaccine-
hesitant.[51] Once such diseases (e.g., Haemophilus influenzae B) decrease in prevalence, people may no
longer appreciate how serious the illness is due to a lack of familiarity with it and become complacent.[51]
The lack of personal experience with these diseases reduces the perceived danger and thus reduces the
perceived benefit of immunization.[52] Conversely, certain illnesses (e.g., influenza) remain so common that
vaccine-hesitant people mistakenly perceive the illness to be non-threatening despite clear evidence that the
illness poses a significant threat to human health.[51] Omission and disconfirmation biases also contribute to
vaccine hesitancy.[51][53]

Various concerns about immunization have been raised. They have been addressed and the concerns are
not supported by evidence.[52] Concerns about immunization safety often follow a pattern. First, some
investigators suggest that a medical condition of increasing prevalence or unknown cause is an adverse
effect of vaccination. The initial study and subsequent studies by the same group have an inadequate
methodology, typically a poorly controlled or uncontrolled case series. A premature announcement is made
about the alleged adverse effect, resonating with individuals suffering from the condition, and
underestimating the potential harm of forgoing vaccination to those whom the vaccine could protect. Other
groups attempt to replicate the initial study but fail to get the same results. Finally, it takes several years to
regain public confidence in the vaccine.[49] Adverse effects ascribed to vaccines typically have an
unknown origin, an increasing incidence, some biological plausibility, occurrences close to the time of
vaccination, and dreaded outcomes.[54] In almost all cases, the public health effect is limited by cultural
boundaries: English speakers worry about one vaccine causing autism, while French speakers worry about
another vaccine causing multiple sclerosis, and Nigerians worry that a third vaccine causes infertility.[55]

Thiomersal

Thiomersal (called "thimerosal" in the US) is an antifungal preservative used in small amounts in some
multi-dose vaccines (where the same vial is opened and used for multiple patients) to prevent contamination
of the vaccine.[56] Despite thiomersal's efficacy, the use of thiomersal is controversial because it can be
metabolized or degraded in the body to ethylmercury (C2 H5 Hg+) and thiosalicylate.[57][58] As a result, in
1999, the Centers for Disease Control (CDC) and the American Academy of Pediatrics (AAP) asked
vaccine makers to remove thiomersal from vaccines as quickly as possible on the precautionary principle.
Thiomersal is now absent from all common US and European vaccines, except for some preparations of
influenza vaccine.[59] Trace amounts remain in some vaccines due to production processes, at an
approximate maximum of one microgramme, around 15% of the average daily mercury intake in the US for
adults and 2.5% of the daily level considered tolerable by the WHO.[58][60] The action sparked concern
that thiomersal could have been responsible for autism.[59] The idea is now considered disproven, as
incidence rates for autism increased steadily even after thiomersal was removed from childhood
vaccines.[61] Currently there is no accepted scientific evidence that exposure to thiomersal is a factor in
causing autism.[62][63] Since 2000, parents in the United States have pursued legal compensation from a
federal fund arguing that thiomersal caused autism in their children.[64] A 2004 Institute of Medicine (IOM)
committee favored rejecting any causal relationship between thiomersal-containing vaccines and autism.[65]
The concentration of thiomersal used in vaccines as an antimicrobial agent ranges from 0.001% (1 part in
100,000) to 0.01% (1 part in 10,000).[66] A vaccine containing 0.01% thiomersal has 25 micrograms of
mercury per 0.5 mL dose, roughly the same amount of elemental mercury found in a three-ounce can of
tuna.[66] There is robust peer-reviewed scientific evidence supporting the safety of thiomersal-containing
vaccines.[66]

MMR vaccine

In the UK, the MMR vaccine was the subject of controversy after the publication in The Lancet of a 1998
paper by Andrew Wakefield and others reporting case histories of twelve children mostly with autism
spectrum disorders with onset soon after administration of the vaccine.[67] At a 1998 press conference,
Wakefield suggested that giving children the vaccines in three separate doses would be safer than a single
vaccination. This suggestion was not supported by the paper, and several subsequent peer-reviewed studies
have failed to show any association between the vaccine and autism.[68] It later emerged that Wakefield had
received funding from litigants against vaccine manufacturers and that he had not informed colleagues or
medical authorities of his conflict of interest.[69] Had this been known, publication in The Lancet would not
have taken place in the way that it did.[70] Wakefield has been heavily criticized on scientific and ethical
grounds for the way the research was conducted[71] and for triggering a decline in vaccination rates, which
fell in the UK to 80% in the years following the study.[72][73] In 2004, the MMR-and-autism interpretation
of the paper was formally retracted by ten of its thirteen coauthors,[74] and in 2010 The Lancet's editors
fully retracted the paper.[75] Wakefield was struck off the UK medical register, with a statement identifying
deliberate falsification in the research published in The Lancet,[76] and is barred from practicing medicine in
the UK.[77]

The CDC, the IOM of the National Academy of Sciences, Australia's Department of Health, and the UK
National Health Service have all concluded that there is no evidence of a link between the MMR vaccine
and autism.[65][78][79][80] A Cochrane review concluded that there is no credible link between the MMR
vaccine and autism, that MMR has prevented diseases that still carry a heavy burden of death and
complications, that the lack of confidence in MMR has damaged public health, and that the design and
reporting of safety outcomes in MMR vaccine studies are largely inadequate.[81] Additional reviews agree,
with studies finding that vaccines are not linked to autism even in high risk populations with autistic
siblings.[82]

In 2009, The Sunday Times reported that Wakefield had manipulated patient data and misreported results in
his 1998 paper, creating the appearance of a link with autism.[83] A 2011 article in the British Medical
Journal described how the data in the study had been falsified by Wakefield so that it would arrive at a
predetermined conclusion.[84] An accompanying editorial in the same journal described Wakefield's work
as an "elaborate fraud" that led to lower vaccination rates, putting hundreds of thousands of children at risk
and diverting energy and money away from research into the true cause of autism.[85]

A special court convened in the United States to review claims under the National Vaccine Injury
Compensation Program ruled on February 12, 2009, that parents of autistic children are not entitled to
compensation in their contention that certain vaccines caused autism in their children.[86]

Vaccine overload
Vaccine overload, a non-medical term, is the notion that giving many vaccines at once may overwhelm or
weaken a child's immature immune system and lead to adverse effects.[87] Despite scientific evidence that
strongly contradicts this idea,[61] there are still parents of autistic children that believe that vaccine overload
causes autism.[88] The resulting controversy has caused many parents to delay or avoid immunizing their
children.[87] Such parental misperceptions are major obstacles towards immunization of children.[89]

The concept of vaccine overload is flawed on several levels.[61] Despite the increase in the number of
vaccines over recent decades, improvements in vaccine design have reduced the immunologic load from
vaccines; the total number of immunological components in the 14 vaccines administered to US children in
2009 is less than ten percent of what it was in the seven vaccines given in 1980.[61] A study published in
2013 found no correlation between autism and the antigen number in the vaccines the children were
administered up to the age of two. There were 1,008 children in the study, one quarter of whom were
diagnosed with autism, and the whole cohort was born between 1994 and 1999, when the routine vaccine
schedule could contain more than 3,000 antigens (in a single shot of DTP vaccine). The vaccine schedule
in 2012 contains several more vaccines, but the number of antigens the child is exposed to by the age of
two is 315.[90][91] Vaccines pose a very small immunologic load compared to the pathogens naturally
encountered by a child in a typical year;[61] common childhood conditions such as fevers and middle-ear
infections pose a much greater challenge to the immune system than vaccines,[92] and studies have shown
that vaccinations, even multiple concurrent vaccinations, do not weaken the immune system[61] or
compromise overall immunity.[93] The lack of evidence supporting the vaccine overload hypothesis,
combined with these findings directly contradicting it, has led to the conclusion that currently recommended
vaccine programs do not "overload" or weaken the immune system.[49][94][95][96]

Any experiment based on withholding vaccines from children is considered unethical,[97] and observational
studies would likely be confounded by differences in the healthcare-seeking behaviors of under-vaccinated
children. Thus, no study directly comparing rates of autism in vaccinated and unvaccinated children has
been done. However, the concept of vaccine overload is biologically implausible, as vaccinated and
unvaccinated children have the same immune response to non-vaccine-related infections, and autism is not
an immune-mediated disease, so claims that vaccines could cause it by overloading the immune system go
against current knowledge of the pathogenesis of autism. As such, the idea that vaccines cause autism has
been effectively dismissed by the weight of current evidence.[61]

Prenatal infection

There is evidence that schizophrenia is associated with prenatal exposure to rubella, influenza, and
toxoplasmosis infection. For example, one study found a sevenfold increased risk of schizophrenia when
mothers were exposed to influenza in the first trimester of gestation. This may have public health
implications, as strategies for preventing infection include vaccination, simple hygiene, and, in the case of
toxoplasmosis, antibiotics.[98] Based on studies in animal models, theoretical concerns have been raised
about a possible link between schizophrenia and maternal immune response activated by virus antigens; a
2009 review concluded that there was insufficient evidence to recommend routine use of trivalent influenza
vaccine during the first trimester of pregnancy, but that the vaccine was still recommended outside the first
trimester and in special circumstances such as pandemics or in women with certain other conditions.[99]
The CDC's Advisory Committee on Immunization Practices, the American College of Obstetricians and
Gynecologists, and the American Academy of Family Physicians all recommend routine flu shots for
pregnant women, for several reasons:[100]

their risk for serious influenza-related medical complications during the last two trimesters;
their greater rates for flu-related hospitalizations compared to non-pregnant women;
the possible transfer of maternal anti-influenza antibodies to children, protecting the children
from the flu; and
 several studies that found no harm to pregnant women or their children from the
vaccinations.

Despite this recommendation, only 16% of healthy pregnant US women surveyed in 2005 had been
vaccinated against the flu.[100]

Ingredient concerns

Aluminum compounds are used as immunologic adjuvants to increase the effectiveness of many
vaccines.[101] The aluminum in vaccines simulates or causes small amounts of tissue damage, driving the
body to respond more powerfully to what it sees as a serious infection and promoting the development of a
lasting immune response.[102][103] In some cases these compounds have been associated with redness,
itching, and low-grade fever,[102] but the use of aluminum in vaccines has not been associated with serious
adverse events.[101][104] In some cases, aluminum-containing vaccines are associated with macrophagic
myofasciitis (MMF), localized microscopic lesions containing aluminum salts that persist for up to 8 years.
However, recent case-controlled studies have found no specific clinical symptoms in individuals with
biopsies showing MMF, and there is no evidence that aluminum-containing vaccines are a serious health
risk or justify changes to immunization practice.[101][104] Infants are exposed to greater quantities of
aluminum in daily life in breastmilk and infant formula than in vaccines.[2] In general, people are exposed
to low levels of naturally occurring aluminum in nearly all foods and drinking water.[105] The amount of
aluminum present in vaccines is small, less than one milligram, and such low levels are not believed to be
harmful to human health.[105]

Vaccine hesitant people have also voiced strong concerns about the presence of formaldehyde in vaccines.
Formaldehyde is used in very small concentrations to inactivate viruses and bacterial toxins used in
vaccines.[106] Very small amounts of residual formaldehyde can be present in vaccines but are far below
values harmful to human health.[107][108] The levels present in vaccines are minuscule when compared to
naturally occurring levels of formaldehyde in the human body and pose no significant risk of toxicity.[106]
The human body continuously produces formaldehyde naturally and contains 50–70 times the greatest
amount of formaldehyde present in any vaccine.[106] Furthermore, the human body is capable of breaking
down naturally occurring formaldehyde as well as the small amount of formaldehyde present in
vaccines.[106] There is no evidence linking the infrequent exposures to small quantities of formaldehyde
present in vaccines with cancer.[106]

Sudden infant death syndrome

Sudden infant death syndrome (SIDS) is most common in infants around the time in life when they receive
many vaccinations.[109] Since the cause of SIDS has not been fully determined, this led to concerns about
whether vaccines, in particular diphtheria-tetanus toxoid vaccines, were a possible causal factor.[109]
Several studies investigated this and found no evidence supporting a causal link between vaccination and
SIDS.[109][110] In 2003, the Institute of Medicine favored rejection of a causal link to DTwP vaccination
and SIDS after reviewing the available evidence.[111] Additional analyses of VAERS data also showed no
relationship between vaccination and SIDS.[109] Studies have shown a negative correlation between SIDs
and vaccination. That is vaccinated children are less likely to die but no causal link has been found. One
suggestion is that infants who are less likely to suffer SIDS are more likely to be presented for
vaccination.[109][110][112]

Anthrax vaccines
In the mid-1990s media reports on vaccines discussed the Gulf War Syndrome, a multi-symptomatic
disorder affecting returning US military veterans of the 1990–1991 Persian Gulf War. Among the first
articles of the online magazine Slate was one by Atul Gawande in which the required immunizations
received by soldiers, including an anthrax vaccination, were named as one of the likely culprits for the
symptoms associated with the Gulf War Syndrome. In the late 1990s Slate published an article on the
"brewing rebellion" in the military against anthrax immunization because of "the availability to soldiers of
vaccine misinformation on the Internet". Slate continued to report on concerns about the required anthrax
and smallpox immunization for US troops after the September 11 attacks and articles on the subject also
appeared on the Salon website.[113] The 2001 anthrax attacks heightened concerns about bioterrorism and
the Federal government of the United States stepped up its efforts to store and create more vaccines for
American citizens.[113] In 2002, Mother Jones published an article that was highly skeptical of the anthrax
and smallpox immunization required by the United States Armed Forces.[113] With the 2003 invasion of
Iraq a wider controversy ensued in the media about requiring US troops to be vaccinated against
anthrax.[113] From 2003 to 2008 a series of court cases were brought to oppose the compulsory anthrax
vaccination of US troops.[113]

Swine flu vaccine

The US swine flu immunization campaign in response

to the 1976 swine flu outbreak has become known as
"the swine flu fiasco" because the outbreak did not lead
to a pandemic as US President Gerald Ford had feared
and the hastily rolled out vaccine was found to increase
the number of Guillain–Barré Syndrome cases two
weeks after immunization. Government officials
stopped the mass immunization campaign due to great
anxiety about the safety of the swine flu vaccine. The
general public was left with greater fear of the U.S. President Gerald Ford receiving his vaccine
vaccination campaign than the virus itself, and for the swine flu.
vaccination policies, in general, were challenged.[114]

During the 2009 flu pandemic, significant controversy broke out regarding whether the 2009 H1N1 flu
vaccine was safe in, among other countries, France. Numerous different French groups publicly criticized
the vaccine as potentially dangerous.[115] Because of similarities between the 2009 influenza A subtype
H1N1 virus and the 1976 influenza A/NJ virus many countries established surveillance systems for
vaccine-related adverse effects on human health. A possible link between the 2009 H1N1 flu vaccine and
Guillain–Barré Syndrome cases was studied in Europe and the United States.[116]

Other safety concerns

Other safety concerns about vaccines have been promoted on the Internet, in informal meetings, in books,
and at symposia. These include hypotheses that vaccination can cause epileptic seizures, allergies, multiple
sclerosis, and autoimmune diseases such as type 1 diabetes, as well as hypotheses that vaccinations can
transmit bovine spongiform encephalopathy, hepatitis C virus, and HIV. These hypotheses have been
investigated, with the conclusion that currently used vaccines meet high safety standards and that criticism
of vaccine safety in the popular press is not justified.[52][96][117][118] Large well-controlled epidemiologic
studies have been conducted and the results do not support the hypothesis that vaccines cause chronic
diseases. Furthermore, some vaccines are probably more likely to prevent or modify than cause or
exacerbate autoimmune diseases.[95][119] Another common concern parents often have is about the pain
associated with administering vaccines during a doctor's office visit.[120] This may lead to parental requests
to space out vaccinations; however, studies have shown a child's stress response is not different when
receiving one vaccination or two. The act of spacing out vaccinations may actually lead to more stressful
stimuli for the child.[2]

Fear of needles
Blood-injection-injury phobia and general fear of needles and injections, can lead people to avoid
vaccinations. One survey conducted in January and February 2021 estimated this was responsible for 10%
of the COVID-19 vaccine hesitancy in the UK at the time.[121][122] A 2012 survey of American parents
found that a fear of needles was the most common reason for adolescents to forgo their second dose of a
HPV vaccine.[123][124]

Various treatments for fear of needles can help overcome this problem, from offering pain reduction at the
time of injection to long-term behavioral therapy.[123] Tensing the stomach muscles can help avoid fainting,
swearing can reduce perceived pain, and distraction can also improve the perceived experience, such as by
pretending to cough, performing a visual task, watching a video, or playing a video game.[123] To avoid
dissuading people who have a needle phobia, vaccine update researchers recommend against using pictures
of needles, people getting an injection, or faces displaying negative emotions (like a crying baby) in
promotional materials. Instead, they recommend medically accurate photos depicting smiling, diverse
people with bandages, vaccination cards, or a rolled-up sleeve; depicting vials instead of needles; and
depicting the people who develop and test vaccines.[125] Development of vaccines that can be administered
orally or with a jet injector can also avoid triggering the fear of needles.[126]

Malpractice and fraud

CIA fake vaccination clinic

In Pakistan, the CIA ran a fake vaccination clinic in an attempt to locate Osama bin Laden.[127][128] As a
direct consequence, there have been several attacks and deaths among vaccination workers. Several
Islamist preachers and militant groups, including some factions of the Taliban, view vaccination as a plot to
kill or sterilize Muslims.[129] Efforts to eradicate polio have furthermore been disrupted by American drone
strikes.[127] This is part of the reason Pakistan and Afghanistan are the only countries where polio remained
endemic as of 2015.[130]

Fake COVID-19 vaccines

In July 2021, Indian police arrested 14 people for administering doses of fake salt water vaccines instead of
the AstraZeneca vaccine at nearly a dozen private vaccination sites in Mumbai. The organizers, including
medical professionals, charged between $10 and 17 for each dose, and more than 2,600 people paid to
receive the vaccine.[131][132] The federal government downplayed the scandal, claiming these cases were
isolated. McAfee stated India was among the top countries to have been targeted by fake apps to lure
people with a promise of vaccines.[133]

In Bhopal, slum residents were misled into thinking they would get an approved COVID-19 vaccine, but
instead were actually part of an experimental clinical trial for the domestic vaccine Covaxin. Only 50% of
participants in the trials received a vaccine with the rest receiving a placebo. One participant stated, "...I
didn't know that there was a possibility you could get a water shot."[134][135]
Medical racism

Some people in groups experiencing medical racism are less willing to trust doctors and modern medicine
due to real historical incidents of unethical human experimentation and involuntary sterilization. Famous
examples include drug trials in Africa without informed consent, the Tuskegee Syphilis Study, the
extraction of profitable cells from Henrietta Lacks, the racist experiments of Cornelius P. Rhoads in Puerto
Rico, and Nazi human experimentation.

To overcome this type of distrust, experts recommend including representative samples of majority and
minority populations in drug trials, including minority groups in study design, being diligent about informed
consent, and being transparent about the process of drug design and testing.[136]

Vaccine myths
Several vaccination myths contribute to parental concerns and vaccine hesitancy. These include the alleged
superiority of natural infection when compared to vaccination, questioning whether the diseases vaccines
prevent are dangerous, whether vaccines pose moral or religious dilemmas, suggesting that vaccines are not
effective, proposing unproven or ineffective approaches as alternatives to vaccines, and conspiracy theories
that center on mistrust of the government and medical institutions.[28]

Autism

The idea of a link between vaccines and autism has been extensively investigated and conclusively shown
to be false.[137][138] The scientific consensus is that there is no relationship, causal or otherwise, between
vaccines and incidence of autism,[49][139][140] and vaccine ingredients do not cause autism.[141]

Nevertheless, the anti-vaccination movement continues to promote myths, conspiracy theories, and
misinformation linking the two.[142] A developing tactic appears to be the "promotion of irrelevant research
[as] an active aggregation of several questionable or peripherally related research studies in an attempt to
justify the science underlying a questionable claim".[143]

Vaccination during illness

Many parents are concerned about the safety of vaccination when their child is sick.[2] Moderate to severe
acute illness with or without a fever is indeed a precaution when considering vaccination.[2] Vaccines
remain effective during childhood illness.[2] The reason vaccines may be withheld if a child is moderately
to severely ill is because certain expected side effects of vaccination (e.g. fever or rash) may be confused
with the progression of the illness.[2] It is safe to administer vaccines to well-appearing children who are
mildly ill with the common cold.[2]

Natural infection

Another common anti-vaccine myth is that the immune system produces a better immune protection in
response to natural infection when compared to vaccination.[2] However, strength and duration of immune
protection gained varies by both disease and vaccine, with some vaccines giving better protection than
natural infection. For example, the HPV vaccine generates better immune protection than natural infection
due to the vaccine containing higher concentrations of a viral coat protein, while also not containing
proteins the HPV viruses use to inhibit immune response.[144]
While it is true that infection with certain illnesses may produce lifelong immunity, many natural infections
do not produce lifelong immunity, while carrying a higher risk of harming a person's health than
vaccines.[2] For example, natural varicella infection carries a higher risk of bacterial superinfection with
Group A streptococci.[2]

Natural measles infection carries a high risk of many serious, and sometimes life-long, complications, all of
which can be avoided by vaccination. Those who suffer measles rarely have a symptomatic
reinfection.[145]

Most people survive measles, though in some cases, complications may occur. About 1 in 4 individuals will
be hospitalized and 1–2 in 1000 will die. Complications are more likely in children under age 5 and adults
over age 20.[146] Pneumonia is the most common fatal complication of measles infection and accounts for
56-86% of measles-related deaths.[147]

Possible consequences of measles virus infection include laryngotracheobronchitis, sensorineural hearing

loss,[148] and—in about 1 in 10,000 to 1 in 300,000 cases[149]—panencephalitis, which is usually
fatal.[150] Acute measles encephalitis is another serious risk of measles virus infection. It typically occurs
two days to one week after the measles rash breaks out and begins with very high fever, severe headache,
convulsions and altered mentation. A person with measles encephalitis may become comatose, and death or
brain injury may occur.[151]

The measles virus can deplete previously acquired immune memory by killing cells that make antibodies,
and thus weakens the immune system which can cause deaths from other diseases.[152][153][154]
Suppression of the immune system by measles lasts about two years and has been epidemiologically
implicated in up to 90% of childhood deaths in third world countries, and historically may have caused
rather more deaths in the United States, the UK and Denmark than were directly caused by measles.[155]
Although the measles vaccine contains an attenuated strain, it does not deplete immune memory.[153]

HPV vaccine

The idea that the HPV vaccine is linked to increased sexual behavior is not supported by scientific
evidence. A review of nearly 1,400 adolescent girls found no difference in teen pregnancy, the incidence of
sexually transmitted infection, or contraceptive counseling regardless of whether they received the HPV
vaccine.[2] Thousands of Americans die each year from cancers preventable by the vaccine.[2]

Vaccine schedule

Other concerns have been raised about the vaccine schedule recommended by the Advisory Committee on
Immunization Practices (ACIP). The immunization schedule is designed to protect children against
preventable diseases when they are most vulnerable. The practice of delaying or spacing out these
vaccinations increases the amount of time the child is susceptible to these illnesses.[2] Receiving vaccines
on the schedule recommended by the ACIP is not linked to autism or developmental delay.[2]

Events following reductions in vaccination

In several countries, reductions in the use of some vaccines were followed by increases in the diseases'
morbidity and mortality.[156][157] According to the Centers for Disease Control and Prevention, continued
high levels of vaccine coverage are necessary to prevent a resurgence of diseases that have been nearly
eliminated.[158] Pertussis remains a major health problem in developing countries, where mass vaccination
is not practiced; the World Health Organization estimates it caused 294,000 deaths in 2002.[159] Vaccine
hesitancy has contributed to the resurgence of preventable disease.
For example, in 2019, the number of measles cases increased by
thirty percent worldwide and many cases occurred in countries that
had nearly eliminated measles.[28]

Stockholm, smallpox (1873–74)

An anti-vaccination campaign motivated by religious objections,

Campaigners in London for expanded
concerns about effectiveness, and concerns about individual rights
vaccination in the developing world
led to the vaccination rate in Stockholm dropping to just over 40%,
compared to about 90% elsewhere in Sweden. A major smallpox
epidemic began there in 1873. It led to a rise in vaccine uptake and
an end of the epidemic.[160]

UK, pertussis (1970s–80s)

In a 1974 report ascribing 36 reactions to whooping cough (pertussis) vaccine, a prominent public-health
academic claimed that the vaccine was only marginally effective and questioned whether its benefits
outweigh its risks, and extended television and press coverage caused a scare. Vaccine uptake in the UK
decreased from 81% to 31%, and pertussis epidemics followed, leading to the deaths of some children. The
mainstream medical opinion continued to support the effectiveness and safety of the vaccine; public
confidence was restored after the publication of a national reassessment of vaccine efficacy. Vaccine uptake
then increased to levels above 90%, and disease incidence declined dramatically.[156]

Sweden, pertussis (1979–96)

In the vaccination moratorium period that occurred when Sweden suspended vaccination against whooping
cough (pertussis) from 1979 to 1996, 60% of the country's children contracted the disease before the age of
10; close medical monitoring kept the death rate from whooping cough at about one per year.[157]

Netherlands, measles (1999–2000)

An outbreak at a religious community and school in the Netherlands resulted in three deaths and 68
hospitalizations among 2,961 cases.[161] The population in the several provinces affected had a high level
of immunization, with the exception of one of the religious denominations, which traditionally does not
accept vaccination. Ninety-five percent of those who contracted measles were unvaccinated.[161]

UK and Ireland, measles (2000)

As a result of the MMR vaccine controversy, vaccination rates dropped sharply in the United Kingdom
after 1996.[162] From late 1999 until the summer of 2000, there was a measles outbreak in North Dublin,
Ireland. At the time, the national immunization level had fallen below 80%, and in parts of North Dublin
the level was around 60%. There were more than 100 hospital admissions from over 300 cases. Three
children died and several more were gravely ill, some requiring mechanical ventilation to recover.[163]

Nigeria, polio, measles, diphtheria (2001–)

In the early first decade of the 21st century, conservative religious leaders in northern Nigeria, suspicious of
Western medicine, advised their followers not to have their children vaccinated with the oral polio vaccine.
The boycott was endorsed by the governor of Kano State, and immunization was suspended for several
months. Subsequently, polio reappeared in a dozen formerly polio-free neighbors of Nigeria, and genetic
tests showed the virus was the same one that originated in northern Nigeria. Nigeria had become a net
exporter of the poliovirus to its African neighbors. People in the northern states were also reported to be
wary of other vaccinations, and Nigeria reported over 20,000 measles cases and nearly 600 deaths from
measles from January through March 2005.[164] In Northern Nigeria, it is a common belief that vaccination
is a strategy created by the westerners to reduce the Northerners' population. As a result of this belief, a
large number of Northerners reject vaccination.[165] In 2006, Nigeria accounted for over half of all new
polio cases worldwide.[166] Outbreaks continued thereafter; for example, at least 200 children died in a
late-2007 measles outbreak in Borno State.[167]

United States, measles (2005–)

In 2000, measles was declared eliminated from the United States because the internal transmission had been
interrupted for one year; the remaining reported cases were due to importation.[168]

A 2005 measles outbreak in the US state of Indiana was attributed to parents who had refused to have their
children vaccinated.[169]

The Centers for Disease Control and Prevention

(CDC) reported that the three biggest outbreaks
of measles in 2013 were attributed to clusters of
people who were unvaccinated due to their
philosophical or religious beliefs. As of August
2013, three pockets of outbreak – New York
City, North Carolina, and Texas – contributed to
64% of the 159 cases of measles reported in 16
states.[170][171]

The number of cases in 2014 quadrupled to

644,[172] including transmission by unvaccinated
visitors to Disneyland in California.[73][173] Some 97% of cases in the first half of the year were confirmed
to be due directly or indirectly to importation (the remainder were unknown), and 49% from the
Philippines. More than half the victims (165 out of 288, or 57%) during that time were confirmed to be
unvaccinated by choice; 30 (10%) were confirmed to have been vaccinated.[174] The final count of measles
in 2014 was 668 cases in 27 states.[175]

From January 1 to June 26, 2015, 178 people from 24 states and the District of Columbia were reported to
have measles. Most of these cases (117 cases [66%]) were part of a large multi-state outbreak linked to
Disneyland in California, continued from 2014. Analysis by the CDC scientists showed that the measles
virus type in this outbreak (B3) was identical to the virus type that caused the large measles outbreak in the
Philippines in 2014.[175] On July 2, 2015, the first confirmed death from measles in twelve years was
recorded. An immunocompromised woman in Washington State was infected and later died of pneumonia
due to measles.[176]

By July 2016, a three-month measles outbreak affecting at least 22 people was spread by unvaccinated
employees of the Eloy, Arizona detention center, an Immigration and Customs Enforcement (ICE) facility
owned by for-profit prison operator CoreCivic. Pinal County's health director presumed the outbreak likely
originated with a migrant, but detainees had since received vaccinations. However convincing CoreCivic's
employees to become vaccinated or demonstrate proof of immunity was much more difficult, he said.[177]
In spring 2017, a measles outbreak occurred in Minnesota. As of June 16, 78 cases of measles had been
confirmed in the state, 71 were unvaccinated and 65 were Somali-Americans.[178][179][180][181][182] The
outbreak has been attributed to low vaccination rates among Somali-American children, which can be
traced back to 2008, when Somali parents began to express concern about disproportionately high numbers
of Somali preschoolers in special education classes who were receiving services for autism spectrum
disorder. Around the same time, disgraced former doctor Andrew Wakefield visited Minneapolis, teaming
up with anti-vaccine groups to raise concerns that vaccines were the cause of autism,[183][184][185][186]
despite the fact that multiple studies have shown no connection between the MMR vaccine and autism.[61]

From fall 2018 to early 2019, New York State experienced an outbreak of over 200 confirmed measles
cases. Many of these cases were attributed to ultra-Orthodox Jewish communities with low vaccination
rates in areas within Brooklyn and Rockland County. State Health Commissioner Howard Zucker stated
that this was the worst outbreak of measles in his recent memory.[187][188]

In January 2019, Washington state reported an outbreak of at least 73 confirmed cases of measles, most
within Clark County, which has a higher rate of vaccination exemptions compared to the rest of the state.
This led state governor Jay Inslee to declare a state of emergency, and the state's congress to introduce
legislation to disallow vaccination exemption for personal or philosophical
reasons.[189][190][191][192][193][194]

Wales, measles (2013–)

In 2013, an outbreak of measles occurred in the Welsh city of Swansea. One death was reported.[195] Some
estimates indicate that while MMR uptake for two-year-olds was at 94% in Wales in 1995, it had fallen to
as low as 67.5% in Swansea by 2003, meaning the region had a "vulnerable" age group.[196] This has been
linked to the MMR vaccine controversy, which caused a significant number of parents to fear allowing
their children to receive the MMR vaccine.[195] June 5, 2017, saw a new measles outbreak in Wales, at
Lliswerry High School in the town of Newport.[197]

United States, tetanus

Most cases of pediatric tetanus in the U.S. occur in unvaccinated children.[198] In Oregon, in 2017, an
unvaccinated boy had a scalp wound that his parents sutured themselves. Later the boy arrived at a hospital
with tetanus. He spent 47 days in the Intensive Care Unit (ICU), and 57 total days in the hospital, for
$811,929, not including the cost of airlifting him to the Oregon Health and Science University,
Doernbecher Children's Hospital, or the subsequent two-and-a-half weeks of inpatient rehabilitation he
required. Despite this, his parents declined the administration of subsequent tetanus boosters or other
vaccinations.[199] Due to privacy regulations, publicly identifying the payer of the costs was
prohibited.[200]

Romania, measles (2016–present)

As of September 2017, a measles epidemic was ongoing across Europe, especially Eastern Europe. In
Romania, there were about 9300 cases, and 34 people (all unvaccinated) had died.[201] This was preceded
by a 2008 controversy regarding the HPV vaccine. In 2012, doctor Christa Todea-Gross published a free
downloadable book online, this book contained misinformation about vaccination from abroad translated
into Romanian, which significantly stimulated the growth of the anti-vaccine movement.[201] The
government of Romania officially declared a measles epidemic in September 2016 and started an
information campaign to encourage parents to have their children vaccinated. By February 2017, however,
the stockpile of MMR vaccines was depleted, and doctors were
overburdened. Around April, the vaccine stockpile had been
restored. By March 2019, the death toll had risen to 62, with
15,981 cases reported.[202]

Samoa, measles (2019)

Play media
The 2019 Samoa measles outbreak began in October 2019 and as Ovidiu Covaciu on how the
of December 12, there were 4,995 confirmed cases of measles and Romanian antivaccine movement
72 deaths, out of a Samoan population of threatens Europe (2017)
201,316.[203][204][205][206] A state of emergency was declared on
November 17, ordering all schools to be closed, barring children
under 17 from public events, and making vaccination mandatory.[207] UNICEF has sent 110,500 vaccines
to Samoa. Tonga and Fiji have also declared states of emergency.[208]

The outbreak has been attributed to a sharp drop in measles vaccination from the previous year, following
an incident in 2018 when two infants died shortly after receiving measles vaccinations, which led the
country to suspend its measles vaccination program.[209] The reason for the two infants' deaths was
incorrect preparation of the vaccine by two nurses who mixed vaccine powder with expired anesthetic.[210]
As of November 30, more than 50,000 people were vaccinated by the government of Samoa.[210]

2019–2020 measles outbreaks

Countermeasures
Vaccine hesitancy is challenging and optimal strategies for approaching it remain uncertain.[211]

Multicomponent initiatives which include targeting undervaccinated populations, improving the

convenience of and access to vaccines, educational initiatives, and mandates may improve vaccination
uptake.[212][213]

The World Health Organization (WHO) published a paper in 2016 intending to aid experts on how to
respond to vaccine deniers in public. The WHO recommends for experts to view the general public as their
target audience rather than the vaccine denier when debating in a public forum. The WHO also suggests for
experts to make unmasking the techniques that the vaccine denier uses to spread misinformation as the goal
of the conversation. The WHO asserts that this will make the public audience more resilient against anti-
vaccine tactics.[214]

Providing information

Many interventions designed to address vaccine hesitancy have been based on the information deficit
model.[53] This model assumes that vaccine hesitancy is due to a person lacking the necessary information
and attempts to provide them with that information to solve the problem.[53] Despite many educational
interventions attempting this approach, ample evidence indicates providing more information is often
ineffective in changing a vaccine-hesitant person's views and may, in fact, have the opposite of the intended
effect and reinforce their misconceptions.[28][53]
It is unclear whether interventions intended to educate parents about vaccines improve the rate of
vaccination.[212] It is also unclear whether citing the reasons of benefit to others and herd immunity
improves parents' willingness to vaccinate their children.[212] In one trial, an educational intervention
designed to dispel common misconceptions about the influenza vaccine decreased parents' false beliefs
about the vaccines but did not improve uptake of the influenza vaccine.[212] In fact, parents with significant
concerns about adverse effects from the vaccine were less likely to vaccinate their children with the
influenza vaccine after receiving this education.[212]

Communication strategies

Several communication strategies are recommended for use when interacting with vaccine-hesitant parents.
These include establishing honest and respectful dialogue; acknowledging the risks of a vaccine but
balancing them against the risk of disease; referring parents to reputable sources of vaccine information; and
maintaining ongoing conversations with vaccine-hesitant families.[2] The American Academy of Pediatrics
recommends healthcare providers directly address parental concerns about vaccines when questioned about
their efficacy and safety.[120] Additional recommendations include asking permission to share information;
maintaining a conversational tone (as opposed to lecturing); not spending excessive amounts of time
debunking specific myths (this may have the opposite effect of strengthening the myth in the person's
mind); focusing on the facts and simply identifying the myth as false; and keeping information as simple as
possible (if the myth seems simpler than the truth, it may be easier for people to accept the simple myth).[53]
Storytelling and anecdote (e.g., about the decision to vaccinate one's own children) can be powerful
communication tools for conversations about the value of vaccination.[53] A New Zealand-based General
Practitioner has used a comic, Jenny & the Eddies, both to educate children about vaccines and address his
patients' concerns through open, trusting, and non-threatening conversations, concluding [that] "I always
listen to what people have to say on any matter. That includes vaccine hesitancy. That's a very important
opening stage to improving the therapeutic relationship. If I'm going to change anyone's attitude, first I need
to listen to them and be open-minded."[215] The perceived strength of the recommendation, when provided
by a healthcare provider, also seems to influence uptake, with recommendations that are perceived to be
stronger resulting in higher vaccination rates than perceived weaker recommendations.[28]

Provider presumption and persistence

Limited evidence suggests that a more paternalistic or presumptive approach ("Your son needs three shots
today.") is more likely to result in patient acceptance of vaccines during a clinic visit than a participatory
approach ("What do you want to do about shots?") but decreases patient satisfaction with the visit.[212] A
presumptive approach helps to establish that this is the normative choice.[53] Similarly, one study found that
the way in which physicians respond to parental vaccine resistance is important.[2] Nearly half of initially
vaccine-resistant parents accepted vaccinations if physicians persisted in their initial recommendation.[53]
The Centers for Disease Control and Prevention has released resources to aid healthcare providers in
having more effective conversations with parents about vaccinations.[216]

Pain mitigation for children

Parents may be hesitant to have their children vaccinated due to concerns about the pain of vaccination.
Several strategies can be used to reduce the child's pain.[120] Such strategies include distraction techniques
(pinwheels); deep breathing techniques; breastfeeding the child; giving the child sweet-tasting solutions;
quickly administering the vaccine without aspirating; keeping the child upright; providing tactile
stimulation; applying numbing agents to the skin; and saving the most painful vaccine for last.[120] As
above, the number of vaccines offered in a particular encounter is related to the likelihood of parental
vaccine refusal (the more vaccines offered, the higher the likelihood of vaccine deferral).[2] The use of
combination vaccines to protect against more diseases but with fewer injections may provide reassurance to
parents.[2] Similarly, reframing the conversation with less emphasis on the number of diseases the
healthcare provider is immunizing against (e.g., "we will do two injections (combined vaccinations) and an
oral vaccine") may be more acceptable to parents than "we're going to vaccinate against seven diseases".[2]

Cultural sensitivity

Cultural sensitivity is important to reducing vaccine hesitancy. For example, pollster Frank Luntz
discovered that for conservative Americans, family is by far the "most powerful motivator" to get a vaccine
(over country, economy, community, or friends).[217] Luntz "also found a very pronounced preference for
the word 'vaccine' over 'jab.' "[217]

Avoiding online misinformation

It is recommended that healthcare providers advise parents against performing their own web search queries
since many websites on the Internet contain significant misinformation.[2] Many parents perform their own
research online and are often confused, frustrated, and unsure of which sources of information are
trustworthy.[53] Additional recommendations include introducing parents to the importance of vaccination
as far in advance of the initial well-child visit as possible; presenting parents with vaccine safety
information while in their pediatrician's waiting room; and using prenatal open houses and postpartum
maternity ward visits as opportunities to vaccinate.[2]

Internet advertising, especially on social networking websites, is purchased by both public health authorities
and anti-vaccination groups. In the United States, the majority of anti-vaccine Facebook advertising in
December 2018 and February 2019 had been paid for one of two groups: Children's Health Defense and
Stop Mandatory Vaccination. The ads targeted women and young couples and generally highlighted the
alleged risks of vaccines, while asking for donations. Several anti-vaccination advertising campaigns also
targeted areas where measles outbreaks were underway during this period. The impact of Facebook's
subsequent advertising policy changes has not been studied.[218][219]

Incentive programs

Several countries have implemented programs to counter vaccine hesitancy, including raffles, lotteries,
rewards and mandates.[220][221][222][223] In the US State of Washington, authorities have given the green
light to licensed cannabis dispensaries to offer free joints as incentives to get COVID-19 vaccination in an
effort dubbed "Joints for Jabs".[224]

Vaccine mandates

Mandatory vaccination is one set of policy measures to address vaccine hesitancy by imposing penalties or
burdens on those who fail to vaccinate. An example of this kind of measure is Australia's vaccine mandates
around childhood vaccination, the No Jab No Pay policy. This policy linked financial payments to
children's vaccine status, and while studies have found significant improvements in vaccination there are
still concerns about the use of these measures.[225][226] Qantas in Australia have issued plans to mandate
COVID-19 vaccination for their work force.[227]

History
Variolation

Early attempts to prevent smallpox involved deliberate

inoculation with the milder form of the disease (Variola
Minor) in the expectation that a mild case would confer
immunity and avoid Variola Major. Originally called
inoculation, this technique was later called variolation to
avoid confusion with cowpox inoculation (vaccination)
when that was introduced by Edward Jenner. Although
variolation had a long history in China and India, it was
first used in North America and England in 1721.
Reverend Cotton Mather introduced variolation to
Boston, Massachusetts, during the 1721 smallpox
An anti-vaccination caricature by James
epidemic.[228] Despite strong opposition in the Gillray, The Cow-Pock – or – The Wonderful
community,[229] Mather convinced Zabdiel Boylston to Effects of the New Inoculation! (1802)
try it. Boylston first experimented on his 6-year-old son,
his slave, and his slave's son; each subject contracted the
disease and was sick for several days until the sickness vanished and they were "no longer gravely ill".[228]
Boylston went on to variolate thousands of Massachusetts residents, and many places were named for him
in gratitude as a result. Lady Mary Wortley Montagu introduced variolation to England. She had seen it
used in Turkey and, in 1718, had her son successfully variolated in Constantinople under the supervision of
Charles Maitland. When she returned to England in 1721, she had her daughter variolated by Maitland.
This aroused considerable interest, and Sir Hans Sloane organized the variolation of some inmates in
Newgate Prison. These were successful, and after a further short trial in 1722, two daughters of Caroline of
Ansbach Princess of Wales were variolated without mishap. With this royal approval, the procedure
became common when smallpox epidemics threatened.[230]

Religious arguments against inoculation were soon advanced. For example, in a 1722 sermon entitled "The
Dangerous and Sinful Practice of Inoculation", the English theologian Reverend Edmund Massey argued
that diseases are sent by God to punish sin and that any attempt to prevent smallpox via inoculation is a
"diabolical operation".[229] It was customary at the time for popular preachers to publish sermons, which
reached a wide audience. This was the case with Massey, whose sermon reached North America, where
there was early religious opposition, particularly by John Williams. A greater source of opposition there
was William Douglass, a medical graduate of Edinburgh University and a Fellow of the Royal Society,
who had settled in Boston.[230]: 114–22

Smallpox vaccination

After Edward Jenner introduced the smallpox vaccine in 1798, variolation declined and was banned in
some countries.[231][232] As with variolation, there was some religious opposition to vaccination, although
this was balanced to some extent by support from clergymen, such as Reverend Robert Ferryman, a friend
of Jenner's, and Rowland Hill,[230]: 221 who not only preached in its favour but also performed vaccination
themselves. There was also opposition from some variolators who saw the loss of a lucrative monopoly.
William Rowley published illustrations of deformities allegedly produced by vaccination, lampooned in
James Gillray's famous caricature depicted on this page, and Benjamin Moseley likened cowpox to
syphilis, starting a controversy that would last into the 20th century.[230]: 203–05

There was legitimate concern from supporters of vaccination about its safety and efficacy, but this was
overshadowed by general condemnation, particularly when legislation started to introduce compulsory
vaccination. The reason for this was that vaccination was introduced before laboratory methods were
developed to control its production and account for its failures.[233] Vaccine was maintained initially
through arm-to-arm transfer and later through production on the
skin of animals, and bacteriological sterility was impossible.
Further, identification methods for potential pathogens were not
available until the late 19th to early 20th century. Diseases later
shown to be caused by contaminated vaccine included erysipelas,
tuberculosis, tetanus, and syphilis. This last, though rare –
estimated at 750 cases in 100 million vaccinations[234] – attracted
particular attention. Much later, Charles Creighton, a leading
medical opponent of vaccination, claimed that the vaccine itself
was a cause of syphilis and devoted a book to the subject.[235] As
cases of smallpox started to occur in those who had been
vaccinated earlier, supporters of vaccination pointed out that these
were usually very mild and occurred years after the vaccination. In
turn, opponents of vaccination pointed out that this contradicted
Jenner's belief that vaccination conferred complete
protection.[233]: 17–21 The views of opponents of vaccination that Edward Jenner
it was both dangerous and ineffective led to the development of
determined anti-vaccination movements in England when
legislation was introduced to make vaccination compulsory.[236]

England

Because of its greater risks, variolation was banned in England by

the 1840 Vaccination Act, which also introduced free voluntary
vaccination for infants. Thereafter Parliament passed successive
acts to enact and enforce compulsory vaccination.[237] The 1853
act introduced compulsory vaccination, with fines for non-
compliance and imprisonment for non-payment. The 1867 act
extended the age requirement to 14 years and introduced repeated
fines for repeated refusal for the same child. Initially, vaccination
regulations were organised by the local Poor Law Guardians, and
in towns where there was strong opposition to vaccination,
sympathetic Guardians were elected who did not pursue
prosecutions. This was changed by the 1871 act, which required Henry Wicklin, age 6, afflicted with
Guardians to act. This significantly changed the relationship smallpox. Smallpox was eradicated
between the government and the public, and organized protests worldwide as a result of mandatory
increased. [237] In Keighley, Yorkshire, in 1876 the Guardians vaccinations.
were arrested and briefly imprisoned in York Castle, prompting
large demonstrations in support of the "Keighley
Seven".[236]: 108–09 The protest movements crossed social boundaries. The financial burden of fines fell
hardest on the working class, who would provide the largest numbers at public demonstrations.[238]
Societies and publications were organized by the middle classes, and support came from celebrities such as
George Bernard Shaw and Alfred Russel Wallace, doctors such as Charles Creighton and Edgar
Crookshank, and parliamentarians such as Jacob Bright and James Allanson Picton.[237] By 1885, with
over 3,000 prosecutions pending in Leicester, a mass rally there was attended by over 20,000
protesters.[239]

Under increasing pressure, the government appointed a Royal Commission on Vaccination in 1889, which
issued six reports between 1892 and 1896, with a detailed summary in 1898.[240] Its recommendations
were incorporated into the 1898 Vaccination Act, which still required compulsory vaccination but allowed
exemption on the grounds of conscientious objection on presentation of a certificate signed by two
magistrates.[13][237] These were not easy to obtain in towns where
magistrates supported compulsory vaccination, and after continued
protests, a further act in 1907 allowed exemption on a simple signed
declaration.[239] Although this solved the immediate problem, the
compulsory vaccination acts remained legally enforceable, and determined
opponents lobbied for their repeal. No Compulsory Vaccination was one
of the demands of the 1900 Labour Party General Election Manifesto.[241]
This was done as a matter of routine when the National Health Service
was introduced in 1948, with "almost negligible" opposition from
supporters of compulsory vaccination.[242]

Vaccination in Wales was covered by English legislation, but the Scottish

legal system was separate. Vaccination was not made compulsory there
until 1863, and a conscientious objection was allowed after vigorous
protest only in 1907.[233]: 10–11
In a postwar poster the
In the late 19th century, Leicester in the UK received much attention Ministry of Health urged
because of how smallpox was managed there. There was particularly British residents to
immunize children against
strong opposition to compulsory vaccination, and medical authorities had
diphtheria.
to work within this framework. They developed a system that did not use
vaccination but was based on the notification of cases, the strict isolation of
patients and contacts, and the provision of isolation hospitals.[243] This
proved successful but required acceptance of compulsory isolation rather than vaccination. C. Killick
Millard, initially, a supporter of compulsory vaccination was appointed Medical Officer of Health in 1901.
He moderated his views on compulsion but encouraged contacts and his staff to accept vaccination. This
approach, developed initially due to overwhelming opposition to government policy, became known as the
Leicester Method.[242][244] In time it became generally accepted as the most appropriate way to deal with
smallpox outbreaks and was listed as one of the "important events in the history of smallpox control" by
those most involved in the World Health Organization's successful Smallpox Eradication Campaign. The
final stages of the campaign generally referred to as "surveillance containment", owed much to the
Leicester method.[245][246]

United States

In the US, President Thomas Jefferson took a close interest in vaccination, alongside Benjamin
Waterhouse, chief physician at Boston. Jefferson encouraged the development of ways to transport vaccine
material through the Southern states, which included measures to avoid damage by heat, a leading cause of
ineffective batches. Smallpox outbreaks were contained by the latter half of the 19th century, a
development widely attributed to the vaccination of a large portion of the population. Vaccination rates fell
after this decline in smallpox cases, and the disease again became epidemic in the late 19th century.[247]

After an 1879 visit to New York by prominent British anti-vaccinationist William Tebb, The Anti-
Vaccination Society of America was founded.[248][249] The New England Anti-Compulsory Vaccination
League formed in 1882, and the Anti-Vaccination League of New York City in 1885.[249] Tactics in the
US largely followed those used in England.[250] Vaccination in the US was regulated by individual states,
in which there followed a progression of compulsion, opposition, and repeal similar to that in England.[251]
Although generally organized on a state-by-state basis, the vaccination controversy reached the US
Supreme Court in 1905. There, in the case of Jacobson v. Massachusetts, the court ruled that states have
the authority to require vaccination against smallpox during a smallpox epidemic.[252]
John Pitcairn, the wealthy founder of the Pittsburgh Plate Glass Company (now PPG Industries), emerged
as a major financier and leader of the American anti-vaccination movement. On March 5, 1907, in
Harrisburg, Pennsylvania, he delivered an address to the Committee on Public Health and Sanitation of the
Pennsylvania General Assembly criticizing vaccination.[253] He later sponsored the National Anti-
Vaccination Conference, which, held in Philadelphia in October 1908, led to the creation of The Anti-
Vaccination League of America. When the league organized later that month, members chose Pitcairn as
their first president.[254]

On December 1, 1911, Pitcairn was appointed by Pennsylvania Governor John K. Tener to the
Pennsylvania State Vaccination Commission and subsequently authored a detailed report strongly opposing
the commission's conclusions.[254] He remained a staunch opponent of vaccination until his death in 1916.

Brazil

In November 1904, in response to years of inadequate sanitation and disease, followed by a poorly
explained public health campaign led by the renowned Brazilian public health official Oswaldo Cruz,
citizens and military cadets in Rio de Janeiro arose in a Revolta da Vacina, or Vaccine Revolt. Riots broke
out on the day a vaccination law took effect; vaccination symbolized the most feared and most tangible
aspect of a public health plan that included other features, such as urban renewal, that many had opposed
for years.[255]

Later vaccines and antitoxins

Opposition to smallpox vaccination continued into the 20th century and was joined by controversy over
new vaccines and the introduction of antitoxin treatment for diphtheria. Injection of horse serum into
humans as used in antitoxin can cause hypersensitivity, commonly referred to as serum sickness. Moreover,
the continued production of the smallpox vaccine in animals and the production of antitoxins in horses
prompted anti-vivisectionists to oppose vaccination.[256]

Diphtheria antitoxin was serum from horses that had been immunized against diphtheria, and was used to
treat human cases by providing passive immunity. In 1901, antitoxin from a horse named Jim was
contaminated with tetanus and killed 13 children in St. Louis, Missouri. This incident, together with nine
deaths from tetanus from contaminated smallpox vaccine in Camden, New Jersey, led directly and quickly
to the passing of the Biologics Control Act in 1902.[257]

Robert Koch developed tuberculin in 1890. Inoculated into individuals who have had tuberculosis, it
produces a hypersensitivity reaction and is still used to detect those who have been infected. However,
Koch used tuberculin as a vaccine. This caused serious reactions and deaths in individuals whose latent
tuberculosis was reactivated by the tuberculin.[258] This was a major setback for supporters of new
vaccines.[233]: 30–31 Such incidents and others ensured that any untoward results concerning vaccination
and related procedures received continued publicity, which grew as the number of new procedures
increased.[259]

In 1955, in a tragedy known as the Cutter incident, Cutter Laboratories produced 120,000 doses of the Salk
polio vaccine that inadvertently contained some live poliovirus along with inactivated virus. This vaccine
caused 40,000 cases of polio, 53 cases of paralysis, and five deaths. The disease spread through the
recipients' families, creating a polio epidemic that led to a further 113 cases of paralytic polio and another
five deaths. It was one of the worst pharmaceutical disasters in US history.[260]
Later 20th-century events included the 1982 broadcast of DPT: Vaccine Roulette, which sparked debate
over the DPT vaccine,[261] and the 1998 publication of a fraudulent academic article by Andrew
Wakefield[262] which sparked the MMR vaccine controversy. Also recently, the HPV vaccine has become
controversial due to concerns that it may encourage promiscuity when given to 11- and 12-year-old
girls.[263][264]

Arguments against vaccines in the 21st century are often similar to those of 19th-century anti-
vaccinationists.[13]

COVID-19

In mid-2020, surveys on whether people would be willing to take

a potential COVID-19 vaccine estimated that 67% or 80% of
people in the US would accept a new vaccination against COVID-
19.[265][266]

In the United Kingdom, a 16 November 2020 YouGov poll

showed that 42% said they were very likely to take the vaccine
and 25% were fairly likely (67% likely overall); 11% would be
very unlikely and 10% fairly unlikely (21% unlikely overall) and
A protest against COVID-19
12% are unsure.[267] There have been a number of reasons
vaccination in London, United
expressed why people might not wish to take COVID-19
Kingdom
vaccines, such as concerns over safety, self-perception of being
"low risk", or questioning the Pfizer-BioNTech vaccine in
particular. 8% of those reluctant to take it say it is because they
oppose vaccinations overall; this amounts to just 2% of the British public.[267]

A December 2020 Ipsos/World Economic Forum 15-country poll asked online respondents whether they
agreed with the statement: "If a vaccine for COVID-19 were available, I would get it." Rates of agreement
were smallest in France (40%), Russia (43%) and South Africa (53%). In the United States, 69% of those
polled agreed with the statement; rates were even higher in Britain (77%) and China (80%).[268][269]

A March 2021 NPR/PBS NewsHour/Marist poll found the difference between white and black Americans
to be within the margin of error, but 47% of Trump supporters said they would refuse a COVID-19
vaccine, compared to 30% of all adults.[270]

In May 2021, a report titled "Global attitudes towards a COVID-19 vaccine" from the Institute of Global
Health Innovation and Imperial College London, which included detailed survey data from March to May
2021 including survey data from 15 countries Australia, Canada, Denmark, France, Germany, Israel, Italy,
Japan, Norway, Singapore, South Korea, Spain, Sweden, the UK, and the US. It found that in 13 of the 15
countries more than 50% of people were confident in covid-19 vaccines. In the UK 87% of survey
respondents said they trusted the vaccines, which showed a significant increase in confidence following
earlier less reliable polls. The survey also found trust in different vaccine brands varied, with the Pfizer–
BioNTech COVID-19 vaccine being the most trusted across all age groups in most countries and
particularly the most trusted for under 65s.[271][272]

Geographical distribution
Vaccine hesitancy is becoming an increasing concern, particularly in industrialized nations. For example,
one study surveying parents in Europe found that 12–28% of surveyed parents expressed doubts about
vaccinating their children.[273] Several studies have assessed socioeconomic and cultural factors associated
with vaccine hesitancy. Both high and low
socioeconomic status as well as high and low
education levels have all been associated with
vaccine hesitancy in different
populations.[120][274][275][276][277][278][279]
Other studies examining various populations
around the world in different countries found that
both high and low socioeconomic status are
associated with vaccine hesitancy.[3] An
Australian study that examined the factors
associated with vaccine attitudes and uptake
separately found that under-vaccination
correlated with lower socioeconomic status but
not with negative attitudes towards vaccines. The Share that agrees that vaccines are important for
researchers suggested that practical barriers are children to have (2018)
more likely to explain under-vaccination among
individuals with lower socioeconomic status.[276]

Studies have demonstrated that children of parents who refused the pertussis vaccine, varicella vaccine, and
pneumococcal vaccine are 23 times more likely to contract pertussis (whooping cough), nine times more
likely to catch varicella (chickenpox), and six times more likely to be hospitalized with severe pneumonia
from Streptococcus pneumoniae (pneumococcus).[53]

Policy implications
Multiple major medical societies including the Infectious Diseases Society of America, the American
Medical Association, and the American Academy of Pediatrics support the elimination of all nonmedical
exemptions for childhood vaccines.[120]

Individual liberty

Compulsory vaccination policies have been controversial as long as they have existed, with opponents of
mandatory vaccinations arguing that governments should not infringe on an individual's freedom to make
medical decisions for themselves or their children, while proponents of compulsory vaccination cite the
well-documented public health benefits of vaccination.[13][280] Others argue that, for compulsory
vaccination to effectively prevent disease, there must be not only available vaccines and a population
willing to immunize, but also sufficient ability to decline vaccination on grounds of personal belief.[281]

Vaccination policy involves complicated ethical issues, as unvaccinated individuals are more likely to
contract and spread disease to people with weaker immune systems, such as young children and the elderly,
and to other individuals in whom the vaccine has not been effective. However, mandatory vaccination
policies raise ethical issues regarding parental rights and informed consent.[282]

In the United States, vaccinations are not truly compulsory, but they are typically required in order for
children to attend public schools. As of January 2021, five states – Mississippi, West Virginia, California,
Maine, and New York – have eliminated religious and philosophical exemptions to required school
immunizations.[283]

Children's rights
Medical ethicist Arthur Caplan argues that children have a right to the best available medical care, including
vaccines, regardless of parental feelings toward vaccines, saying "Arguments about medical freedom and
choice are at odds with the human and constitutional rights of children. When parents won't protect them,
governments must."[284][285]

A review of court cases from 1905 to 2016 found that, of the nine courts that have heard cases regarding
whether not vaccinating a child constitutes neglect, seven have held vaccine refusal to be a form of child
neglect.[286]

To prevent the spread of disease by unvaccinated individuals, some schools and doctors' surgeries have
prohibited unvaccinated children from being enrolled, even where not required by law.[287][288] Refusal of
doctors to treat unvaccinated children may cause harm to both the child and public health, and may be
considered unethical, if the parents are unable to find another healthcare provider for the child.[289] Opinion
on this is divided, with the largest professional association, the American Academy of Pediatrics, saying
that exclusion of unvaccinated children may be an option under narrowly defined circumstances.[120]

Religion
Since most religions were started far before vaccinations were invented, scriptures do not specifically
address the topic of vaccination.[2] However, vaccination has been opposed on religious grounds ever since
it was first introduced. When vaccination was first becoming widespread, some Christian opponents argued
that preventing smallpox deaths would be thwarting God's will and that such prevention is sinful.[229]
Religious opposition continues to the present day, on various grounds, raising ethical difficulties when the
number of unvaccinated children threatens harm to the entire population.[290] Many governments allow
parents to opt out of their children's otherwise mandatory vaccinations for religious reasons; some parents
falsely claim religious beliefs to get vaccination exemptions.[291]

Many Jewish community leaders support vaccination.[292] Among early Hasidic leaders, Rabbi Nachman
of Breslov (1772–1810) was known for his criticism of the doctors and medical treatments of his day.
However, when the first vaccines were successfully introduced, he stated: "Every parent should have his
children vaccinated within the first three months of life. Failure to do so is tantamount to murder. Even if
they live far from the city and have to travel during the great winter cold, they should have the child
vaccinated before three months."[293]

Although gelatin can be derived from many animals, Jewish and Islamic scholars have determined that
since the gelatin is cooked and not consumed as food, vaccinations containing gelatin are acceptable.[2]
However, in 2015 and again in 2020, the possible use of porcine-based gelatin in vaccines raised religious
concerns among Muslims and Orthodox Jews about the halal or kosher status of several vaccinations
against COVID-19.[294] The Muslim Council of Britain argued against the use of intranasal influenza
vaccine in 2019 due to the presence of gelatin in the vaccine and consider such vaccines to be non-halal
(unclean).[295]

In India, in 2018, a three-minute doctored clip circulated among Muslims claiming that the MR-VAC
vaccine against measles and rubella was a "Modi government-RSS conspiracy" to stop the population
growth of Muslims. The clip was taken from a TV show that exposed the baseless rumors.[296] Hundreds
of madrassas in the state of Uttar Pradesh refused permission to health department teams to administer
vaccines because of rumors spread using WhatsApp.[297]

Some Christians have objected to the use of cell cultures of some viral vaccines, and the virus of the rubella
vaccine,[298] on the grounds that they are derived from tissues taken from therapeutic abortions performed
in the 1960s. The principle of double effect, originated by Thomas Aquinas, holds that actions with both
good and bad consequences are morally acceptable in specific circumstances.[299] The Vatican Curia has
said that for vaccines originating from embryonic cells, Catholics have "a grave responsibility to use
alternative vaccines and to make a conscientious objection", but concluded that it is acceptable for
Catholics to use the existing vaccines until an alternative becomes available.[300]

In the United States, some parents falsely claim religious exemptions when their real motivation for
avoiding vaccines is supposed safety concerns.[301] For a number of years, only Mississippi, West Virginia,
and California did not provide religious exemptions. Following the 2019 measles outbreaks, Maine and
New York repealed their religious exemptions, and the state of Washington did so for the measles
vaccination.[302]

According to a March 2021 poll conducted by The Associated Press/NORC, vaccine skepticism is more
widespread among white evangelicals than most other blocs of Americans. Forty percent of white
evangelical Protestants said they were not likely to get vaccinated against COVID-19.[303]

Alternative medicine
Many forms of alternative medicine are based on philosophies that oppose vaccination (including germ
theory denialism) and have practitioners who voice their opposition. As a consequence, the increase in
popularity of alternative medicine in the 1970s planted the seed on the modern anti-vaccination
movement.[304] More specifically, some elements of the chiropractic community, some homeopaths, and
naturopaths developed anti-vaccine rhetoric.[35] The reasons for this negative vaccination view are
complicated and rest at least in part on the early philosophies that shaped the foundation of these groups.[35]

Chiropractic

Historically, chiropractic strongly opposed vaccination based on its belief that all diseases were traceable to
causes in the spine and therefore could not be affected by vaccines. Daniel D. Palmer (1845–1913), the
founder of chiropractic, wrote: "It is the very height of absurdity to strive to 'protect' any person from
smallpox or any other malady by inoculating them with a filthy animal poison."[305] Vaccination remains
controversial within the profession.[306] Most chiropractic writings on vaccination focus on its negative
aspects.[305] A 1995 survey of US chiropractors found that about one third believed there was no scientific
proof that immunization prevents disease.[306] While the Canadian Chiropractic Association supports
vaccination,[305] a survey in Alberta in 2002 found that 25% of chiropractors advised patients for, and 27%
advised against, vaccinations for patients or for their children.[307]

Although most chiropractic colleges try to teach about vaccination in a manner consistent with scientific
evidence, several have faculty who seem to stress negative views.[306] A survey of a 1999–2000 cross-
section of students of Canadian Memorial Chiropractic College (CMCC), which does not formally teach
anti-vaccination views, reported that fourth-year students opposed vaccination more strongly than did first-
year students, with 29.4% of fourth-year students opposing vaccination.[308] A follow-up study on 2011–
12 CMCC students found that pro-vaccination attitudes heavily predominated. Students reported support
rates ranging from 84% to 90%. One of the study's authors proposed the change in attitude to be due to the
lack of the previous influence of a "subgroup of some charismatic students who were enrolled at CMCC at
the time, students who championed the Palmer postulates that advocated against the use of
vaccination".[309]

Policy positions
The American Chiropractic Association and the International Chiropractic Association support individual
exemptions to compulsory vaccination laws.[306] In March 2015, the Oregon Chiropractic Association
invited Andrew Wakefield, chief author of a fraudulent research paper, to testify against Senate Bill
442,[310] "a bill that would eliminate nonmedical exemptions from Oregon's school immunization
law".[311] The California Chiropractic Association lobbied against a 2015 bill ending belief exemptions for
vaccines. They had also opposed a 2012 bill related to vaccination exemptions.[312]

Homeopathy

Several surveys have shown that some practitioners of homeopathy, particularly homeopaths without any
medical training, advise patients against vaccination.[313] For example, a survey of registered homeopaths
in Austria found that only 28% considered immunization an important preventive measure, and 83% of
homeopaths surveyed in Sydney, Australia, did not recommend vaccination.[35] Many practitioners of
naturopathy also oppose vaccination.[35]

Homeopathic "vaccines" (nosodes) are ineffective because they do not contain any active ingredients and
thus do not stimulate the immune system. They can be dangerous if they take the place of effective
treatments.[314] Some medical organizations have taken action against nosodes. In Canada, the labeling of
homeopathic nosodes require the statement: "This product is neither a vaccine nor an alternative to
vaccination."[315]

Financial motives
Alternative medicine proponents gain from promoting vaccine conspiracy theories through the sale of
ineffective and expensive medications, supplements, and procedures such as chelation therapy and
hyperbaric oxygen therapy, sold as able to cure the 'damage' caused by vaccines.[316] Homeopaths in
particular gain through the promotion of water injections or 'nosodes' that they allege have a 'natural'
vaccine-like effect.[317] Additional bodies with a vested interest in promoting the "unsafeness" of vaccines
may include lawyers and legal groups organizing court cases and class action lawsuits against vaccine
providers.

Conversely, alternative medicine providers have accused the vaccine industry of misrepresenting the safety
and effectiveness of vaccines, covering up and suppressing information, and influencing health policy
decisions for financial gain.[13] In the late 20th century, vaccines were a product with low profit
margins,[318] and the number of companies involved in vaccine manufacture declined. In addition to low
profits and liability risks, manufacturers complained about low prices paid for vaccines by the CDC and
other US government agencies.[319] In the early 21st century, the vaccine market greatly improved with the
approval of the vaccine Prevnar, along with a small number of other high-priced blockbuster vaccines, such
as Gardasil and Pediarix, which each had sales revenues of over $1 billion in 2008.[318] Despite high
growth rates, vaccines represent a relatively small portion of overall pharmaceutical profits. As recently as
2010, the World Health Organization estimated vaccines to represent 2–3% of total sales for the
pharmaceutical industry.[320]

War
The United States has a very complex history with compulsory vaccination, particularly in enforcing
compulsory vaccinations both domestically and abroad to protect American soldiers during times of war.
There are hundreds of thousands of examples of soldier deaths that were not the result of combat wounds
but were instead from disease.[321] Among wars with high death tolls from disease is the Civil War where
an estimated 620,000 soldiers died from disease.
American soldiers in other countries have spread
diseases that ultimately disrupted entire societies and
healthcare systems with famine and poverty.[321]

Spanish–American War

The Spanish–American War began in April 1898 and

ended in August 1898. During this time the United
States gained control of Cuba, Puerto Rico, and the
Philippines from Spain. As a military police power and
Judge's cartoon of Rudyard Kipling's famous
as colonizers the United States took a very hands-on
poem "The White Man's Burden" published in
approach in administering healthcare particularly
1899. The poem's philosophy quickly was utilized
vaccinations to natives during the invasion and
to explain/justify the United States' response to
conquest of these countries.[321] Although the Spanish– the annexation of the Philippines. The United
American War occurred during the era of States used the "white man's burden" as an
"bacteriological revolution" where knowledge of argument for imperial control of the Philippines
disease was bolstered by germ theory, more than half of and Puerto Rico based on the moral necessity to
the soldier casualties in this war were from disease.[321] ensure the spread of civility and modernity.
Unknowingly, American soldiers acted as agents of
disease transmission, fostering bacteria in their
haphazardly made camps. These soldiers invaded Cuba, Puerto Rico, and the Philippines and connected
parts of these countries that had never before been connected due to low population density, thereby
beginning epidemics.[321] The mobility of American soldiers around these countries encouraged newfound
mobility of disease that quickly infected natives.

Military personnel used Rudyard's Kipling's poem "The White Man's Burden" to explain their imperialistic
actions in Cuba, the Philippines, and Puerto Rico and the need for the United States to help the "dark-
skinned Barbarians"[321] reach modern sanitary standards. American actions abroad before, during, and
after the war emphasized a need for proper sanitation habits especially on behalf of the natives. Natives
who refuse to oblige with American health standards and procedures risked fines or imprisonment.[321]
One penalty in Puerto Rico included a $10 fine for a failure to vaccinate and an additional $5 fine for any
day a person continued to be unvaccinated; refusal to pay resulted in ten or more days of imprisonment. If
entire villages refused the army's current sanitation policy at any given time they risked being burnt to the
ground to preserve the health and safety of soldiers from endemic smallpox and yellow fever.[321] Vaccines
were forcibly administered to the Puerto Ricans, Cubans, and Filipinos. Military personnel in Puerto Rico
provided Public Health services that culminated in military orders that mandated vaccinations for children
before they were six months old and a general vaccination order.[321] By the end of 1899 in Puerto Rico
alone the U.S. military and other hired native vaccinators called practicantes, vaccinated an estimated
860,000 natives in a five-month period. This period began the United States' movement toward an
expansion of medical practices that included "tropical medicine" in an attempt to protect the lives of soldiers
abroad.[321]

Vietnam War

During the Vietnam War, vaccination was necessary for soldiers to fight overseas. Because disease follows
soldiers,[322] they had to receive vaccines preventing cholera, influenza, measles, meningococcemia,
Bubonic plague, poliovirus, smallpox, tetanus, diphtheria, typhoid, typhus, and yellow fever. However, the
diseases mainly prevalent in Vietnam at this time were measles and polio. After arriving in Vietnam, the
United States Military conducted the "Military Public Health Assistance Project".[323] This public health
program was a joint United States Military and Government of Vietnam concept to create or expand public
medical facilities throughout South Vietnam.[324] Local villages in Vietnam were inoculated. The United
States military screened patients, dispensed medication, distributed clothing and food, and even passed out
propaganda such as comic books.[325]

Information warfare
An analysis of tweets from July 2014 through September 2017 revealed an active campaign on Twitter by
the Internet Research Agency (IRA), a Russian troll farm accused of interference in the 2016 U.S.
elections, to sow discord about the safety of vaccines.[326][327] The campaign used sophisticated Twitter
bots to amplify polarizing pro-vaccine and anti-vaccine messages, containing the hashtag #VaccinateUS,
posted by IRA trolls.[326]

Confidence in vaccines varies over place and time and among different vaccines. The London School of
Hygiene & Tropical Medicine's Vaccine Confidence Project in 2016 found that confidence was lower in
Europe than in the rest of the world. Refusal of the MMR vaccine has increased in twelve European states
since 2010. The project published a report in 2018 assessing vaccine hesitancy among the public in all the
28 EU member states and among general practitioners in ten of them. Younger adults in the survey had less
confidence than older people. Confidence had risen in France, Greece, Italy, and Slovenia since 2015 but
had fallen in the Czech Republic, Finland, Poland, and Sweden. 36% of the GPs surveyed in the Czech
Republic and 25% of those in Slovakia did not agree that the MMR vaccine was safe. Most of the GPs did
not recommend the seasonal influenza vaccine. Confidence in the population correlated with confidence
among GPs.[328] A study of vaccine-hesitant U.S. college students found that after they interviewed
survivors of vaccine-preventable diseases, they were more likely to become pro-vaccine than a control
group.[329]

Parties opposed to the use of vaccines frequently refer to data obtained from the US Vaccine Adverse Event
Reporting System (VAERS). This is a database of reports of issues associated with vaccines which has
been useful for investigation, but since any claim can be entered into the VAERS, its data is not all reliable.
Dubious claims about vaccines against hepatitis B, HPV and other diseases have been propagated based on
misuse of data from VAERS.[330]

See also
Chemophobia
Measles resurgence in the United States
Misinformation related to vaccination
Therapeutic nihilism
Vaccine shedding

References
1. "Vaccine hesitancy: a generation at risk" (https://www.thelancet.com/journals/lanchi/article/PI
IS2352-4642(19)30092-6/fulltext). The Lancet. doi:10.1016/S2352-4642(19)30092-6 (https://
doi.org/10.1016%2FS2352-4642%2819%2930092-6).
2. Smith, MJ (November 2015). "Promoting Vaccine Confidence". Infectious Disease Clinics of
North America (Review). 29 (4): 759–69. doi:10.1016/j.idc.2015.07.004 (https://doi.org/10.10
16%2Fj.idc.2015.07.004). PMID 26337737 (https://pubmed.ncbi.nlm.nih.gov/26337737).
 3. Larson, HJ; Jarrett, C; Eckersberger, E; Smith, DM; Paterson, P (April 2014). "Understanding
vaccine hesitancy around vaccines and vaccination from a global perspective: a systematic
review of published literature, 2007–2012". Vaccine. 32 (19): 2150–59.
doi:10.1016/j.vaccine.2014.01.081 (https://doi.org/10.1016%2Fj.vaccine.2014.01.081).
PMID 24598724 (https://pubmed.ncbi.nlm.nih.gov/24598724).
4. Cataldi, Jessica; O’Leary, Sean (2021). "Parental vaccine hesitancy: scope, causes, and
potential responses" (https://journals.lww.com/co-infectiousdiseases/Fulltext/2021/10000/Pa
rental_vaccine_hesitancy__scope,_causes,_and.19.aspx?casa_token=aWELckabcbQAAA
AA:Pom2T2qU10D9vOY0WcCHIgniEUg12biw0hY65e8WiQrLc204KdX7LqwEHUk0dGrKT
mGa1m6_MLLIevKPSI9Qxk6o). Current Opinion in Infectious Diseases.
doi:10.1097/QCO.0000000000000774 (https://doi.org/10.1097%2FQCO.000000000000077
4).
5. Hinsliff, Gaby (November 16, 2020). "It's the 'vaccine hesitant', not anti-vaxxers, who are
troubling public health experts" (https://www.theguardian.com/commentisfree/2020/nov/16/v
accine-hesitant-anti-vaxxers-public-health-experts-covid).
6. SAGE, Working Group (October 1, 2014). "Report of the SAGE working group on vaccine
hesitancy" (https://www.who.int/immunization/sage/meetings/2014/october/1_Report_WOR
KING_GROUP_vaccine_hesitancy_final.pdf) (PDF). WHO.
7. "Communicating science-based messages on vaccines" (https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC5689193). Bulletin of the World Health Organization. 95 (10): 670–71. October
2017. doi:10.2471/BLT.17.021017 (https://doi.org/10.2471%2FBLT.17.021017).
PMC 5689193 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5689193). PMID 29147039
(https://pubmed.ncbi.nlm.nih.gov/29147039).
8. "Why do some people oppose vaccination?" (https://www.vox.com/2018/8/21/17588104/vac
cine-opposition-anti-vaxxer). Vox. Retrieved November 26, 2018.
9. Ceccarelli L. "Defending science: How the art of rhetoric can help" (https://theconversation.c
om/defending-science-how-the-art-of-rhetoric-can-help-68210). The Conversation.
Retrieved November 26, 2018.
10. U.S. Department of Health and Human Services. "Vaccines.gov" (https://www.vaccines.gov/
basics/safety/index.html). Vaccines.gov. Retrieved August 5, 2018.
11. "Frequently Asked Questions (FAQ)" (https://web.archive.org/web/20131017113035/http://w
ww.childrenshospital.org/centers-and-services/division-of-infectious-diseases/faq-resurgenc
e-of-measles). Boston Children's Hospital. Archived from the original (http://www.childrensh
ospital.org/centers-and-services/division-of-infectious-diseases/faq-resurgence-of-measles)
on October 17, 2013. Retrieved February 11, 2014.
12. Phadke VK, Bednarczyk RA, Salmon DA, Omer SB (March 2016). "Association Between
Vaccine Refusal and Vaccine Preventable Diseases in the United States: A Review of
Measles and Pertussis" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5007135). JAMA.
315 (11): 1149–58. doi:10.1001/jama.2016.1353 (https://doi.org/10.1001%2Fjama.2016.135
3). PMC 5007135 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5007135).
PMID 26978210 (https://pubmed.ncbi.nlm.nih.gov/26978210).
13. Wolfe RM, Sharp LK (August 2002). "Anti-vaccinationists past and present" (https://www.ncb
i.nlm.nih.gov/pmc/articles/PMC1123944). BMJ. 325 (7361): 430–32.
doi:10.1136/bmj.325.7361.430 (https://doi.org/10.1136%2Fbmj.325.7361.430).
PMC 1123944 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1123944). PMID 12193361
(https://pubmed.ncbi.nlm.nih.gov/12193361).
14. Poland GA, Jacobson RM (January 2011). "The age-old struggle against the
antivaccinationists" (https://semanticscholar.org/paper/ef30916a843202d73362f06b38ed50
84e31eb8aa). The New England Journal of Medicine. 364 (2): 97–99.
doi:10.1056/NEJMp1010594 (https://doi.org/10.1056%2FNEJMp1010594). PMID 21226573
(https://pubmed.ncbi.nlm.nih.gov/21226573). S2CID 39229852 (https://api.semanticscholar.o
rg/CorpusID:39229852).
15. Wallace A (October 19, 2009). "An epidemic of fear: how panicked parents skipping shots
endangers us all" (https://www.wired.com/magazine/2009/10/ff_waronscience/all/1). Wired.
Retrieved October 21, 2009.
16. Poland GA, Jacobson RM (March 2001). "Understanding those who do not understand: a
brief review of the anti-vaccine movement". Vaccine. 19 (17–19): 2440–45.
doi:10.1016/S0264-410X(00)00469-2 (https://doi.org/10.1016%2FS0264-410X%2800%290
0469-2). PMID 11257375 (https://pubmed.ncbi.nlm.nih.gov/11257375).
17. "Ten threats to global health in 2019" (https://web.archive.org/web/20190627025209/http://w
ww.who.int/emergencies/ten-threats-to-global-health-in-2019). Who.int. Archived from the
original (http://www.who.int/emergencies/ten-threats-to-global-health-in-2019) on June 27,
2019. Retrieved December 9, 2020.
18. PM, Aristos Georgiou (January 15, 2019). "The anti-vax movement has been listed by WHO
as one of its top 10 health threats for 2019" (https://www.newsweek.com/world-health-organi
zation-who-un-global-health-air-pollution-anti-vaxxers-1292493). Retrieved January 16,
2019.
19. Gerber JS, Offit PA (February 2009). "Vaccines and autism: a tale of shifting hypotheses" (htt
ps://www.ncbi.nlm.nih.gov/pmc/articles/PMC2908388). Clinical Infectious Diseases. 48 (4):
456–61. doi:10.1086/596476 (https://doi.org/10.1086%2F596476). PMC 2908388 (https://w
ww.ncbi.nlm.nih.gov/pmc/articles/PMC2908388). PMID 19128068 (https://pubmed.ncbi.nlm.
nih.gov/19128068).
20. "The Long History of America's Anti-Vaccination Movement" (http://discovermagazine.com/2
018/dec/fostering-fear). DiscoverMagazine.com. Retrieved February 2, 2019.
21. Young Z (November 21, 2018). "How anti-vax went viral" (https://www.politico.eu/article/how
-anti-vax-went-viral/). Retrieved February 2, 2019.
22. "How the anti-vaxxers are winning in Italy" (https://www.independent.co.uk/news/world/euro
pe/anti-vaxxers-italy-vaccine-measles-epidemic-europe-us-vaccination-global-health-securit
y-agenda-a8560021.html). September 28, 2018. Retrieved February 2, 2019.
23. Chang J (July 12, 2017). " 'Civil liberties' at center of vaccination debate in Texas" (https://w
ww.mystatesman.com/news/state--regional-govt--politics/civil-liberties-center-vaccination-de
bate-texas/lWzq91qhSyAKcY8MiaWnYM/). Mystatesman. Austin American-Statesman.
24. Elliman D, Bedford H (March 23, 2014). "In Britain, Vaccinate With Persuasion, not
Coercion" (https://www.nytimes.com/roomfordebate/2014/03/23/making-vaccination-mandat
ory-for-all-children/in-britain-vaccinate-with-persuasion-not-coercion). The New York Times.
25. "Anti-vaxxers have embraced social media. We're paying for fake news with real lives" (http
s://health.spectator.co.uk/anti-vaxxers-have-embraced-social-media-were-paying-for-fake-ne
ws-with-real-lives/). June 28, 2017. Retrieved February 2, 2019.
26. Bourree Lam, Vaccines Are Profitable, So What? (https://www.theatlantic.com/business/arch
ive/2015/02/vaccines-are-profitable-so-what/385214/). The Atlantic Feb. 10, 2015
27. Christenson, Brith; Lundbergh, Per; Hedlund, Jonas; Örtqvist, Åke (March 2001). "Effects of
a large-scale intervention with influenza and 23-valent pneumococcal vaccines in adults
aged 65 years or older: a prospective study". The Lancet. 357 (9261): 1008–11.
doi:10.1016/S0140-6736(00)04237-9 (https://doi.org/10.1016%2FS0140-6736%2800%2904
237-9). PMID 11293594 (https://pubmed.ncbi.nlm.nih.gov/11293594). S2CID 8125882 (http
s://api.semanticscholar.org/CorpusID:8125882).
28. Jacobson, RM; St Sauver, JL; Griffin, JM; MacLaughlin, KL; Finney Rutten, LJ (April 2020).
"How health care providers should address vaccine hesitancy in the clinical setting:
Evidence for presumptive language in making a strong recommendation" (https://www.ncbi.n
lm.nih.gov/pmc/articles/PMC7553710). Human Vaccines & Immunotherapeutics. 16 (9):
2131–2135. doi:10.1080/21645515.2020.1735226 (https://doi.org/10.1080%2F21645515.20
20.1735226). PMC 7553710 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7553710).
PMID 32242766 (https://pubmed.ncbi.nlm.nih.gov/32242766).
29. Fenner F, Henderson DA, Arita I, Ježek Z, Ladnyi ID (1988). Smallpox and its Eradication (ht
tp://whqlibdoc.who.int/smallpox/9241561106.pdf) (PDF). Geneva: World Health
Organization. ISBN 978-92-4-156110-5. Retrieved September 4, 2007.
30. Sutter RW, Maher C (2006). "Mass vaccination campaigns for polio eradication: an essential
strategy for success". Mass Vaccination: Global Aspects – Progress and Obstacles. Curr
Top Microbiol Immunol. Current Topics in Microbiology and Immunology. 304. pp. 195–220.
doi:10.1007/3-540-36583-4_11 (https://doi.org/10.1007%2F3-540-36583-4_11). ISBN 978-
3-540-29382-8. PMID 16989271 (https://pubmed.ncbi.nlm.nih.gov/16989271).
31. Centers for Disease Control Prevention (CDC) (March 2002). "Progress toward elimination
of Haemophilus influenzae type b invasive disease among infants and children – United
States, 1998–2000" (https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5111a4.htm).
Morbidity and Mortality Weekly Report. 51 (11): 234–37. PMID 11925021 (https://pubmed.nc
bi.nlm.nih.gov/11925021).
32. Park, Alice (June 2, 2008). "How safe are vaccines?" (https://web.archive.org/web/20080528
022614/http://www.time.com/time/health/article/0,8599,1808438-1,00.html). Time Magazine.
Archived from the original (http://www.time.com/time/health/article/0,8599,1808438-1,00.htm
l) on May 28, 2008.
33. "Some common misconceptions about vaccination and how to respond to them" (https://we
b.archive.org/web/20150120055820/http://www.cdc.gov/vaccines/vac-gen/6mishome.htm).
National Center for Immunization and Respiratory Diseases, Centers for Disease Control
and Prevention. Archived from the original (https://www.cdc.gov/vaccines/vac-gen/6mishom
e.htm) on January 20, 2015. Retrieved September 28, 2012.
34. Novella, Steven; Novella, Bob; Santa Maria, Cara; Novella, Jay; Bernstein, Evan (2018).
The Skeptics' Guide to the Universe: How to Know What's Really Real in a World
Increasingly Full of Fake. Grand Central Publishing. p. 185. ISBN 9781538760512.
35. Ernst E (October 2001). "Rise in popularity of complementary and alternative medicine:
reasons and consequences for vaccination". Vaccine. 20 (Suppl 1): S90–93, discussion
S89. doi:10.1016/S0264-410X(01)00290-0 (https://doi.org/10.1016%2FS0264-410X%280
1%2900290-0). PMID 11587822 (https://pubmed.ncbi.nlm.nih.gov/11587822).
36. Johnston, Martin (July 3, 2006). "Vaccine campaign beating meningococcal epidemic" (htt
p://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10389468). The New Zealand
Herald. Auckland.
37. Wane, Joanna. "The case for vaccination" (http://www.biocsl.co.nz/docs/957/642/NorthSouth
_case-for-accination.pdf) (PDF). North & South. Retrieved July 3, 2015.
38. Fine, P.; Eames, K.; Heymann, D. L. (March 22, 2011). " 'Herd Immunity': A Rough Guide" (ht
tps://doi.org/10.1093%2Fcid%2Fcir007). Clinical Infectious Diseases. 52 (7): 911–16.
doi:10.1093/cid/cir007 (https://doi.org/10.1093%2Fcid%2Fcir007). PMID 21427399 (https://p
ubmed.ncbi.nlm.nih.gov/21427399).
39. Heymann, D. L.; Aylward, R. B. (2006). "Mass Vaccination: When and Why" (https://semantic
scholar.org/paper/274c516d5c4296ad8178acdeb8bd4f6077243f3d). Mass Vaccination:
Global Aspects – Progress and Obstacles. Current Topics in Microbiology and Immunology.
304. pp. 1–16. doi:10.1007/3-540-36583-4_1 (https://doi.org/10.1007%2F3-540-36583-4_1).
ISBN 978-3-540-29382-8. PMID 16989261 (https://pubmed.ncbi.nlm.nih.gov/16989261).
S2CID 25259803 (https://api.semanticscholar.org/CorpusID:25259803).
40. Bester JC (September 2017). "Measles Vaccination is Best for Children: The Argument for
Relying on Herd Immunity Fails". Journal of Bioethical Inquiry. 14 (3): 375–84.
doi:10.1007/s11673-017-9799-4 (https://doi.org/10.1007%2Fs11673-017-9799-4).
PMID 28815434 (https://pubmed.ncbi.nlm.nih.gov/28815434). S2CID 3177668 (https://api.se
manticscholar.org/CorpusID:3177668).
41. "Immunization" (https://www.cdc.gov/features/ReasonsToVaccinate). CDC. August 30, 2018.
42. Zhou F, Santoli J, Messonnier ML, Yusuf HR, Shefer A, Chu SY, Rodewald L, Harpaz R
(December 2005). "Economic evaluation of the 7-vaccine routine childhood immunization
schedule in the United States, 2001" (https://doi.org/10.1001%2Farchpedi.159.12.1136).
Archives of Pediatrics & Adolescent Medicine. 159 (12): 1136–44.
doi:10.1001/archpedi.159.12.1136 (https://doi.org/10.1001%2Farchpedi.159.12.1136).
PMID 16330737 (https://pubmed.ncbi.nlm.nih.gov/16330737).
43. Fine PE, Clarkson JA (December 1986). "Individual versus public priorities in the
determination of optimal vaccination policies". American Journal of Epidemiology. 124 (6):
1012–20. doi:10.1093/oxfordjournals.aje.a114471 (https://doi.org/10.1093%2Foxfordjournal
s.aje.a114471). PMID 3096132 (https://pubmed.ncbi.nlm.nih.gov/3096132).
44. Buttenheim AM, Asch DA (December 2013). "Making vaccine refusal less of a free ride" (http
s://www.ncbi.nlm.nih.gov/pmc/articles/PMC4162060). Human Vaccines &
Immunotherapeutics. 9 (12): 2674–75. doi:10.4161/hv.26676 (https://doi.org/10.4161%2Fhv.
26676). PMC 4162060 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4162060).
PMID 24088616 (https://pubmed.ncbi.nlm.nih.gov/24088616).
45. Reich, Jennifer (June 13, 2019). "I've talked to dozens of parents about why they don't
vaccinate. Here's what they told me" (https://www.vox.com/first-person/2019/5/8/18535944/je
ssica-biel-measles-2019-outbreak-anti-vax). Vox. Retrieved July 5, 2019.
46. The Lancet Infectious Diseases (April 2007). "Tackling negative perceptions towards
vaccination". The Lancet Infectious Diseases. 7 (4): 235. doi:10.1016/S1473-
3099(07)70057-9 (https://doi.org/10.1016%2FS1473-3099%2807%2970057-9).
PMID 17376373 (https://pubmed.ncbi.nlm.nih.gov/17376373).
47. "Possible Side-effects from Vaccines" (https://www.cdc.gov/vaccines/vac-gen/side-effects.ht
m#mmr). Centers for Disease Control and Prevention. August 26, 2013. Retrieved
January 3, 2014.
48. Chen RT, Hibbs B (July 1998). "Vaccine Safety: Current and Future Challenges" (http://sites.
utoronto.ca/virology/mby480/VaccineSafe/VaccineSafe.htm). Pediatric Annals. 27 (7): 445–
55. doi:10.3928/0090-4481-19980701-11 (https://doi.org/10.3928%2F0090-4481-19980701-
11). PMID 9677616 (https://pubmed.ncbi.nlm.nih.gov/9677616). Retrieved January 3, 2014.
49. Bonhoeffer, Jan; Heininger, Ulrich (June 2007). "Adverse events following immunization:
perception and evidence" (https://semanticscholar.org/paper/b4aae434337cd6e9cdc415b0a
b47869524fe957a). Current Opinion in Infectious Diseases. 20 (3): 237–46.
doi:10.1097/QCO.0b013e32811ebfb0
(https://doi.org/10.1097%2FQCO.0b013e32811ebfb0). PMID 17471032 (https://pubmed.ncb
i.nlm.nih.gov/17471032). S2CID 40669829 (https://api.semanticscholar.org/CorpusID:40669
829).
50. Mooney C (June 2009). "Why does the vaccine/autism controversy live on?" (http://discover
magazine.com/2009/jun/06-why-does-vaccine-autism-controversy-live-on). Discover.
51. Jacobson, RM; St Sauver, JL; Finney Rutten, LJ (November 2015). "Vaccine Hesitancy" (htt
ps://doi.org/10.1016%2Fj.mayocp.2015.09.006). Mayo Clinic Proceedings. 90 (11): 1562–
68. doi:10.1016/j.mayocp.2015.09.006 (https://doi.org/10.1016%2Fj.mayocp.2015.09.006).
PMID 26541249 (https://pubmed.ncbi.nlm.nih.gov/26541249).
52. Marshall, GS (2013). "Roots of vaccine hesitancy". S D Med. Spec no: 52–57.
PMID 23444592 (https://pubmed.ncbi.nlm.nih.gov/23444592).
53. McClure, CC; Cataldi, JR; O'Leary, ST (August 2017). "Vaccine Hesitancy: Where We Are
and Where We Are Going" (https://doi.org/10.1016%2Fj.clinthera.2017.07.003). Clinical
Therapeutics. 39 (8): 1550–62. doi:10.1016/j.clinthera.2017.07.003 (https://doi.org/10.1016%
2Fj.clinthera.2017.07.003). PMID 28774498 (https://pubmed.ncbi.nlm.nih.gov/28774498).
54. Leask J, Chapman S, Cooper Robbins SC (2009). " 'All manner of ills': The features of
serious diseases attributed to vaccination". Vaccine. 28 (17): 3066–3070.
doi:10.1016/j.vaccine.2009.10.042 (https://doi.org/10.1016%2Fj.vaccine.2009.10.042).
PMID 19879997 (https://pubmed.ncbi.nlm.nih.gov/19879997).
55. Goldacre B (2009). Bad Science. London: Fourth Estate. pp. 292–94. ISBN 978-
0007284870.
56. Baker JP (February 2008). "Mercury, vaccines, and autism: one controversy, three histories"
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2376879). American Journal of Public
Health. 98 (2): 244–53. doi:10.2105/AJPH.2007.113159 (https://doi.org/10.2105%2FAJPH.2
007.113159). PMC 2376879 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2376879).
PMID 18172138 (https://pubmed.ncbi.nlm.nih.gov/18172138).
57. "Thimerosal in vaccines" (https://web.archive.org/web/20080726010009/https://www.fda.go
v/cber/vaccine/thimerosal.htm). Center for Biologics Evaluation and Research, U.S. Food
and Drug Administration. June 3, 2008. Archived from the original (https://www.fda.gov/cber/
vaccine/thimerosal.htm) on July 26, 2008. Retrieved July 25, 2008.
58. Center for Biologics Evaluation and Research (April 5, 2019). "Thimerosal and Vaccines" (ht
tps://www.fda.gov/vaccines-blood-biologics/safety-availability-biologics/thimerosal-and-vacc
ines). FDA. fda.gov.
59. Offit PA (September 2007). "Thimerosal and vaccines – a cautionary tale" (https://semantics
cholar.org/paper/c2f25efef0ed507beef6bce8f4bf33cb6f51e524). The New England Journal
of Medicine. 357 (13): 1278–79. doi:10.1056/NEJMp078187 (https://doi.org/10.1056%2FNE
JMp078187). PMID 17898096 (https://pubmed.ncbi.nlm.nih.gov/17898096).
S2CID 36318722 (https://api.semanticscholar.org/CorpusID:36318722).
60. Bose-O'Reilly S, McCarty KM, Steckling N, Lettmeier B (September 2010). "Mercury
exposure and children's health" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096006).
Current Problems in Pediatric and Adolescent Health Care. 40 (8): 186–215.
doi:10.1016/j.cppeds.2010.07.002 (https://doi.org/10.1016%2Fj.cppeds.2010.07.002).
PMC 3096006 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096006). PMID 20816346
(https://pubmed.ncbi.nlm.nih.gov/20816346).
61. Gerber JS, Offit PA (February 2009). "Vaccines and autism: a tale of shifting hypotheses" (htt
ps://www.ncbi.nlm.nih.gov/pmc/articles/PMC2908388). Clinical Infectious Diseases. 48 (4):
456–61. doi:10.1086/596476 (https://doi.org/10.1086%2F596476). PMC 2908388 (https://w
ww.ncbi.nlm.nih.gov/pmc/articles/PMC2908388). PMID 19128068 (https://pubmed.ncbi.nlm.
nih.gov/19128068). Lay summary (https://web.archive.org/web/20110225143641/http://www.
idsociety.org/Content.aspx?id=13336) – IDSA (January 30, 2009).
62. Doja A, Roberts W (November 2006). "Immunizations and autism: a review of the literature"
(https://doi.org/10.1017%2Fs031716710000528x). The Canadian Journal of Neurological
Sciences. 33 (4): 341–46. doi:10.1017/s031716710000528x (https://doi.org/10.1017%2Fs03
1716710000528x). PMID 17168158 (https://pubmed.ncbi.nlm.nih.gov/17168158).
63. Spencer, JP; Trondsen Pawlowski, RH; Thomas, S (June 2017). "Vaccine Adverse Events:
Separating Myth from Reality" (https://www.aafp.org/afp/2017/0615/p786.html). American
Family Physician. 95 (12): 786–94. PMID 28671426 (https://pubmed.ncbi.nlm.nih.gov/28671
426).
64. Sugarman SD (September 2007). "Cases in vaccine court – legal battles over vaccines and
autism" (https://works.bepress.com/stephen_sugarman/77). The New England Journal of
Medicine. 357 (13): 1275–77. doi:10.1056/NEJMp078168 (https://doi.org/10.1056%2FNEJM
p078168). PMID 17898095 (https://pubmed.ncbi.nlm.nih.gov/17898095).
65. Immunization Safety Review Committee (2004). Immunization Safety Review: Vaccines and
Autism (http://www.nap.edu/catalog.php?record_id=10997). The National Academies Press.
doi:10.17226/10997 (https://doi.org/10.17226%2F10997). ISBN 978-0-309-09237-1.
PMID 20669467 (https://pubmed.ncbi.nlm.nih.gov/20669467).
66. "Thimerosal and Vaccines" (https://www.fda.gov/vaccines-blood-biologics/safety-availability-
biologics/thimerosal-and-vaccines#pres). fda.gov. U.S. Food and Drug Administration. April
5, 2019.
67. Wakefield AJ, Murch SH, Anthony A, Linnell J, Casson DM, Malik M, Berelowitz M, Dhillon
AP, Thomson MA, Harvey P, Valentine A, Davies SE, Walker-Smith JA (February 1998).
"Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental
disorder in children". Lancet. 351 (9103): 637–41. doi:10.1016/S0140-6736(97)11096-0 (http
s://doi.org/10.1016%2FS0140-6736%2897%2911096-0). PMID 9500320 (https://pubmed.nc
bi.nlm.nih.gov/9500320). S2CID 439791 (https://api.semanticscholar.org/CorpusID:439791).
(Retracted)
68. National Health Service (2015). "MMR vaccine" (https://www.nhs.uk/conditions/vaccinations/
mmr-vaccine/). Retrieved July 4, 2018.
69. Deer B (February 22, 2004). "Revealed: MMR research scandal" (http://www.timesonline.co.
uk/tol/news/uk/health/article1027603.ece). The Sunday Times. Retrieved September 23,
2007.
70. Horton R (March 2004). "The lessons of MMR". Lancet. 363 (9411): 747–49.
doi:10.1016/S0140-6736(04)15714-0 (https://doi.org/10.1016%2FS0140-6736%2804%2915
714-0). PMID 15016482 (https://pubmed.ncbi.nlm.nih.gov/15016482). S2CID 5357597 (http
s://api.semanticscholar.org/CorpusID:5357597).
71. "MMR scare doctor 'paid children' " (http://news.bbc.co.uk/2/hi/health/6289166.stm). BBC
News. July 16, 2007.
72. "Doctors issue plea over MMR jab" (http://news.bbc.co.uk/2/hi/health/5118166.stm). BBC
News. June 26, 2006. Retrieved November 23, 2007.
73. Alazraki M (January 12, 2011). "The Autism Vaccine Fraud: Dr. Wakefield's Costly Lie to
Society" (https://web.archive.org/web/20111027104603/http://www.dailyfinance.com/2011/0
1/12/autism-vaccine-fraud-wakefield-cost-money-deaths/). DailyFinance, AOL Money &
Finance. Archived from the original (http://www.dailyfinance.com/2011/01/12/autism-vaccine
-fraud-wakefield-cost-money-deaths/) on October 27, 2011. Retrieved October 18, 2011.
74. Murch SH, Anthony A, Casson DH, Malik M, Berelowitz M, Dhillon AP, Thomson MA,
Valentine A, Davies SE, Walker-Smith JA (March 2004). "Retraction of an interpretation".
Lancet. 363 (9411): 750. doi:10.1016/S0140-6736(04)15715-2 (https://doi.org/10.1016%2FS
0140-6736%2804%2915715-2). PMID 15016483 (https://pubmed.ncbi.nlm.nih.gov/1501648
3). S2CID 5128036 (https://api.semanticscholar.org/CorpusID:5128036).
75. The Editors Of The Lancet (February 2010). "Retraction – Ileal-lymphoid-nodular
hyperplasia, non-specific colitis, and pervasive developmental disorder in children". Lancet.
375 (9713): 445. doi:10.1016/S0140-6736(10)60175-4 (https://doi.org/10.1016%2FS0140-6
736%2810%2960175-4). PMID 20137807 (https://pubmed.ncbi.nlm.nih.gov/20137807).
S2CID 26364726 (https://api.semanticscholar.org/CorpusID:26364726). Lay summary (http://
news.bbc.co.uk/2/low/health/8493753.stm) – BBC News (February 2, 2010).
76. "General Medical Council, Fitness to Practise Panel Hearing, 24 May 2010, Andrew
Wakefield, Determination of Serious Professional Misconduct" (https://web.archive.org/web/
20130512115524/http://www.gmc-uk.org/Wakefield_SPM_and_SANCTION.pdf_32595267.
pdf) (PDF). General Medical Council. Archived from the original (http://www.gmc-uk.org/Wak
efield_SPM_and_SANCTION.pdf_32595267.pdf) (PDF) on May 12, 2013. Retrieved
September 18, 2011.
77. Meikle, James; Boseley, Sarah (May 24, 2010). "MMR row doctor Andrew Wakefield struck
off register" (https://www.theguardian.com/society/2010/may/24/mmr-doctor-andrew-wakefiel
d-struck-off). The Guardian. London. Archived (https://web.archive.org/web/2010052700393
1/http://www.guardian.co.uk/society/2010/may/24/mmr-doctor-andrew-wakefield-struck-off)
from the original on May 27, 2010. Retrieved May 24, 2010.
78. "Concerns about autism" (http://cdc.gov/vaccinesafety/Concerns/Autism/Index.html). Centers
for Disease Control and Prevention. January 15, 2010.
79. "MMR The facts" (https://web.archive.org/web/20070615000359/http://www.mmrthefacts.nh
s.uk/). United Kingdom National Health Service. Archived from the original (http://www.mmrt
hefacts.nhs.uk/) on June 15, 2007. Retrieved June 13, 2007.
80. "Are Vaccines Safe?" (https://www.health.gov.au/health-topics/immunisation/about-immunis
ation/are-vaccines-safe#no-established-link-between-vaccines-and-autism). health.gov.au.
Australia Department of Health. October 24, 2017.
81. Demicheli V, Rivetti A, Debalini MG, Di Pietrantonj C (February 2012). Demicheli V (ed.).
"Vaccines for measles, mumps and rubella in children" (https://www.ncbi.nlm.nih.gov/pmc/art
icles/PMC6458016). The Cochrane Database of Systematic Reviews. 2 (2): CD004407.
doi:10.1002/14651858.CD004407.pub3 (https://doi.org/10.1002%2F14651858.CD004407.p
ub3). PMC 6458016 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6458016).
PMID 22336803 (https://pubmed.ncbi.nlm.nih.gov/22336803).
82. DeStefano, Frank; Shimabukuro, Tom T. (April 15, 2019). "The MMR Vaccine and Autism" (h
ttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC6768751). Annual Review of Virology. 6 (1):
585–600. doi:10.1146/annurev-virology-092818-015515 (https://doi.org/10.1146%2Fannure
v-virology-092818-015515). ISSN 2327-0578 (https://www.worldcat.org/issn/2327-0578).
PMC 6768751 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6768751). PMID 30986133
(https://pubmed.ncbi.nlm.nih.gov/30986133).
83. Deer B (February 8, 2009). "MMR doctor Andrew Wakefield fixed data on autism" (http://ww
w.timesonline.co.uk/tol/life_and_style/health/article5683671.ece). Sunday Times. Retrieved
February 9, 2009.
84. Deer B (January 2011). "How the case against the MMR vaccine was fixed" (https://doi.org/1
0.1136%2Fbmj.c5347). BMJ. 342: c5347. doi:10.1136/bmj.c5347 (https://doi.org/10.1136%2
Fbmj.c5347). PMID 21209059 (https://pubmed.ncbi.nlm.nih.gov/21209059).
85. Godlee F, Smith J, Marcovitch H (January 2011). "Wakefield's article linking MMR vaccine
and autism was fraudulent" (https://semanticscholar.org/paper/9766637ea6e30ff6feea94379
372f0f80f36ac56). BMJ. 342: c7452. doi:10.1136/bmj.c7452 (https://doi.org/10.1136%2Fbmj.
c7452). PMID 21209060 (https://pubmed.ncbi.nlm.nih.gov/21209060). S2CID 43640126 (htt
ps://api.semanticscholar.org/CorpusID:43640126).
86. Vaccine court and autism:
"Vaccine didn't cause autism, court rules" (http://www.cnn.com/2009/HEALTH/02/12/auti
sm.vaccines/index.html?iref=allsearch). CNN. February 12, 2009. Retrieved
February 12, 2009.
Theresa Cedillo and Michael Cedillo, as parents and natural guardians of Michelle
Cedillo vs. Secretary of Health and Human Services, 98-916V (ftp://autism.uscfc.uscourt
s.gov/autism/vaccine/Hastings-Cedillo.pdf) (United States Court of Federal Claims 2009-
02-12).
87. Hilton S, Petticrew M, Hunt K (May 2006). " 'Combined vaccines are like a sudden onslaught
to the body's immune system': parental concerns about vaccine 'overload' and 'immune-
vulnerability' ". Vaccine. 24 (20): 4321–27. doi:10.1016/j.vaccine.2006.03.003 (https://doi.or
g/10.1016%2Fj.vaccine.2006.03.003). PMID 16581162 (https://pubmed.ncbi.nlm.nih.gov/16
581162).
88. Hurst L (October 30, 2009). "Vaccine phobia runs deep" (https://www.thestar.com/news/articl
e/718829). Toronto Star. Retrieved November 4, 2009.
89. Heininger U (September 2006). "An internet-based survey on parental attitudes towards
immunization". Vaccine. 24 (37–39): 6351–55. doi:10.1016/j.vaccine.2006.05.029 (https://do
i.org/10.1016%2Fj.vaccine.2006.05.029). PMID 16784799 (https://pubmed.ncbi.nlm.nih.gov/
16784799).
90. Willingham, Emily (March 29, 2013). "Vaccines Not Linked To Autism. Again" (https://www.fo
rbes.com/sites/emilywillingham/2013/03/29/vaccines-not-linked-to-autism-again/). Forbes.
Retrieved April 4, 2013.
91. DeStefano F, Price CS, Weintraub ES (August 2013). "Increasing exposure to antibody-
stimulating proteins and polysaccharides in vaccines is not associated with risk of autism" (h
ttp://www.jpeds.com/webfiles/images/journals/ympd/JPEDSDeStefano.pdf) (PDF). The
Journal of Pediatrics. 163 (2): 561–77. CiteSeerX 10.1.1.371.2592 (https://citeseerx.ist.psu.e
du/viewdoc/summary?doi=10.1.1.371.2592). doi:10.1016/j.jpeds.2013.02.001 (https://doi.or
g/10.1016%2Fj.jpeds.2013.02.001). PMID 23545349 (https://pubmed.ncbi.nlm.nih.gov/2354
5349).
92. Immune challenges:
Murphy TF (June 1996). "Branhamella catarrhalis: epidemiology, surface antigenic
structure, and immune response" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC23944
3). Microbiological Reviews. 60 (2): 267–79. doi:10.1128/MMBR.60.2.267-279.1996 (http
s://doi.org/10.1128%2FMMBR.60.2.267-279.1996). PMC 239443 (https://www.ncbi.nlm.n
ih.gov/pmc/articles/PMC239443). PMID 8801433 (https://pubmed.ncbi.nlm.nih.gov/8801
433).
Sloyer JL, Howie VM, Ploussard JH, Ammann AJ, Austrian R, Johnston RB (June 1974).
"Immune response to acute otitis media in children. I. Serotypes isolated and serum and
middle ear fluid antibody in pneumococcal otitis media" (https://www.ncbi.nlm.nih.gov/p
mc/articles/PMC414928). Infection and Immunity. 9 (6): 1028–32.
doi:10.1128/IAI.9.6.1028-1032.1974 (https://doi.org/10.1128%2FIAI.9.6.1028-
1032.1974). PMC 414928 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC414928).
PMID 4151506 (https://pubmed.ncbi.nlm.nih.gov/4151506).
93. Vaccine burden:
Miller E, Andrews N, Waight P, Taylor B (March 2003). "Bacterial infections, immune
overload, and MMR vaccine. Measles, mumps, and rubella" (https://www.ncbi.nlm.nih.go
v/pmc/articles/PMC1719482). Archives of Disease in Childhood. 88 (3): 222–23.
doi:10.1136/adc.88.3.222 (https://doi.org/10.1136%2Fadc.88.3.222). PMC 1719482 (http
s://www.ncbi.nlm.nih.gov/pmc/articles/PMC1719482). PMID 12598383 (https://pubmed.n
cbi.nlm.nih.gov/12598383).
Hviid A, Wohlfahrt J, Stellfeld M, Melbye M (August 2005). "Childhood vaccination and
nontargeted infectious disease hospitalization" (https://doi.org/10.1001%2Fjama.294.6.6
99). JAMA. 294 (6): 699–705. doi:10.1001/jama.294.6.699 (https://doi.org/10.1001%2Fja
ma.294.6.699). PMID 16091572 (https://pubmed.ncbi.nlm.nih.gov/16091572).
94. Gregson AL, Edelman R (November 2003). "Does antigenic overload exist? The role of
multiple immunizations in infants". Immunology and Allergy Clinics of North America. 23 (4):
649–64. doi:10.1016/S0889-8561(03)00097-3 (https://doi.org/10.1016%2FS0889-8561%28
03%2900097-3). PMID 14753385 (https://pubmed.ncbi.nlm.nih.gov/14753385).
95. Offit, Paul A.; Hackett, Charles J. (2003). "Addressing Parents' Concerns: Do Vaccines
Cause Allergic or Autoimmune Diseases?" (https://doi.org/10.1542%2Fpeds.111.3.653).
Pediatrics. 111 (3): 653–59. doi:10.1542/peds.111.3.653 (https://doi.org/10.1542%2Fpeds.1
11.3.653). PMID 12612250 (https://pubmed.ncbi.nlm.nih.gov/12612250).
96. Schneeweiss B, Pfleiderer M, Keller-Stanislawski B (August 2008). "Vaccination safety
update" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2680557). Deutsches Ärzteblatt
International. 105 (34–35): 590–95. doi:10.3238/arztebl.2008.0590 (https://doi.org/10.3238%
2Farztebl.2008.0590). PMC 2680557 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC26805
57). PMID 19471677 (https://pubmed.ncbi.nlm.nih.gov/19471677).
97. Deen JL, Clemens JD (November 2006). "Issues in the design and implementation of
vaccine trials in less developed countries". Nature Reviews. Drug Discovery. 5 (11): 932–
40. doi:10.1038/nrd2159 (https://doi.org/10.1038%2Fnrd2159). PMID 17080029 (https://pub
med.ncbi.nlm.nih.gov/17080029). S2CID 413230 (https://api.semanticscholar.org/CorpusID:
413230).
 98. Fineberg AM, Ellman LM (May 2013). "Inflammatory cytokines and neurological and
neurocognitive alterations in the course of schizophrenia" (https://www.ncbi.nlm.nih.gov/pm
c/articles/PMC3641168). Biological Psychiatry. 73 (10): 951–66.
doi:10.1016/j.biopsych.2013.01.001 (https://doi.org/10.1016%2Fj.biopsych.2013.01.001).
PMC 3641168 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3641168). PMID 23414821
(https://pubmed.ncbi.nlm.nih.gov/23414821).
99. Skowronski DM, De Serres G (July 2009). "Is routine influenza immunization warranted in
early pregnancy?". Vaccine. 27 (35): 4754–70. doi:10.1016/j.vaccine.2009.03.079 (https://do
i.org/10.1016%2Fj.vaccine.2009.03.079). PMID 19515466 (https://pubmed.ncbi.nlm.nih.gov/
19515466).
100. Fiore AE, Shay DK, Haber P, Iskander JK, Uyeki TM, Mootrey G, Bresee JS, Cox NJ (July
2007). "Prevention and control of influenza. Recommendations of the Advisory Committee
on Immunization Practices (ACIP), 2007" (https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5
606a1.htm). MMWR. Recommendations and Reports. 56 (RR-6): 1–54. PMID 17625497 (htt
ps://pubmed.ncbi.nlm.nih.gov/17625497).
101. Principi, N; Esposito, S (September 2018). "Aluminum in vaccines: Does it create a safety
problem?". Vaccine. 36 (39): 5825–31. doi:10.1016/j.vaccine.2018.08.036 (https://doi.org/10.
1016%2Fj.vaccine.2018.08.036). PMID 30139653 (https://pubmed.ncbi.nlm.nih.gov/301396
53).
102. Baylor NW, Egan W, Richman P (May 2002). "Aluminum salts in vaccines – US
perspective". Vaccine. 20 (Suppl 3): S18–23. doi:10.1016/S0264-410X(02)00166-4 (https://d
oi.org/10.1016%2FS0264-410X%2802%2900166-4). PMID 12184360 (https://pubmed.ncbi.
nlm.nih.gov/12184360).
103. Leslie M (July 2013). "Solution to vaccine mystery starts to crystallize". Science. 341 (6141):
26–27. Bibcode:2013Sci...341...26L (https://ui.adsabs.harvard.edu/abs/2013Sci...341...26L).
doi:10.1126/science.341.6141.26 (https://doi.org/10.1126%2Fscience.341.6141.26).
PMID 23828925 (https://pubmed.ncbi.nlm.nih.gov/23828925).
104. François G, Duclos P, Margolis H, et al. (November 2005). "Vaccine safety controversies and
the future of vaccination programs". The Pediatric Infectious Disease Journal. 24 (11): 953–
61. doi:10.1097/01.inf.0000183853.16113.a6 (https://doi.org/10.1097%2F01.inf.000018385
3.16113.a6). PMID 16282928 (https://pubmed.ncbi.nlm.nih.gov/16282928).
S2CID 10484014 (https://api.semanticscholar.org/CorpusID:10484014).
105. "Vaccine Ingredients" (http://vk.ovg.ox.ac.uk/vaccine-ingredients#aluminium). Vaccine
Knowledge Project. Centre for Clinical Vaccinology and Tropical Medicine, Churchill
Hospital, University of Oxford.
106. "Common Ingredients Used in U.S. Licensed Vaccines" (https://www.fda.gov/vaccines-blood
-biologics/safety-availability-biologics/common-ingredients-us-licensed-vaccines). fda.gov.
U.S. Food and Drug Administration. April 19, 2019.
107. "Vaccine Ingredients-Formaldehyde" (https://www.chop.edu/centers-programs/vaccine-educ
ation-center/vaccine-ingredients/formaldehyde). chop.edu/. Children's Hospital of
Philadelphia. November 6, 2014.
108. "Vaccine Ingredients" (https://www.vaccines.gov/basics/vaccine_ingredients). vaccines.gov/.
U.S. Department of Health and Human Services. April 26, 2021.
109. Moon, RY; Task Force on Sudden Infant Death Syndrome (November 2016). "SIDS and
Other Sleep-Related Infant Deaths: Evidence Base for 2016 Updated Recommendations for
a Safe Infant Sleeping Environment" (https://pediatrics.aappublications.org/content/138/5/e2
0162940.long). Pediatrics. 138 (5): e20162940. doi:10.1542/peds.2016-2940 (https://doi.org/
10.1542%2Fpeds.2016-2940). PMID 27940805
(https://pubmed.ncbi.nlm.nih.gov/27940805).
110. Task Force on Sudden Infant Death Syndrome (November 2016). "SIDS and Other Sleep-
Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping
Environment" (https://pediatrics.aappublications.org/content/138/5/e20162938.long).
Pediatrics. 138 (5): e20162938. doi:10.1542/peds.2016-2938 (https://doi.org/10.1542%2Fpe
ds.2016-2938). PMID 27940804 (https://pubmed.ncbi.nlm.nih.gov/27940804). Retrieved
December 13, 2019.
111. Institute of Medicine (US) Immunization Safety Review Committee; Stratton, K; Almario, DA;
Wizemann, TM; McCormick, MC (2003). Immunization Safety Review: Vaccinations and
Sudden Unexpected Death in Infancy (https://www.ncbi.nlm.nih.gov/books/NBK221466/pdf/
Bookshelf_NBK221466.pdf) (PDF). Washington D.C.: National Academies Press (US).
PMID 25057654 (https://pubmed.ncbi.nlm.nih.gov/25057654). Retrieved December 13,
2019.
112. Vennemann, MM; Höffgen, M; Bajanowski, T; Hense, HW; Mitchell, EA (June 2007). "Do
immunisations reduce the risk for SIDS? A meta-analysis". Vaccine. 25 (26): 4875–79.
doi:10.1016/j.vaccine.2007.02.077 (https://doi.org/10.1016%2Fj.vaccine.2007.02.077).
PMID 17400342 (https://pubmed.ncbi.nlm.nih.gov/17400342).
113. Hausman, Bernice L. (2019). Anti/Vax: Reframing the Vaccination Controversy. Cornell
University Press. pp. 28, 39–42. ISBN 9781501735639.
114. Chatterjee, Archana (2013). Vaccinophobia and Vaccine Controversies of the 21st Century.
Springer Science & Business Media. p. 8. ISBN 9781461474388.
115. Ward JK (June 2016). "Rethinking the antivaccine movement concept: A case study of
public criticism of the swine flu vaccine's safety in France". Social Science & Medicine. 159:
48–57. doi:10.1016/j.socscimed.2016.05.003 (https://doi.org/10.1016%2Fj.socscimed.2016.
05.003). PMID 27173740 (https://pubmed.ncbi.nlm.nih.gov/27173740).
116. Chatterjee, Archana (2013). Vaccinophobia and Vaccine Controversies of the 21st Century.
Springer Science & Business Media. p. 325. ISBN 9781461474388.
117. Mailand, MT; Frederiksen, JL (June 2017). "Vaccines and multiple sclerosis: a systematic
review". Journal of Neurology. 264 (6): 1035–50. doi:10.1007/s00415-016-8263-4 (https://do
i.org/10.1007%2Fs00415-016-8263-4). PMID 27604618 (https://pubmed.ncbi.nlm.nih.gov/27
604618). S2CID 4005599 (https://api.semanticscholar.org/CorpusID:4005599).
118. Rewers, M; Ludvigsson, J (June 2016). "Environmental risk factors for type 1 diabetes" (http
s://www.ncbi.nlm.nih.gov/pmc/articles/PMC5571740). Lancet. 387 (10035): 2340–48.
doi:10.1016/S0140-6736(16)30507-4 (https://doi.org/10.1016%2FS0140-6736%2816%2930
507-4). PMC 5571740 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5571740).
PMID 27302273 (https://pubmed.ncbi.nlm.nih.gov/27302273).
119. Elwood, JM; Ameratunga, R (September 2018). "Autoimmune diseases after hepatitis B
immunization in adults: Literature review and meta-analysis, with reference to
'autoimmune/autoinflammatory syndrome induced by adjuvants' (ASIA)". Vaccine
(Systematic Review & Meta-Analysis). 36 (38): 5796–802.
doi:10.1016/j.vaccine.2018.07.074 (https://doi.org/10.1016%2Fj.vaccine.2018.07.074).
PMID 30100071 (https://pubmed.ncbi.nlm.nih.gov/30100071).
120. Edwards, Kathryn M.; Hackell, Jesse M. (August 29, 2016). "Countering Vaccine Hesitancy"
(https://doi.org/10.1542%2Fpeds.2016-2146). Pediatrics. 138 (3): e20162146.
doi:10.1542/peds.2016-2146 (https://doi.org/10.1542%2Fpeds.2016-2146). PMID 27573088
(https://pubmed.ncbi.nlm.nih.gov/27573088). Lay summary (http://www.aappublications.org/
news/2016/08/29/VaccineHesitancy082916) – AAP News (August 29, 2016).
121. Daniel Freeman (June 16, 2021). "Needle phobia could be the cause of 10% of COVID
vaccine hesitancy in the UK – new research" (https://theconversation.com/needle-phobia-co
uld-be-the-cause-of-10-of-covid-vaccine-hesitancy-in-the-uk-new-research-162678). The
Conversation.
122. Daniel Freeman; Bao Sheng Loe; Ly-Mee Yu; Jason Freeman; Andrew Chadwick; Cristian
Vaccari (May 16, 2021). "Effects of different types of written vaccination information on
COVID-19 vaccine hesitancy in the UK (OCEANS-III): a single-blind, parallel-group,
randomised controlled trial" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8116130). The
Lancet. 6 (6): e416–e427. doi:10.1016/S2468-2667(21)00096-7 (https://doi.org/10.1016%2F
S2468-2667%2821%2900096-7). PMC 8116130 (https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC8116130). PMID 33991482 (https://pubmed.ncbi.nlm.nih.gov/33991482).
123. Amy Baxter m (June 11, 2021). "Over half of adults unvaccinated for COVID-19 fear needles
– here's what's proven to help" (https://theconversation.com/over-half-of-adults-unvaccinated
-for-covid-19-fear-needles-heres-whats-proven-to-help-161636). The Conversation.
124. Clark, Sarah; Cowan, Anne; Filipp, Stephanie; Fisher, Allison; Stokley, Shannon (May 1,
2016). "Understanding Non-Completion of the Human Papillomavirus Vaccine Series:
Parent-Reported Reasons for Why Adolescents Might Not Receive Additional Doses,
United States, 2012" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4869083). Public
Health Reports. 131 (3): 390–395. doi:10.1177/003335491613100304 (https://doi.org/10.117
7%2F003335491613100304). PMC 4869083 (https://www.ncbi.nlm.nih.gov/pmc/articles/PM
C4869083). PMID 27252558 (https://pubmed.ncbi.nlm.nih.gov/27252558).
125. Holly Seale; Jessica Kaufman (April 8, 2021). "Pictures of COVID injections can scare the
pants off people with needle phobias. Use these instead" (https://theconversation.com/pictur
es-of-covid-injections-can-scare-the-pants-off-people-with-needle-phobias-use-these-instea
d-157963). The Conversation.
126. Vasso Apostolopoulos; Maja Husaric; Maximilian de Courten (September 30, 2020). "A
COVID-19 vaccine may come without a needle, the latest vaccine to protect without jabbing"
(https://theconversation.com/a-covid-19-vaccine-may-come-without-a-needle-the-latest-vacc
ine-to-protect-without-jabbing-146564). The Conversation.
127. Kennedy, Jonathan (October 2017). "How Drone Strikes and a Fake Vaccination Program
Have Inhibited Polio Eradication in Pakistan: An Analysis of National Level Data" (http://qmr
o.qmul.ac.uk/xmlui/handle/123456789/25135). International Journal of Health Services:
Planning, Administration, Evaluation. 47 (4): 807–25. doi:10.1177/0020731417722888 (http
s://doi.org/10.1177%2F0020731417722888). ISSN 1541-4469 (https://www.worldcat.org/iss
n/1541-4469). PMID 28764582 (https://pubmed.ncbi.nlm.nih.gov/28764582).
S2CID 25844860 (https://api.semanticscholar.org/CorpusID:25844860).
128. Jr, Donald G. McNeil (July 9, 2012). "C.I.A. Vaccine Ruse May Have Harmed the War on
Polio" (https://www.nytimes.com/2012/07/10/health/cia-vaccine-ruse-in-pakistan-may-have-h
armed-polio-fight.html). The New York Times. ISSN 0362-4331 (https://www.worldcat.org/iss
n/0362-4331). Retrieved July 3, 2020.
129. Aizenman, Nurith (January 23, 2018). "Pakistan Raises Its Guard After 2 Polio Vaccinators
Are Gunned Down" (https://www.npr.org/sections/goatsandsoda/2018/01/23/580002283/pak
istan-raises-its-guard-after-two-polio-vaccinators-are-gunned-down). NPR.
130. "Seven shot dead in Pakistan polio attack" (https://www.bbc.com/news/world-asia-3609089
1). BBC News. April 20, 2016 – via bbc.com.
131. Kumar, Hari (July 4, 2021). "Indian police investigate whether scammers gave thousands of
shots of salt water instead of vaccine" (https://www.nytimes.com/2021/07/04/world/asia/india
-covid-vaccine-scam.html). The New York Times. ISSN 0362-4331 (https://www.worldcat.or
g/issn/0362-4331). Retrieved July 7, 2021.
132. "Thousands Given Fake Vaccines Through Scam In India" (https://www.npr.org/2021/07/09/
1014512227/thousands-given-fake-vaccines-through-scam-in-india). NPR.org. Retrieved
July 10, 2021.
133. "India: Fake vaccines undermine fight against COVID | DW | 01.07.2021" (https://www.dw.co
m/en/india-fake-vaccines-undermine-fight-against-covid/a-58122010). Deutsche Welle.
Retrieved July 10, 2021.
134. Esha Mitra and Julia Hollingsworth. "More than a dozen slum residents in an Indian city say
they didn't know they were part of a clinical vaccine trial" (https://www.cnn.com/2021/02/25/a
sia/india-vaccine-trials-covid-ethics-intl-dst-hnk/index.html). CNN. Retrieved July 11, 2021.
135. Bhuyan, Anoo (January 14, 2021). "How Covaxin Trial Participants in Bhopal Were Misled"
(https://science.thewire.in/health/peoples-hospital-bhopal-covaxin-clinical-trials-exploitation-
ethics-ground-report/). The Wire Science. Retrieved July 11, 2021.
136. Dezimey Kum (December 28, 2020). "Fueled by a History of Mistreatment, Black Americans
Distrust the New COVID-19 Vaccines" (https://time.com/5925074/black-americans-covid-19-
vaccine-distrust/). Time.
137. Taylor, Luke E.; Swerdfeger, Amy L.; Eslick, Guy D. (June 17, 2014). "Vaccines are not
associated with autism: an evidence-based meta-analysis of case-control and cohort
studies". Vaccine. 32 (29): 3623–29. doi:10.1016/j.vaccine.2014.04.085 (https://doi.org/10.10
16%2Fj.vaccine.2014.04.085). ISSN 1873-2518 (https://www.worldcat.org/issn/1873-2518).
PMID 24814559 (https://pubmed.ncbi.nlm.nih.gov/24814559).
138. Smith, IM; MacDonald, NE (August 2017). "Countering evidence denial and the promotion of
pseudoscience in autism spectrum disorder". Autism Research (Review). 10 (8): 1334–37.
doi:10.1002/aur.1810 (https://doi.org/10.1002%2Faur.1810). PMID 28544626 (https://pubme
d.ncbi.nlm.nih.gov/28544626). S2CID 205456548 (https://api.semanticscholar.org/CorpusID:
205456548).
139. Boseley S (February 2, 2010). "Lancet retracts 'utterly false' MMR paper" (https://www.thegu
ardian.com/society/2010/feb/02/lancet-retracts-mmr-paper). The Guardian. Retrieved
February 2, 2010.
140. Taylor LE, Swerdfeger AL, Eslick GD (June 2014). "Vaccines are not associated with autism:
an evidence-based meta-analysis of case-control and cohort studies". Vaccine. 32 (29):
3623–29. doi:10.1016/j.vaccine.2014.04.085 (https://doi.org/10.1016%2Fj.vaccine.2014.04.
085). PMID 24814559 (https://pubmed.ncbi.nlm.nih.gov/24814559).
141. "Vaccines Do Not Cause Autism Concerns" (https://www.cdc.gov/vaccinesafety/concerns/au
tism.html). Centers for Disease Control and Prevention. December 12, 2018. Retrieved
February 7, 2019.
142. "How autism myths came to fuel anti-vaccination movements" (https://www.popsci.com/timeli
ne-autism-myth-anti-vaccine). Popular Science. February 2019.
143. Foster, Craig A.; Ortiz, Sarenna M. (2017). "Vaccines, Autism, and the Promotion of
Irrelevant Research: A Science-Pseudoscience Analysis" (https://web.archive.org/web/2018
1006204019/https://www.csicop.org/si/show/vaccines_autism_and_the_promotion_of_irrele
vant_research_a_science-pseudosc). Skeptical Inquirer. 41 (3): 44–48. Archived from the
original (https://www.csicop.org/si/show/vaccines_autism_and_the_promotion_of_irrelevant
_research_a_science-pseudosc) on October 6, 2018. Retrieved October 6, 2018.
144. Shivkumar, Maitreyi (October 20, 2020). "A vaccine can provide better immunity than an
actual infection. Here's why" (https://edition.cnn.com/2020/10/02/health/vaccine-better-immu
nity-than-infection-wellness-partner/index.html). CNN. "For instance, the human
papillomavirus (HPV) vaccine elicits a stronger immune response than infection by the virus
itself. One reason for this is that the vaccine contains high concentrations of a viral coat
protein, more than what would occur in a natural infection. This triggers strongly neutralizing
antibodies, making the vaccine very effective at preventing infection. The natural immunity
against HPV is especially weak, as the virus uses various tactics to evade the host immune
system. Many viruses, including HPV, have proteins that block the immune response or
simply lie low to avoid detection. Indeed, a vaccine that provides accessible antigens in the
absence of these other proteins may allow us to control the response in a way that a natural
infection does not."
145. Centers for Disease Control (CDC) (May 1982). "Recommendation of the Immunization
Practices Advisory Committee (ACIP). Measles prevention" (https://www.cdc.gov/mmwr/prev
iew/mmwrhtml/00001090.htm). MMWR. Morbidity and Mortality Weekly Report. 31 (17):
217–24, 229–31. PMID 6804783 (https://pubmed.ncbi.nlm.nih.gov/6804783).
146. "Measles Complications" (https://www.cdc.gov/measles/about/complications.html). Centers
for Disease Control and Prevention (CDC). February 25, 2019. Retrieved May 14, 2019.
147. Di Pietrantonj, C; Rivetti, A; Marchione, P; Debalini, MG; Demicheli, V (April 2020).
"Vaccines for measles, mumps, rubella, and varicella in children" (https://www.ncbi.nlm.nih.g
ov/pmc/articles/PMC7169657). Cochrane Database of Systematic Reviews. 4: CD004407.
doi:10.1002/14651858.CD004407.pub4 (https://doi.org/10.1002%2F14651858.CD004407.p
ub4). PMC 7169657 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7169657).
PMID 32309885 (https://pubmed.ncbi.nlm.nih.gov/32309885).
148. Cohen BE, Durstenfeld A, Roehm PC (July 2014). "Viral causes of hearing loss: a review for
hearing health professionals" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4222184).
Trends in Hearing. 18: 2331216514541361. doi:10.1177/2331216514541361 (https://doi.or
g/10.1177%2F2331216514541361). PMC 4222184 (https://www.ncbi.nlm.nih.gov/pmc/articl
es/PMC4222184). PMID 25080364 (https://pubmed.ncbi.nlm.nih.gov/25080364).
149. Noyce RS, Richardson CD (September 2012). "Nectin 4 is the epithelial cell receptor for
measles virus". Trends in Microbiology. 20 (9): 429–39. doi:10.1016/j.tim.2012.05.006 (http
s://doi.org/10.1016%2Fj.tim.2012.05.006). PMID 22721863 (https://pubmed.ncbi.nlm.nih.go
v/22721863).
150. "NINDS Subacute Sclerosing Panencephalitis Information Page" (http://www.ninds.nih.gov/
disorders/subacute_panencephalitis/subacute_panencephalitis.htm). Archived (https://web.
archive.org/web/20141017073411/http://www.ninds.nih.gov/disorders/subacute_panenceph
alitis/subacute_panencephalitis.htm) from the original on October 17, 2014. Retrieved
March 26, 2018. "NINDS Subacute Sclerosing Panencephalitis Information Page"
151. 14-193b. (http://www.merck.com/mmpe/sec14/ch193/ch193b.html) at Merck Manual of
Diagnosis and Therapy Professional Edition
152. GRIFFIN, ASHLEY HAGEN (May 18, 2019). "Measles and Immune Amnesia" (https://asm.or
g/Articles/2019/May/Measles-and-Immune-Amnesia). asm.org. American Society for
Microbiology. Archived (https://archive.today/20200118042959/https://asm.org/Articles/2019/
May/Measles-and-Immune-Amnesia) from the original on January 18, 2020. Retrieved
January 18, 2020.
153. Mina MJ, Kula T, Leng Y, Li M, de Vries RD, Knip M, et al. (November 1, 2019). "Measles
virus infection diminishes preexisting antibodies that offer protection from other pathogens"
(https://doi.org/10.1126%2Fscience.aay6485). Science. 366 (6465): 599–606.
Bibcode:2019Sci...366..599M (https://ui.adsabs.harvard.edu/abs/2019Sci...366..599M).
doi:10.1126/science.aay6485 (https://doi.org/10.1126%2Fscience.aay6485). ISSN 0036-
8075 (https://www.worldcat.org/issn/0036-8075). PMID 31672891 (https://pubmed.ncbi.nlm.n
ih.gov/31672891). Lay summary (https://www.nytimes.com/2019/10/31/health/measles-vacci
ne-immune-system.html).
154. Guglielmi, Giorgia (October 31, 2019). "Measles erases immune 'memory' for other
diseases" (https://www.nature.com/articles/d41586-019-03324-7). Nature.
doi:10.1038/d41586-019-03324-7 (https://doi.org/10.1038%2Fd41586-019-03324-7).
PMID 33122832 (https://pubmed.ncbi.nlm.nih.gov/33122832). S2CID 208489179 (https://ap
i.semanticscholar.org/CorpusID:208489179). Retrieved November 3, 2019.
155. Mina MJ, Metcalf CJ, de Swart RL, Osterhaus AD, Grenfell BT (May 2015). "Long-term
measles-induced immunomodulation increases overall childhood infectious disease
mortality" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4823017). Science. 348 (6235):
694–9. Bibcode:2015Sci...348..694M (https://ui.adsabs.harvard.edu/abs/2015Sci...348..694
M). doi:10.1126/science.aaa3662 (https://doi.org/10.1126%2Fscience.aaa3662).
PMC 4823017 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4823017). PMID 25954009
(https://pubmed.ncbi.nlm.nih.gov/25954009). Lay summary (http://well.blogs.nytimes.com/20
15/05/07/measles-may-increase-susceptibility-to-other-infections).
156. Gangarosa EJ, Galazka AM, Wolfe CR, Phillips LM, Gangarosa RE, Miller E, Chen RT
(January 1998). "Impact of anti-vaccine movements on pertussis control: the untold story".
Lancet. 351 (9099): 356–61. doi:10.1016/S0140-6736(97)04334-1 (https://doi.org/10.1016%
2FS0140-6736%2897%2904334-1). PMID 9652634 (https://pubmed.ncbi.nlm.nih.gov/96526
34). S2CID 35969647 (https://api.semanticscholar.org/CorpusID:35969647).
157. Allen A (2002). "Bucking the herd" (http://immunize.org/exemptions/allen.htm). The Atlantic.
290 (2): 40–42. Retrieved November 7, 2007.
158. "What would happen if we stopped vaccinations?" (https://www.cdc.gov/vaccines/vac-gen/w
hatifstop.htm). Centers for Disease Control and Prevention. June 12, 2007. Retrieved
April 25, 2008.
159. Centers for Disease Control and Prevention (2007). "Pertussis" (https://www.cdc.gov/vaccin
es/pubs/pinkbook/downloads/pert.pdf) (PDF). In Atkinson W, Hamborsky J, McIntyre L,
Wolfe S (eds.). Epidemiology and Prevention of Vaccine-Preventable Diseases.
Washington, DC: Public Health Foundation. ISBN 978-0-01-706605-3.
160. Nelson MC, Rogers J (December 1992). "The right to die? Anti-vaccination activity and the
1874 smallpox epidemic in Stockholm". Social History of Medicine. 5 (3): 369–88.
doi:10.1093/shm/5.3.369 (https://doi.org/10.1093%2Fshm%2F5.3.369). PMID 11645870 (htt
ps://pubmed.ncbi.nlm.nih.gov/11645870).
161. Centers for Disease Control and Prevention (April 2000). "Measles outbreak – Netherlands,
April 1999 – January 2000" (https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4914a2.htm).
Morbidity and Mortality Weekly Report. 49 (14): 299–303. PMID 10825086 (https://pubmed.n
cbi.nlm.nih.gov/10825086).
162. Pepys MB (December 2007). "Science and serendipity" (https://www.ncbi.nlm.nih.gov/pmc/a
rticles/PMC4954362). Clinical Medicine. 7 (6): 562–78. doi:10.7861/clinmedicine.7-6-562 (ht
tps://doi.org/10.7861%2Fclinmedicine.7-6-562). PMC 4954362 (https://www.ncbi.nlm.nih.go
v/pmc/articles/PMC4954362). PMID 18193704 (https://pubmed.ncbi.nlm.nih.gov/18193704).
163. Ireland measles outbreak:
"Measles outbreak feared" (http://news.bbc.co.uk/2/hi/health/769381.stm). BBC News.
May 30, 2000.
McBrien J, Murphy J, Gill D, Cronin M, O'Donovan C, Cafferkey MT (July 2003).
"Measles outbreak in Dublin, 2000". The Pediatric Infectious Disease Journal. 22 (7):
580–84. doi:10.1097/00006454-200307000-00002 (https://doi.org/10.1097%2F0000645
4-200307000-00002). PMID 12867830 (https://pubmed.ncbi.nlm.nih.gov/12867830).
164. Clements, Christopher; Greenough, Paul; Shull, Diana (January 1, 2006). "How Vaccine
Safety can Become Political – The Example of Polio in Nigeria". Current Drug Safety. 1 (1):
117–19. doi:10.2174/157488606775252575 (https://doi.org/10.2174%2F157488606775252
575). PMID 18690921 (https://pubmed.ncbi.nlm.nih.gov/18690921).
165. Public Health Nigeria (October 2018). "Challenges of Immunization in Nigeria" (https://public
healthng.com/immunization-nigeria-challenges-benefits-prevention/). PublichealthNg.com.
Retrieved October 28, 2018.
166. "Wild poliovirus 2000–2008" (https://web.archive.org/web/20070927204139/http://www.polio
eradication.org/content/general/casecount.pdf) (PDF). Global Polio Eradication Initiative.
February 5, 2008. Archived from the original (http://www.polioeradication.org/content/genera
l/casecount.pdf) (PDF) on September 27, 2007. Retrieved February 11, 2008.
167. " 'Hundreds' dead in measles outbreak" (http://irinnews.org/Report.aspx?ReportId=75883).
IRIN. December 14, 2007. Retrieved February 10, 2008.
168. "Frequently Asked Questions about Measles in U.S" (https://www.cdc.gov/measles/about/fa
qs.html). Centers for Disease Control and Prevention. August 28, 2018.
169. Parker AA, Staggs W, Dayan GH, Ortega-Sánchez IR, Rota PA, Lowe L, Boardman P,
Teclaw R, Graves C, LeBaron CW (August 2006). "Implications of a 2005 measles outbreak
in Indiana for sustained elimination of measles in the United States" (https://semanticscholar.
org/paper/9b464d9d3d2dd10d3590a905e7db409843946a12). The New England Journal of
Medicine. 355 (5): 447–55. doi:10.1056/NEJMoa060775 (https://doi.org/10.1056%2FNEJMo
a060775). PMID 16885548 (https://pubmed.ncbi.nlm.nih.gov/16885548). S2CID 34529542
(https://api.semanticscholar.org/CorpusID:34529542).
170. Jaslow, Ryan (September 12, 2013). "CDC: Vaccine "philosophical differences" driving up
U.S. measles rates" (https://www.cbsnews.com/8301-204_162-57602677/cdc-vaccine-philo
sophical-differences-driving-up-u.s-measles-rates/). CBS News. Retrieved September 19,
2013.
171. Centers for Disease Control Prevention (CDC) (September 2013). "National, state, and local
area vaccination coverage among children aged 19–35 months – United States, 2012" (http
s://www.cdc.gov/mmwr/preview/mmwrhtml/mm6236a1.htm). Morbidity and Mortality Weekly
Report. 62 (36): 733–40. PMC 4585572 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC458
5572). PMID 24025754 (https://pubmed.ncbi.nlm.nih.gov/24025754).
172. Rañoa R, Zarracina J (January 15, 2015). "The spread of Disneyland measles outbreak" (htt
ps://www.latimes.com/visuals/graphics/la-me-g-spread-of-disneyland-measles-outbreak-201
50113-htmlstory.html). Los Angeles Times.
173. Glenza J (January 19, 2015). "Measles outbreak worsens in US after unvaccinated woman
visits Disneyland" (https://www.theguardian.com/us-news/2015/jan/14/measles-outbreak-spr
eads-unvaccinated-woman-disneyland). The Guardian. Retrieved June 1, 2015.
174. Gastañaduy PA, Redd SB, Fiebelkorn AP, Rota JS, Rota PA, Bellini WJ, Seward JF,
Wallace GS (June 2014). "Measles – United States, January 1 – May 23, 2014" (https://www.
cdc.gov/mmwr/preview/mmwrhtml/mm6322a4.htm?s_cid=mm6322a4_w). Morbidity and
Mortality Weekly Report. 63 (22): 496–99. PMC 5779360 (https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC5779360). PMID 24898167 (https://pubmed.ncbi.nlm.nih.gov/24898167).
175. CDC (June 30, 2015). "Measles Cases and Outbreaks" (https://www.cdc.gov/measles/cases
-outbreaks.html). Retrieved July 2, 2015.
176. Press Release (July 2, 2015). "Measles led to death of Clallam Co. woman; first in US in a
dozen years" (http://www.doh.wa.gov/Newsroom/2015NewsReleases/15119WAMeaslesRel
atedDeath). Washington Department of Health.
177. Arizona measles outbreak: immigration workers blamed for refusing vaccines (https://www.th
eguardian.com/us-news/2016/jul/08/arizona-measles-outbreak-immigration-detention-worke
rs), The Guardian, July 8, 2016. Retrieved March 10, 2019.
178. "Measles – Minnesota Dept. of Health" (http://www.health.state.mn.us/divs/idepc/diseases/m
easles/). Health.state.mn.us.
179. Sun LH (June 1, 2017). "Measles outbreak in Minnesota surpasses last year's total for the
entire country" (https://www.washingtonpost.com/national/health-science/imams-in-us-take-o
n-the-anti-vaccine-movement-during-ramadan/2017/05/26/8660edc6-41ad-11e7-8c25-44d0
9ff5a4a8_story.html). The Washington Post.
180. Howard J (May 8, 2017). "Anti-vaccine groups blamed in Minnesota measles outbreak" (htt
p://www.cnn.com/2017/05/08/health/measles-minnesota-somali-anti-vaccine-bn/index.html).
CNN. Retrieved May 26, 2017.
181. "Minnesota measles outbreak follows anti-vaccination campaign" (https://www.newscientist.
com/article/mg23431253-200-minnesota-measles-outbreak-follows-antivaccination-campaig
n/). New Scientist (3125) (published May 13, 2017). May 10, 2017. Retrieved May 26, 2017.
182. Zdechlik M (May 3, 2017). "Unfounded Autism Fears Are Fueling Minnesota's Measles
Outbreak" (https://www.npr.org/sections/health-shots/2017/05/03/526723028/autism-fears-fu
eling-minnesotas-measles-outbreak). NPR.org. Retrieved May 26, 2017.
183. Howard J. "Anti-vaccine groups blamed in Minnesota measles outbreak" (https://edition.cnn.
com/2017/05/08/health/measles-minnesota-somali-anti-vaccine-bn/index.html). CNN.
Retrieved November 13, 2018.
184. Sohn E (May 3, 2017). "Understanding The History Behind Communities' Vaccine Fears" (ht
tps://www.npr.org/sections/health-shots/2017/05/03/526595475/understanding-the-history-b
ehind-communities-vaccine-fears). NPR. Retrieved February 15, 2019.
185. Dyer, Owen (May 16, 2017). "Measles outbreak in Somali American community follows anti-
vaccine talks". BMJ. 357: j2378. doi:10.1136/bmj.j2378 (https://doi.org/10.1136%2Fbmj.j237
8). PMID 28512183 (https://pubmed.ncbi.nlm.nih.gov/28512183). S2CID 27124692 (https://a
pi.semanticscholar.org/CorpusID:27124692).
186. Sun, Lena H. (May 5, 2017). "Anti-vaccine activists spark a state's worst measles outbreak in
decades" (https://www.washingtonpost.com/national/health-science/anti-vaccine-activists-sp
ark-a-states-worst-measles-outbreak-in-decades/2017/05/04/a1fac952-2f39-11e7-9dec-764
dc781686f_story.html). The Washington Post. Retrieved February 17, 2019.
187. Otterman S (January 17, 2019). "New York Confronts Its Worst Measles Outbreak in
Decades" (https://www.nytimes.com/2019/01/17/nyregion/measles-outbreak-jews-nyc.html).
The New York Times. ISSN 0362-4331 (https://www.worldcat.org/issn/0362-4331).
Retrieved January 19, 2019.
188. Howard J (January 8, 2019). "NY tackles 'largest measles outbreak' in state's recent history"
(https://www.cnn.com/2019/01/08/health/measles-outbreak-ny-bn/index.html). CNN.
Retrieved January 19, 2019.
189. Goldstein-Street, Jake (January 28, 2019). "Amid measles outbreak, legislation proposed to
ban vaccine exemptions" (https://www.seattletimes.com/seattle-news/amid-measles-outbrea
k-legislation-proposed-to-ban-vaccine-exemptions/). The Seattle Times. Retrieved
January 28, 2019.
190. "Washington state is averaging more than one measles case per day in 2019" (https://www.n
bcnews.com/storyline/measles-outbreak/measles-outbreak-southwestern-washington-rises-
50-cases-n966751). NBC News.
191. "Amid Measles Outbreak, Anti-Vaxx Parents Have Put Others' Babies At Risk" (https://www.
msn.com/en-ph/lifestyle/family/amid-measles-outbreak-anti-vaxx-parents-have-put-others-e2
-80-99-babies-at-risk/ar-BBTbIBq). MSN.
192. Belluz, Julia (January 27, 2019). "Washington declared a public health emergency over
measles. Thank vaccine-refusing parents" (https://www.vox.com/2019/1/27/18199514/measl
es-outbreak-2018-clark-county-washington). Vox.
193. " "Dangerous" anti-vaxx warning issued by Washington officials as cases in measles
outbreak continue to rise" (https://www.newsweek.com/dangerous-anti-vaxx-warning-issued
-washington-officials-cases-measles-1306997). Newsweek. January 28, 2019.
194. "Public health emergency declared over measles in anti-vax hotspot near Portland, Oregon"
(https://www.cbsnews.com/news/measles-outbreak-public-health-emergency-declared-in-an
ti-vax-hotspot-near-portland-oregon-clark-county-washington/). Cbsnews.com. Retrieved
February 5, 2019.
195. "Swansea measles epidemic officially over" (https://www.bbc.com/news/uk-wales-2316851
9). BBC News. July 3, 2013. Retrieved October 8, 2014. "Large numbers of children in the
10–18 age group were not given the MMR vaccine as babies, the result of a scare that
caused panic among parents. It followed research by Dr. Andrew Wakefield in the late 1990s
that linked the vaccine with autism and bowel disease. His report, which was published in
The Lancet medical journal, was later discredited, with health officials insisting the vaccine
was completely safe."
196. "Swansea measles epidemic: Worries over MMR uptake after outbreak" (https://www.bbc.co
m/news/uk-wales-politics-23244628). BBC News. July 10, 2013. Retrieved October 8, 2014.
197. "600 children get MMR jab after measles outbreak in Newport" (https://www.bbc.co.uk/news/
uk-wales-south-east-wales-40366937). BBC News. BBC. June 22, 2017.
198. Fair E, Murphy TV, Golaz A, Wharton M (January 2002). "Philosophic objection to
vaccination as a risk for tetanus among children younger than 15 years" (https://doi.org/10.1
542%2Fpeds.109.1.e2). Pediatrics. 109 (1): E2. doi:10.1542/peds.109.1.e2 (https://doi.org/1
0.1542%2Fpeds.109.1.e2). PMID 11773570 (https://pubmed.ncbi.nlm.nih.gov/11773570).
199. An unvaccinated child contracted tetanus. It took two months and more than $800K to save
him. (https://www.washingtonpost.com/health/2019/03/08/an-unvaccinated-child-contracted-t
etanus-it-took-two-months-more-than-k-save-him/), Washington Post, Amy Wang, March 8,
2019. Retrieved March 10, 2019.
200. Unvaccinated boy nearly died from tetanus. The cost of his care was almost $1 million. (http
s://www.nbcnews.com/health/kids-health/unvaccinated-boy-almost-died-tetanus-hospital-bill
-was-more-800-n981256), NBC News, Linda Carroll, March 8, 2019. Retrieved March 10,
2019.
201. Ovidiu Covaciu (November 5, 2017). "How the Romanian anti-vaccine movement threatens
Europe" (https://ghostarchive.org/varchive/youtube/20211030/wFpAiHCQ85g). European
Skeptics Congress. European Council of Skeptical Organisations. Archived from the original
(https://www.youtube.com/watch?v=wFpAiHCQ85g) on October 30, 2021. Retrieved
November 6, 2017.
202. "Centrul Național de Supraveghere şi Control al Bolilor Transmisibile – Informări
săptămanale" (http://www.cnscbt.ro/index.php/informari-saptamanale/rujeola-1/1143-situatia
-rujeolei-in-romania-la-data-de-01-03-2019). cnscbt.ro. Retrieved March 7, 2019.
203. "Australia – Oceania :: Samoa – The World Factbook" (https://www.cia.gov/the-world-factbo
ok/countries/samoa/). cia.gov – Central Intelligence Agency (July 2018 est.). Retrieved
December 6, 2019.
204. "Measles death toll rises to 68 in Samoa" (https://www.rnz.co.nz/international/pacific-news/4
05090/measles-death-toll-rises-to-68-in-samoa). RNZ. December 8, 2019. Retrieved
December 8, 2019.
205. "Latest update: 4,357 measles cases have been reported since the outbreak with 140
recorded in the last 24 hours. mainly children under four years old" (https://twitter.com/samoa
govt/status/1202707973048418304).
206. Beat, Pacific (November 26, 2019). "Samoa makes measles vaccinations compulsory after
outbreak kills 32" (https://www.abc.net.au/news/2019-11-26/samoa-measles-emergency-clai
ms-32-lives-as-death-toll-rises/11738138). ABC News. Retrieved November 26, 2019.
207. "Samoa declares state of emergency over deadly measles outbreak" (https://www.abc.net.a
u/news/2019-11-17/samoa-declares-state-of-emergency-over-measles-outbreak/11711576).
ABC News. November 17, 2019. Retrieved November 26, 2019.
208. "Samoa measles outbreak worsens" (https://www.bbc.com/news/world-asia-50528834).
November 23, 2019. Retrieved November 26, 2019.
209. France-Presse, Agence (November 28, 2019). "Samoa measles outbreak: WHO blames
anti-vaccine scare as death toll hits 39" (https://www.theguardian.com/world/2019/nov/28/sa
moa-measles-outbreak-who-blames-anti-vaccine-scare-death-toll). The Guardian. Retrieved
November 30, 2019.
210. Beat, Pacific (August 2, 2019). " 'Her body was turning black': Samoan nurses jailed for
infant vaccination deaths" (https://www.abc.net.au/news/2019-08-02/samoa-nurses-sentenc
ed-manslaughter-infant-vaccination-deaths/11378494). ABC News. Retrieved
November 29, 2019.
211. Dubé, E; Gagnon, D; MacDonald, NE; SAGE Working Group on Vaccine Hesitancy. (August
2015). "Strategies intended to address vaccine hesitancy: Review of published reviews" (htt
ps://doi.org/10.1016%2Fj.vaccine.2015.04.041). Vaccine (Review). 33 (34): 4191–4203.
doi:10.1016/j.vaccine.2015.04.041 (https://doi.org/10.1016%2Fj.vaccine.2015.04.041).
PMID 25896385 (https://pubmed.ncbi.nlm.nih.gov/25896385).
212. Brelsford, D; Knutzen, E; Neher, JO; Safranek, S (December 2017). "Clinical Inquiries:
Which interventions are effective in managing parental vaccine refusal?" (https://mdedge-file
s-live.s3.us-east-2.amazonaws.com/files/s3fs-public/Document/November-2017/JFP06612e
12.PDF) (PDF). Journal of Family Practice. 66 (12): E12-14. PMID 29202149 (https://pubme
d.ncbi.nlm.nih.gov/29202149).
213. Jarrett, C; Wilson, R; O'Leary, M; Eckersberger, E; Larson, HJ; SAGE Working Group on
Vaccine Hesitancy. (August 2015). "Strategies for addressing vaccine hesitancy – A
systematic review" (https://zenodo.org/record/1009492). Vaccine. 33 (34): 4180–90.
doi:10.1016/j.vaccine.2015.04.040 (https://doi.org/10.1016%2Fj.vaccine.2015.04.040).
PMID 25896377 (https://pubmed.ncbi.nlm.nih.gov/25896377).
214. How to respond to vocal vaccine deniers in public: World Health Organization (2016).
https://www.who.int/immunization/sage/meetings/2016/october/8_Best-practice-guidance-
respond-vocal-vaccine-deniers-public.pdf
215. McKenzie, Peter (January 24, 2021). "Covid-19: Doctor using comics to confront vaccine
conspiracy theories" (https://www.stuff.co.nz/national/health/300212725/covid19-doctor-usin
g-comics-to-confront-vaccine-conspiracy-theories). Stuff (New Zealand). Retrieved
March 23, 2021.
216. "Provider Resources for Vaccine Conversations with Parents" (https://www.cdc.gov/vaccine
s/hcp/conversations/index.html). cdc.gov. Centers for Disease Control and Prevention. May
28, 2019.
217. Kenen, Joanne (March 8, 2021). "Vaccine-skeptical Trump country poses challenge to
immunization push" (https://www.politico.com/news/2021/03/08/coronavirus-vaccine-rural-a
merica-473940). Politico.
218. Jamison, A.M.; Broniatowski, D. A.; Dredze, M. (November 13, 2019). "Vaccine-related
advertising in the Facebook Ad Archive" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC695
4281). Vaccine. 38 (3): 512–20. doi:10.1016/j.vaccine.2019.10.066 (https://doi.org/10.1016%
2Fj.vaccine.2019.10.066). PMC 6954281 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC69
54281). PMID 31732327 (https://pubmed.ncbi.nlm.nih.gov/31732327).
219. Sun, Lena H. (November 15, 2019). "Majority of anti-vaccine ads on Facebook were funded
by two groups" (https://www.washingtonpost.com/health/2019/11/15/majority-anti-vaccine-ad
s-facebook-were-funded-by-two-groups/). The Washington Post. Archived (https://web.archiv
e.org/web/20191117003403/https://www.washingtonpost.com/health/2019/11/15/majority-an
ti-vaccine-ads-facebook-were-funded-by-two-groups/) from the original on November 17,
2019. Retrieved November 16, 2019.
220. "Politicians in the Philippines are holding raffles to boost vaccination" (https://www.economi
st.com/asia/2021/06/12/politicians-in-the-philippines-are-holding-raffles-to-boost-vaccinatio
n). The Economist. June 12, 2021.
221. "Win a cow, avoid COVID: Philippines tempts vaccine hesitant" (https://www.aljazeera.com/
news/2021/6/14/win-a-cow-avoid-covid-philippines-tempts-vaccine-hesitant). Al Jazeera.
June 14, 2021.
222. Tanya Lewis (June 17, 2021). "From $1-Million Lotteries to Free Beer: Do COVID
Vaccination Incentives Work?" (https://www.scientificamerican.com/article/from-1-million-lott
eries-to-free-beer-do-covid-vaccination-incentives-work/). Scientific American.
223. ZEN SOO (June 17, 2021). "Get a jab, win a condo: Hong Kong tries vaccine incentives" (htt
ps://abcnews.go.com/Health/wireStory/jab-win-condo-hong-kong-vaccine-incentives-78330
532). ABC News.
224. Ben Farmer (June 8, 2021). " 'Joints for jabs': US state offers free cannabis as vaccine
incentive" (https://www.telegraph.co.uk/global-health/science-and-disease/joints-jabs-washi
ngton-state-allows-free-cannabis-covid-19-vaccination/). The Telegraph.
225. Hull, Brynley P; Beard, Frank H; Hendry, Alexandra J; Dey, Aditi; Macartney, Kristine (2020).
" "No jab, no pay": catch‐up vaccination activity during its first two years" (https://www.ncbi.nl
m.nih.gov/pmc/articles/PMC7692886). Med J Aust. 213 (8): 364–369.
doi:10.5694/mja2.50780 (https://doi.org/10.5694%2Fmja2.50780). PMC 7692886 (https://ww
w.ncbi.nlm.nih.gov/pmc/articles/PMC7692886). PMID 32951230 (https://pubmed.ncbi.nlm.ni
h.gov/32951230).
226. Li, Ang.; Toll, Mathew. (2020). "Removing conscientious objection: The impact of 'No Jab No
Pay' and 'No Jab No Play' vaccine policies in Australia" (https://www.sciencedirect.com/scie
nce/article/abs/pii/S0091743520304370). Preventive Medicine. 145: 106406.
doi:10.1016/j.ypmed.2020.106406 (https://doi.org/10.1016%2Fj.ypmed.2020.106406).
PMID 33388333 (https://pubmed.ncbi.nlm.nih.gov/33388333). S2CID 230489130 (https://ap
i.semanticscholar.org/CorpusID:230489130).
227. Williams, Jane; Seale, Holly. "If you're going to mandate COVID vaccination at your
workplace, here's how to do it ethically" (https://theconversation.com/if-youre-going-to-mand
ate-covid-vaccination-at-your-workplace-heres-how-to-do-it-ethically-166110). The
Conversation.
228. Allen A (2007). Vaccine: The Controversial Story of Medicine's Greatest Lifesaver (https://arc
hive.org/details/vaccinecontrover00arth). New York: W. W. Norton & Company, Inc. pp. 25–
36. ISBN 978-0-393-05911-3.
229. Early religious opposition:
White AD (1896). "Theological opposition to inoculation, vaccination, and the use of
anæsthetics" (http://abob.libs.uga.edu/bobk/whitem10.html). A History of the Warfare of
Science with Theology in Christendom. New York: Appleton.
Bazin H (September 2001). "The ethics of vaccine usage in society: lessons from the
past". Endeavour. 25 (3): 104–08. doi:10.1016/S0160-9327(00)01376-4 (https://doi.org/1
0.1016%2FS0160-9327%2800%2901376-4). PMID 11725304 (https://pubmed.ncbi.nlm.
nih.gov/11725304).
Noble M (December 2005). "Ethics in the trenches: a multifaceted analysis of the stem
cell debate". Stem Cell Reviews. 1 (4): 345–76. CiteSeerX 10.1.1.465.2410 (https://cites
eerx.ist.psu.edu/viewdoc/summary?doi=10.1.1.465.2410). doi:10.1385/SCR:1:4:345 (htt
ps://doi.org/10.1385%2FSCR%3A1%3A4%3A345). PMID 17142878 (https://pubmed.nc
bi.nlm.nih.gov/17142878). S2CID 21775014 (https://api.semanticscholar.org/CorpusID:2
1775014).
230. Williams G (2010). Angel Of Death; the story of smallpox. Basingstoke, UK: Palgrave
Macmillan. pp. 87–94. ISBN 978-0-230-27471-6.
231. Bazin H (October 2003). "A brief history of the prevention of infectious diseases by
immunisations". Comparative Immunology, Microbiology and Infectious Diseases. 26 (5–6):
293–308. doi:10.1016/S0147-9571(03)00016-X (https://doi.org/10.1016%2FS0147-9571%2
803%2900016-X). PMID 12818618 (https://pubmed.ncbi.nlm.nih.gov/12818618).
232. Ellner PD (1998). "Smallpox: gone but not forgotten". Infection. 26 (5): 263–69.
doi:10.1007/BF02962244 (https://doi.org/10.1007%2FBF02962244). PMID 9795781 (https://
pubmed.ncbi.nlm.nih.gov/9795781). S2CID 23658644 (https://api.semanticscholar.org/Corp
usID:23658644).
233. Baxby D (2001). Smallpox Vaccine, Ahead of its Time. Berkeley, UK: the Jenner Museum.
pp. 12–21. ISBN 0-9528695-1-9.
234. Bazin H (2000). The Eradication of Smallpox. London: Academic Press. p. 122. ISBN 0-12-
083475-8.
235. Creighton C (1887). The Natural History of Cowpox and Vaccinal Syphilis. London: Cassell.
236. Williamson S (2007). The Vaccination Controversy; the rise, reign and decline of compulsory
vaccination. Liverpool: Liverpool University Press. ISBN 978-1846310867.
237. Porter D, Porter R (July 1988). "The politics of prevention: anti-vaccinationism and public
health in nineteenth-century England" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11398
81). Medical History. 32 (3): 231–52. doi:10.1017/s0025727300048225 (https://doi.org/10.10
17%2Fs0025727300048225). PMC 1139881 (https://www.ncbi.nlm.nih.gov/pmc/articles/PM
C1139881). PMID 3063903 (https://pubmed.ncbi.nlm.nih.gov/3063903).
238. Durbach N (April 2000). " 'They might as well brand us': working-class resistance to
compulsory vaccination in Victorian England". Social History of Medicine. 13 (1): 45–62.
doi:10.1093/shm/13.1.45 (https://doi.org/10.1093%2Fshm%2F13.1.45). PMID 11624425 (htt
ps://pubmed.ncbi.nlm.nih.gov/11624425).
239. Baxby, Derrick (1999). "The End of Smallpox". History Today. 49 (3): 14–16.
PMID 21384695 (https://pubmed.ncbi.nlm.nih.gov/21384695).
240. (Royal Commission) (1898). Vaccination and its Results; a Report based on the Evidence
taken by the Royal Commission. London: New Sydenham Society.
241. "Labour Party Manifesto 1900" (https://suacs.wordpress.com/2014/04/20/labour-party-manife
sto-1900/). Voice of Anti-Capitalism in Guildford. April 20, 2014. Retrieved July 2, 2015.
242. Millard CK (December 1948). "The end of compulsory vaccination" (https://www.ncbi.nlm.ni
h.gov/pmc/articles/PMC2092290). British Medical Journal. 2 (4589): 1073–75.
doi:10.1136/bmj.2.4589.1073 (https://doi.org/10.1136%2Fbmj.2.4589.1073). PMC 2092290
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2092290). PMID 18121624 (https://pubmed.
ncbi.nlm.nih.gov/18121624).
243. Mooney, Graham (2015). Intrusive Interventions: Public Health, Domestic Space, and
Infectious Disease Surveillance in England, 1840–1914 (http://www.urpress.com/store/viewIt
em.asp?idProduct=14810). Rochester, NY: University of Rochester Press. ISBN 978-
1580465274. Retrieved April 2, 2016.
244. Fraser SM (July 1980). "Leicester and smallpox: the Leicester method" (https://www.ncbi.nl
m.nih.gov/pmc/articles/PMC1082657). Medical History. 24 (3): 315–32.
doi:10.1017/s0025727300040345 (https://doi.org/10.1017%2Fs0025727300040345).
PMC 1082657 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1082657). PMID 6997656 (htt
ps://pubmed.ncbi.nlm.nih.gov/6997656).
245. Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID (1988). Smallpox and its Eradication.
Geneva: World Health Organization. pp. 247, 275. ISBN 978-9241561105.
246. Henderson DA (2009). Smallpox; the death of a disease. Amherst, NY: Prometheus Books.
pp. 90–92. ISBN 978-1-59102-722-5.
247. Henderson DA, Moss B (1999). "Public health" (https://www.ncbi.nlm.nih.gov/books/NBK72
93/). In Plotkin SA, Orenstein WA (ed.). Vaccines (https://www.ncbi.nlm.nih.gov/books/NBK7
291/) (3rd ed.). Philadelphia: W. B. Saunders. ISBN 0-7216-7443-7.
248. Wolfe RM, Sharp LK (August 2002). "Anti-vaccinationists past and present" (https://www.ncb
i.nlm.nih.gov/pmc/articles/PMC1123944). BMJ. 325 (7361): 430–32.
doi:10.1136/bmj.325.7361.430 (https://doi.org/10.1136%2Fbmj.325.7361.430).
PMC 1123944 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1123944). PMID 12193361
(https://pubmed.ncbi.nlm.nih.gov/12193361). "In 1879, after a visit to New York by William
Tebb, the leading British anti-vaccinationist, the Anti-Vaccination Society of America was
founded. Subsequently, the New England Anti-Compulsory Vaccination League was formed
in 1882 and the Anti-Vaccination League of New York City in 1885."
249. "History of Anti-vaccination Movements" (http://www.historyofvaccines.org/content/articles/hi
story-anti-vaccination-movements). College of Physicians of Philadelphia. March 8, 2012.
Retrieved February 11, 2015. "The Anti Vaccination Society of America was founded in
1879, following a visit to America by leading British anti-vaccinationist William Tebb. Two
other leagues, the New England Anti Compulsory Vaccination League (1882) and the Anti-
Vaccination League of New York City (1885) followed. ..."
250. Kaufman M (1967). "The American anti-vaccinationists and their arguments". Bulletin of the
History of Medicine. 41 (5): 463–78. PMID 4865041 (https://pubmed.ncbi.nlm.nih.gov/48650
41).
251. Hopkins DR (2002). The Greatest Killer; smallpox in history (https://archive.org/details/great
estkillersm0000hopk). Chicago: University of Chicago Press. pp. 83–84 (https://archive.org/d
etails/greatestkillersm0000hopk/page/83). ISBN 978-0226351667.
252. Mariner WK, Annas GJ, Glantz LH (April 2005). "Jacobson v Massachusetts: it's not your
great-great-grandfather's public health law" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC
1449224). American Journal of Public Health. 95 (4): 581–90.
doi:10.2105/AJPH.2004.055160 (https://doi.org/10.2105%2FAJPH.2004.055160).
PMC 1449224 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449224). PMID 15798113
(https://pubmed.ncbi.nlm.nih.gov/15798113).
253. Pitcairn J (1907). Vaccination (https://archive.org/details/vaccination00pitcgoog). Anti-
Vaccination League of Pennsylvania. OCLC 454411147 (https://www.worldcat.org/oclc/4544
11147).
254. Higgins CM (1920). "Life sketch of John Pitcairn by a Philadelphia friend" (https://archive.or
g/details/horrorsvaccinat00higggoog). Horrors of Vaccination Exposed and Illustrated.
Brooklyn, NY: C.M. Higgins. pp. 73–75. OCLC 447437840 (https://www.worldcat.org/oclc/44
7437840).
255. Meade T (1989). " 'Living worse and costing more': resistance and riot in Rio de Janeiro,
1890–1917". J Lat Am Stud. 21 (2): 241–66. doi:10.1017/S0022216X00014784 (https://doi.o
rg/10.1017%2FS0022216X00014784).
256. Ciok, Amy E. "Horses and the diphtheria antitoxin." Academic Medicine 75.4 (2000): 396.
257. Lilienfeld DE (2008). "The first pharmacoepidemiologic investigations: national drug safety
policy in the United States, 1901–1902". Perspectives in Biology and Medicine. 51 (2): 188–
98. doi:10.1353/pbm.0.0010 (https://doi.org/10.1353%2Fpbm.0.0010). PMID 18453724 (http
s://pubmed.ncbi.nlm.nih.gov/18453724). S2CID 30767303 (https://api.semanticscholar.org/C
orpusID:30767303).
258. Gradman C (2009). Laboratory Disease; Robert Koch's medical bacteriology. Baltimore:
Johns Hopkins University Press. pp. 133–36. ISBN 978-0-8018-9313-1.
259. Brock, Thomas. Robert Koch: A life in medicine and bacteriology. ASM Press: Washington
DC, 1999. Print.
260. Offit PA (April 2005). "The Cutter incident, 50 years later". The New England Journal of
Medicine. 352 (14): 1411–12. doi:10.1056/NEJMp048180 (https://doi.org/10.1056%2FNEJM
p048180). PMID 15814877 (https://pubmed.ncbi.nlm.nih.gov/15814877).
261. "Scientist: autism paper had catastrophic effects" (https://www.npr.org/templates/story/story.p
hp?storyId=123472234). NPR. February 7, 2010.
262. Goldacre B (August 30, 2008). "The MMR hoax" (https://web.archive.org/web/20150206073
230/http://www.theguardian.com/society/2008/aug/30/mmr.health.media). The Guardian.
London. Archived from the original (https://www.theguardian.com/society/2008/aug/30/mmr.h
ealth.media) on February 6, 2015. Retrieved August 30, 2008. Alt URL (http://www.badscien
ce.net/2008/08/the-medias-mmr-hoax/)
263. Knox, Richard (September 19, 2011). "HPV Vaccine: The Science Behind The Controversy"
(https://www.npr.org/2011/09/19/140543977/hpv-vaccine-the-science-behind-the-controvers
y). NPR.org. NPR. Retrieved September 30, 2015.
264. Chatterjee A, O'Keefe C (May 2010). "Current controversies in the USA regarding vaccine
safety". Expert Review of Vaccines. 9 (5): 497–502. doi:10.1586/erv.10.36 (https://doi.org/10.
1586%2Ferv.10.36). PMID 20450324 (https://pubmed.ncbi.nlm.nih.gov/20450324).
S2CID 24443783 (https://api.semanticscholar.org/CorpusID:24443783).
265. Malik, Amyn A; McFadden, SarahAnn M; Elharake, Jad; Omer, Saad B (2020).
"Determinants of COVID-19 vaccine acceptance in the US" (https://www.ncbi.nlm.nih.gov/p
mc/articles/PMC7423333). EClinicalMedicine, the Lancet. 26: 100495.
doi:10.1016/j.eclinm.2020.100495 (https://doi.org/10.1016%2Fj.eclinm.2020.100495).
ISSN 2589-5370 (https://www.worldcat.org/issn/2589-5370). PMC 7423333 (https://www.ncb
i.nlm.nih.gov/pmc/articles/PMC7423333). PMID 32838242 (https://pubmed.ncbi.nlm.nih.gov/
32838242).
266. Linda Thunström, Madison Ashworth, David Finnoff, and Stephen C. Newbold. 2020.
Hesitancy towards a COVID-19 vaccine and prospects for herd immunity. Covid Economics
35 (https://cepr.org/file/9287/download?token=Ba6cin7P): 7 July 2020
267. McDonnell, Adam (November 16, 2020). "How many Britons are willing to take a
coronavirus vaccine?" (https://yougov.co.uk/topics/health/articles-reports/2020/11/16/how-m
any-britons-are-willing-take-coronavirus-vacc). YouGov. Retrieved December 10, 2020.
268. "Less than half of French want Covid vaccine: poll" (https://news.yahoo.com/less-half-french
-want-covid-173848670.html). Yahoo News. AFP. December 29, 2020. Retrieved
December 31, 2020.
269. "U.S. and U.K. are optimistic indicators for COVID-19 vaccination uptake" (https://web.archiv
e.org/web/20210718141218/https://www.ipsos.com/en/global-attitudes-covid-19-vaccine-de
cember-2020). Ipsos. Archived from the original (https://www.ipsos.com/en/global-attitudes-c
ovid-19-vaccine-december-2020) on July 18, 2021. Retrieved December 31, 2020.
270. Summers, Juana (March 12, 2021). "Little Difference In Vaccine Hesitancy Among White
And Black Americans, Poll Finds" (https://www.npr.org/sections/coronavirus-live-updates/20
21/03/12/976172586/little-difference-in-vaccine-hesitancy-among-white-and-black-american
s-poll-find). NPR.
271. Mahase, Elisabeth (June 4, 2021). "Covid-19: UK has highest vaccine confidence and
Japan and South Korea the lowest, survey finds" (https://www.bmj.com/content/373/bmj.n14
39). BMJ. 373: n1439. doi:10.1136/bmj.n1439 (https://doi.org/10.1136%2Fbmj.n1439).
PMID 34088703 (https://pubmed.ncbi.nlm.nih.gov/34088703). Retrieved June 14, 2021.
272. Institute of Global Health Innovation (May 2021). "Global attitudes towards a COVID-19
vaccine" (https://www.imperial.ac.uk/media/imperial-college/institute-of-global-health-innova
tion/GlobalVaccineInsights_ICL-YouGov-Covid-19-Behaviour-Tracker_20210520_v2.pdf)
(PDF). Imperial College London. Covid Data Hub. Retrieved June 14, 2021.
273. Attwell, K; Wiley, KE; Waddington, C; Leask, J; Snelling, T (October 2018). "Midwives'
attitudes, beliefs and concerns about childhood vaccination: A review of the global
literature". Vaccine. 36 (44): 6531–39. doi:10.1016/j.vaccine.2018.02.028 (https://doi.org/10.
1016%2Fj.vaccine.2018.02.028). PMID 29483029 (https://pubmed.ncbi.nlm.nih.gov/294830
29).
274. Pearce A, Law C, Elliman D, Cole TJ, Bedford H (April 2008). "Factors associated with
uptake of measles, mumps, and rubella vaccine (MMR) and use of single antigen vaccines
in a contemporary UK cohort: prospective cohort study" (https://www.ncbi.nlm.nih.gov/pmc/ar
ticles/PMC2287222). BMJ. 336 (7647): 754–57. doi:10.1136/bmj.39489.590671.25 (https://d
oi.org/10.1136%2Fbmj.39489.590671.25). PMC 2287222 (https://www.ncbi.nlm.nih.gov/pm
c/articles/PMC2287222). PMID 18309964 (https://pubmed.ncbi.nlm.nih.gov/18309964).
275. Yang YT, Delamater PL, Leslie TF, Mello MM (January 2016). "Sociodemographic Predictors
of Vaccination Exemptions on the Basis of Personal Belief in California" (https://www.ncbi.nl
m.nih.gov/pmc/articles/PMC4695929). American Journal of Public Health. 106 (1): 172–77.
doi:10.2105/AJPH.2015.302926 (https://doi.org/10.2105%2FAJPH.2015.302926).
PMC 4695929 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4695929). PMID 26562114
(https://pubmed.ncbi.nlm.nih.gov/26562114).
276. Toll, Mathew; Li, Ang (2020). "Vaccine sentiments and under-vaccination: Attitudes and
behaviour around Measles, Mumps, and Rubella vaccine (MMR) in an Australian cohort" (htt
ps://www.sciencedirect.com/science/article/pii/S0264410X20314614). Vaccine. 39 (4): 751–
759. doi:10.1016/j.vaccine.2020.11.021 (https://doi.org/10.1016%2Fj.vaccine.2020.11.021).
PMID 33218781 (https://pubmed.ncbi.nlm.nih.gov/33218781). S2CID 227100012 (https://ap
i.semanticscholar.org/CorpusID:227100012).
277. Ogilvie G, Anderson M, Marra F, McNeil S, Pielak K, Dawar M, McIvor M, Ehlen T, Dobson S,
Money D, Patrick DM, Naus M (May 2010). "A population-based evaluation of a publicly
funded, school-based HPV vaccine program in British Columbia, Canada: parental factors
associated with HPV vaccine receipt" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC28642
99). PLOS Medicine. 7 (5): e1000270. doi:10.1371/journal.pmed.1000270 (https://doi.org/10.
1371%2Fjournal.pmed.1000270). PMC 2864299 (https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC2864299). PMID 20454567 (https://pubmed.ncbi.nlm.nih.gov/20454567).
278. Amit Aharon A, Nehama H, Rishpon S, Baron-Epel O (April 2017). "Parents with high levels
of communicative and critical health literacy are less likely to vaccinate their children".
Patient Education and Counseling. 100 (4): 768–75. doi:10.1016/j.pec.2016.11.016 (https://d
oi.org/10.1016%2Fj.pec.2016.11.016). PMID 27914735 (https://pubmed.ncbi.nlm.nih.gov/27
914735).
279. Kim SS, Frimpong JA, Rivers PA, Kronenfeld JJ (February 2007). "Effects of maternal and
provider characteristics on up-to-date immunization status of children aged 19 to 35 months"
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1781415). American Journal of Public
Health. 97 (2): 259–66. doi:10.2105/AJPH.2005.076661 (https://doi.org/10.2105%2FAJPH.2
005.076661). PMC 1781415 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1781415).
PMID 17194865 (https://pubmed.ncbi.nlm.nih.gov/17194865).
280. Colgrove J, Bayer R (April 2005). "Manifold restraints: liberty, public health, and the legacy
of Jacobson v Massachusetts" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1449222).
American Journal of Public Health. 95 (4): 571–76. doi:10.2105/AJPH.2004.055145 (https://
doi.org/10.2105%2FAJPH.2004.055145). PMC 1449222 (https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC1449222). PMID 15798111 (https://pubmed.ncbi.nlm.nih.gov/15798111).
281. Salmon DA, Teret SP, MacIntyre CR, Salisbury D, Burgess MA, Halsey NA (February 2006).
"Compulsory vaccination and conscientious or philosophical exemptions: past, present, and
future". Lancet. 367 (9508): 436–42. doi:10.1016/s0140-6736(06)68144-0 (https://doi.org/10.
1016%2Fs0140-6736%2806%2968144-0). PMID 16458770 (https://pubmed.ncbi.nlm.nih.go
v/16458770). S2CID 19344405 (https://api.semanticscholar.org/CorpusID:19344405).
282. Moodley, Keymanthri; Hardie, Kate; Selgelid, Michael J.; Waldman, Ronald J.; Strebel,
Peter; Rees, Helen; Durrheim, David N. (February 7, 2013). "Ethical considerations for
vaccination programmes in acute humanitarian emergencies" (https://www.who.int/bulletin/v
olumes/91/4/12-113480/en/). Bulletin of the World Health Organization. 91 (4): 290–97.
doi:10.2471/BLT.12.113480 (https://doi.org/10.2471%2FBLT.12.113480). PMC 3629456 (htt
ps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3629456). PMID 23599553 (https://pubmed.ncb
i.nlm.nih.gov/23599553).
283. "States With Religious and Philosophical Exemptions From School Immunization
Requirements" (https://archive.today/20201022191725/https://www.ncsl.org/research/health/
school-immunization-exemption-state-laws.aspx). National Conference of State
Legislatures. Archived from the original (https://www.ncsl.org/research/health/school-immuni
zation-exemption-state-laws.aspx) on October 22, 2020. Retrieved January 2, 2021.
284. Caplan AL. "Do Children Have Vaccination Rights?" (https://www.medscape.com/viewarticl
e/902956). Medscape Business of Medicine.
285. "Anti-vaccine misinformation denies children's rights" (https://www.seattletimes.com/opinion/
anti-vaccine-misinformation-denies-childrens-rights/). April 18, 2018.
286. Parasidis E, Opel DJ (January 2017). "Parental Refusal of Childhood Vaccines and Medical
Neglect Laws" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5308147). American Journal
of Public Health. 107 (1): 68–71. doi:10.2105/AJPH.2016.303500 (https://doi.org/10.2105%2
FAJPH.2016.303500). PMC 5308147 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC53081
47). PMID 27854538 (https://pubmed.ncbi.nlm.nih.gov/27854538).
287. "Should Pediatricians Refuse Unvaccinated Kids?" (http://live.huffingtonpost.com/r/segment/
should-pediatricians-refuse-unvaccinated-kids/53285f162b8c2a24f700070f). The Huffington
Post. Retrieved July 4, 2015.
288. Bachai, Sabrina (June 24, 2014). "NYC Schools Are Now Allowed To Ban Unvaccinated
Kids, Rules Federal Judge" (http://www.medicaldaily.com/nyc-schools-are-now-allowed-ban
-unvaccinated-kids-rules-federal-judge-289614). Medical Daily. Retrieved July 4, 2015.
289. Halperin, Beth; Melnychuk, Ryan; Downie, Jocelyn; Macdonald, Noni (December 2007).
"When is it permissible to dismiss a family who refuses vaccines? Legal, ethical and public
health perspectives" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2532570). Paediatrics
& Child Health. 12 (10): 843–45. doi:10.1093/pch/12.10.843 (https://doi.org/10.1093%2Fpc
h%2F12.10.843). PMC 2532570 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2532570).
PMID 19043497 (https://pubmed.ncbi.nlm.nih.gov/19043497).
290. May T, Silverman RD (2005). "Free-riding, fairness and the rights of minority groups in
exemption from mandatory childhood vaccination". Human Vaccines. 1 (1): 12–15.
doi:10.4161/hv.1.1.1425 (https://doi.org/10.4161%2Fhv.1.1.1425). PMID 17038833 (https://p
ubmed.ncbi.nlm.nih.gov/17038833). S2CID 39321188 (https://api.semanticscholar.org/Corp
usID:39321188).
291. LeBlanc S (October 17, 2007). "Parents use religion to avoid vaccines" (https://www.usatoda
y.com/news/nation/2007-10-17-19819928_x.htm). USA Today. Retrieved November 24,
2007.
292. "Statement on Vaccinations from the OU and Rabbinical Council of America." (https://www.o
u.org/news/statement-vaccinations-ou-rabbinical-council-america/) Orthodox Union. 14
November 2018. 21 May 2019.
293. Avaneha Barzel p. 31 #34
294. Milko, Victoria (December 20, 2020). "Concern among Muslims over halal status of COVID-
19 vaccine" (https://abcnews.go.com/Health/wireStory/concern-muslims-halal-status-covid-1
9-vaccine-74826269). ABC News. Associated Press (AP). Retrieved December 30, 2020.
295. Priyanka Deladia (November 9, 2014). "Pork gelatine flu spray concerns" (https://www.bbc.c
om/news/health-30118984). BBC.
296. "Shot of life: saving vaccination drive from rumours and fake news" (https://www.hindustanti
mes.com/india-news/shot-of-life-saving-vaccination-drive-from-rumours-and-fake-news/story
-WHgsXRDorzKxpjPWpdCx7M.html). Hindustan Times. May 19, 2018.
297. "Uttar Pradesh: WhatsApp rumours make 100s of UP madrassas reject vaccination" (https://t
imesofindia.indiatimes.com/city/meerut/madrassas-in-west-up-say-no-to-measles-rubella-va
ccination/articleshow/67184011.cms). The Times of India.
298. Plotkin SA, Buser F (1985). "History of RA27/3 rubella vaccine". Reviews of Infectious
Diseases. 7 (Suppl 1): S77–78. doi:10.1093/clinids/7.supplement_1.s77 (https://doi.org/10.1
093%2Fclinids%2F7.supplement_1.s77). PMID 3890107 (https://pubmed.ncbi.nlm.nih.gov/3
890107).
299. Grabenstein JD (1999). "Moral considerations with certain viral vaccines" (https://web.archiv
e.org/web/20110718001330/http://www.immunizationinfo.org/files/nnii/files/Moral_Consider
ations_With_Certain_Viral_Vaccines.pdf) (PDF). Christ Pharm. 2 (2): 3–6. Archived from the
original (http://www.immunizationinfo.org/files/nnii/files/Moral_Considerations_With_Certain
_Viral_Vaccines.pdf) (PDF) on July 18, 2011. Retrieved May 11, 2009.
300. Pontifical Academy for Life (2005). "Moral reflections on vaccines prepared from cells
derived from aborted human foetuses" (https://web.archive.org/web/20060507072740/http://
www.academiavita.org/template.jsp?sez=Documenti&pag=testo%2Fvacc%2Fvacc&lang=e
nglish). Medicina e Morale. Archived from the original (http://www.academiavita.org/templat
e.jsp?sez=Documenti&pag=testo/vacc/vacc&lang=english) on May 7, 2006. Retrieved
December 3, 2008.
301. "Parents Fake Religion To Avoid Vaccines" (https://www.cbsnews.com/news/parents-fake-re
ligion-to-avoid-vaccines/). CBS News. AP. October 17, 2007.
302. "State Vaccination Exemptions for Children Entering Public Schools" (http://vaccines.proco
n.org/view.resource.php?resourceID=003597). Vaccines.procon.org.
303. "Vaccine skepticism runs deep among white evangelicals in US" (https://apnews.com/articl
e/coronavirus-vaccine-skepticism-white-evangelicals-us-32898166bbb673ad87842af24c8d
aefb). AP NEWS. April 5, 2021. Retrieved April 7, 2021.
304. Beinart, Peter (August 2019). "What the Measles Epidemic Really Says About America" (htt
ps://www.theatlantic.com/magazine/archive/2019/08/measles-as-metaphor/592756/). The
Atlantic. Retrieved July 8, 2019.
305. Busse JW, Morgan L, Campbell JB (June 2005). "Chiropractic antivaccination arguments" (h
ttp://jmptonline.org/article/S0161-4754(05)00111-9/fulltext). Journal of Manipulative and
Physiological Therapeutics. 28 (5): 367–73. doi:10.1016/j.jmpt.2005.04.011 (https://doi.org/1
0.1016%2Fj.jmpt.2005.04.011). PMID 15965414 (https://pubmed.ncbi.nlm.nih.gov/1596541
4).
306. Campbell JB, Busse JW, Injeyan HS (April 2000). "Chiropractors and vaccination: A
historical perspective" (http://pediatrics.aappublications.org/cgi/content/full/105/4/e43).
Pediatrics. 105 (4): E43. doi:10.1542/peds.105.4.e43 (https://doi.org/10.1542%2Fpeds.105.
4.e43). PMID 10742364 (https://pubmed.ncbi.nlm.nih.gov/10742364).
307. Russell ML, Injeyan HS, Verhoef MJ, Eliasziw M (December 2004). "Beliefs and behaviours:
understanding chiropractors and immunization". Vaccine. 23 (3): 372–79.
doi:10.1016/j.vaccine.2004.05.027 (https://doi.org/10.1016%2Fj.vaccine.2004.05.027).
PMID 15530683 (https://pubmed.ncbi.nlm.nih.gov/15530683).
308. Busse JW, Wilson K, Campbell JB (November 2008). "Attitudes towards vaccination among
chiropractic and naturopathic students". Vaccine. 26 (49): 6237–43.
doi:10.1016/j.vaccine.2008.07.020 (https://doi.org/10.1016%2Fj.vaccine.2008.07.020).
PMID 18674581 (https://pubmed.ncbi.nlm.nih.gov/18674581).
309. Lameris M, Schmidt C, Gleberzon B, Ogrady J (September 2013). "Attitudes toward
vaccination: A cross-sectional survey of students at the Canadian Memorial Chiropractic
College" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3743647). The Journal of the
Canadian Chiropractic Association. 57 (3): 214–20. PMC 3743647 (https://www.ncbi.nlm.ni
h.gov/pmc/articles/PMC3743647). PMID 23997247 (https://pubmed.ncbi.nlm.nih.gov/239972
47).
310. Yoo S (February 24, 2015), "Vaccine researcher Wakefield to testify in Oregon" (http://www.s
tatesmanjournal.com/story/news/health/2015/02/24/andrew-wakefield-vaccine-oregon/2396
7797/), Statesman Journal, retrieved March 3, 2015
311. Yoo S (February 26, 2015), "Meeting on vaccine mandate bill canceled" (http://www.statesm
anjournal.com/story/news/health/2015/02/25/meeting-vaccine-mandate-bill-canceled/24020
213/), Statesman Journal, retrieved March 3, 2015
312. Mason M (March 5, 2015). "Chiropractors lobby against bill ending belief exemptions for
vaccines" (https://www.latimes.com/local/political/la-me-pc-vaccine-bill-chiropractors-20150
305-story.html). Los Angeles Times. Retrieved March 6, 2015.
313. Schmidt K, Ernst E (March 2003). "MMR vaccination advice over the Internet". Vaccine. 21
(11–12): 1044–47. doi:10.1016/S0264-410X(02)00628-X (https://doi.org/10.1016%2FS0264
-410X%2802%2900628-X). PMID 12559777 (https://pubmed.ncbi.nlm.nih.gov/12559777).
314. Crislip M (November 5, 2010). "Homeopathic Vaccines" (http://www.sciencebasedmedicine.
org/?p=8003).
315. Stop Nosodes/Bad Science Watch (August 2015). "Nosode Use in Canada" (http://www.stop
nosodes.org/the-problem/the-extent-of-nosode-use-in-canada/).
316. Kerr MA (2009). "Movement impact" (https://web.archive.org/web/20110718173710/http://et
d.library.pitt.edu/ETD/available/etd-04302009-115908/unrestricted/Kerr_FINAL.pdf) (PDF).
The Autism Spectrum Disorders / vaccine link debate: a health social movement. University
of Pittsburgh. pp. 194–203. Archived from the original (http://etd.library.pitt.edu/ETD/availabl
e/etd-04302009-115908/unrestricted/Kerr_FINAL.pdf) (PDF) on July 18, 2011. Retrieved
February 25, 2010.
317. Weeks, Carly. "Health experts question lack of crackdown on 'homeopathic vaccines' " (http
s://www.theglobeandmail.com/news/national/health-experts-question-lack-of-crackdown-on-
homeopathic-vaccines/article23019800/). The Globe and Mail. Retrieved July 4, 2015.
318. Sheridan C (June 2009). "Vaccine market boosters". Nature Biotechnology. 27 (6): 499–501.
doi:10.1038/nbt0609-499 (https://doi.org/10.1038%2Fnbt0609-499). PMID 19513043 (https://
pubmed.ncbi.nlm.nih.gov/19513043). S2CID 205268563 (https://api.semanticscholar.org/Co
rpusID:205268563).
319. Allen A (2007). "Epilogue: our best shots" (https://archive.org/details/vaccinecontrover00art
h). Vaccine: the Controversial Story of Medicine's Greatest Lifesaver. W.W. Norton. pp. 421–
42. ISBN 978-0-393-05911-3.
320. Miloud Kaddar. "Global Vaccine Market Features and Trends" (https://www.who.int/influenza
_vaccines_plan/resources/session_10_kaddar.pdf) (PDF).
321. Willrich M (2010). Pox: An American History. New York: Penguin Group. pp. 117–65.
ISBN 978-1101476222.
322. Clara E. Councell. "War and Infectious Disease." Public Health Reports (1896-1970), vol.
56, no. 12, 1941, pp. 547–573. JSTOR, www.jstor.org/stable/4583663. Accessed 16 May
2021.
323. Grabenstein, J. D.; Pittman, PR; Greenwood, JT; Engler, RJ (June 1, 2006). "Immunization to
Protect the US Armed Forces: Heritage, Current Practice, and Prospects" (https://doi.org/10.
1093%2Fepirev%2Fmxj003). Epidemiologic Reviews. 28 (1): 3–26.
doi:10.1093/epirev/mxj003 (https://doi.org/10.1093%2Fepirev%2Fmxj003). PMID 16763072
(https://pubmed.ncbi.nlm.nih.gov/16763072).
324. Worthington B (March 17, 2011). "The Night the Viet Cong Stopped the War" (http://www.hist
orynet.com/the-night-the-viet-cong-stopped-the-war.htm). History Net: Where History Comes
Alive – World & US History Online. Retrieved November 18, 2015.
325. Rahman TA, Al-Haj P (2008). Profiles of Malaysia's Foreign Ministers. Kuala Lumpur:
Institute of Diplomacy and Foreign Relations (IDFR), Ministry of Foreign Affairs. ISBN 978-
9832220268. OCLC 774064073 (https://www.worldcat.org/oclc/774064073).
326. Broniatowski DA, Jamison AM, Qi S, AlKulaib L, Chen T, Benton A, Quinn SC, Dredze M
(October 2018). "Weaponized Health Communication: Twitter Bots and Russian Trolls
Amplify the Vaccine Debate" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6137759).
American Journal of Public Health. 108 (10): 1378–84. doi:10.2105/AJPH.2018.304567 (http
s://doi.org/10.2105%2FAJPH.2018.304567). PMC 6137759 (https://www.ncbi.nlm.nih.gov/p
mc/articles/PMC6137759). PMID 30138075 (https://pubmed.ncbi.nlm.nih.gov/30138075).
327. Glenza J (August 23, 2018). "Russian trolls 'spreading discord' over vaccine safety online"
(https://www.theguardian.com/society/2018/aug/23/russian-trolls-spread-vaccine-misinforma
tion-on-twitter). The Guardian. Retrieved August 23, 2018.
328. "The State of Vaccine Confidence in the EU: 2018" (https://www.vaccineconfidence.org/rese
arch/the-state-of-vaccine-confidence-in-the-eu-2018/). Vaccine Confidence Project. London
School of Hygiene & Tropical Medicine. Retrieved December 2, 2018.
329. Johnson, Deborah K.; Mello, Emily J.; Walker, Trent D.; Hood, Spencer J.; Jensen, Jamie L.;
Poole, Brian D. (May 12, 2019). "Combating Vaccine Hesitancy with Vaccine-Preventable
Disease Familiarization: An Interview and Curriculum Intervention for College Students" (htt
ps://www.ncbi.nlm.nih.gov/pmc/articles/PMC6631173). Vaccines. 7 (2): 39.
doi:10.3390/vaccines7020039 (https://doi.org/10.3390%2Fvaccines7020039).
PMC 6631173 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6631173). PMID 31083632
(https://pubmed.ncbi.nlm.nih.gov/31083632).
330. Hall, Harriet (November 2018). "Diving into the VAERS Dumpster" (https://www.csicop.org/s
i/show/diving_into_the_vaers_dumpster_fake_news_about_vaccine_injuries). CSI. Center
for Inquiry. Retrieved December 15, 2018.

Further reading
Largent, Mark A. (2012). Vaccine: The Debate in Modern America. Johns Hopkins University
Press. ISBN 978-1421406077.
Bedford H, Elliman D (January 2000). "Concerns about immunisation" (https://www.ncbi.nlm.
nih.gov/pmc/articles/PMC1117437). BMJ. 320 (7229): 240–43.
doi:10.1136/bmj.320.7229.240 (https://doi.org/10.1136%2Fbmj.320.7229.240).
PMC 1117437 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117437). PMID 10642238
(https://pubmed.ncbi.nlm.nih.gov/10642238).
Davies P, Chapman S, Leask J (July 2002). "Antivaccination activists on the world wide
web" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1751143). Archives of Disease in
Childhood. 87 (1): 22–25. doi:10.1136/adc.87.1.22 (https://doi.org/10.1136%2Fadc.87.1.22).
PMC 1751143 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1751143). PMID 12089115
(https://pubmed.ncbi.nlm.nih.gov/12089115).
Richardson PD, Mohammed SF, Mason RG, Steiner M, Kane R (2004). "Dynamics of
platelet interaction with surfaces in steady flow conditions" (https://www.ncbi.nlm.nih.gov/pm
c/articles/PMC524574). Transactions of the American Society for Artificial Internal Organs.
25 (7473): 147–51. doi:10.1136/bmj.329.7473.1049 (https://doi.org/10.1136%2Fbmj.329.747
3.1049). PMC 524574 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC524574).
PMID 524574 (https://pubmed.ncbi.nlm.nih.gov/524574).
Friedlander E (2007). "The anti-immunization activists: a pattern of deception" (http://www.pa
thguy.com/antiimmu.htm). Retrieved November 13, 2007.
Hanratty B, Holt T, Duffell E, Patterson W, Ramsay M, White JM, Jin L, Litton P (October
2000). "UK measles outbreak in non-immune anthroposophic communities: the implications
for the elimination of measles from Europe" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC
2869610). Epidemiology and Infection. 125 (2): 377–83. doi:10.1017/S0950268899004525
(https://doi.org/10.1017%2FS0950268899004525). PMC 2869610 (https://www.ncbi.nlm.nih.
gov/pmc/articles/PMC2869610). PMID 11117961 (https://pubmed.ncbi.nlm.nih.gov/1111796
1).
Herlihy SM, Hagood EA, Offit PA (2012). Your Baby's Best Shot: Why Vaccines Are Safe
and Save Lives. Rowman & Littlefield Publishers. ISBN 978-1442215788.
Miller CL (February 1985). "Deaths from measles in England and Wales, 1970–83" (https://w
ww.ncbi.nlm.nih.gov/pmc/articles/PMC1417782). British Medical Journal. 290 (6466): 443–
44. doi:10.1136/bmj.290.6466.443 (https://doi.org/10.1136%2Fbmj.290.6466.443).
PMC 1417782 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1417782). PMID 3918622 (htt
ps://pubmed.ncbi.nlm.nih.gov/3918622).
Myers MG, Pineda D (2008). Do Vaccines Cause That?! A Guide for Evaluating Vaccine
Safety Concerns. Galveston, TX: Immunizations for Public Health (i4ph). ISBN 978-0-
9769027-1-3.
Naono, Atsuko (2006). "Vaccination Propaganda: The Politics of Communicating Colonial
Medicine in Nineteenth-Century Burma" (https://archive.org/download/VaccinationPropagan
 daThePoliticsOfCommunicatingColonialMedicineIn/4.1naono.pdf) (PDF). SOAS Bulletin of
Burma Research. 4 (1): 30–44.
Offit, Paul A. (2008). Autism's False Prophets: Bad Science, Risky Medicine, and the Search
for a Cure. Columbia University Press. ISBN 978-0-231-14636-4.
Offit, Paul A. (2012). Deadly Choices: How the Anti-Vaccine Movement Threatens Us All.
Basic Books. ISBN 978-0465029624.
Orenstein WA, Hinman AR (October 1999). "The immunization system in the United States –
the role of school immunization laws". Vaccine. 17 (Suppl 3): S19–24. doi:10.1016/S0264-
410X(99)00290-X (https://doi.org/10.1016%2FS0264-410X%2899%2900290-X).
PMID 10559531 (https://pubmed.ncbi.nlm.nih.gov/10559531).
Spier RE (November 1998). "Ethical aspects of vaccines and vaccination" (https://www.ncbi.
nlm.nih.gov/pmc/articles/PMC7173252). Vaccine. 16 (19): 1788–94. doi:10.1016/S0264-
410X(98)00169-8 (https://doi.org/10.1016%2FS0264-410X%2898%2900169-8).
PMC 7173252 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7173252). PMID 9795382 (htt
ps://pubmed.ncbi.nlm.nih.gov/9795382).
Vermeersch E (October 1999). "Individual rights versus societal duties". Vaccine. 17 (Suppl
3): S14–17. doi:10.1016/s0264-410x(99)00289-3 (https://doi.org/10.1016%2Fs0264-410x%2
899%2900289-3). PMID 10627239 (https://pubmed.ncbi.nlm.nih.gov/10627239).
Wolfe RM, Sharp LK, Lipsky MS (June 2002). "Content and design attributes of
antivaccination web sites" (https://doi.org/10.1001%2Fjama.287.24.3245). JAMA. 287 (24):
3245–48. doi:10.1001/jama.287.24.3245 (https://doi.org/10.1001%2Fjama.287.24.3245).
PMID 12076221 (https://pubmed.ncbi.nlm.nih.gov/12076221).
"Six common misconceptions about immunization" (https://www.who.int/immunization_safet
y/aefi/immunization_misconceptions/en/). World Health Organization. February 16, 2006.
Retrieved November 2, 2006.
Lewandowsky et al. Anti-Vax Psychology Study ReportMooney, Chris (October 2, 2013). "If
You Distrust Vaccines, You're More Likely to Think NASA Faked the Moon Landings" (http
s://www.motherjones.com/environment/2013/10/vaccine-denial-conspiracy-theories-gmos-cl
imate). Mother Jones. Retrieved February 2, 2016.
National Academies of Sciences, Engineering, and Medicine 2020. Vaccine Accessand
Hesitancy: Part One of a Workshop Series: Proceedings of a Workshop inBrief. Washington,
DC: The National Academies Press. https://doi.org/10.17226/25895.

External links
Vaccination (https://curlie.org/Society/Issues/Health/Vaccination) at Curlie
"Immunizations, vaccines and biologicals" (https://www.who.int/immunization/en/). World
Health Organization.
"Vaccines & immunizations" (https://www.cdc.gov/vaccines/). Centers for Disease Control
and Prevention. September 4, 2018.
The Vaccine War (https://www.pbs.org/wgbh/pages/frontline/vaccines/). Frontline. April 27,
2010. PBS.
Institute of Global Health Innovation (May 2021). "Global attitudes towards a COVID-19
vaccine" (https://www.imperial.ac.uk/media/imperial-college/institute-of-global-health-innova
tion/GlobalVaccineInsights_ICL-YouGov-Covid-19-Behaviour-Tracker_20210520_v2.pdf)
(PDF). Imperial College London. Covid Data Hub.
"Vaccine Education Center" (https://www.chop.edu/centers-programs/vaccine-education-cen
ter). Children's Hospital of Philadelphia. Children's Hospital of Philadelphia.

Retrieved from "https://en.wikipedia.org/w/index.php?title=Vaccine_hesitancy&oldid=1052786696"

This page was last edited on 31 October 2021, at 02:21 (UTC).

Text is available under the Creative Commons Attribution-ShareAlike License; additional terms may apply. By using
this site, you agree to the Terms of Use and Privacy Policy. Wikipedia® is a registered trademark of the Wikimedia
Foundation, Inc., a non-profit organization.