Anti-vaccine activism

Anti-vaccine activism, also called the "anti-vax" movement,

Ideas that would eventually coalesce into anti-vaccine activism have existed for longer than vaccines themselves.[4] Some philosophical approaches (e.g. homeopathy, vitalism) are incompatible with the microbiological paradigm that explains how the immune system and vaccines work. Vaccine hesitancy and anti-vaccine activism exist within a broader context that involves cultural tradition, religious belief, approaches to health and disease, and political affiliation.^[3]

Opposition to

Vaccination itself was invented by British physician Edward Jenner, who published his findings on the efficacy of the practice for smallpox in 1798. By 1801, the practice had been widely endorsed in the scientific community, and by several world leaders. Philadelphia physician John Redman Coxe, noting that even then false accounts were circulated of negative effects of vaccination, wrote,

"Such are the falsehoods which impede the progress of the brightest discovery which has ever been made! But the contest is in vain! Time has drawn aside the veil which obstructed our knowledge of this invaluable blessing; and in the examples of the Emperor of Constantinople, of the Dowager Empress of Russia, and the King of Spain, we may date the downfall of further opposition."^[9]

Coxe's expectation of an end to opposition to vaccination proved premature, and through much of the nineteenth century, the principles, practices and impact of vaccination were matters of active scientific debate. The principles behind vaccination were not clearly understood until the end of the nineteenth century. The importance of hygiene in the preparation, storage, and administration of vaccines was not always understood or practiced. Reliable statistics on vaccine efficacy and side effects were difficult to obtain before the 1930s.^[3]

Anti-Compulsory Vaccination League

In the United Kingdom, the Compulsory Vaccination Act of 1853 required that every child be vaccinated within three or four months of birth.^[10] It set a precedent for the state regulation of physical bodies, and was fiercely resisted.^[11] The following year, in 1854, John Gibbs published the first anti-compulsory-vaccination pamphlet, Our Medical Liberties.^[12] By the 1860s, anti-vaccinationism in Britain was active in the working class, labor aristocracy, and lower middle class. It had become associated with alternative medicine and was part of a larger culture of social and political dissent that included both labor unions and religious dissenters. ^[11][13]

In June 1867, the publication "Human Nature" campaigned in the United Kingdom against "The Vaccination Humbug",^[14] reporting that many petitions had been presented to Parliament against Compulsory Vaccination for smallpox, including from parents who alleged that their children had died through the procedure, and complaining that these petitions had not been made public. The journal reported the formation of the Anti-Compulsory Vaccination League "To overthrow this huge piece of physiological absurdity and medical tyranny", and quoted Richard Gibbs (a cousin of John Gibbs) who ran the Free Hospital at the same address as stating "I believe we have hundreds of cases here, from being poisoned with vaccination, I deem incurable. One member of a family dating syphilitic symptoms from the time of vaccination, when all the other members of the family have been clear. We strongly advise parents to go to prison, rather than submit to have their helpless offspring inoculated with scrofula, syphilis, and mania".^[14]

Notable members of the Anti-Compulsory Vaccination League included James Burns, George Dornbusch and Charles Thomas Pearce.^[15] After the death of Richard B. Gibbs in 1871, the Anti-Compulsory Vaccination League "languished"^[10] until 1876 when it was revived under the leadership of Mary Hume-Rothery and the Rev. W. Hume-Rothery.^[16] The Anti-Compulsory Vaccination League published the Occasional Circular which later merged into the National Anti-Compulsory Vaccination Reporter.^[17]

Anti-Vaccination Society of America

In the United States, many states and local school boards established immunization requirements, beginning with a compulsory school vaccination law in Massachusetts in 1855.^[12] The

A series of American legal cases, beginning in various states and culminating with that of Henning Jacobson of Massachusetts in 1905, upheld the mandating of compulsory smallpox vaccination for the good of the public. The court ruled in Jacobson v. Massachusetts that "the liberty secured by the Constitution of the United States to every person within its jurisdiction does not import an absolute right in each person to be, at all times and in all circumstances, wholly freed from restraint. There are manifold restraints to which every person is necessarily subject for the common good".^[12]

London Society for the Abolition of Compulsory Vaccination

In 1880, William Tebb enlarged and reorganized the Anti-Compulsory Vaccination League in the UK with the formation of the London Society for the Abolition of Compulsory Vaccination, with William Young as secretary.^[17] The Vaccination Inquirer, established by Tebb in 1879, was adopted as the official organ of the Society.^[17] A series of fourteen "Vaccination Tracts" was begun by Young in 1877 and completed by Garth Wilkinson in 1879. William White was the first editor of the Vaccination Inquirer and after his death in 1885, he was succeeded by Alfred Milnes.^[17] Frances Hoggan and her husband authored an article for the Vaccination Inquirer in September 1883 which argued against compulsory vaccination.^[21] The London Society focused on lobbying parliamentary support in the 1880s and early 1890s.^[17] They gained support from several members of the House of Commons of which the most prominent was Peter Alfred Taylor, the member for Leicester, which was described as the "Mecca of antivaccination".^[22]

The National Anti-Vaccination League

The UK movement grew, and as the influence of the London Society overshadowed the Hume-Rotherys and it took the national lead,

In 1908, the Anti-Vaccination League of America was created by Charles M. Higgins and industrialist John Pitcairn Jr.,^[25] with anti-vaccination campaigns focused on New York and Pennsylvania.^[25] Members were opposed to compulsory vaccination laws.^[26] Higgins was the League's chief spokesman and pamphleteer.^[27] Historian James Colgrove noted that Higgins "attempted to overturn the New York State's law mandating vaccination of students in public schools".^[26] The League should not be confused with the Anti-Vaccination Society of America, that was formed in 1879.^[25] Higgins was criticized by medical experts for spreading misinformation and ignoring facts as to the efficacy of vaccination.^[28][29] The League dissolved after the death of Higgins in 1929.^[30]

20th century

Anti-vaccine activism ebbed for much of the twentieth century, but never completely vanished. In the UK, the National Anti-Vaccination League continued to publish new issues of its journal until 1972,

New vaccines were developed and used against diseases such as diphtheria and whooping cough. In the UK, these were often introduced on a voluntary basis, without arousing the same kind of anti-vaccination response that had accompanied compulsory smallpox vaccination.^[31]

In the United States, numerous measles outbreaks occurred in the 1960s and 1970s, and were shown to be more frequent in states that lacked mandatory vaccination requirements. This led to calls in the 1970s for a national level vaccination requirement for children entering schools.

Anti-vaccine activism in the 2000s regained prominence through exploratory research based on 12 cases that made claims about a link between the MMR vaccine and autism.^[32] These claims were subsequently extensively investigated and found to be false, and the original study turned out to be based on faked data. The scientific consensus is that there is no link between the MMR vaccine and autism, and that the MMR vaccine's benefits in preventing measles, mumps, and rubella greatly outweigh its potential risks.^[33]

The idea of an autism link was first suggested in the early 1990s and came to public notice largely as a result of the 1998 Lancet MMR autism fraud, which Dennis K Flaherty at the University of Charleston characterised as "perhaps the most damaging medical hoax of the last 100 years".^[34] The fraudulent research paper authored by Andrew Wakefield and published in The Lancet falsely claimed the vaccine was linked to colitis and autism spectrum disorders. The paper was retracted in 2010^[35] but is still cited by anti-vaccine activists.^[36]

The claims in the paper were widely reported,

The Lancet paper was partially retracted in 2004 and fully retracted in 2010, when Lancet's editor-in-chief

Wakefield continues to promote anti-vaccine beliefs and conspiracy theories in the United States.[65] In February 2015, Wakefield denied that he bore any responsibility for the

The anti-vaccination movement was historically apolitical, but in the 2010s and 2020s the movement in the United States has increasingly targeted conservatives.^[2] As measles outbreaks increased, so did calls to eliminate exemptions from vaccine administration. As of 2015, 19 American states had suggested legislation to eliminate or increase the difficulty of exemptions, including California.^[12] Concurrently, American anti-vaccine activists reached out to libertarian and right-leaning groups such as the Tea Party movement to broaden their base. While earlier anti-vaccination activists focused on health impacts and safety of vaccines, recent themes increasingly involve philosophical arguments about liberty, medical freedom and parental rights.^[2]

With the growing anti-vaccine movement from the 2010s onwards, the United States has seen a resurgence of certain

Vaccine hesitancy led to declining rates of vaccination for measles, culminating in the 2019–2020 measles outbreaks. The most significant of these in proportion to national population was the 2019 Samoa measles outbreak.^[72]

In July 2018, two 12-month-old children died in Samoa after receiving incorrectly prepared MMR vaccinations.^[73] These two deaths were picked up by anti-vaccine groups and used to incite fear towards vaccination on social media, causing the government to suspend its measles vaccination programme for ten months, despite advice from the WHO.^[74][75] The incident caused many Samoan residents to lose trust in the healthcare system.^[76] UNICEF and the World Health Organization estimate that the measles vaccination rate in Samoa fell from 74% in 2017 to 34% in 2018,^[77][78] similar to some of the poorest countries in Africa.^[79]

In August 2019, an infected passenger on one of the more than 8,000 annual flights between New Zealand and Samoa probably brought the disease from Auckland to Upolu.^[73] A full outbreak of measles began on the island in October 2019 and continued for the next four months. As of 6 January 2020, there were over 5,700 cases of measles and 83 deaths, out of a Samoan population of 200,874.^[80][81] Over three per cent of the population were infected.^[82] The cause of the outbreak was attributed to decreased vaccination rates, from 74% in 2017 to 31–34% in 2018, even though nearby islands had rates near 99%.^[82][81] a rate of 14.3 deaths per 1000 infected) and 5,520 cases (2.75% of the population) of measles in Samoa.^[83][82][81] 61 out of the first 70 deaths were four years old and under, and all but seven were under 15.^[84][85] After the outbreak, anti-vaxxers employed racist tropes and misinformation to credit the scores of measles deaths to poverty and poor nutrition or even to the vaccine itself, but this has been discounted by the international emergency medical support that arrived in November and December.^[73] There was no evidence of acute malnutrition, clinical vitamin A deficiency, or immune deficiency as claimed by various anti-vaxxers.^[73]

COVID-19 pandemic activism

During the COVID-19 pandemic, anti-vaccine activists undertook various efforts to hinder people who wanted to receive the vaccines, with such activities occurring in countries including Australia,^[86] Israel,^[87] the United Kingdom,^[88] and the United States.^[89] These included attempts to physically blockade vaccination sites, and making false reservations for vaccination appointments to clog up vaccination booking systems. Protests were also organized by the activists to raise awareness for their cause.^[90]

In some instances, anti-vaccine rhetoric has been traced to

Anti-vaccine activists have falsely claimed in social media posts that numerous deaths or injuries had to do with reactions to vaccines. In one highly publicized instance in early 2023, after Buffalo Bills football player Damar Hamlin experienced an in-game episode of commotio cordis, there was an increase in rhetoric and disinformation from figures such as Charlie Kirk and Drew Pinsky making unfounded claims about Hamlin's cardiac arrest and COVID-19 vaccines.^[96][97][98] In another 2023 incident, college basketball player Bronny James experienced cardiac arrest at the Galen Center at the University of Southern California, leading to assertions that this was a result of receiving a COVID-19 vaccine; it was later revealed that the episode had been caused by a congenital heart defect.^[99] Also, anti-vaccine activists believed Foo Fighters drummer Taylor Hawkins died in 2022 from the COVID-19 vaccine, while in actuality it was a drug overdose.^[100] In December 2023, The New York Times published a detailed investigation of the distortion and misrepresentation of the circumstances surrounding the death of 24-year-old George Watts Jr. by Robert F. Kennedy Jr. and other anti-vaccine activists.^[101]

Prominent biomedical researcher

In some instances, anti-vaccine organizations have used names intended to sound non-partisan on the issue: e.g. National Vaccine Information Center (USA), Vaccination Risk Awareness Network (Canada), Australian Vaccination Network.^[95] In November 2013 the Australian Vaccination Network was ordered by the New South Wales Administrative Decisions Tribunal to change their name so that consumers are aware of the anti-vaccination nature of the group. Lateline reported that former AVN president Meryl Dorey "claimed she was a victim of hate groups and vested interests" in response to the ruling.^[106]

Information quality

Although physicians and nurses are still rated as the most trusted source for vaccine information, some vaccine-hesitant individuals report being more comfortable discussing vaccines with providers of complementary and alternative (CAM) treatments.^[3] With the rise of the internet, many people have turned online for medical information.^[107] In some instances, anti-vaccine activists seek to steer people away from vaccination and health-care providers and towards alternative medicines sold by certain of the activists.^[108]

Anti-vaccination writings on the internet have been argued to be characterized by a number of differences from medical and scientific literature. These include:

• Promiscuous copying and reduplication.^[109]
• Ignoring corrections, even when an initial report or data point is shown to be false.^[95][110]
• Lack of references, difficulty in checking sources and claims.^[111]
• Personal attacks on individual doctors.^[112][2][95]
• A high degree of interlinkage between sites.^[109][113]
• Dishonest or fallacious arguments.^[114][95]

For example, a 2020 study examined Instagram posts related to the HPV vaccine, which can prevent some types of cancer. Anti-vaccine posts were more likely than pro-vaccine posts to be sent by non-healthcare individuals, to include personal narratives, and to reference other Instagram users, links, or reposts. Anti-vaccine posts were also more likely to involve concealment or distortion, particularly conspiracy theories and unsubstantiated claims. 72.3% of antivaccine posts made inaccurate claims, including exaggerating the risks of vaccines and minimizing risks of disease.^[115]

Disinformation tactics

A number of specific disinformation tactics have been noted in anti-vaccination messaging, including:^[95][116]

• Conspiracies theories alleging lies, trickery, cover-ups, and secret knowledge^[116]
• Messages crafted for psychological appeal rather than truthfulness^[117]
• Fake experts^[116]
• Impossible expectations:^[116] claiming that anything less than 100% certainty in a scientific claim implies doubt, and that doubt means there is no consensus^[118]
• Selective cherry-picking: using obscure or debunked sources while ignoring counter-evidence and scientific consensus^[116][95]
• Shifting hypotheses: Continually introducing new theories about vaccines being harmful; moving to new claims when existing ones are shown to be false^[95]
• Misrepresentation, false logic and illogical analogies^[116][95]
• Personal attacks on critics, ranging from online criticism, publicly revealing personal details, and threats, to offline acitivities such as legal actions, targeting of employers, and violence^[95][112][2]

Economics of vaccine disinformation

Information is more likely to be believed after repeated exposure. Disinformers use this illusory truth effect as a tactic, repeating false information to make it feel familiar and influence belief.^[119] Anti-vaccine activists have leveraged social media to develop interconnected networks of influencers that shape people's opinion, recruit allies, impact policy^[2] and monetize vaccine-related disinformation.^[120] In 2022, the Journal of Communication published a study of the political economy underlying vaccine disinformation. Researchers identified 59 English-language "actors" that provided "almost exclusively anti-vaccination publications". Their websites monetized disinformation through appeals for donations, sales of content-based media and other merchandise, third-party advertising, and membership fees. Some maintained a group of linked websites, attracting visitors with one site and appealing for money and selling merchandise on others. Their activities to gain attention and obtain funding displayed a "hybrid monetization strategy". They attracted attention by combining eye-catching aspects of "junk news" and online celebrity promotion. At the same time, they developed campaign-specific communities to publicize and legitimize their position, similar to radical social movements.^[120]

Misrepresentation of the Vaccine Adverse Event Reporting System

In the United States, the

Since Republicans gained a majority in the House in January 2023, the House Judiciary Committee has used legal action to actively oppose both disinformation research and government involvement in fighting disinformation. One of the projects targeted is the Virality Project, which has examined the spread of false claims about vaccines. The House Judiciary Committee has sent letters, subpoenas, and threats of legal action to researchers, demanding notes, emails and other records from researchers and even student interns, dating back to 2015. Institutions include the Stanford Internet Observatory at Stanford University, the University of Washington, the Atlantic Council's Digital Forensic Research Lab and the social media analytics firm Graphika. Researchers emphasize that they have academic freedom to study disinformation as well as freedom of speech to report their results.^{[123][124][125]}

Despite conservative claims that the government acted to censor speech online, "no evidence has emerged that government officials coerced the companies to take action against accounts".^[123] The actions of the House Judiciary Committee have been described as an "attempt to chill research,”^[123] creating a "chilling effect"^[124] through increased time demands, legal costs and online harassment of researchers.^[124][123]

Harassment

Persons undertaking efforts to counter vaccine misinformation, including public health experts who use social media, have been targeted for harassment by anti-vaccine activists.^[2][112] For example, Slovakian physician Vladimír Krčméry was a prominent member of the government advisory team during the COVID-19 pandemic in Slovakia, and was the first person to in that country to receive a COVID-19 vaccine. Due to his prominent role in the vaccination campaign, Krčméry and his family became a target of anti-vaccine activists, who physically threatened him and his family.^[126]

In June 2023, Texas-based physician and researcher Peter Hotez tweeted his concerns about Robert F. Kennedy Jr. sharing misinformation about vaccines on Joe Rogan's podcast. Rogan, Kennedy, and Twitter owner Elon Musk asked Hotez to participate in a debate on the podcast. Upon declining the invitation, Hotez was harassed by their fans, with anti-vaccine activist Alex Rosen confronting him at his home.^{[112][127][128]}

In his book The Deadly Rise of Anti-science: A Scientist's Warning, Hotez describes how he and other scientists who publicly defend vaccines have been attacked on social media, harassed with threatening emails, intimidated, and confronted physically by opponents of vaccination. He attributes the increase in aggressiveness of the anti-vaccination movement to the influence of the extreme wing of the Republican Party.^[129][130] Hotez estimates that roughly 200,000 preventable deaths from COVID-19, mainly among Republicans, occurred in the US because of refusal to be vaccinated.^[131][132]

At the extreme end, opposition to vaccination has resulted in substantial violence against vaccinators. In Pakistan, "more than 200 polio team workers have lost their lives" (team members include not only vaccinators but police and security personnel) from "targeted killing and terrorism" while working on polio vaccination campaigns.^[133]

Countering anti-vaccine activism

Various efforts have been suggested and undertaken to address concerns about vaccines and counter anti-vaccine disinformation. Efforts include social media advertising campaigns, by public health organizations, in support of public health goals.^[134][105]

Best practices for combating vaccine mis- and disinformation include addressing issues openly, clearly identifying areas of scientific consensus and areas of uncertainty, and being sensitive to the cultural and religious values of communities.^{[135][136][32]} In countering anti-vaccine disinformation, both factual and emotional aspects need to be addressed.^[137]

Whether people will update a mistaken belief is complicated and involves psychological factors and social goals as well as accuracy of information.^{[138][119][117]} There is some evidence that both debunking and "pre-bunking" of disinformation can be effective, at least in the short term.^{[119][117][139][140]} Elements that may help to correct inaccurate information include: warning people before they are exposed to misinformation; high perceived credibility of message sources, affirmations of identity and social norms; graphical presentation; and focusing attention on clear core messages.^[141] Alternative explanations of a situation need to fit plausibly into the original scenario and ideally indicate why the incorrect explanation was previously thought to be correct.^[138]

The cultivation of critical thinking, health and science awareness, and media literacy skills are all recommended to help people more critically assess the credibility of the information they see.^[32] People who seek out multiple reputable news sources at local and national levels are more likely to detect disinformation than those who rely on few sources from a particular viewpoint.^[142] Particularly on social media, beware of sensational headlines that appeal to emotion, fact-check information broadly (not just through your usual sources), and consider possible agendas or conflicts of interest of those relaying information.^[143][144]

Operation of social media

Other suggestions for countering anti-vaccine activism focus on changing the operation of social media platforms. Interventions such as accuracy nudges and source labelling change the context in which information is presented.^[145] For example, correct information can be directly presented to counter disinformation.^[146][147] Other possibilities include flagging or removing misleading information on social media platforms.^{[148][149][150]} Research suggests that a majority of individuals in the United States would support the removal of harmful misinformation posts and the suspension of accounts. This position is less popular with Republicans than Democrats.^[151]

While private entities like Facebook, Twitter and Telegram could legally establish guidelines for moderation of information and disinformation on their platforms (subject to local and international laws)^{[152][144][153]} such companies do not have strong incentives to control disinformation or to self-regulate. Algorithms that are used to maximize user engagement and profits can lead to unbalanced, poorly sourced, and actively misleading information.^{[154][155][156]}

Criticized for its role in vaccine hesitancy, Facebook announced in March 2019 that it would provide users with "authoritative information" on the topic of vaccines.^[157] Facebook introduced several policies chosen to reduce the impact of anti-vaccine content, without actually removing it. These included reducing the ranking of anti-vaccine sources in searches and not recommending them; rejecting ads and targeted advertising that contained vaccine misinformation; and using banners to present vaccine information from authoritative sources. A study examined the six months before and after the policy changes. It found a moderate but significant decrease in the number of likes for anti-vaccine posts following the policy changes. Likes of pro-vaccine posts were unchanged.^[158] Facebook has been criticized for not being more aggressive in countering disinformation.^[159] In response to efforts to police misinformation, anti-vaccine communities on social media have adopted coded language to refer to vaccinated persons and the vaccines themselves.^[160]

Supply-side interventions reduce circulation of misinformation directly at their sources through actions such as application of social media policies, regulation, and legislation.^[145] A study published in the journal Vaccine examined advertisements posted in the three months prior to the Facebook's 2019 policy changes. It found that 54% of the anti-vaccine advertisements on Facebook were placed by just two organizations, funded by well-known anti-vaccination activists.^[161][162] The Children's Health Defense / World Mercury Project chaired by Robert F. Kennedy Jr. and Stop Mandatory Vaccination, run by campaigner Larry Cook, posted 54% of the advertisements. The ads often linked to commercial products, such as natural remedies and books.^[163] Kennedy was suspended from Facebook in August 2022,^[164] but reinstated in June 2023.^[165]

In 2023, however, state governments that were politically aligned with anti-vaccine activists successfully sought a

Algorithms and user data can be used to identify selected subgroups who can then be provided with specialized content. This type of approach has been used both by anti-vaccine activists[32]^[2] and by health providers who hope to counter vaccine-related disinformation.^{[168][169][170]} For example, in the United States, the CDC’s Social Vulnerability Index (SVI) has been used to identify communities that have traditionally been under-served or are at elevated risk for infection, morbidity, and mortality.^[168] Programs have been developed in such communities to address disinformation and vaccine hesitancy.^[171]

Community engagement

Steps have been taken to counter anti-vaccine messaging by directly engaging with communities. Outreach efforts include call centers and texting campaigns, partnering with local community leaders, and holding community-based vaccine clinics.^{[171][169][172]} Creating digital and science literacy resources and distributing them via schools, libraries, municipal offices, churches and other community groups can help to counter misinformation in under-resourced communities.^[173]

The Black Doctors Covid-19 Consortium in Philadelphia is one example of a successful direct outreach initiative.^[174] Another is the New York State Vaccine Equity Task Force.^[171] In line with the Strategic Advisory Group of Experts (SAGE)'s 3C's model, outreach to communities has focused on addressing mistrust and increasing Confidence, providing information to improve risk assessment (Complacency), and improving access to COVID-19 vaccines (Convenience). It has been necessary to counter disinformation in all three areas.^[170][171]

Recommendations for combating vaccine disinformation include increasing the presence of trusted health agencies and credible information on social media, partnering with social media platforms to promote evidence-based public health information, and identifying and responding to emerging concerns and disinformation campaigns.^[170] Networked communities of public health officials and other stakeholders, connecting with the public through a variety of credible and trusted messengers, are recommended. Sharing of messages through such networks could help to debunk and counter highly networked and coordinated disinformation attacks.^[2]

A networked community approach would differ from the current model of US public health communication, which tends to rely on a single credible messenger (e.g. Anthony Fauci) and is susceptible to disinformation attacks. To deal with disinformation, community networks would need to address issues of liberty and human rights as well as vaccine safety, effectiveness and access. Networks could also help to show support for those attacked by anti-vaccine activists.^[2]

See also

• Anti-vaccinationism in chiropractic
• Big Pharma conspiracy theories
• COVID-19 vaccine misinformation and hesitancy
• Germ theory denialism
• List of anti-vaccination groups
• oral polio AIDS hypothesis
• Vaccine misinformation
• Vaccines and autism
  • MMR vaccine and autism
  • Thiomersal and vaccines

References