Vaccine hesitancy
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Vaccine hesitancy is a delay in acceptance, or refusal, of
Vaccine hesitancy is complex and context-specific, varying across time, place and vaccines.[17] It can be influenced by factors such as lack of proper scientifically based knowledge and understanding about how vaccines are made or work, as well as psychological factors including fear of needles[2] and distrust of public authorities, 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.[18]
"Anti-vaccinationism" refers to total opposition to vaccination; in more recent years, anti-vaccinationists have been known as "anti-vaxxers" or "anti-vax".[19] The specific hypotheses raised by anti-vaccination advocates have been found to change over time.[18] Anti-vaccine activism has been increasingly connected to political and economic goals.[20][21] Although myths,
Proposed laws that mandate vaccination, such as
Effectiveness
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?"[36]
Another rallying cry of the anti-vaccine movement is to call for randomized
Other critics argue that the immunity granted by vaccines is only temporary and requires boosters, whereas those who survive the disease become permanently immune.[11] As discussed below, the philosophies of some alternative medicine practitioners are incompatible with the idea that vaccines are effective.[38]
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 window between the disappearance of maternal antibody and seroconversion means that vaccinated children are frequently still vulnerable. Strong herd immunity reduces this vulnerability. Increasing herd immunity during an outbreak or when there is a risk of an outbreak is perhaps the most widely accepted justification for mass vaccination. When a new vaccine is introduced, mass vaccination can help increase coverage rapidly.[42]
If enough of a population is vaccinated, herd immunity takes effect, decreasing risk to people who cannot receive vaccines because they are too young or old, immunocompromised, or have severe allergies to the ingredients in the vaccine.[43] The outcome for people with compromised immune systems who get infected is often worse than that of the general population.[44]
Cost-effectiveness
Commonly used vaccines are a cost-effective and preventive way of promoting health, compared to the treatment of acute or chronic disease. In 2001, the United States spent approximately $2.8 billion to promote and implement routine childhood immunizations against seven diseases. The societal benefits of those vaccinations were estimated to be $46.6 billion, yielding a benefit-cost ratio of 16.5.[45]
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.
Safety concerns
While some anti-vaccinationists openly deny the improvements vaccination has made to public health or believe in
The overwhelming success of certain vaccinations has made certain diseases rare, and, consequently, has led to incorrect
Various concerns about immunization have been raised. They have been addressed and the concerns are not supported by evidence.
Thiomersal
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.[69] 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.[70] 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: Wakefield reportedly stood to earn up to $43 million per year selling diagnostic kits.[71][72] Had this been known, publication in The Lancet would not have taken place in the way that it did.[73] Wakefield has been heavily criticized on scientific and ethical grounds for the way the research was conducted[74] and for triggering a decline in vaccination rates, which fell in the UK to 80% in the years following the study.[75][76] In 2004, the MMR-and-autism interpretation of the paper was formally retracted by ten of its thirteen coauthors,[77] and in 2010 The Lancet's editors fully retracted the paper.[78][79] Wakefield was struck off the UK medical register, with a statement identifying deliberate falsification in the research published in The Lancet,[80] and is barred from practicing medicine in the UK.[81]
The CDC, the IOM of the
In 2009,
A special court convened in the United States to review claims under the
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.[91] Despite scientific evidence that strongly contradicts this idea,[18] there are still parents of autistic children that believe that vaccine overload causes autism.[92] The resulting controversy has caused many parents to delay or avoid immunizing their children.[91] Such parental misperceptions are major obstacles towards immunization of children.[93]
The concept of vaccine overload is flawed on several levels.
Any experiment based on withholding vaccines from children is considered unethical,[101] 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.[18]
Prenatal infection
There is evidence that
- 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.[104]
Ingredient concerns
Aluminum compounds are used as immunologic adjuvants to increase the effectiveness of many vaccines.[105] 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.[106][107] In some cases these compounds have been associated with redness, itching, and low-grade fever,[106] but the use of aluminum in vaccines has not been associated with serious adverse events.[105][108] 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.[105][108] 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.[109] 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.[109]
In 2015., N. Petrovsky, summarizing the current evidence on the vaccine adjuvants, writes: "Unfortunately, adjuvant research has lagged behind other vaccine areas... the biggest remaining challenge in the adjuvant field is to decipher the potential relationship between adjuvants and rare vaccine adverse reactions, such as narcolepsy, macrophagic myofasciitis or Alzheimer's disease. While existing adjuvants based on aluminium salts have a strong safety record, there are ongoing needs for new adjuvants and more intensive research into adjuvants and their effects."[110] In 2023, Łukasz Bryliński writes: "Even though its toxicity is well-documented, the role of Al in the pathogenesis of several neurological diseases remains debatable...Despite poor absorption via mucosa, the biggest amount of Al comes with food, drinking water, and inhalation. Vaccines introduce negligible amounts of Al, while the data on skin absorption (which might be linked with carcinogenesis) is limited and requires further investigation...Although we know for sure that Al accumulates in the brain, it is not fully understood how it reaches it."[111]
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.[112] Very small amounts of residual formaldehyde can be present in vaccines but are far below values harmful to human health.[113][114] 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.[112] The human body continuously produces formaldehyde naturally and contains 50–70 times the greatest amount of formaldehyde present in any vaccine.[112] Furthermore, the human body is capable of breaking down naturally occurring formaldehyde as well as the small amount of formaldehyde present in vaccines.[112] There is no evidence linking the infrequent exposures to small quantities of formaldehyde present in vaccines with cancer.[112]
Sudden infant death syndrome
Anthrax vaccines
In the mid-1990s media reports on vaccines discussed the
Swine flu vaccine
The US
During the
Blood transfusion
After the introduction of COVID-19 vaccines, vaccine hesitant people have at times demanded that they get donor blood from donors that have not received the vaccine. In the US and Canada, blood centers do not keep data on whether a donor has been COVID-19 infected or vaccinated, and in August 2021 it was estimated that 60-70% of US blood donors had COVID-19 antibodies. Research director Timothy Caulfield said that "This really highlights, I think, how powerful misinformation can be. It can really have an impact in a way that can be dangerous ... There is no evidence to support these concerns."[123][124][125]
As of August 2021, such demands are rare in the US.[123] Doctors in Alberta, Canada, warned in November 2022 that the demands were becoming more common.[125]
In Italy and New Zealand, parents have gone to court to stop their children's urgent heart surgery, unless COVID-19 vaccine free blood was provided. In both cases the parents were ruled against, though they stated that they could provide willing donors they found acceptable.[126][127][128] The New Zealand Blood Service does not label blood according to the donor's COVID-19 vaccine history,[129] and as of 2022, about 90% of New Zealand's population over twelve years of age has had two COVID-19 vaccinations.[130] In another Italian case, a blood transfusion for a sick 90-year-old man was refused by his two daughters, due to vaccine hesitancy concerns.[126] Another New Zealand couple stated that they were trying to arrange their child to have her next heart surgery in India, to avoid her being given blood from COVID-19 vaccinated donors.[131]
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
Psychology
The rise in vaccine hesitancy has led to research on the psychology of those who oppose vaccines. A 24-nation investigation led by the University of Queensland and reported in Health Psychology in 2018 found that the largest psychological factors leading to anti-vaccination attitudes were conspiratorial thinking, reactance, disgust regarding blood or needles, and individualistic or hierarchical worldviews. In contrast, demographic variables were not significant.[136]
Researchers have also investigated the psychological roots of vaccine hesitancy with regard to specific vaccines. For instance, a 2021 study published in Nature Communications investigated psychological characteristics associated with COVID-19 vaccine hesitancy and resistance in Ireland and the UK. The study found that vaccine hesitant or resistant respondents in the two countries varied across socio-demographic and health-related variables, however, they were similar in range of psychological factors. Such respondents were less likely to obtain information about the pandemic from authoritative and traditional media sources and demonstrated similar skepticism towards these sources compared to respondents who accepted the vaccine.[137]
Fear of needles
Various
Malpractice and fraud
CIA fake vaccination clinic
In Pakistan, the CIA ran a fake vaccination clinic in an attempt to locate Osama bin Laden.[144][145] 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.[146] Efforts to eradicate polio have furthermore been disrupted by American drone strikes.[144] Pakistan is among the only countries where polio remained endemic as of 2015.[147]
Fake COVID-19 vaccines
In July 2021, Indian police arrested 14 people for administering doses of saline solution 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 what they thought was the vaccine.[148][149] 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.[150]
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."[151][152]
Unethical human experimentation and medical racism
Some people in groups experiencing
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.[155]
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
Autism
The idea of a link between vaccines and autism has been extensively investigated and conclusively shown to be false.[156][157] The scientific consensus is that there is no relationship, causal or otherwise, between vaccines and incidence of autism,[52][158][159] and vaccine ingredients do not cause autism.[160]
Nevertheless, the anti-vaccination movement continues to promote myths, conspiracy theories, and misinformation linking the two.[161] 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", to quote the Skeptical Inquirer.[162]
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
While it is true that infection with certain illnesses may produce lifelong
Natural measles infection carries a high risk of many serious, and sometimes life-long, complications, all of which can be avoided by vaccination. Those infected with measles rarely have a symptomatic reinfection.[164]
Most people survive measles, though in some cases, complications may occur. Among those that experience complications, 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.[165] Pneumonia is the most common fatal complication of measles infection and accounts for 56–86% of measles-related deaths.[166]
Possible consequences of measles virus infection include
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.[171][172][173] 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.[174] Although the measles vaccine contains an attenuated strain, it does not deplete immune memory.[172]
HPV vaccine
The idea that the
There remains a disproportionate rate of HPV-related cancers amongst LatinX populations, leading researchers to explore how messaging may be made more effective to address vaccine hesitancy.[175]
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
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In several countries, reductions in the use of some vaccines were followed by increases in the diseases' morbidity and mortality.[176][177] 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.[178] 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.[179] 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.[31]
Stockholm, smallpox (1873–74)
An anti-vaccination campaign motivated by religious objections, concerns about effectiveness, and concerns about individual rights 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.[180]
UK, pertussis (1970s–80s)
In a 1974 report ascribing 36 reactions to
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.[177]
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.[181] 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.[181]
UK and Ireland, measles (2000)
As a result of the
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.[184] 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.[185] In 2006, Nigeria accounted for over half of all new polio cases worldwide.[186] Outbreaks continued thereafter; for example, at least 200 children died in a late-2007 measles outbreak in Borno State.[187]
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.[188]
A 2005 measles outbreak in the US state of Indiana was attributed to parents who had refused to have their children vaccinated.[189]
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.[190][191]
The number of cases in 2014 quadrupled to 644,[192] including transmission by unvaccinated visitors to Disneyland in California, during the Disneyland measles outbreak.[76][193] 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 patients (165 out of 288, or 57%) during that time were confirmed to be unvaccinated by choice; 30 (10%) were confirmed to have been vaccinated.[194] The final count of measles in 2014 was 668 cases in 27 states.[195]
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.
By July 2016, a three-month measles outbreak affecting at least 22 people was spread by unvaccinated employees of the
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.
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
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.[209][210][211][212][213][214]
Wales, measles (2013–)
In 2013, an outbreak of measles occurred in the Welsh city of Swansea. One death was reported.
United States, tetanus
Most cases of pediatric
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.[220] 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.[220] 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.[221]
Samoa, measles (2019)
The 2019 Samoa measles outbreak began in October 2019 and as of December 12, there were 4,995 confirmed cases of measles and 72 deaths, out of a Samoan population of 201,316.[222][223][224][225] 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.[226] UNICEF has sent 110,500 vaccines to Samoa. Tonga and Fiji have also declared states of emergency.[227]
The outbreak has been attributed to a sharp drop in
2019–2020 measles outbreaks
Countermeasures
Vaccine hesitancy is challenging and optimal strategies for approaching it remain uncertain.[230][22]
Multicomponent initiatives which include targeting undervaccinated populations, improving the convenience of and access to vaccines, educational initiatives, and mandates may improve vaccination uptake.[231][232]
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.[233]
Providing information
Many interventions designed to address vaccine hesitancy have been based on the information deficit model.[56] 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.[56] 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.[31][56]
It is unclear whether interventions intended to educate parents about vaccines improve the rate of vaccination.[231] It is also unclear whether citing the reasons of benefit to others and herd immunity improves parents' willingness to vaccinate their children.[231] 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.[231] 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.[231]
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.[135] 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).[56] 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.[56] 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."[234] 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.[31]
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.[231] A presumptive approach helps to establish that this is the normative choice.[56] 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.[56] The Centers for Disease Control and Prevention has released resources to aid healthcare providers in having more effective conversations with parents about vaccinations.[235]
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.[135] 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.[135] 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).[236] Luntz "also found a very pronounced preference for the word 'vaccine' over 'jab.'"[236]
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.[56] 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
Incentive programs
Several countries have implemented programs to counter vaccine hesitancy, including raffles, lotteries, rewards and mandates.
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
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 epidemic.[247] Despite strong opposition in the community,[248] Mather convinced Zabdiel Boylston to 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".[247] 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.[249]
Smallpox vaccination
After Edward Jenner introduced the smallpox vaccine in 1798, variolation declined and was banned in some countries.[250][251] 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,[249]: 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.[249]: 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.[252] 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[253] – 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.[254] 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.[252]: 17–21 The views of opponents of vaccination that 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.[255]
England
Because of its greater risks,
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.[259] 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.[11][256] 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.[258] 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.[260] 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.[261]
Vaccination in Wales was covered by English legislation, but the
In the late 19th century, Leicester in the UK received much attention because of how smallpox was managed there. There was particularly strong opposition to compulsory vaccination, and medical authorities had 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.
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.[266]
After an 1879 visit to New York by prominent British anti-vaccinationist
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.[273] 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.[274]
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
Diphtheria antitoxin was serum from horses that had been immunized against diphtheria, and was used to treat human cases by providing
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.[278] This was a major setback for supporters of new vaccines.[252]: 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.[279]
In 1955, in a tragedy known as the
Later 20th-century events included the 1982 broadcast of DPT: Vaccine Roulette, which sparked debate over the
Arguments against vaccines in the 21st century are often similar to those of 19th-century anti-vaccinationists.[11] Around 2014, anti-vaccine rhetoric shifted from being mostly scientific and medical arguments, such as the idea that vaccines were harming children, to political arguments, such as what David Broniatowski of George Washington University has called a "don't-tell-me-what-to-do freedom movement." At the same time, according to Renée DiResta, a researcher at the Stanford Internet Observatory, anti-vaxxers began networking with Tea Party and Second Amendment activists in a "weird libertarian crossover". This happened partly due to anti-vaccine medical arguments failing to stop the passage of SB277 in California.[285]
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.[287][288]
In the United Kingdom, a 16 November 2020
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%).[290][291]
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.[292]
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.[293][294]
A January 2022 report from Time magazine noted that the anti-vaccine movement "has repositioned itself as an opposition to mandates and government overreach."[295] A May 2022 report from The New York Times noted that "A wave of parents has been radicalized by Covid-era misinformation to reject ordinary childhood immunizations—with potentially lethal consequences."[285]
Geographical distribution
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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.[296] 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.[135][297][298][299][300][301][302] 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]
Studies have demonstrated that children of parents who refused the
Migrant populations
Migrants and refugees arriving and living in Europe face various difficulties in getting vaccinated and many of them are not fully vaccinated. People arriving from Africa, Eastern Europe, the Eastern Mediterranean, and Asia are more likely to be under-vaccinated (partial or delayed vaccination). Also, recently arrived refugees, migrants and seekers of asylum were less likely to be fully vaccinated than other people from the same groups. Those with little contact to healthcare services, no citizenship and lower income are also more likely to be under-vaccinated.[303][304]
Vaccination barriers for migrants include language/literacy barriers, lack of understanding of the need for or their entitlement to vaccines, concerns about the side-effects, health professionals lack of knowledge of vaccination guidelines for migrants, and practical/legal issues, for example, having no fixed address. Vaccines uptake of migrants can be increased by customised communications, clear policies, community-guided interventions (such as vaccine advocates), and vaccine offers in local accessible settings.[303][304]
Australia
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 researchers suggested that practical barriers are more likely to explain under-vaccination among individuals with lower socioeconomic status.[299] A 2012 Australian study found that 52% of parents had concerns about the safety of vaccines.[305]
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.[135]
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.[11][306] 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.[307]
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.[308]
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.[309]
Children's rights
Medical
A review of American 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.[312]
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.[313][314] 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.[315] 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.[135]
Religion
Since most religions predate the invention of vaccines, scriptures do not specifically address the topic of vaccination.[2] However, vaccination has been opposed by some 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.[248] Opposition from some religious groups continues to the present day, on various grounds, raising ethical difficulties when the number of unvaccinated children threatens harm to the entire population.[316] 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.[317]
Many Jewish community leaders support vaccination.
Although
In India, in 2018, a three-minute doctored clip circulated among Muslims claiming that the MR-VAC vaccine against measles and rubella was a "
Some Christians have objected to the use of cell cultures of some viral vaccines, and the virus of the
In the United States, some parents falsely claim religious exemptions when their real motivation for avoiding vaccines is supposed safety concerns.
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.[329]
Alternative medicine
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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 seeds of the modern anti-vaccination movement.[330] More specifically, some elements of the chiropractic community, some homeopaths, and naturopaths developed anti-vaccine rhetoric.[38] 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.[38]
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."[331] Vaccination remains controversial within the profession.[332] Most chiropractic writings on vaccination focus on its negative aspects.[331] A 1995 survey of US chiropractors found that about one third believed there was no scientific proof that immunization prevents disease.[332] While the Canadian Chiropractic Association supports vaccination,[331] 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.[333]
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.[332] 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.[334] 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".[335]
Policy positions
The
Homeopathy
Several surveys have shown that some practitioners of homeopathy, particularly homeopaths without any medical training, advise patients against vaccination.[339] 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.[38] Many practitioners of naturopathy also oppose vaccination.[38]
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.[340] 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."[341]
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.[342] Homeopaths in particular gain through the promotion of water injections or 'nosodes' that they allege have a 'natural' vaccine-like effect.[343] 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.
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.[347] 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.[347]
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 as colonizers the United States took a very hands-on approach in administering healthcare particularly vaccinations to natives during the invasion and conquest of these countries.[347] Although the Spanish–American War occurred during the era of "bacteriological revolution" where knowledge of disease was bolstered by germ theory, more than half of the soldier casualties in this war were from disease.[347] 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.[347] 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"[347] 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.[347] 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.[347] 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.[347] 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.[347]
Vietnam War
During the Vietnam War, vaccination was necessary for soldiers to fight overseas. Because disease follows soldiers,
Information warfare
An analysis of
Confidence in vaccines varies over place and time and among different vaccines. The
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.[356]
See also
- Chemophobia
- COVID-19 vaccine misinformation and hesitancy
- Measles resurgence in the United States
- Vaccine misinformation
- Therapeutic nihilism
- Vaccine shedding
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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". BMJ. 320 (7229): 240–43. PMID 10642238.
- Davies P, Chapman S, Leask J (July 2002). "Antivaccination activists on the world wide web". Archives of Disease in Childhood. 87 (1): 22–25. PMID 12089115.
- Richardson PD, Mohammed SF, Mason RG, Steiner M, Kane R (2004). "Dynamics of platelet interaction with surfaces in steady flow conditions". Transactions of the American Society for Artificial Internal Organs. 25 (7473): 147–51. PMID 524574.
- Friedlander E (2007). "The anti-immunization activists: a pattern of deception". 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". Epidemiology and Infection. 125 (2): 377–83. PMID 11117961.
- Herlihy SM, ISBN 978-1442215788.
- Miller CL (February 1985). "Deaths from measles in England and Wales, 1970–83". British Medical Journal. 290 (6466): 443–44. PMID 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" (PDF). SOAS Bulletin of Burma Research. 4 (1): 30–44.
- ISBN 978-0-231-14636-4.
- 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. PMID 10559531.
- Spier RE (November 1998). "Ethical aspects of vaccines and vaccination". Vaccine. 16 (19): 1788–94. PMID 9795382.
- Vermeersch E (October 1999). "Individual rights versus societal duties". Vaccine. 17 (Suppl 3): S14–17. PMID 10627239.
- Wolfe RM, Sharp LK, Lipsky MS (June 2002). "Content and design attributes of antivaccination web sites". JAMA. 287 (24): 3245–48. PMID 12076221.
- "Six common misconceptions about immunization". World Health Organization. February 16, 2006. Archived from the original on December 26, 2003. 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". 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 at Curlie
- "Immunizations, vaccines and biologicals". World Health Organization.
- "Vaccines & immunizations". Centers for Disease Control and Prevention. September 4, 2018.
- The Vaccine War. Frontline. April 27, 2010. PBS.
- Institute of Global Health Innovation (May 2021). "Global attitudes towards a COVID-19 vaccine" (PDF). Imperial College London. Covid Data Hub.
- "Vaccine Education Center". Children's Hospital of Philadelphia. November 19, 2014.