Counteracting the Anti-Vaccine Movement

IN JANUARY 2019, the anti-vaccine movement was officially named one of the 10 greatest risks to global health by the World Health Organization (WHO). According to WHO, the thriving anti-vax movement is potentially as dangerous as the vaccine-preventable diseases themselves because it threatens to reverse decades of public health progress. In a report on the topic, WHO concedes the reasons why people choose to forgo vaccination are complex, but some of the main sources of pushback include mistrust of the pharmaceutical industry; skepticism regarding scientific facts; complacency among those who were born after many communicable diseases were eradicated by vaccines; and difficulty accessing and/or affording medical care. Then, there are those who avoid vaccination for personal reasons such as religious exemption. No matter the reason, vaccine avoidance is a trend that frustrates many in the healthcare community who recognize the important role vaccines play when it comes to global disease prevention, clearly a top-of-mind topic with the COVID-19 pandemic. “Vaccination is one of the most cost-effective ways to prevent diseases. It currently avoids two to three million deaths a year, and another 1.5 million could be avoided if vaccine coverage were improved in the world,” reported WHO.¹

Vaccine-Hesitation: A Parental Prerogative

When it comes to childhood vaccines, a strong majority of parents in the United States do comply with recommended vaccination schedules. Still, the anti-vax movement in both the U.S. and globally has steadily been on the rise. The question is: Who are the “anti-vaxxers,” and what do they have in common? Understanding the psychological and demographic makeup of this highly vocal contingent may be the first step in formulating a plan to combat pervasive anti-vaccine agendas. A 2018 study published in the Journal of the Missouri State Medical Association tackled this question and uncovered some interesting commonalities, while also dispelling a few stereotypes. For example, the study found no real correlation between vaccine attitudes and socioeconomic status or education level, stating better predictors include a high level of conspiratorial thinking; a low tolerance for infringement on perceived personal freedom; aversion to needles or blood; and religious-based concerns. But regardless of individual belief systems and mind-sets, the most significant consumers of vaccine misinformation are concerned parents, specifically mothers.²

When it comes to raising children and managing healthcare choices, mothers are without question critical decision-makers. As a group, they also tend to be very active and vocal in online forums. One study on the topic of mass communication and society found mothers who contributed frequently to online conversations about healthcare topics shared several common traits. Those who didn’t strongly support childhood vaccinations were more likely to seek, pay attention to, forward information and speak out about the issue compared to those who do support childhood vaccinations. Also, those who believed vaccinations were an important issue (whether they were for or against them) were more likely to express an opinion, while those who opposed vaccinations were more likely to post their beliefs online.²

Addressing the Abundance of Misinformation

From social media posts to fully dedicated anti-vaccination websites, access to online misinformation about the safety and efficacy of vaccines abounds. One German study demonstrated individuals will perceive increased risk to vaccination after spending only five to 10 minutes scrolling through an anti-vaccination website.³ Additionally, a Canadian study suggested the odds of parents perceiving vaccines as unsafe rose considerably for those who searched for vaccine safety information online.⁴

On the flip side, access to pro-vaccination messages online has not proven to be effective when it comes to combating pre-existing bias; researchers in the 2018 Missouri study concluded that a large part of the reason people buy into the anti-vaccination mind-set is due to what’s known as “confirmation bias”; when presented with evidence opposing existing beliefs, individuals will forgo critical thinking and reject contradictory information outright. Given this bias, some direct pro-vaccination messages have actually backfired; a randomized trial on pro-vaccine communications found attempts to directly educate concerned parents with materials from the Centers for Disease Control and Prevention (CDC) served only to further reinforce their already exaggerated perception of risk.⁵ According to the study’s authors, “None of the interventions increased parental intent to vaccinate a future child. Refuting claims of an MMR/autism link successfully reduced misperceptions that vaccines cause autism but nonetheless decreased intent to vaccinate among parents who had the least favorable vaccine attitudes.”

Understanding the Money Motivation

The anti-vaccination sentiments popularized in recent decades were in part fueled by the 1998 publication of a series of articles in The Lancet by former British doctor Andrew Wakefield. Dr. Wakefield suggested a connection between the measles, mumps and rubella (MMR) vaccine and development of autism in young children. Despite his flawed research methodology and conflict of interest in funding of the study, MMR vaccine rates continued to drop dramatically, and panicked parents continued to share the articles’ findings with one another. Even after Dr. Wakefield had his United Kingdom medical license revoked, he continued to oppose state bills against vaccine exemptions and personally profit from promoting anti-vax misinformation, including through his 2016 film titled “Vaxxed: From Cover-Up to Catastrophe.” Not surprisingly, members of the anti-vaccine movement still cite Dr. Wakefield’s discredited research as a talking point in refuting vaccinations.

But Dr. Wakefield is not the only one benefiting financially from the spread of anti-vax media. For example, conspiracy theory websites like InfoWars and Natural News regularly discredit medical science while benefiting from the sale of natural supplements and products that claim to offer alternative treatments for vaccine-preventable diseases.⁶ The Washington Post reports that while one of the nation’s oldest anti-vaccine advocacy groups has claimed it is supported primarily by small donations and concerned parents, over the past decade, a single donor has contributed more than $2.9 million to its cause, accounting for about 40 percent of the organization’s funding. Court records show that donor, osteopathic physician Joseph Mercola, has amassed a fortune selling natural health products, including vitamin supplements he claims are alternatives to vaccines.⁷ And, selling supplements and making films are not the only ways to profit from promoting an anti-vaccine agenda; anti-vaccine books, seminars, speaking engagements and online ads are all revenue-generators that can clearly muddy the waters when it comes to the movement’s purported altruistic motives.

Combating Fear with Education and Legislation

In 2019, Peter Hotez, MD, PhD, FAAP, professor of pediatrics and dean of the National School of Tropical Medicine at Baylor College of Medicine, in Houston, Texas, addressed an audience at the American Academy of Pediatrics (AAP) Annual Conference and Exhibition in New Orleans, La. His session, “The Anti-Vaccine Movement in Post-Measles America: What’s Next?” offered key insights into how to address the anti-vax movement, beginning with combating laws that allow parents to attain nonmedical exemptions to vaccination.⁸

Currently, all 50 states have legislation requiring specified vaccines for students. Although exemptions vary from state to state, all school immunization laws grant exemptions to children for medical reasons. Forty-five states and Washington, D.C., grant religious exemptions for people who have religious objections to immunizations, and currently, 15 states allow philosophical exemptions for those who object to immunizations because of personal, moral or other beliefs.⁹ “The anti-vaccine movement has grown into its own political and media empire,” Dr. Hotez said. “We have to work to close nonmedical exemptions, especially in the states allowing nonmedical vaccine exemptions for personal or philosophical beliefs.”⁸

Dr. Hotez believes the first step to reversing the damage done by anti-vaccine propaganda is to dismantle the anti-vaccine media materials that are major contributors to the problem. Critics to this approach argue that stifling anti-vaccination commentary or limiting sales of anti-vaccine materials violates the First Amendment, but Dr. Hotez likens it to any retailer having the freedom to restrict the types of products they are willing to sell. Deliberate targeting of specific groups to lower vaccination rates by anti-vaccination promoters is also a widespread problem, he said, coupled with the absence of a robust pro-vaccination campaign. “Australians have done this. They put out a $12 million public service campaign,” he explained. “We need to have a more visible national public health leadership. Right now, the default is the defense of vaccines falling to a handful of academic pediatricians.”⁸

Anti-Vaxxers in the Age of COVID-19

Few global events stand poised to confront anti-vaccine viewpoints as dramatically as the COVID-19 pandemic. As the world’s scientists and pharmaceutical companies actively race to bring a vaccine to market, anti-vaxxers are already actively bracing for plans of resistance. “Refuse, demonstrate,” sums up attitudes on a British Facebook page in response to a post asking people how they would react if a COVID-19 vaccine became mandatory.¹⁰

Despite early resistance, polls show sentiments in parts of Europe may be gradually changing. In France, for example, a 2018 poll showed one in three people did not view vaccines as safe, but just 18 percent said they would refuse a coronavirus vaccine today, according to a March 2020 poll of approximately 1,000 people. The poll was taken just one day after France issued its COVID-19 lockdown. “If a vaccine were made available tomorrow, everyone would jump to get it,” said Laurent-Henri Vignaud, who co-authored a history of France’s anti-vax movement.¹⁰

Given the common mind-sets of anti-vaccine proponents, including a low tolerance for perceived risks to personal freedoms, it’s not surprising the possibility of a mandatory vaccine would raise a collective cry of protest. At the time of this writing, it remains difficult to assess what overall public sentiment may be to a coronavirus vaccine once it finally becomes available. If history is any indicator, timing is everything when it comes to vaccine receptivity. For example, there was high demand for the polio vaccine in the 1950s because the risk level of the disease was very visible and present; images of children confined in iron lungs presented a compelling reason toward vaccine compliance. On the other hand, concerns about a vaccine being “rushed” to market during the 2009 H1N1 “swine flu” pandemic led to widespread vaccine resistance amid concerns about the vaccine’s safety. Piggybacking on that line of thinking, some anti-vax groups are already using references to COVID-19 vaccine trial participants as “guinea pigs,” references that have the potential to create backlash long before an actual vaccine is made available to the public.¹

Another hurdle presented by the COVID-19 pandemic is that access to routine immunization programs may have been interrupted as health resources have been directed elsewhere and annual well-visits for both children and adults take a back seat to pandemic intervention measures. “While it may be harder to routinely vaccinate people if health resources are directed elsewhere, and there is difficulty or reluctance to go to the doctor or other places where vaccination takes place (such as schools due to closure), making the best use of the vaccines already available is crucial to avoid other disease outbreaks on top of COVID-19,” said Samantha Vanderslott, a postdoctoral researcher in social sciences at the University of Oxford.¹¹

A Multipronged Approach May Hold Promise

At a time in America when public opinion is divided on many major fronts, perhaps one approach that might begin to bridge the conversational debate about vaccine safety is a simple one: open and honest communication. Doug Opel, MD, a pediatrician at Seattle Children’s Hospital, is pioneering a study with collaborators at the University of Colorado, Denver, in which physicians are trained to use what’s called the presumptive method when conversing with parents about vaccines. Dr. Opel explains the first step is simply asking parents what their vaccine concerns are. Physicians are then counseled to validate those concerns; they should tell parents that this is a hard decision, that it is confusing to hear so much conflicting information, and that, yes, unfortunately, vaccines are not 100 percent safe. Only then should pediatricians say their expert opinion — having looked at all the available data — is that vaccinating is unequivocally the right choice. “There is this tendency to dismiss these parents who have concerns as not being knowledgeable or being exposed to some really bad information on the Internet,” says Jason Glanz, PhD, a senior research investigator with Kaiser Permanente’s Institute for Health Research in Colorado. “That’s partly true, but really they’re concerned for their children. I think it’s a small proportion who are adamantly against vaccination.”¹²

Dr. Glanz’s research on vaccine-hesitant parents uses online tools where participants can engage with information about shots with their healthcare providers, rather than just receiving a pamphlet or looking up information online. Dr. Glanz says it’s crucial to acknowledge a parent’s fears rather than dismiss his or her concerns about potential vaccine risks. Instead, physicians have to be honest with their patients; there are risks, they’re just exceedingly small and are far outweighed by the benefits. Dr. Glanz notes it’s also important for pediatricians to start vaccine conversations early during pregnancy, since his studies found parents begin forming their opinions on vaccines well before their child is born.

In addressing the recent anti-vax upsurge in measles cases and vaccine resistance in general, Dr. Glanz said, “I think there’s not going to be one solution to this. A multipronged approach involving national public health messaging, physician communication strategies and better online resources is probably how we’re going to accomplish a goal that all of us, even vaccine-hesitant parents, share: fewer measles cases.

“It took a while, but the smoking campaign worked. That used multiple modes, and it took many, many years, but it worked. We might be dealing with something similar here.”¹²