ArticlePDF Available

Impact of anti-vaccine movements on pertussis control: The untold story


Abstract and Figures

To assess the impact of anti-vaccine movements that targeted pertussis whole-cell vaccines, we compared pertussis incidence in countries where high coverage with diphtheria-tetanus-pertussis vaccines (DTP) was maintained (Hungary, the former East Germany, Poland, and the USA) with countries where immunisation was disrupted by anti-vaccine movements (Sweden, Japan, UK, The Russian Federation, Ireland, Italy, the former West Germany, and Australia). Pertussis incidence was 10 to 100 times lower in countries where high vaccine coverage was maintained than in countries where immunisation programs were compromised by anti-vaccine movements. Comparisons of neighbouring countries with high and low vaccine coverage further underscore the efficacy of these vaccines. Given the safety and cost-effectiveness of whole-cell pertussis vaccines, our study shows that, far from being obsolete, these vaccines continue to have an important role in global immunisation.
Content may be subject to copyright.
Impact of anti-vaccine movements on pertussis control: the
untold story
E J Gangarosa, A M Galazka, C R Wolfe, L M Phillips, R E Gangarosa, E Miller, R T Chen
Group I includes countries in which use of whole-cell
pertussis vaccine (in DTP) has lasted decades—eg, Hungary, the
former East Germany, Poland, and the USA. These countries
have provided comprehensive DTP coverage with little or no
interruption by anti-vaccine movements.
Group II includes countries in which peer-reviewed
publications documented that anti-vaccine movements affected
pertussis-control programmes. We defined opposition to whole-
cell pertussis vaccines as activities of groups that actively or
passively opposed use of the vaccines. Sweden, Japan, the UK,
and The Russian Federation had active opposition to whole-cell
vaccines—that is, well-organised movements that sought to stop
their use by means of news stories, television interviews, lectures,
popular articles, books, and other writings. Distraught parents
whose children suffered adverse events blamed on whole-cell
pertussis vaccination featured prominently. Some outspoken
medical authorities became leaders in these movements.
Italy, the former West Germany, Ireland, and Australia had
less organised, passive movements against whole-cell pertussis
vaccines, in which health-care providers withheld vaccines
because of safety concerns. Religious groups that oppose
vaccination have been most prominent in passive movements
against the vaccines. Parents concerned about vaccine safety did
not feature prominently in passive movements. Characteristics of
active and passive movements often overlap. Practitioners and
followers of natural, alternative, and chiropractic medicine, and
homoeopathy, have been prominent in both active and passive
anti-vaccine movements.
We used country-specific incidences reported to WHO to
compare pertussis-vaccination experiences. The numerator is
number of cases, the denominator is per 100 000 of the total
population. These data underestimate true incidence: pertussis is
underdiagnosed, especially without classic whoop and
paroxysmal cough; laboratory capabilities vary substantially;
cultures are rarely undertaken for cases not admitted to hospital;
reporting systems are usually passive; and surveillance efficiency
varies from country to country. Although not quantitatively
precise, surveillance data show overall trends and patterns.1,5
Group 1: countries with sustained use of whole-cell
pertussis vaccines
Hungary’s pertussis-control programme has
been exemplary.6Surveillance, including mandatory
reporting, began in 1931. Immunisation with whole-cell
pertussis vaccine has continued without interruption
Of the vaccine-preventable diseases, pertussis rivals
measles and neonatal tetanus in importance and severity
among young children in the developing world. Millions
of cases and hundreds of thousands of deaths occur each
year. Complications are common: pneumonia in 15% of
infants under 6 months of age, and severe neurological
sequelae in 0·1–4·0% of patients. Pertussis is an
exhausting illness that often lasts months.1Because the
disease is so serious and so difficult to treat, prevention is
Whole-cell vaccines, whether monovalent or in
diphtheria-tetanus-pertussis (DTP), have been important
in the control of pertussis.1The decrease in pertussis
incidence resulting from vaccination may have created
the impression that pertussis was becoming milder and
more scarce owing to medical and social development.2,3
As pertussis became rarer, attention shifted from the
disease to the adverse events—often unrelated—that
sometimes follow vaccination.4In several countries,
publicity surrounding such adverse events gave rise to
movements opposed to whole-cell pertussis vaccination.
This paper describes these anti-vaccine movements, their
impact on pertussis control, and the future role of whole-
cell pertussis vaccines.
We searched the literature, studied English translations of
contemporary news stories, and analysed country-specific
incidence of pertussis, whole-cell vaccine coverage, and
vaccination schedules from data compiled by the US Centers for
Disease Control and Prevention, and by WHO. We also studied
books and other publications intended for lay audiences written
by advocates against vaccination. From available relevant data,
we compared the pertussis experiences of two groups of
356 THE LANCET • Vol 351 • January 31, 1998
1998; 351: 356–61
Gangarosa International Health Foundation and Rollins School of
Public Health, Emory University, Atlanta, GA, USA
(Prof E J Gangarosa MD); World Health Organization, Geneva,
Switzerland (Prof A M Galazka MD); Centers for Disease Control
and Prevention, Georgia (GA), USA (C R Wolfe BA, R T Chen MD,
L M Phillips MPH); and PHLS Communicable Disease Surveillance
Centre, London, UK (E Miller FRCPath)
Correspondence to: Prof E J Gangarosa, 5305 Greencastle Way,
Stone Mountain, GA 30087-1427, USA
To assess the impact of anti-vaccine movements that targeted pertussis whole-cell vaccines, we compared pertussis
incidence in countries where high coverage with diphtheria-tetanus-pertussis vaccines (DTP) was maintained
(Hungary, the former East Germany, Poland, and the USA) with countries where immunisation was disrupted by anti-
vaccine movements (Sweden, Japan, UK, The Russian Federation, Ireland, Italy, the former West Germany, and
Australia). Pertussis incidence was 10 to 100 times lower in countries where high vaccine coverage was maintained
than in countries where immunisation programs were compromised by anti-vaccine movements. Comparisons of
neighbouring countries with high and low vaccine coverage further underscore the efficacy of these vaccines. Given
the safety and cost-effectiveness of whole-cell pertussis vaccines, our study shows that, far from being obsolete,
these vaccines continue to have an important role in global immunisation.
THE LANCET • Vol 351 • January 31, 1998 357
country had only one to two cases per 100 000 during
1980-90, whereas the former West Germany had an
incidence well over 100 times higher.7
since 1960, pertussis has been controlled in
Poland by means of a schedule of three primary doses
and a single booster dose, resulting in more than 95%
coverage. Reported incidence fell from 100–200 per
100 000 in the prevaccine era to about one per 100 000
after vaccination (figure 1).
pertussis has been controlled in the USA, though
there has been an upward trend in incidence since 1981
(figure 1). Concerns over safety of whole-cell pertussis
vaccine peaked in the early 1980s after the television
programme “Vaccine Roulette” and publication of the
book A Shot in the Dark.8These gave rise to a movement
against whole-cell vaccines, instigated several lawsuits
against vaccine manufacturers, substantially increased
vaccine prices, and caused some companies to stop
production of the vaccines.4Nevertheless, several
developments have favoured pertussis control. Vaccines
manufactured in the USA have generally been highly
efficacious.9,10 Paediatric and primary-care organisations
have strongly advocated vaccination. School-entry
immunisation requirements further contributed to
90–95% DTP coverage at primary-school entry. A strong
infrastructure promotes vaccination, surveillance of
adverse events, and, since 1988, compensation for post-
vaccination injuries.4,11
Group 2: countries with pertussis-control programmes
affected by active or passive movements against whole-
cell vaccines
This group initially had varying success in controlling
pertussis—first with monovalent whole-cell vaccine, and
subsequently with DTP. Reported incidence exceeded
100 per 100 000 in the late 1940s and early 1950s, when
vaccination programmes began. Coverage accelerated
during the 1960s, reaching roughly 80% during the
1970s. The consequent fall in reported incidence, ranging
from ten-fold to 100-fold, set the stage for movements
against whole-cell pertussis vaccines.
pertussis vaccination began in the 1950s. A
substantial drop in incidence followed. In 1967, an
influential medical leader, Justus Ström claimed that
pertussis had become a milder disease owing to
economic, social, and medical progress; this claim led
him to question the need for pertussis vaccines.2By 1975,
Swedish paediatricians had lost confidence in the vaccine
as the incidence of pertussis increased. Some cases
occurred in immunised children, and some neurological
events were blamed on the vaccine. DTP coverage
decreased rapidly from 90% in 1974 to 12% in 1979.12 In
1979, the Swedish medical society abandoned whole-cell
pertussis vaccine and decided to wait for a new, safer,
more effective vaccine—a strategy that was soon adopted
as national policy. During 1980-83, annual incidence for
children aged 0–4 years increased to 3370 per 100 000,12
with rates of serious complications approaching global
rates.1In subsequent years, Sweden reported more than
10 000 cases annually with an incidence exceeding 100
per 100 000, comparable to rates reported in some
developing countries1(figure 2).
vaccination against pertussis began in 1947. By
1974, there were few cases and no deaths.13 During a
since 1955. Vaccine coverage with three primary and two
booster doses has been nearly 100%. Reported incidences
fell from more than 100 per 100 000 in the prevaccine era
to less than one per 100 000 after vaccination, where they
have remained for almost 30 years (figure 1).
The former East Germany
Germany before unification
provides striking contrast in pertussis experiences. The
former West Germany adopted a non-compulsory
vaccination policy, resulting in low coverage. The former
East Germany, however, achieved control (figure 1) by
requiring vaccination to consist of three primary doses
and a single booster dose of DTP. Thus, in 1989, DTP
coverage in the former East Germany was 95%. The
1945 1960 1975 1990
1974 76 78 80 82 84 86 88 90 92 94 96
1960 1970 1980
Former East Germany
76 78 80 82 84 86 88 90 92 94 96
Incidence per 100 000 Incidence per 100 000 Incidence per 100 000 Incidence per 100 000
Figure 1: Incidence of pertussis in countries with sustained
use of whole-cell vaccines
Note that scales vary.
older than 2 years. Pertussis coverage for infants fell from
nearly 80% in 1974 to 10% in 1976.13 A pertussis
epidemic occurred in 1979 with more than 13 000 cases
and 41 deaths. Japan began replacing whole-cell with
acellular pertussis vaccines in 1981, and a striking fall in
pertussis incidence followed (figure 2).
after a 1974 report, ascribing 36 neurological
reactions to whole-cell pertussis vaccine,16 persistent
television and press coverage interrupted a successful
vaccination programme (figure 2). A prominent public-
health academic, Dr Gordon Stewart, claimed that the
protective effect of the vaccine was marginal and did not
outweigh its danger.3Others reached opposite
conclusions based on the fall in pertussis incidence after
introduction of the vaccine in the 1950s.17 Although
health authorities resisted pressure to withdraw the
vaccine, loss of confidence in it led to a sharp reduction
in coverage. Pertussis epidemics followed (figure 2).
Confidence was restored after publication of a national
reassessment of vaccine efficacy that showed
“outstanding value in preventing serious disease”.18
Provision of financial incentives for general practitioners
who achieved the target of vaccine coverage contributed
to the recovery.19 Disease incidence declined dramatically,
and has since been low (figure 2).
The Russian Federation
The Soviet Union assigned
high priority to compulsory immunisation, thereby
achieving control of vaccine-preventable diseases,
including pertussis. The anti-government bias of
Perestroika gave rise to an active anti-vaccine movement
that targeted DTP. Inspired by the virologist Galina
Chervonskaya, the mass media initiated an active
campaign to discredit vaccination. Another prominent
physician, A V Pichnohkov, asserted that the vaccine
would cause leukaemia and was “stressful” for the child's
system. Chervonskaya, Pichnohkov, and other
paediatricians have propounded an excessive list of
contraindications, specifying more than 50 diagnoses in
which DTP vaccine should not be given. A series of
“unbalanced statements” about the dangers and
ineffectiveness of vaccines were featured in medical
journals, on radio, on television, and in the popular press.
Parents and physicians lost confidence in vaccines, and
chose not to immunise children. DTP coverage fell by
30%, setting the stage for diphtheria and pertussis
epidemics.20 Along with perhaps the largest postwar
diphtheria outbreak, The Russian Federation has
reported one of the highest incidences of pertussis in the
developed world (figure 2).
Ireland’s vaccination programme initially
lowered pertussis incidence from 79 per 100 000 in 1955
to about ten per 100 000 in the mid-1970s. The trend
reversed in the mid-1970s with opposition to whole-cell
pertussis vaccine in the UK.21 Vaccine coverage fell from
more than 60% in the early 1970s to 30% after 1976.
Epidemics occurred in 1985 and 1989. In 1990, only
65% of infants had received three primary doses.
Incidence remained higher than ten per 100 000 through
1993 (figure 3).
Binkin and colleagues22 studied pertussis in Italy
(figure 3) using a national vaccination-coverage survey
done in 1985, sales data from vaccine manufacturers, and
Italy’s infectious-diseases surveillance system. Fewer than
40% of children under 5 years were vaccinated, and
national debate about adverse events resulting from
smallpox vaccine, news reports of neurological reactions
after DTP vaccination gave rise to Japan's movement
against whole-cell pertussis vaccines. Activists alarmed
the public with “unbalanced arguments concerning
vaccine risks” and claimed that “vaccination would no
longer be needed” because “there was practically no more
pertussis in the community”.14 This national debate
effectively created “a social problem”.15 In response, the
Okayama Prefectural Medical Association switched from
DTP to diphtheria-tetanus vaccine (DT) only. After two
infants died within 24 h of receiving DTP, the Ministry of
Health and Welfare eliminated whole-cell pertussis
vaccine altogether. They later allowed it only for children
358 THE LANCET • Vol 351 • January 31, 1998
The Russian Federation
England and Wales
1955 65 75
85 95
1940 1950 1960 1970
1980 1990
55 70
Whole-cell vaccine coverage
substantially decreased
Movements against whole-cell pertussls vaccines
DTP introduced
DTP introduced
Acellular vaccine
introduced 1981
DTP Introduced 1947
Incidence per 100 000Incidence per 100 000Incidence per 100 000Incidence per 100 000
Figure 2: Incidence of pertussis in countries affected by active
anti-vaccine movements
Note that scales vary.
THE LANCET • Vol 351 • January 31, 1998 359
vaccine efficacy with the exception of reported
anomalies27—eg, low efficacy in Canada28 and in a 1996
field trial in Europe.29 Higher vaccine coverage in
Norway, Portugal, Hungary, and the USA corresponded
to a pertussis incidence ten to 100 times smaller than in
each country's respective lower-protected neighbour—ie,
Sweden, Spain, Greece, and Canada (figure 4). The most
striking comparison, between the former West Germany
and East Germany, cannot be quantified because
pertussis was not reportable in West Germany.
Our findings provide strong evidence of a causal relation
between movements against whole-cell pertussis vaccine
and pertussis epidemics, based on Hill’s criteria:30
strength of association (eg, incidence ratios exceeding
100 to 1, Sweden vs Norway; 150 to 20 comparing peak
incidence for Sweden in 1990 during antivaccine era vs
Sweden in 1972 with highest whole-cell vaccine
coverage); consistency of findings under different
surveillance systems, time periods, and populations;
specificity of infection affecting primarily unvaccinated or
undervaccinated individuals; temporal relation
about 25% had experienced clinical pertussis by the age
of 5 years. Among children younger than 1 year, one in
14 was admitted to hospital for pertussis, and one in 850
of these admissions died. The reported annual incidence
between 1980 and 1989 was 22 times higher than in the
USA. A seroepidemiological study of pertussis by
Stroffolini and colleagues confirmed “a great exposure of
children” and “extremely low” vaccine coverage in
Palermo.23 In a 1991 telephone survey,22 Binkin found
that paediatricians’ attitudes about whole-cell pertussis
vaccine varied widely. In some regions, only 20% of
paediatricians recommended DTP, compared with 100%
in other regions. By contrast, another survey showed that
mothers accepted the vaccine—87% perceived pertussis
as a dangerous disease, 69% were aware that the vaccine
was available, 90% believed that the vaccine was
protective, and 87% said they would accept their
paediatrician's advice on vaccination. Binkin reported
that the factors that gave rise to Italy's pertussis dilemma
were the attitudes, knowledge, and practices of physician
providers.22 In 1995, only 50% of children in Italy had
received three primary doses and a single booster as part
of their routine schedule.
Australia controlled pertussis during the
1970s, with an incidence rate as low as one per 100 000
(figure 3). However, confidence in the vaccine waned
when news was received from the UK about alleged
neurological reactions associated with the vaccine.24 In a
postal survey from the early 1990s, McIntryre and Nolan
found that up to 58% of randomly selected vaccine
providers would give DT when DTP was indicated.25 In
1993, Lester and Nolan warned that “geographically
clustered populations of children who have inadequate
pertussis protection could promote epidemic
outbreaks”.25 A large outbreak with more than 5000 cases
occurred in 1994 (figure 3).
Dr Viera Scheibner, Australia's prominent opponent of
whole-cell pertussis vaccines, claims that these vaccines
are ineffective and “constitute an assault on the immune
system”. Her 1996 book has been marketed as “the most
well documented evidence against vaccines to be found
anywhere in the world”.26
The former West Germany
the contrast between the
former West Germany and East Germany provides
perhaps the most striking example of the national danger
of antivaccine movements. Finger and colleagues
analysed vaccination histories and incidence of pertussis
among West German children at school entrance.7
Coverage with whole-cell pertussis vaccine was fairly
constant at 11·0% and 11·2% for children born in 1976
or 1983, respectively. Pertussis was reported in 35%
(1976) and 37% (1983) of these children. The authors
estimated that incidence in West Germany was 180 per
100 000 during this period. They attributed the high
incidence to health-care providers who believed the
disease to be a “normal” childhood illness.
Contrasting experiences of neighbouring countries with
high and low DTP protection, 1985-95
The efficacy of whole-cell vaccine is also evident in the
comparison of experiences in adjacent countries with
different DTP protection—measured by the percentage
of infants covered and the number of primary and booster
doses in immunisation schedules. Without complete
information, we assume a generally uniform whole-cell
1974 76 78 80 82 84
86 88 90 92
Incidence per 100 000Incidence per 100 000
Incidence per 100 000
1974 76 78 80 82 84
86 88 90 92 94 96
7876 80 82 84 86 88 90 92 94
Figure 3: Incidence of pertussis in countries affected by
passive anti-vaccine movements
Note that scales vary.
360 THE LANCET • Vol 351 • January 31, 1998
eradication, in which high vaccine coverage prevents
disease through mass vaccination and surveillance-
containment strategies.
This study shows overall trends, though not a precise
comparison of reported incidence, since practices of
pertussis diagnosis and surveillance differ according to
country.1A policy against whole-cell pertussis vaccination
had a qualitatively similar adverse impact in Sweden,
Japan, the UK, The Russian Federation, Ireland, Italy,
the former West Germany, and Australia. Conversely,
sustained vaccination has controlled pertussis in
Hungary, Poland, the former East Germany, and the
USA. A dose-response relation is evident: extremes of
vaccination coverage (eg, Hungary vs Sweden) spanned
reported incidence of ten to 100 times, whereas smaller
differences in coverage or efficacy (eg, USA vs Canada)
showed intermediate effects.
Anti-vaccine advocates do not mention, minimise, or
deny the consequences of compromised immunisation
programmes.8,26 This article documents those
consequences. Cases among children deprived of vaccine
may have exceeded hundreds of thousands, and disease-
related clinical complications (eg, pneumonia,
encephalopathy, and seizures) may have numbered tens
of thousands. Anti-vaccine movements have had some
beneficial effects. Their call for safer vaccines
underscored the need for acellular vaccines against
pertussis, and their efforts have encouraged surveillance
of adverse events and development of vaccine-injury
compensation programmes.
Our findings also corroborate Fine and Clarkson's
analysis31 that once high vaccine uptake and herd
immunity are attained, perceived vaccine risks tend to
deter individuals from being vaccinated. The result is a
lowering of vaccine uptake, contrary to the community's
common interest in maintaining high numbers of
immunised individuals. What follows is a “tragedy of the
commons”—a loss of confidence in vaccine and a
resurgence of disease.32 These tragedies were abetted by
anti-vaccine advocates through unbalanced news media
accounts of perceived vaccine risks.33 Some of these
advocates have been prominent figures in science and
medicine.2,3,26,34 They have argued that vaccines
compromise the immune system, inappropriately
questioned vaccine efficacy when sporadic cases occurred
in immunised children,35 advocated a long list of
unwarranted contraindications to vaccination, warned
that adverse events to the vaccine might be more
common than reported, and attributed “disappearance”
of pertussis to social and medical developments rather
than vaccination. These messages undermined
confidence in whole-cell pertussis vaccines, and, though
discredited in medical literature, are still commonly cited
in anti-vaccine literature.8,26
Severe side-effects of whole-cell pertussis vaccines are
so rare that they defy measurement. The American
Academy of Pediatrics, the USA's National Vaccine
Advisory Committee, and the Advisory Committee on
Immunization Practices, concur that whole-cell pertussis
vaccine is not a proven cause of brain damage, sudden
infant death syndrome (SIDS), infantile spasms, or
Reye's syndrome.36,37 Anaphylactic reactions to DTP
components are exceedingly rare. In the USA, lawsuits
have favoured plaintiffs alleging complications related to
whole-cell pertussis vaccination, but the High Court of
the UK ruled that a causal link had not been proven.38
(epidemics follow cessation of vaccination and recede
with resumed vaccine coverage); biological gradient
(dose-response effect seen—eg, in incidence vs vaccine
coverage in the UK, 1963-95); plausibility that
vaccination is protective, that herd immunity suppresses
transmission, and that successful disease-control
encourages complacency4; coherence of evidence—ie, no
conflict with the natural history of pertussis; and
experimental evidence plus analogy—eg, smallpox
1974 76 78 80 82 84
86 88 90 92 94 96
1974 76 78 80 82 84
86 88 90 92 94 96
1974 76 78 80 82 84
86 88 90 92 94 96
1974 76 78 80 82 84
86 88 90 92 94 96
Sweden: no DTP coverage
Spain: 88% coverage
/4-dose schedule
Greece: 78% coverage
/5-dose schedule
Canada: 93% coverage/5-dose schedule
with reduced-potency vaccine
Norway: 92% coverage
/3-dose schedule
Portugal: 93% coverage/5-dose schedule
100% coverage/5-dose schedule
Sweden and Norway
Spain and Portugal
Greece and Hungary
Canada and the USA
USA: 94% coverage/5-dose schedule
Incidence per 100 000 Incidence per 100 000 Incidence per 100 000 Incidence per 100 000
Figure 4: Incidence of pertussis in neighbouring countries with
low DTP vaccine coverage
Note that scales vary. Information on coverage and dose schedules
based on 1993-95 data.
THE LANCET • Vol 351 • January 31, 1998 361
Mild local and systemic reactions (fever, fussiness,
drowsiness, and brief loss of appetite) are fairly common
with the vaccine, whereas moderate reactions (long
periods of crying, sometimes at an unusually high pitch,
limpness, and pallor) are rare.
Since acellular vaccines cause fewer side-effects,9,27,29
some developed countries (eg, the USA) plan to switch to
such vaccines after using up existing supplies of whole-
cell pertussis vaccines. However, use of whole-cell
pertussis vaccines in the UK will probably continue
pending studies of acellular pertussis vaccine’s relative
efficacy, reactivity, and compatibility with Haemophilus
influenzae type-B vaccine.39 The choice between whole-
cell and acellular pertussis vaccines involves trade-offs
between safety, efficacy, practicality, and cost. In addition
to fewer mild or moderate reactions, acellular vaccine
could interrupt disease transmission by means of its
potential use in adolescents and adults. However, the best
acellular vaccines may not provide protection equal to
that of the best whole-cell vaccines.27 Replacement of
whole-cell pertussis vaccines with acellular vaccines might
conceivably lead to less effective control at substantially
higher costs. Despite the advantages of acellular vaccines,
we believe that lower costs and better protection are
compelling reasons for use of whole-cell pertussis
vaccines to continue in many countries, particularly those
with limited resources.40 Scientists and physicians who
choose acellular vaccine for their country have a special
responsibility to strengthen their surveillance to monitor
disease impact, costs, and rare adverse events—
information that will guide others in the future.
Whereas our study focused on morbidity following
anti-vaccine movements against whole-cell vaccines,
other reports indicate that pertussis mortality also
increased. Excess sudden postperinatal deaths were
inversely related to vaccination coverage during pertussis
outbreaks in several observational studies and in two
ecological studies—one in the UK41 and the other in
1 Galazka A. Control of pertussis in the world. World Health Stat Q
1992; 45: 238–47.
2 Ström J. Is universal vaccination against pertussis always justified?
BMJ 1960; 2: 1184–86.
3 Stewart GT. Vaccination against whooping-cough. Lancet 1977; i:
4 Chen RT, Rastogi SC, Mullen JR, et al. The vaccine adverse event
reporting system (VAERS). Vaccine 1994; 12: 542–50.
5 Sutter RW, Cochi SL. Pertussis hospitalizations and mortality in the
United States, 1985-1988: evaluation of the completeness of national
reporting. JAMA 1992; 267: 386–91.
6 Joo I. Epidemiology of pertussis in Hungary. In: Symposium on
pertussis: valuation and research on acellular pertussis vaccines.
Dev Biol Stand 1991; 73: 357–59.
7 Finger H, Wirsing von Konig CH, Tacken A, and Wassilak SG. The
epidemiological situation of pertussis in the Federal Republic of
Germany. In: Symposium on pertussis: evaluation and research on
acellular pertussis vaccines. Dev Biol Stand 1991; 73: 343–55.
8 Coulter HL, Fisher BL. DTP: a shot in the dark: why the P in the
DTP vaccination may be hazardous to your child's health. New York,
Garden City Park: Avery Publishing Group Inc, 1991.
9 Centers for Disease Control and Prevention. Pertussis vaccination: use
of acellular pertussis vaccines among infants and young children:
recommendations of the Advisory Committee on Immunization
Practices. MMWR CDC Surveill Sum 1997; 46 (RR-7): 1–25.
10 Onorato IM, Wassilak SG, Mead B. Efficacy of whole-cell pertussis
vaccine in preschool children in the United States. JAMA 1992; 267:
11 Evans G. Vaccine liability and safety: a progress report. Pediatric Infect
Dis J 1996; 15: 477–78.
12 Romanus V, Jonsell R, Bergquist S. Pertussis in Sweden after the
cessation of general immunization in 1979. Pediatr Infect Dis J 1987; 6:
13 Kimura M, Kuno-Sakai H. Developments in pertussis immunisation
in Japan. Lancet 1990; 336: 30–32.
14 Kanai K. Japan's experience in pertussis epidemiology and vaccination
in the past thirty years. Jpn J Med Sci Biol 1980; 33: 107–43.
15 Kimura M, Kuno-Sakai H. Immunization system in Japan.
Acta Paediatr Jpn 1988; 30: 109–26.
16 Kulenkampff M, Schwartzman JS, Wilson J. Neurological
complications of pertussis inoculation. Arch Dis Child 1974; 49:
17 Malleson PN, Bennett JC. Whooping-cough admissions to a paediatric
hospital over 10 years: the protective value of immunisation. Lancet
1977; i: 237–39.
18 PHLS epidemiological research laboratory. Efficacy of pertussis
vaccination in England. BMJ 1982; 285: 357–59.
19 Salisbury D. The immunization program in England: 25th National
Immunization Conference Proceedings 1991, Centers for Disease
Control and Prevention, Atlanta, GA, 1992: 49–52.
20 Velimirovic B. Hostility to immunization, presented at the WHO
Meeting of National Programme Managers, St. Vincent/Val d'Aosta.
Copenhagen: World Health Organization/Expanded Programme on
Immunizations/European Regional Office, 1991.
21 Howell F, Jennings S. The epidemiology of pertussis in the Republic
of Ireland. Commun Dis Rep CDR Rev 1992; 2: R31–33.
22 Binkin NJ, Salmaso S, Tozzi AE, Scuderi G. Epidemiology of
pertussis in a developed country with low vaccination coverage: Italian
experience. Pediatr Infect Dis J 1992; 11: 653–61.
23 Stroffolini T, Giammanco A, De Crescenzo L, et al. Prevalence of
pertussis IgG antibodies in children in Palermo, Italy. Infection 1989;
17: 280–83.
24 McIntyre CR, Nolan T. Attitudes of Victorian vaccine providers to
pertussis vaccine. Med J Austr 1994; 161: 295–99.
25 Lester R, Nolan T. DT vaccine in place of DTP vaccine for children
(editorial). Med J Austr 1993; 159: 631.
26 Scheibner V. Vaccination: 100 years of orthodox research shows that
vaccines represent a medical assault on the immune system. Santa Fe,
NM: New Atlantean Press, 1996.
27 Plotkin SA, Cadoz M. The acellular pertussis vaccine trials: an
interpretation. Pediatr Infect Dis J 1997;16: 508–17.
28 Halperin SA, Bortolussi R, MacLean D, Chisholm N. Persistence of
pertussis in an immunized population: results of the Nova Scotia
enhanced pertussis surveillance program. J Pediatr 1989; 115: 686–93.
29 Greco D, Salmaso S, Mastrantonio P, et al. A controlled trial of two
acellular vaccines and one whole-cell vaccine against pertussis.
N Engl J Med 1996; 334: 341–48.
30 Hill AB. The environment and disease: association or causation?: the
President's address. Proc R Soc Med 1965; 58: 295–300.
31 Fine PEM, Clarkson JA. Individual versus public priorities in the
determination of optimal vaccination policies. Am J Epidemiol 1986;
124: 1012–20.
32 Hardin G. The tragedy of the commons. Science 1968; 162:
33 Freed GL, Katz SL, Clark SJ. Safety of vaccinations: Miss America,
the media, and public health. JAMA 1996; 276: 1869–1918.
34 Mendelsohn R. Immunizations: the terrible risks your children face
that your doctor won't reveal. Evanston, IL: The Peoples Doctor Inc,
35 Orenstein WA, Bernier RH, Hinman AR. Assessing vaccine efficacy in
the field. Epidemiol Rev 1988; 10: 212–41.
36 Committee on Infectious Diseases (the Red Book Committee). The
relationship between pertussis vaccine and central nervous system
sequelae: continuing assessment. Pediatrics 1996; 97: 279–81.
37 Centers for Disease Control and Prevention. Update: vaccine side
effects, adverse reactions, contraindications, and precautions after
DTP vaccination: recommendations of the Advisory Committee on
Immunization Practices (ACIP). MMWR CDC Surveill Summ 1996;
45: 22–35.
38 Griffith AH. Permanent brain damage and pertussis vaccination: is the
end of the saga in sight? Vaccine 1989; 7: 199–210.
39 Miller E. Pertussis vaccine trials: public health implications: United
Kingdom. Dev Biol Stand 1996; 89: 301–02.
40 Taylor CE, Cutts F, Taylor ME. Ethical dilemmas in current planning
for polio eradication. Am J Public Health 1997; 87: 922–25.
41 Nicholl A, Gardner A. Whooping cough and unrecognized
postperinatal mortality. Arch Dis Child 1988; 63: 41–47.
42 Lindgren C, Milerad J, Lagercrantz H. Sudden infant death and
prevalence of whooping cough in the Swedish and Norwegian
communities. Eur J Paediatr 1997; 156: 405–09.
... Provision of financial incentives for general practitioners who achieved the target of vaccine coverage contributed to the recovery. Disease incidence declined dramatically, and has since been low (Gangarosa et al, 1998). Also from the mid of 1990, in the UK public concern about possible reported links of MMR to autism and inflammatory bowel disease (IBD) has significantly reduced vaccine uptake to level that may allow reappearance of wild virus activity, In 1998 Dr. Andrew ...
... Pertussis can also cause severe pneumonia or seizures (Offit and Bell, 2003). Tetanus is the only vaccine-preventable disease that is infectious but is not contagious, tetanus particularly the neonatal form remains a significant public health problem in non-industrialized countries (Gangarosa et al, 1998). The CDC recommends that adults receive a booster vaccine every ten years, and standard care practice in many places is to give the booster to any patient with a puncture wound who is uncertain of when he or she was last vaccinated, or if he or she has had fewer than 3 lifetime doses of the Subsequent routine Td boosters are recommended every 10 years (Allender, 2005). ...
... Despite substantial evidence of vaccine safety and effectiveness, the media have played a role in keeping vaccination concerns existing. Several studies have shown that media controversy has a negative impact on vaccine uptake [38][39][40][41][42][43][44]. Although most people with health concerns still consult health experts, the Internet has become a crucial source of information [45]. ...
Full-text available
(1) Background: vaccine hesitancy can put the public's health at risk from vaccine-preventable diseases. This study aimed to address vaccine hesitancy in Saudi Arabia and understand the problem's magnitude and causes. (2) Methods: this was a descriptive observational study using quantitative and qualitative evaluation methods conducted in Saudi Arabia between December 2020 and February 2021. Public survey forms, exit interviews, and healthcare professional survey forms were used. (3) Results: our study involved 2030 public survey participants, 119 exit interviews of caregivers, and 500 healthcare professionals, demonstrating that vaccine hesitancy was relatively low. Ninety percent of the participants agreed that it was essential for everyone to receive the recommended vaccines with their children (p < 0.001), 92% believed that vaccines are safe for their children (p < 0.001), 91% of the participants agreed to give their new children all the recommended doses (p < 0.001), 86% welcomed mass/school vaccination campaigns (p < 0.001), and 81% were willing to pay for additional vaccines for themselves and their children (p < 0.001). (4) Conclusions: vaccine hesitancy is low in Saudi Arabia, and a positive attitude toward vaccination was detected among most of the participants. Vaccination decision-making is complex and includes emotional, cultural, social, spiritual, and political aspects.
... Vaccine hesitancy has been an age-old challenge faced not only in India 9 but even in developed countries. 10 Despite the contributions of vaccines to public health, many parents are hesitant towards vaccines, either delaying them or not giving them at all for their children. This has repercussions not only on the individual health but also on the society in case of outbreaks. ...
Full-text available
Background: Despite the acceptance of COVID-19 vaccination by adults, the parents are hesitant to vaccinate their children due to safety, side effects and efficiency concerns. The objective of the present study is to find acceptance of the COVID-19 vaccine for children among mothers. Materials and Method: This was a cross-sectional study conducted among mothers of children 2-12 years residing in a village of field practice area of Chettinad Hospital and Research Institute, Chengalpet district. A pre-tested, semi-structured questionnaire was used. Vaccine hesitancy was scored with the Likert scale. The data collected was entered and analysed with SPSS IBM version 22.0. Results: Among the study participants, the majority of the mothers 121 (90%) had more than 4 visits during their antenatal period. Institutional deliveries 124 (92%) were reported by mothers. The majority of the children 114 (82%) were fully vaccinated as per the immunisation schedule. Few of the mothers 46 (34.3%) reported that adults in the family are yet to be completely vaccinated for COVID-19. 13 (10%) of the mothers reported that there was a COVID-19 related death in the family or neighbourhood. Among the mothers, 50 (37%) had COVID-19 vaccine hesitancy and were not willing to vaccinate their children. Mothers’ education, COVID-19 deaths in family or neighbourhood, fathers’ education were the determining factors for vaccine acceptance. Conclusion: Before planning vaccination on a mass scale, we need to increase the acceptance rate through awareness and educational programmes.
... Despite the study concluding that these complications were extremely rare and the risks of immunisation outweighed the risks of disease [9], many parents in Britain refused to vaccinate their children against pertussis throughout the 1970s and 1980s. Between 1971 and 1974, vaccination rates dropped significantly from 78.5% to 37% [11], leading to severe strain on the NHS [12,13]. ...
Full-text available
Vaccine hesitancy is an ongoing concern, presenting a major threat to global health. SARS-CoV-2 COVID-19 vaccinations are no exception as misinformation began to circulate on social media early in their development. Twitter’s Application Programming Interface (API) for Python was used to collect 137,781 tweets between 1 July 2021 and 21 July 2021 using 43 search terms relating to COVID-19 vaccines. Tweets were analysed for sentiment using Microsoft Azure (a machine learning approach) and the VADER sentiment analysis model (a lexicon-based approach), where the Natural Language Processing Toolkit (NLTK) assessed whether tweets represented positive, negative or neutral opinions. The majority of tweets were found to be negative in sentiment (53,899), followed by positive (53,071) and neutral (30,811). The negative tweets displayed a higher intensity of sentiment than positive tweets. A questionnaire was distributed and analysis found that individuals with full vaccination histories were less concerned about receiving and were more likely to accept the vaccine. Overall, we determined that this sentiment-based approach is useful to establish levels of vaccine hesitancy in the general public and, alongside the questionnaire, suggests strategies to combat specific concerns and misinformation.
Full-text available
Vaccine hesitancy is currently recognized by the WHO as a major threat to global health. Recently, especially during the COVID-19 pandemic, there has been a growing interest in the role of social media in the propagation of false information and fringe narratives regarding vaccination. Using a sample of approximately 60 billion tweets, we conduct a large-scale analysis of the vaccine discourse on Twitter. We use methods from deep learning and transfer learning to estimate the vaccine sentiments expressed in tweets, then categorize individual-level user attitude towards vaccines. Drawing on an interaction graph representing mutual interactions between users, we analyze the interplay between vaccine stances, interaction network, and the information sources shared by users in vaccine-related contexts. We find that strongly anti-vaccine users frequently share content from sources of a commercial nature; typically sources which sell alternative health products for profit. An interesting aspect of this finding is that concerns regarding commercial conflicts of interests are often cited as one of the major factors in vaccine hesitancy. Further, we show that the debate is highly polarized, in the sense that users with similar stances on vaccination interact preferentially with one another. Extending this insight, we provide evidence of an epistemic echo chamber effect, where users are exposed to highly dissimilar sources of vaccine information, depending the vaccination stance of their contacts. Our findings highlight the importance of understanding and addressing vaccine mis- and dis-information in the context in which they are disseminated in social networks.
Vaccination is one of the essential areas of preventive medicine for protecting the population from diseases and infections. They have helped reduce the incidence of severe childhood diseases and, in some cases, have even eradicated some of the world’s infectious diseases. However, since the first available vaccine against smallpox, antivaccine prophylaxis has always accompanied an antivaccine movement based on various myths. More recently, the development of this movement is connected for many reasons. First of all, it is associated with forgetting the world’s population of the severity of many infectious diseases, the consequences of epidemics, and the availability of any information on the Internet. Leading to myths, parents refuse to vaccinate their children, resulting in reduced vaccination coverage, reduced collective immunity and outbreaks of diseases that have already been considered conquered. The article reviews the literature on the results of anti-vaccination research conducted in the Russian Federation and abroad concerning the causes, main postulates of this movement, trends and directions. Scientific evidence is presented that disproves anti-vaccination myths, and the primary arguments for vaccination are presented. The article describes the anti-vaccination movement’s worldwide trend and the Russian features. The position of WHO is presented about overcoming barriers to the adoption and use of vaccines.
Introduction: The COVID-19 pandemic spread rapidly across the world, prompting governments to impose lengthy restrictions on both movement and trade. While lockdowns reduce the prevalence of COVID-19 disease, they may have a negative impact on the economy and job levels. Dental medicine has been one of the most severely impacted industries during this crisis. Dental professionals are exposed to environments with high levels of occupational hazards, additional risks of viral exposure, and transmission. Methods: We analyzed 705 anonymous questionnaires filled out by dentists, dental students, and postgraduate students about their willingness to consider a new SARS-CoV-2 vaccine. Results: Our findings show a statistically significant relationship between an individual's unemployment rate and their ability to be immunized with a SARS-CoV-2 vaccine. Conclusion: As part of the global vaccination program's alertness, these data may be used to forecast patterns in vaccine adoption or denial depending on economic burden during the COVID-19 pandemic by various industries.
We want to present the book “Current Challenges of Human Rights, Rule of Law and Democracy,” which is the result of a collaboration of young scholars from member states of the Council of Europe, an international organization comprising 47 countries from the continent. The volume consists of fourteen articles by fifteen scholars representing prestigious research centers involved in in-depth research on law and human rights. The authors of the texts included in this book are academics and practitioners from ten university centers from Poland, Italy, Bosnia and Herzegovina, and Ukraine. The current challenges addressed in the book are global and cross-border in nature, requiring collaboration and an integrated approach. The book consists of three parts, reflecting the richness of the subject matter undertaken by young researchers. The editors aim to present the current challenges faced by Europe and integrate the community of young lawyers in this part of Europe. The collected material is divided into three sections, each containing four scholarly papers addressing current challenges. The different parts of the book deal with human rights, democracy, and the rule of law, respectively, i.e., the pillars of the Council of Europe. Part one of the book, entitled “New and Emerging Human Rights Issues in the COVID-19 Crisis,” addresses current social, political, and legal developments. In this part of the monograph, the agenda begins with Michał Lewandowski’s text entitled “Nullum crimen sine lege – Stefan Glaser’s concept AD 1942”, concerning a fundamental principle that should guide all democratic states. On the other hand, in the paper entitled “Criminal Law and Pandemic: a Brief Overview of Criminal Law Regulation of Crimes Against Health in Bosnia and Herzegovina,” Ena Kazić-Çakar presents the unexpected consequences of the pandemic in the sphere of criminal law and human rights. In the later part of the book, Oksana V. Kiriiak provides a thorough analysis of the substantive law of human rights in the paper “The Right to Be Forgotten: the Emerging Legal Issues.” The first part of the book is concluded with apt remarks by Katarzyna Kucharska, Agnieszka Skoczylas and Robert Tabaszewski on the role of nurses and caregivers in shaping vaccination attitudes from the perspective of child rights and human rights. Part two of the book, entitled “Social Rights and Employment Issues in a Democratic Society,” reflects on contemporary social rights issues in a democratic society. It begins with an in-depth analysis by Mateusz Hypiak entitled “The Right to Work as a Human Right.” The author very aptly presents the content of this right, referring to both national, international, and European regulations. Łucja Kobroń-Gąsiorowska, based on the example of Poland, presents “Limitations on the Level of Whistleblower Protections in the Labor Law –Poland.” In the paper entitled “Defamation and Deformation of the Judge’s Image,” Inna Spasibo-Fateeva presented the judge’s behavior in the proceedings and everyday life. Dariusz Kała conducted a comprehensive analysis in his paper “Organization of Voluntary Fire Services in Poland as an Emanation of the Democratic System of Contemporary Poland.” This part of the volume is concluded with reflections by Svitlana I. Zapara, entitled “Protection of the Rights and Freedoms of Ukrainian Labor Migrants in the Era of Globalization,” which presents a comprehensive analysis of the legal situation of a labor migrant in the context of national and European conditions. The starting point for the book’s third part, entitled “Preparing for a Post-COVID-19 the Rule of Law” is the rule of law. Comprehensive knowledge of “The Right of Indigenous Peoples to Land: an American Perspective” is provided by Dawid Majchrzak’s text, which presents the human rights institutions of the inter-American system. The legal analysis opens with a research paper by Martino Reviglio entitled “Soft Law and Externalisation of European Border Management: between Political Effectivity and Legal Validity.” The author addresses the very topical issue of the migration process, proposing practical solutions to this issue, using Italy as an example. In contrast, a multifaceted analysis of legal conflict resolution was included by Svitlana Yaroslavivna Fursa and Yevhen Ivanovych Fursa. Their text entitled “Resolving a Legal Dispute in Preventive Challenges: Actualities of Theory and Practice” may become a good starting point in further discussion of the problems of extrajudicial dispute resolution. The considerations in this section and the entire volume conclude with the paper “The Right to Dispose of the Property in the Human Rights System” by Yuri Zaika. The topicality of the issues addressed within each paper may encourage repeated reading. To make it easier, all papers are concluded with short summaries and keywords. The book, which has a scholarly nature, is addressed to law theoreticians and practitioners and all those interested in human rights and representatives of related sciences: sociology, political science, administration, and international relations. Special thanks are due to the reviewers for their valuable comments that allowed us to achieve the final outline of this paper. The editors hope that you all enjoy reading this book and that it may offer inspiration for further, perhaps their own, in-depth research on the issues raised.
Reassessment of the role of whole-cell pertussis vaccine as a cause of permanent neurologic damage is necessitated by the 10-year follow-up of the National Childhood Encephalopathy Study (NCES) in Great Britain. The findings of this study demonstrate that infants and young children with serious acute neurologic disorders are at an increased risk of later neurologic impairment or death, irrespective of the initial precipitating event. The results, however, do not establish a causal relationship between pertussis vaccination and chronic neurologic abnormalities. The Academy reaffirms its earlier conclusion that whole-cell pertussis vaccine has not been proven to be a cause of brain damage and continues to recommend pertussis vaccination in accordance with the guidelines in the 1994 Red Book.
In Sweden, as in several other countries, neurological complications after pertussis (triple) vaccination have been observed. A nation-wide investigation showed that 36 cases of such complications had occurred in about 215,000 vaccinated children (1 in 6,000) during 1955–8. Most of these consisted of convulsions, coma, or collapse, and the children were restored to health; but there were four deaths, of which two were sudden, and nine cases indicative of encephalopathies with severe lesions (1 in 17,000). An investigation of the incidence of neurological complications after pertussis showed that this was not so high as after vaccination. The increasingly mild nature of whooping-cough and the very low mortality in this disease in Sweden makes it questionable whether universal vaccination against it is justified. The same question may perhaps arise in some other countries. © 1960, British Medical Journal Publishing Group. All rights reserved.
Objective. —To evaluate the efficacy of currently used whole-cell pertussis vaccines.Design. —Active surveillance to detect pertussis cases in Baltimore, Md, Denver, Colo, and Milwaukee, Wis, and investigation of secondary attack rates in 347 household contacts, aged 1 through 4 years, to estimate vaccine efficacy.Outcome Measure. —Vaccine efficacy was estimated using different case definitions for pertussis.Results. —Vaccine efficacy was 64%, 81%, and 95% for case definitions of mild cough, paroxysmal cough, and severe clinical illness, respectively. Requiring laboratory confirmation increased efficacy to 95% to 98% for culture-positive children and to 77% to 95% for culture- or serology-confirmed cases, depending on disease severity. Vaccine efficacy for typical paroxysmal cough increased from 44% for one diphtheria, tetanus, and pertussis vaccine dose to 80% for four or more doses.Conclusions. —The trend toward increasing vaccine efficacy with different case definitions may be due to improved efficacy in preventing severe illness and to case definitions that are more specific for pertussis. Whole-cell pertussis vaccine was highly effective in preventing pertussis in preschool children exposed to infection within their households. Direct side-by-side efficacy studies of whole-cell vaccine and the recently licensed acellular vaccine will be necessary to assure that comparable protection is afforded by the new vaccines if they are to be used for immunization of infants.(JAMA. 1992;267:2745-2749)
ON SEPTEMBER 17,1994, Heather Whitestone was chosen as Miss America, the first ever with a disability. Her deafness has been the subject of much media attention. On September 16, 1994, the Atlanta Constitution ran a story in its front section about Whitestone stating, "At age 18 months, [she] almost died from an adverse reaction to a routine DPT (diphtheria, pertussis, tetanus) vaccination. It wiped out all but a tiny sliver of her hearing."1 On September 18, the New York Times ran an Associated Press story in its first section stating "Miss Whitestone... lost her hearing at 18 months because of a reaction to a diphtheria-tetanus shot."2 On September 19 the New York Times ran another story ascribing her deafness to a vaccination.3 Not until September 26 did the New York Times publish a story stating that Whitestone's deafness was not due to a vaccination but actually resulted