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Vaccine Rejection and Hesitancy: A Review and Call to Action

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Vaccine refusal has been a recurring story in the media for well over a decade. Though there is scant evidence that refusal is genuinely increasing in the population, multiple studies have demonstrated concerning patterns of decline of confidence in vaccines, the medical professionals who administer vaccines, and the scientists who study and develop vaccines. As specialists in microbiology, immunology, and infectious diseases, scientists are content experts but often lack the direct contact with individuals considering vaccination for themselves or their children that healthcare professionals have daily. This review examines the arguments and players in the United States anti-vaccination scene, and discusses ways that experts in infectious diseases can become more active in promoting vaccination to friends, family, and the public at large.
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Vaccine rejection and hesitancy: a review and call to action
Tara C. Smith, PhD
The author declares she has no commercial or other association that might pose a conflict of
interest.
No financial support was provided for this manuscript.
Correspondence:
Tara C. Smith, PhD
College of Public Health
Kent State University
Kent, OH 44242
Tsmit176@kent.edu
330-672-3946
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Abstract
Vaccine refusal has been a recurring story in the media for well over a decade. Though there is
scant evidence that refusal is genuinely increasing in the population, multiple studies have
demonstrated concerning patterns of decline of confidence in vaccines, the medical
professionals who administer vaccines, and the scientists who study and develop vaccines. As
specialists in microbiology, immunology, and infectious diseases, scientists are content experts
but often lack the direct contact with individuals considering vaccination for themselves or their
children that healthcare professionals have daily. This review examines the arguments and
players in the United States anti-vaccination scene, and discusses ways that experts in infectious
diseases can become more active in promoting vaccination to friends, family, and the public at
large.
Keywords: vaccine hesitancy, vaccine denial, anti-vaccination, misinformation, internet
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Background and Introduction
Since the late 1990s, concern has grown regarding a resurgence of the “anti-vaccine
movement,” a loosely-defined group of individuals who sow doubt about the effectiveness and
safety of vaccines. Though the most current iteration of this scare can be traced to the
publication of Andrew Wakefield’s (since-retracted) paper linking the measles-mumps-rubella
(MMR) vaccine to autism in 1998, anti-immunization sentiment in reality pre-dates the process
of vaccination, dating back to objections to the process of variolation in the early 18th century to
reduce smallpox morbidity and mortality [1, 2].
While vaccine rates have remained high in the United States as a whole [2, 3], national
surveys can overlook pockets of vaccine refusal which exist in many communities [4]. Areas with
low vaccination rates have resulted in localized outbreaks of vaccine-preventable diseases,
including measles and pertussis [5]. Measles cases in the U.S. reached a 20-year high in 2014
[6]; 90% of those were among individuals who had not been vaccinated or whose vaccination
status was unknown [6, 7], suggesting the unvaccinated are drivers of outbreaks. Further,
vaccines are victims of their own success. Today, even many physicians have not seen a case of
measles, diphtheria, or other vaccine-preventable diseases; parents are a generation more
removed from the scourges that polio and rubella represented. As such, anti-vaccine activists
have been able to describe these diseases as harmless consequences of childhood, and vaccines
are presented as the danger rather than the disease.
Though public health and medical practitioners have been concerned about increasing
anti-vaccine sentiment, programs that have been implemented to change minds and attitudes
have been largely ineffective [8, 9].
This review aims to provide infectious disease experts with grounding in the current
rhetoric of vaccine denial; to introduce the cast of characters who play a role in perpetuating
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vaccine misinformation and driving vaccine fear; and to discuss ways scientists can respond in
various venues to demonstrate support of vaccines and the very principles of vaccination.
The arguments
The arguments against vaccination have changed little over time [1, 2]. These are
summarized in Table 1 and will be discussed here briefly. Most objections to vaccination are
currently cached in language that makes them highly palatable to parents and difficult for
scientists to object to, using terms such as “informed consent,” “health freedom,” and “vaccine
safety” [10]. A recent article in Natural Mother Magazine makes it explicit that anti-vaccine
advocates should use language that frames vaccines as dangerous or unnatural, substituting
“vaccine-free” or “intact immune system” for “unvaccinated”, and “vaccine-associated diseases”
instead of “vaccine-preventable diseases” [11], for instance.
Many of the arguments focus on areas of distrust in medical science. They advance the
notion that vaccines are “unavoidably” dangerous because of nebulous “toxins” introduced into
the body via vaccination. Some of these chemicals are present in small amounts (aluminum as
an adjuvant, for example); others, such as “antifreeze,” are not and never have been present in
vaccines [12]. Another commonly feared “toxin,” the ethyl mercury that is part of the
preservative thimerosal, has been removed from most routine vaccinations since 2001 (and was
never present in live vaccine formulations), despite no evidence of harm [13]. Still, many argue
that children are purposely “poisoned” via vaccines because it benefits the bottom line of “Big
Pharma” and the physicians pharmaceutical companies work with.
Other arguments stem from misinformation regarding the immune system and vaccine
response, claiming vaccines “overwhelm” the immune system, and that natural immunity is
better than immunity induced by vaccines. The latter argument misses the point of vaccination
entirely, and the former ignores the fact that the body is seeded by thousands of species of
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microbes and is exposed to countless antigens from birth onward; the relatively few additional
antigens introduced via vaccination are, relatively speaking, a drop in the bucket [14].
As a result of the spread and increased acceptance of these arguments, researchers have
documented reduced trust in medical practitioners by parents, and an increase in concerns
about vaccines. While only 19% of parents noted “concerns about vaccines” in a 2000 survey
[15], by 2009, 50% of parents had concerns [16] (reviewed in [17]).
The cast of characters
Though many parents may repeat uncritically the information they receive from vaccine
denial groups, these claims rarely originate with the parent de novo. As noted above, iterations
of the same arguments against and fears about vaccines have been employed for well over a
century, and are merely recycled and updated to better reflect the modern science landscape and
language. These updated vaccine myths are then circulated by a variety of influential individuals
and organizations (Table 2) and are read and repeated by parents and other media consumers.
Collectively, this “influencer” group has undue sway over the media when it comes to vaccine
information, as some media stories on vaccination strive for “balance” in reporting. As this idea
of “balance” is false [18]far more physicians and scientists support vaccines than notthe
same anti-vaccine individuals are interviewed for news pieces repeatedly, increasing their
exposure and profile in the news media.
Many of these “influencers” rely on the internet to spread their message (together, the
individuals and organizations included in Table 2 have over 7 million Facebook followers,
though some overlap in followers may be expected). Recent work has demonstrated that
approximately 80% of individuals use the internet yearly to search for health information [19],
and relatively few discuss these findings with a healthcare professional. Kata [10] notes that
“common assertions found online included: that vaccines cause illness; that they are ineffective;
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that they are part of a medical/pharmaceutical/government conspiracy; and that mainstream
medicine is incorrect or corrupt. Misinformation was widespread, in the form of inaccuracies or
outright deception.” While the effect of online misinformation on vaccination attitudes and
decision-making has not been carefully quantified, parents have often listed concerns similar to
those on anti-vaccine websites when asked by researchers why they did not vaccinate [20, 21],
suggesting permeation into community groups from anti-vaccine books and internet sites or
similar sources of misinformation. Further, even short exposure to vaccine-critical Internet sites
has been shown to increase perceived risks of vaccinating and minimize the risks of vaccine-
preventable diseases [22].
Though many of the individuals who spread vaccine misinformation are ordinary
citizens, the sources of most anti-vaccine tropes are individuals or groups who benefit from the
spread of such inaccuracies. Many of the primary anti-vaccine “thought leaders” have written
books or produced movies that characterize vaccines as dangerous and unsafe (see
Supplemental Information for examples of anti-vaccine books and sites). Others run groups
dependent on donations from individuals who support their ideas. Still others rely on clicks,
advertising revenue, and product sales from online sites where they share articles on the
dangers of vaccines. A recent analysis of anti-vaccination websites demonstrated that every
website examined except one “contained arguments against vaccination that could be
considered disingenuous [23], supporting their role in the dissemination of misinformation
about vaccines. Further, “mommy blogs” in particular have been analyzed and found to tell
persuasive stories suggesting that vaccines pose a threat to children, which may be circulated to
large numbers of readers [24].
While many of the anti-vaccine arguments which parents refer to may ultimately stem
from or be promoted by such celebrities and/or websites, parents may not always believe or
know their information has been filtered through these individuals, nor that they have been
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influenced by such. Additionally, an individual’s personal history of vaccination or medical care
for themselves or their children may also color their view of vaccinations, independent of or
reinforced by exposure to media on vaccines. There is wide heterogeneity in individuals who
doubt vaccines [17, 25], so while understanding individuals and groups involved in anti-vaccine
messaging is important, scientists should not assume that all individuals who express skepticism
about vaccines share the same background, media consumption, or views.
It should also not be assumed that individuals who question vaccines have merely
absorbed anti-vaccine messages (including those from the above sites and individuals) in a
vacuum. Both vaccine hesitancy and vaccine promotion are influenced by the social and cultural
contexts in which messages are received [26] as discussed below.
The spectrum of vaccine skepticism
There are many different sub-populations of individuals with divergent reasons for not
vaccinating or delaying vaccines [27]. This may be due to a variety of factors, including
complacency (low risk perceptions of vaccine-preventable diseases); lack of convenient access to
vaccine services; or lack of confidence in vaccines due to concerns about safety and other vaccine
issues [25, 28].
While many may characterize all individuals who eschew vaccines as “anti-vaccine” or
“vaccine deniers,” in reality there is a broad spectrum of individuals who choose not to have
themselves or their children vaccinated. These range from individuals who are solidly anti-
vaccine, frequently termed “vaccine rejectors,” to those who may accept or even advocate for
most vaccines, but have concerns over one or more vaccines. Hagood and Mintzer Herlihy [29]
suggest a 3-category model, characterizing individuals as vaccine rejectors (VRj), vaccine-
resistant (VR), or vaccine-hesitant (VH). Vaccine rejectors are those who are “unyieldingly
entrenched in their refusal to consider vaccine information,” prone to conspiracy theory
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thinking, and may eschew traditional medical providers altogether in favor of “complementary”
or “alternative” medical practices—and as such, very unlikely to change their opinions on
vaccines. The vaccine-resistant are those who may currently reject vaccination but are still
willing to consider information, and have a lower incidence of belief in conspiracy theories than
VRj individuals. Vaccine-hesitant individuals tend to have anxiety about vaccinations but are
not committed to vaccine refusal [29]. These groups correspond roughly to the “refusers,”
“late/selective vaccinators,” and “the hesitant” identified in [30]. Interventions targeted at
changing minds or attitudes in order to increase vaccine acceptance need to take into
consideration this spectrum of beliefs regarding vaccines in order to be properly tailored to the
targeted audience [26, 31], rather than assuming that all individuals with vaccine concerns have
a single cohesive belief system.
As the above demonstrates, there is no “one size fits all” model for responding to vaccine
hesitancy/denial. In the experience of the author, most of the ideas scientists commonly have
about vaccine rejection seem to fit in more with the “vaccine rejectors” group. While this group
may be the most vocal about their vaccine concerns, it is likely that they are in the minority in
the spectrum of individuals adverse to vaccines; Leask et al. suggest that less than 2% of all
parents are outright “refusers” [30]. However, these active rejectors may cause damage in the
general public by amplifying myths and misinformation about vaccination and shift the opinions
of others away from vaccine acceptance [32].
What to do and how to respond as an expert lacking patient contact?
Most interventions in recent years have focused on the vaccine-hesitant. Vaccine
hesitancy has been defined as “delay in acceptance or refusal of vaccines despite availability of
vaccination services” [25], in order to separate them from individuals or children who may be
delayed on vaccines through lack of services or access rather than a philosophical belief. This
group is generally thought to be the most amenable to interventions, as they typically are not
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solidly anti-vaccine and may be considered “fence-sitters” on many vaccine issues, who have not
strongly committed to either a “pro” or “anti” vaccine stance. Some concerns these parents
express over vaccines are seemingly minor, including pain during injections and fevers following
vaccination [33], but they may also have concerns about autism and the MMR vaccine, Guillain-
Barré syndrome and the influenza vaccine, or others [33].
Most articles examining interventions for the vaccine-hesitant were written with
healthcare providers as primary targets, e.g. [30, 34, 35]. While microbiologists and infectious
disease experts may not always have direct patient care responsibilities, they likely have
extensive knowledge of the concepts underlying vaccination, and of the diseases which vaccines
prevent. However, scientists do not always know the rhetorical tricks and tactics [10] that
vaccine rejectors and their leaders (see Table 2) frequently employ; engaging them can be a
mistake without understanding not only the science, but also the objections and references that
vaccine rejectors may use. Understanding the arguments and concerns that individuals have
about vaccines, and from where they originate, can allow for better communication regarding
vaccines on the part of scientists.
Furthermore, scientists should realize that engaging directly with active rejectors will be
very unlikely to change minds, though less is known about the effectiveness of this tactic on
“lurkers” or other readers or listeners who may be following along with a conversation but not
participating. Prior research has documented that exposure to social information online can
impact attitudes and behavior [36], though this has not been tested explicitly with readers of
vaccine information, either pro-vaccine or anti-vaccine.
As noted previously, one impulse many scientists may have is to simply educate the
public. Known as the “information deficit model” of science communication, this model assumes
that the public is merely uneducated or under-educated about vaccines, and that providing
additional factual information will fill this knowledge gap and lead people toward vaccinating
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[28]. Unfortunately, information alone has not been shown to increase vaccine confidence
among hesitant parents [9, 37].
This isn’t to suggest that providing knowledge is unimportant. Filling in data gaps and
acting as a reliable, factual source of information is an essential service to those genuinely
seeking science-based evidence about vaccination. This information can be communicated in
person with friends or family members (particularly those with shared values) [38, 39],
submitted to local newspapers as opinion pieces or letters to editors [40], or provided online
through blog posts, social media updates, or other sites on the internet, where it may be
inadvertently “stumbled upon” by searches or references from other links. Individuals should be
aware that such educational efforts are likely to backfire for individuals deeply entrenched in
vaccine rejection [8], but have been cited in “conversion” stories of individuals who moved
across the spectrum from vaccine doubter to advocate [41].
Further, the frequent use of conspiracy theory thinking among anti-vaccine thought
leaders engenders a lack of trust towards the medical and scientific communities. As such,
providing more education to some on the spectrum of vaccine refusal/hesitancy will be
ineffective [23], as it is unlikely to be sufficient to simply reassure many vaccine-hesitant
parents that expert groups have confirmed that vaccines are safe and effective when these
parents already distrust the “experts” [23].
Still, biomedical scientists who are vocal in their support for vaccines can serve to
cement the idea that vaccination is “normal” and expected. Kestenbaum and Feemster note that
a “…parent’s motivation to vaccinate their children is also influenced by social norms, which are
the rules that a group uses for appropriate and inappropriate values, beliefs, attitudes, and
behaviors” [34]. A recent Pew survey found that 82% of U.S. adults agree that “healthy children
should be required to be vaccinated to attend school because of potential risk to others,” and
88% agree that vaccine benefits outweigh the risks [42]. While vaccine hesitancy does exist,
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vaccination on schedule is still the norm for the great majority of families. As a professional who
accepts vaccines as a part of life for yourself and your children, conveying that information to
your networks can help to subtly shift opinion on what Shelby and Ernst call “the greatest story
never told: the uneventful vaccination” [43] (see Figure 1). While stories of uncomplicated
vaccine administration are less likely to “go viral” than stories of injured children [43, 44], these
stories can further ingrain the idea that vaccines are being given every day without incident.
For those who want to get more deeply involved, Shelby and Ernst put forward the idea
of a “vaccine ambassador” program at physician offices [43]. The authors noted that “There is a
growing passion among parents who vaccinate to begin speaking up about the importance of
immunization, and yet we continue to hear from these parents that they don’t know how to
help.” They suggest that physicians put a call out to their patients, and willing parents could
provide contact information that can be given to vaccine-hesitant parents. The “ambassadors”
would receive training and share the reasons why they decided to vaccinate their own children
[43]. Particularly if this is done amongst individuals with shared values [26], such a program
may be beneficial.
Ambassadors may benefit from using the C.A.S.E. method outlined by Singer [45], which
includes steps to corroborate parents’ fears, offer information about the educator and their
personal experience with vaccines, provide information about the science regarding vaccines
and explain recommendations, all within a context of empathy and an established relationship
[29, 45]. A recent publication by Schoeppe et al. [46] involved parents as immunization
advocates to address vaccine hesitancy in Washington state, whose school entry exemption rate
was three times the national average. Though lacking a control group, they found that vaccine
hesitancy was reduced in their population, from 23% to 14%, and the number of parents who
agreed vaccination is a good idea rose. Scientists may adapt recommendations from papers
targeting healthcare professionals to work with such groups [30, 35].
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Though many scientists may hesitate to “get political,” vaccine policy is set at the state
level; as such, privately contacting state legislators and advocating for the strengthening of
vaccine exemption policies is another way to protect herd immunity, as states with stricter
exemption criteria have higher rates of vaccination compliance [47]. California recently passed
SB277, which eliminated religious and philosophical exemption for school admittance. In their
first year of data analysis, they found that vaccination rates rose in students attending
kindergarten 2.8 percentage points [48]. Similarly in Michigan, state officials issued a regulation
requiring consultation with local health departments prior to obtaining a vaccine waiver,
resulting in 35% fewer vaccine exemptions in the first year [49]. In each case, an outbreak may
have helped both to sway legislators and mobilize parents (the Disneyland measles outbreak in
California, and a large outbreak of pertussis associated with a Traverse City charter school in
Michigan), but one need not wait for an emergency situation in order to push state legislators to
strengthen vaccine regulations. This is one way scientists can work “behind the scenes,” to
advocate for and promote such legislation.
Academics can also examine vaccine policies at their own institutions. My current
institution requires only the MMR for admission, while many universities have more rigorous
vaccine requirements. The University of California system will expand their vaccine
requirements as of fall 2017, requiring students be vaccinated for hepatitis B, measles, mumps
and rubella; chicken pox; meningococcus; and tetanus, diphtheria and whooping cough prior to
registration. Advocating for vaccine protection for college students is another way scientists can
use their expertise to increase vaccination rates and demonstrate the importance of
immunization.
Finally, while there may be no single leader of an anti-vaccine “movement,” many of
those listed in Table 2 are highly media-savvy and unafraid to push their opinions that vaccines
are dangerous, full stop. Scientists, by our training and often by our nature, are often loathe to
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think of issues without bringing in shades of gray, while vaccine thought leaders frequently
express strict black-and-white thinking. Advocating for vaccines isn’t always easy; it may
necessitate leaving one’s comfort zone, and open one up as a target of harassment [50]. But with
so much at stake, shouldn’t subject experts be on the forefront of this fight?
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Table 1. The arguments.
Vaccines are “toxic” and contain antifreeze, mercury, ether, aluminum, human aborted
fetal tissue, antibiotics, and other dangerous chemicals which can lead to autism and
an assortment of chronic health conditions. Slogan: “Green our Vaccines”.
Vaccines are a tool of “Big Pharma;” individuals who promote them are merely
profiting off of harm to children and/or paid off by pharmaceutical companies
(“Pharma shills”).
A child’s immune system is too immature to handle vaccines; they are given “too many,
too soon” and the immune system becomes “overwhelmed,” leading to autism and an
assortment of chronic health conditions.
“Natural immunity is better;” most vaccine-preventable diseases are harmless to most
children, and natural exposure provides more long-lasting immunity. e.g., “I had the
chickenpox as a kid and I was just fine.” Some individuals may also have the mistaken
belief that all “natural” infections confer life-long immunity, while all vaccine-derived
immunity is short-lived.
Vaccines have never been tested in a true “vaccinated versus unvaccinated” study; the
vaccines in the current schedule have never been tested collectively.
Diseases declined on their own due to improved hygiene and sanitation; “vaccines
didn’t save us.”
Vaccines “shed” (can be transmitted by vaccinated individuals to others); therefore,
cases of vaccine-preventable diseases in the population are driven by the vaccinated,
not the unvaccinated.
Adapted from [2, 10, 23]; see Supplemental information for a list of comprehensive rebuttals.
Accepted Manuscript
Table 2: Thought Influencers in the Anti-Vaccine Movement
Category
Name
Description
The Doctors
Andrew
Wakefield
Former British physician; lead author of 1998 study in The Lancet
suggesting MMR vaccination led to autism [1], since retracted.
Discredited after an investigation into the study demonstrated
undisclosed conflicts of interest and unethical conduct;
subsequently, Wakefield lost his medical license. He currently lives
in United States and remains active promoting anti-vaccine ideas,
including the 2016 documentary VAXXED (see Supplemental
Information for books, movies, and web sites from anti-vaccine
thought influencers). Active on social media via the VAXXED page
(~67,000 followers on Facebook).
Robert
Sears
California physician, author of “The Vaccine Book”. Formulated an
“alternative” vaccine schedule which delays many vaccines from the
CDC recommended schedule; this schedule has been widely
promoted by other anti-vaccine activists and is often cited by
parents, and reinforces the idea that children receive “too many, too
soon” (see Table 1). Active on social media (~65,000 followers on
Facebook).
Sherri
Tenpenny
Private practice physician in Ohio, author of “Vaccines: The Risks,
the Benefits, the Choices, a Resource Guide for Parents” and
“Saying No to Vaccines: A Resource Guide for All Ages”. Co-
founder of the International Medical Council on Vaccination
(http://www.vaccinationcouncil.org/), whose purpose is to “counter
the messages asserted by pharmaceutical companies, the
Accepted Manuscript
government and medical agencies that vaccines are safe, effective
and harmless.” Active on social media (~215,000 followers on
Facebook).
Toni Bark
Private practice physician at “The Center for Disease Prevention
and Reversal” in Illinois; prior vice-president of the American
Institute of Homeopathy. Featured in Oprah.com and the recent
web series “The Truth about Vaccines.” Active on social media
(~6,000 followers on Facebook).
Susanne
Humphries
Private practice physician in Maine and Virginia, author of
Dissolving Illusions: Disease, Vaccines and the Forgotten History”.
Active on social media (~31,000 followers on Facebook).
Larry
Palevsky
Private practice and holistic/integrative physician in New York.
Featured in the web series “The Truth about Vaccines” and the anti-
HPV vaccine documentary “The Greater Good”. Active on social
media (~13,000 followers on Facebook).
Joseph
Mercola
Former private practice physician in Illinois, runs the website and
business Mercola.com. Author of “The Great Bird Flu Hoax: The
Truth They Don't Want You to Know About the ‘Next Big
Pandemic". Founder of “Health Liberty” (“A nonprofit coalition
formed by Mercola.com, National Vaccine Information Center,
Fluoride Action Network , Institute for Responsible Technology ,
Organic Consumers Association, and Consumers for Dental Choice,
to help protect every American's freedom to make voluntary health
choices”. Active on social media (~1,600,000 followers on
Facebook).
Accepted Manuscript
The
Celebrity
Jenny
McCarthy
Actress and comedian, “Mommy warrior,” Generation Rescue
spokesperson, parent of autistic child. Author of “Louder Than
Words: A Mother's Journey in Healing Autism”; “Mother Warriors:
A Nation of Parents Healing Autism Against All Odds”; and
Healing and Preventing Autism: A Complete Guide”. Active on
social media (~1,100,000 followers on Facebook).
The
Organizers
J.B.
Handley
Activist and parent of autistic child, co-founder of Generation
Rescue and co-founder and contributor to the Age of Autism blog.
Both organizations suggest that vaccines are a major factor driving
the development of autism. Active on social media (~25,000
followers on Facebook).
Robert F.
Kennedy
Jr.
Environmental lawyer, author of “Thimerosal: Let the Science
Speak” and controversial 2005 article, “Deadly Immunity,”
published in Rolling Stone and Salon but later retracted. Reported
in 2017 to have been appointed to lead a vaccine safety commission
for President Trump. Active on social media (~20,000 followers on
Facebook).
Barbara
Loe Fisher
Activist and founder of the National Vaccine Information Center
(NVIC), originally Dissatisfied Parents Together (DPT). Fisher
began speaking out against vaccines after her son suffered what she
believes is a vaccine injury. Co-author of “A Shot in the Dark” and
Vaccines, Autism & Chronic Inflammation: The New Epidemic”.
Via the NVIC, Fisher is active in tracking and responding to local
and state vaccine-related legislation. Active on social media via the
NVIC (~193,000 followers on Facebook).
Accepted Manuscript
The
“mommy
bloggers”
Sarah Pope
Nutrition and parenting blogger who has dubbed herself the
“Healthy Home Economist.” Appeared on the “Late Show with Jon
Stewart” to defend her anti-vaccine stance. Active on social media
(~155,000 followers on Facebook).
Megan
Heimer
Mother of five, naturopath, and “wellness” blogger at “Living
Whole.” Heimer posts self-declared “common sense” information
about healthy living, which includes avoiding vaccines. Active on
social media (~26,000 followers on Facebook).
Kate Tietje
Mother of five, cooking and parenting blogger at “Modern
Alternative Mama;” sells “health and wellness” products at
Earthley.com. Active on social media (~70,000 followers on
Facebook).
The
opportunists
Vani Hari
The “Food Babe;” influential “food safety” advocate who and social
media star who has argued against vaccines. Hari recently had her
first child and joined the ranks of the “mommy bloggers,”
recommending against vaccines. Instead of accepting the influenza
vaccine during pregnancy, she recommended “wash hands often,
reduce stress, exercise, drink lots of filtered water, eat fermented
foods, and avoid industrial toxins”. Active on social media
(~1,200,000 followers on Facebook).
Mike
Adams
Owner/operator of “Natural News” website; has dubbed himself
“The Health Ranger.” Adams is a key purveyor of conspiracy
theories, suggesting the government is lying to the public about
vaccines, Ebola, influenza, and much more, simultaneously denying
Zika exists and profiting from Zika mosquito repellent
Accepted Manuscript
(https://www.healthrangerstore.com/collections/Health-Rangers-
Bugs-Away-Spray-defense-against-the-Zika-Mosquitos). Active on
social media (~2,200,000 followers on Facebook).
Accepted Manuscript
Figure 1
Figure 1: Examples of photos posted to the author’s social media accounts. Panel A: The author
(middle) and her older children after receipt of seasonal influenza vaccines. Panel B: The
author’s youngest child at Walt Disney World, wearing a shirt saying “Fully Vaccinated. You’re
Welcome.” Both techniques can serve as conversation-starters around vaccination.

Supplementary resource (1)

... Selain itu, keraguan akan penggunaan vaksin mengalami peningkatan secara global termasuk pada kampanye yang dilakukan sejak bulan Agustus 2018 terjadi banyak penolakan oleh beberapa kelompok di beberapa wilayah tanah air [13]. Seperti yang dijelaskan dalam artikel seminar nasional sains, penolakan vaksin terjadi di beberapa negara di asia tenggara termasuk Indonesia, Malaysia, dan Thailand [14], Eropa [8] dan Amerika [15]. ...
... Di Amerika, penolakan vaksin telah menjadi cerita yang berulang di media selama lebih dari satu dekade [15]. Penentangan terhadap vaksin muncul setelah diperkenalkannya vaksin cacar pada akhir abad ke-18 [38]. ...
... Penyebab terjadinya keraguan vaksinasi di Amerika adalah penurunan kepercayaan pada vaksin, profesional medis yang memberikan vaksin, dan ilmuwan yang mempelajari serta mengembangkan vaksin [15], adanya mitos serta ketidakpercayaan akan vaksin, peran orang tua atau pengasuh yang salah mencari sumber informasi, pengalaman pribadi dengan layanan kesehatan, masalah sosial [38] alasan agama dan filosofi [39]. Ketidakpercayaan terhadap vaksin di Amerika juga terjadi karena adanya mitos yang berkembang dimana mereka beranggapan bahwa vaksin MMR dan campak menyebabkan terjadinya autisme [37]. ...
... 6 Anti-vaccination movements including vaccine hesitancy or rejection can have many causes. [7][8][9][10][11] To ensure the success of vaccination campaigns, healthcare professionals must set an example in the field of vaccination, especially when doubts about the vaccine increase and vaccine safety rather than efficacy attract more public attention. [12][13][14][15] Since health professionals administer vaccines and have a sound knowledge of vaccines and vaccination, they have a key role in shaping the attitude towards vaccines in society. ...
... Questionnaire on views on childhood anti-vaccination, roles and responsibilities regarding prevention of anti-vaccination: The questionnaire form was prepared by the researchers in accordance with the relevant literature 2,7,9,11,13,16 and a pilot study was conducted. The finalized questionnaire consisted of questions on the views of nurses on childhood vaccines and anti-vaccination, roles in preventing anti-vaccination attitudes, and responsibilities in raising awareness about vaccination in the prevention of anti-vaccination, in society. ...
Article
Aim: This study was conducted to determine the opinions of nurses on childhood anti-vaccination and their roles and responsibilities in the prevention of anti-vaccination in society.Method: This cross-sectional study was conducted between May 2020 and August 2020. The sample of the study consisted of 199 nurses working in a university hospital. After obtaining the necessary permission the data were collected with an introductory information form and a questionnaire on views on childhood anti-vaccination, roles, and responsibilities regarding prevention of anti-vaccination in society, prepared by the researchers. Descriptive statistical analyzes were used in the assessment of the data.Results: In this study, 80.9% of the nurses found childhood vaccination necessary; 19.1% reported hesitations about vaccination. The reasons perceived by the nurses regarding anti-vaccination, in society included that 58.3% of the individuals thought that the vaccine had side effects and was unsafety of vaccines followed by a rate of 42.7%. The opinions were determined about roles and responsibilities of nurses in preventing anti-vaccination attitudes and in raising awareness, in society; to inform parents by training, counseling, and being a role model, raising awareness through social media, congresses, symposiums and public service ads, conducting evidence-based studies and following scientific publications.Conclusion: It is recommended to develop policies for the prevention of childhood anti-vaccination, to increase awareness of nurses about the issue through in-service trainings and scientific activities, and to take an active role in preventing anti-vaccination.
... Par la suite, les scientifiques ont découvert que Wakefield était en réalité concerné 37. Ces chiffres sont en réalité sous-estimés puisqu'ils ne tiennent pas compte des contenus ou des échanges privés, ni des recherches liées à des vaccins particuliers. (Smith, 2017). Les facteurs cités plus haut peuvent se traduire par une crainte de la vaccination qui peut amener la population à la refuser ou à tarder de l'accepter. ...
... D'autres influenceurs dirigent des groupes qui dépendent des dons de personnes qui soutiennent leurs idées. D'autres encore comptent sur la consultation des pages Internet, les recettes publicitaires et la vente de produits sur des sites en ligne où ils proposent des articles sur les « dangers » des vaccins (Smith, 2017 ;Johnson et al., 2020). ...
Book
Ce livret a pour objectif de présenter les controverses et les débats à l'oeuvre dans l'hésitation vaccinale pour favoriser la construction d'une opinion raisonnée critique, nuancée et argu-mentée sur cette question socialement vive. ce qu'ils contiennent, comment ils sont conçus et choisis. La deuxième partie porte sur le les cancers dus aux papillomavirus humains, dont les vaccins (l'un recommandé, les deux autres obligatoires) sont controversés. La troisième partie est axée sur le nouveau concept d'hésitation vaccinale nombreux autres vaccins suscitant une hésitation sont abordés comme celui de la grippe de 2009 et l'actualité à propos de la pandémie de la COVID-19 n'a pas été ignorée.
... Parents have insufficient knowledge regarding vaccine preventable disease, need for multiple doses, when and where they take it, fear of adverse effect and false perceptions about contraindication, or parents perceive vaccine as ineffective way to prevent diseases [11] However, parent's knowledge is not only lack of information it could be misconception about vaccination's side effects. one of causes of withholding vaccines is parents think their children gets ill after give vaccines [12]. ...
... In this sense, those HCWs do not believe in the vaccination and are actively engaged in searching for information about the vaccine. According to Smith [43], individuals in this kind of profile are "refusers", "late/selective vaccinators". We may speculate that in HCWs this may be to some degree related the progressive emergence of SARS-CoV-2 variants of concern, to the (mis)concepts/knowledge about protection from infection vs protection from severe disease and to fear for "waning immunity". ...
Article
Full-text available
Vaccine hesitancy and conspiracy beliefs among healthcare workers (HCWs) represent operational priorities that require urgent attention. Identifying and classifying specific subpopula-tion of hesitancy is crucial to customize educational and intervention strategies to enhance the acceptance and uptake rate of vaccination. Thus, the main purpose of our study was to empirically identify latent profiles of vaccine hesitancy among Italian HCWs adopting a person-centered approach and investigating their relationships with antecedents and intention to get a fourth dose of COVID-19 vaccine. We conducted latent profile analyses (LPA) to identify different configurations of vaccine hesitancy based on five antecedents of vaccination: confidence, complacency, constraints , calculation, and collective responsibility among a sample of Italian HCWs (N = 573). LPA revealed four distinct profiles: believer (61.5%), middler (24.7%), hesitant (9.00%), and rejecter (4.7%). Having conspiracy beliefs was associated with a greater likelihood of membership in all but believer. Finally, the likelihood of intention to get a fourth dose of COVID-19 vaccine was lowest in the rejector and hesitant profiles. Theoretical contributions and implications for practice are discussed .
... Bulaşıcı hastalıkların önlenmesi ve sağlığın sürdürülmesi konusunda en önemli halk sağlığı uygulamalarından biri aşılamadır (Yüksel ve Topuzoğlu 2019). Aşı karşıtlığı günümüzde ortaya çıkan bir kavram olmayıp, aşılamanın başlangıcıyla beraber başlamıştır (Smith 2017 ...
... Covid-19 aşı karşıtlığının cinsiyet ile ilişkili olduğuna dair literatürde farklı bilgiler yer aldığı görülmektedir.Bu çalışmaya dahil olan katılımcıların aşı karşıtlığı puan ortalamalarının eğitim düzeyine anlamlı bir şekilde farklılaştığı, ilk-öğretim ve lise öğrenimine sahip katılımcıların puan ortalamaları lisansüstü öğrenime sahip katılımcıların puan ortalamalarına göre anlamlı düzeyde daha yüksek olduğu görülmüştür. Önceki yıllarda aşı karşıtlığı sıklıkla düşük eğitim düzeyi ile ilişkilendirilirken aşı karşıtlığı günümüzde gelişmiş ülkelerde yaşayan, eğitim düzeyi yüksek bireyler arasında artan bir eğilim olmaya başlamıştır(Smith, 2017). Makarovs ve Achterberg tarafından yapılan çalışmaya(2017)göre modern toplumlarda yaşayan eğitimli insanların daha az gelişmiş toplumlarda yaşayan eğitimsiz insanlara göre aşıya daha çok karşı çıktıkları ortaya konmuştur. ...
Article
Ülkemizde Covid-19 hakkında çok fazla yanlış bilginin dolaşması nedeniyle Covid-19 aşılama çalışmalarına şüphe ile yaklaşılmakta ve aşı olmak istemeyen vatandaşların sayısal çoğunluğu dikkat çekmektedir. Bu çalışma 18 yaş üstü vatandaşların Covid-19 aşı karşıtlığı nedenlerinin çeşitli değişkenler açısından incelenmesini amaçlamaktadır. Tanımlayıcı türdeki bu nicel çalışmanın evrenini Konya ilinde yaşayan 18 yaş üstü vatandaşlar örneklemini ise 385 katılımcı oluşturmuştur. Araştırma verileri online platformlar üzerinden toplanmıştır. Elde edilen verilen SPSS 20.0 istatistik programı ile analiz edilmiştir. Covid-19 aşı karşıtı olan bireylerin koronavirüsü ölümcül bir hastalık olarak görmedikleri; daha çok aşıların yan etkileri, aşıların yabancı üretim olması, deneysel çalışmaların yetersiz olması, koruyuculuğa inanmama, saklama koşulları, aşı fobisi, dini inanca aykırı olmak gibi nedenlerden dolayı Covid-19 aşılarına karşı oldukları; katılımcıların çoğunun Covid-19 aşıları hakkında kısmen bilgi sahibi oldukları, etkili bilgi kaynaklarının sosyal medya, TV kanalları, akademik yayınlar, sağlık otoriteleri gibi kaynaklar olduğu görülmüştür.
... The authors perceived that this effort would help counter pseudo journalism activities in the long run. As vaccine refusal individuals are 'highly media-savvy and unafraid to push their opinions that vaccines are dangerous' ( [36], p. 6), strategic approaches are pertinent. Through these efforts, the authors recommended that the Malaysia media providers to be more pronounced in their attitudes to approach anti-vaxxers and combat anti-vaccination phenomenon with the aim of moving towards literate society. ...
Chapter
Full-text available
The resurgence of vaccine-preventable diseases such as polio, diphtheria, measles and the like shows that the anti-vaccine movement is gaining popularity and effectiveness in bolstering its views. Multiple studies have shown worrying trends of distrust towards vaccines, medical professionals, vaccine scientists and the government agencies that promote vaccination. It is observed that the current anti-vaccine discourses and misinformation about vaccines on social media are fuelling fear of vaccination among the public. To minimise the spread of vaccine-preventable diseases, the media has considerable potential to influence the public’s understanding of how vaccines function. Therefore, this chapter proposed the adoption of a media guide to assist media practitioners in reporting vaccination stories. It will highlight an influential role that the media can play by enlisting the assistance of experts and health professionals to dispel erroneous beliefs about vaccinations and aggressively promote vaccination among influential persons and the general public. This chapter argued that responsible and ethical reporting will aid in raising awareness of the public health implications of the anti-vaccine sentiment, thereby combating the transmission of messages that drive vaccine fear and rejection. The chapter also addressed how insights provided by Ihlen on rhetorical communication can enhance the effectiveness of delivering vaccine-related messages.
Preprint
With COVID-19 vaccines slowly being rolled out in many countries, it is important to understand the public’s acceptance of being vaccinated. This study aims to study the willingness and motivations among residents of the cities of Caloocan, Malabon, and Navotas, Philippines to be vaccinated against COVID-19. Based on an online survey of 137 respondents, who willingly participated in the study, 71% will take a COVID-19 vaccine if it becomes available, with similar rates among respondents from Caloocan (82%), Malabon (83 %), and Navotas (81%). If a vaccine is proven safe and effective, more respondents (82%) will take a COVID-19 vaccine. Furthermore, safety against COVID-19 as well as the safety and effectiveness of vaccines are the primary factors why respondents are willing or unwilling to get a vaccine. The results highlight the need for effective messaging that promotes COVID-19 vaccination, with emphasis on the safety and effectiveness of the vaccine, and its benefits to the public, especially that the vaccines that will be delivered in the country in the next few months are not the most preferred brands by the respondents.
Article
Full-text available
Background: With the help of vaccines, the world has witnessed a substantial decrease and even the eradication of many infectious diseases. Many factors influenced the public's acceptance and compliance with the COVID-19 vaccine. Methods: This is a cross-sectional study that was conducted in Saudi Arabia. The questionnaire link was distributed through social media platforms. The questionnaire tool assessed the participants' general knowledge and the barriers to taking the COVID-19 vaccine. All people who are currently living in Saudi Arabia and are at least 16 years old were included in the study and formed the study population. Based on our inclusion criteria, a total of 2,198 individuals were enrolled in this study. Results: Participants who were willing to take the vaccine were 68%. After vaccination, 10% of the participants think they can stop wearing face masks and washing their hands. Two-thirds of the participants think that the vaccine is effective in preventing COVID-19 infection. A total of 44.0% of the participants were afraid of the vaccine. The most common reasons were fear of unknown side effects (53.9%) and believing that the vaccine was not tested enough (27%). More than half of the study participants had a preference for receiving the Pfizer vaccine (52%). Conclusion: The public's acceptance of the COVID-19 vaccine in Saudi Arabia is insufficient. Unknown side effects, widespread misconceptions, and a lack of adequate safety trials are all important reasons for concern among Saudis. More educational materials and awareness efforts will help to alleviate the fear that surrounds it. This will boost the vaccine's acceptance rate in the long run. Keywords: COVID-19 vaccine; Saudi Arabia; attitude; beliefs; knowledge.
Article
Full-text available
Background Social media offer an unprecedented opportunity to explore how people talk about health care at a very large scale. Numerous studies have shown the importance of websites with user forums for people seeking information related to health. Parents turn to some of these sites, colloquially referred to as “mommy blogs,” to share concerns about children’s health care, including vaccination. Although substantial work has considered the role of social media, particularly Twitter, in discussions of vaccination and other health care–related issues, there has been little work on describing the underlying structure of these discussions and the role of persuasive storytelling, particularly on sites with no limits on post length. Understanding the role of persuasive storytelling at Internet scale provides useful insight into how people discuss vaccinations, including exemption-seeking behavior, which has been tied to a recent diminution of herd immunity in some communities. Objective To develop an automated and scalable machine-learning method for story aggregation on social media sites dedicated to discussions of parenting. We wanted to discover the aggregate narrative frameworks to which individuals, through their exchange of experiences and commentary, contribute over time in a particular topic domain. We also wanted to characterize temporal trends in these narrative frameworks on the sites over the study period. Methods To ensure that our data capture long-term discussions and not short-term reactions to recent events, we developed a dataset of 1.99 million posts contributed by 40,056 users and viewed 20.12 million times indexed from 2 parenting sites over a period of 105 months. Using probabilistic methods, we determined the topics of discussion on these parenting sites. We developed a generative statistical-mechanical narrative model to automatically extract the underlying stories and story fragments from millions of posts. We aggregated the stories into an overarching narrative framework graph. In our model, stories were represented as network graphs with actants as nodes and their various relationships as edges. We estimated the latent stories circulating on these sites by modeling the posts as a sampling of the hidden narrative framework graph. Temporal trends were examined based on monthly user-poststatistics. Results We discovered that discussions of exemption from vaccination requirements are highly represented. We found a strong narrative framework related to exemption seeking and a culture of distrust of government and medical institutions. Various posts reinforced part of the narrative framework graph in which parents, medical professionals, and religious institutions emerged as key nodes, and exemption seeking emerged as an important edge. In the aggregate story, parents used religion or belief to acquire exemptions to protect their children from vaccines that are required by schools or government institutions, but (allegedly) cause adverse reactions such as autism, pain, compromised immunity, and even death. Although parents joined and left the discussion forums over time, discussions and stories about exemptions were persistent and robust to these membership changes. Conclusions Analyzing parent forums about health care using an automated analytic approach, such as the one presented here, allows the detection of widespread narrative frameworks that structure and inform discussions. In most vaccination stories from the sites we analyzed, it is taken for granted that vaccines and not vaccine preventable diseases (VPDs) pose a threat to children. Because vaccines are seen as a threat, parents focus on sharing successful strategies for avoiding them, with exemption being the foremost among these strategies. When new parents join such sites, they may be exposed to this endemic narrative framework in the threads they read and to which they contribute, which may influence their health care decision making.
Article
Full-text available
This paper presents results of a study determining the efficacy of a values based approach to changing vaccination attitudes. It reports an evaluation survey of the "I Immunise" campaign, conducted in Fremantle, Western Australia, in 2014. "I Immunise" explicitly engaged with values and identity; formulated by locals in a community known for its alternative lifestyles and lower-than-national vaccine coverage rates. Data was collected from 304 online respondents. The campaign polarised attitudes towards vaccination and led some to feel more negatively. However, it had an overall positive response with 79.6% of participants. Despite the campaign only resonating positively with a third of parents who had refused or doubted vaccines, it demonstrates an important in-road into this hard-to-reach group.
Article
The anti-vaccination movement threatens public health by reducing the likelihood of disease eradication. With social media’s purported role in disseminating anti-vaccine information, it is imperative to understand the drivers of attitudes among participants involved in the vaccination debate on a communication channel critical to the movement: Twitter. Using four years of longitudinal data capturing vaccine discussions on Twitter, we identify users who persistently hold pro and anti attitudes, and those who newly adopt anti attitudes towards vaccination. After gathering each user’s entire Twitter timeline, totaling to over 3 million tweets, we explore differences in the individual narratives across the user cohorts. We find that those with long-term anti-vaccination attitudes manifest conspiratorial thinking, mistrust in government, and are resolute and in-group focused in language. New adoptees appear to be predisposed to form anti-vaccination attitudes via similar government distrust and general paranoia, but are more social and less certain than their long-term counterparts. We discuss how this apparent predisposition can interact with social media-fueled events to bring newcomers into the anti-vaccination movement. Given the strong base of conspiratorial thinking underlying anti-vaccination attitudes, we conclude by highlighting the need for alternatives to traditional methods of using authoritative sources such as the government when correcting misleading vaccination claims.
Article
Parental concerns about vaccine safety have grown in the United States and abroad, resulting in delayed or skipped immunizations (often called "vaccine hesitancy"). To address vaccine hesitancy in Washington State, a public-private partnership of health organizations implemented and evaluated a 3-year community intervention, called the "Immunity Community." The intervention mobilized parents who value immunization and provided them with tools to engage in positive dialogue about immunizations in their communities. The evaluation used qualitative and quantitative methods, including focus groups, interviews, and pre and post online surveys of parents, to assess perceptions about and reactions to the intervention, assess facilitators and barriers to success, and track outcomes including parental knowledge and attitudes. The program successfully engaged parent volunteers to be immunization advocates. Surveys of parents in the intervention communities showed statistically significant improvements in vaccine-related attitudes: The percentage concerned about other parents not vaccinating their children increased from 81.2% to 88.6%, and the percentage reporting themselves as "vaccine-hesitant" decreased from 22.6% to 14.0%. There were not statistically significant changes in parental behaviors. This study demonstrates the promise of using parent advocates as part of a community-based approach to reduce vaccine hesitancy.
Article
Childhood vaccination is widely considered to be one of the most successful public health interventions. Yet, the effective delivery of vaccination depends upon public willingness to vaccinate. Recently, many countries have faced problems with vaccine hesitancy, where a growing number of parents perceive vaccination to be unsafe or unnecessary, leading some to delay or refuse vaccines for their children. Effective intervention strategies for countering this problem are currently sorely lacking, however. Here, we propose that this may be because existing strategies are grounded more in intuition than insights from psychology. Consequently, such strategies are sometimes at variance with basic psychological principles and assumptions. By going against the grain of cognition, such strategies potentially run the risk of undermining persuasive efforts to reduce vaccine hesitancy. We demonstrate this by drawing on key insights from cognitive and social psychology to show how various known features of human psychology can lead many intuitively appealing intervention strategies to backfire, yielding unintended and undesirable repercussions. We conclude with a summary of potential avenues of investigation that may be more effective in addressing vaccine hesitancy. Our key message is that intervention strategies must be crafted that go with the grain of cognition by incorporating key insights from the psychological sciences.
Article
Importance Parents hesitant to vaccinate their children may delay routine immunizations or seek exemptions from state vaccine mandates. Recent outbreaks of vaccine-preventable diseases in the United States have drawn attention to this phenomenon. Improved understanding of the association between vaccine refusal and the epidemiology of these diseases is needed.Objective To review the published literature to evaluate the association between vaccine delay, refusal, or exemption and the epidemiology of measles and pertussis, 2 vaccine-preventable diseases with recent US outbreaks.Evidence Review Search of PubMed through November 30, 2015, for reports of US measles outbreaks that have occurred since measles was declared eliminated in the United States (after January 1, 2000), endemic and epidemic pertussis since the lowest point in US pertussis incidence (after January 1, 1977), and for studies that assessed disease risk in the context of vaccine delay or exemption.Findings We identified 18 published measles studies (9 annual summaries and 9 outbreak reports), which described 1416 measles cases (individual age range, 2 weeks-84 years; 178 cases younger than 12 months) and more than half (56.8%) had no history of measles vaccination. Of the 970 measles cases with detailed vaccination data, 574 cases were unvaccinated despite being vaccine eligible and 405 (70.6%) of these had nonmedical exemptions (eg, exemptions for religious or philosophical reasons, as opposed to medical contraindications; 41.8% of total). Among 32 reports of pertussis outbreaks, which included 10 609 individuals for whom vaccination status was reported (age range, 10 days-87 years), the 5 largest statewide epidemics had substantial proportions (range, 24%-45%) of unvaccinated or undervaccinated individuals. However, several pertussis outbreaks also occurred in highly vaccinated populations, indicating waning immunity. Nine reports (describing 12 outbreaks) provided detailed vaccination data on unimmunized cases; among 8 of these outbreaks from 59% through 93% of unvaccinated individuals were intentionally unvaccinated.Conclusions and Relevance A substantial proportion of the US measles cases in the era after elimination were intentionally unvaccinated. The phenomenon of vaccine refusal was associated with an increased risk for measles among people who refuse vaccines and among fully vaccinated individuals. Although pertussis resurgence has been attributed to waning immunity and other factors, vaccine refusal was still associated with an increased risk for pertussis in some populations.