|This article is part of a series on|
Vaccine hesitancy, also known as anti-vaccination or anti-vax, is a reluctance or refusal to be vaccinated or to have one's children vaccinated against contagious diseases despite the availability of vaccination services. It was identified by the World Health Organization as one of the top ten global health threats of 2019. The term encompasses outright refusal to vaccinate, delaying vaccines, accepting vaccines but remaining uncertain about their use, or using certain vaccines but not others. Arguments against vaccination are contradicted by overwhelming scientific consensus about the safety and efficacy of vaccines.
Hesitancy primarily results from public debates around the medical, ethical and legal issues related to vaccines. Vaccine hesitancy stems from multiple key factors including a person's lack of confidence (mistrust of the vaccine and/or healthcare provider), complacency (the person does not see a need for the vaccine or does not see the value of the vaccine), and convenience (access to vaccines). It has existed since the invention of vaccination, and pre-dates the coining of the terms "vaccine" and "vaccination" by nearly 80 years. The specific hypotheses raised by anti-vaccination advocates have been found to change over time. Vaccine hesitancy often results in disease outbreaks and deaths from vaccine-preventable diseases.
Bills for mandatory vaccination have been considered for legislation, including California Senate Bill 277 and Australia's No Jab No Pay, all of which have been strenuously opposed by anti-vaccination activists. Opposition to mandatory vaccination may be based on anti-vaccine sentiment, concern that it violates civil liberties or reduces public trust in vaccination, or suspicion of profiteering by the pharmaceutical industry.
Scientific evidence for the effectiveness of large-scale vaccination campaigns is well established. Two to three million deaths are prevented each year worldwide due to vaccination and an additional 1.5 million deaths could be prevented each year if all recommended vaccines were used. Vaccination campaigns helped eradicate smallpox, which once killed as many as one in seven children in Europe, and have nearly eradicated polio. As a more modest example, infections caused by Haemophilus influenzae (Hib), a major cause of bacterial meningitis and other serious diseases in children, have decreased by over 99% in the US since the introduction of a vaccine in 1988. It is estimated that full vaccination, from birth to adolescence, of all US children born in a given year would save 33,000 lives and prevent 14 million infections.
Some argue that these reductions in infectious disease are a result of improved sanitation and hygiene (rather than vaccination), or that these diseases were already in decline before the introduction of specific vaccines. These claims are not supported by scientific data; the incidence of vaccine-preventable diseases tended to fluctuate over time until the introduction of specific vaccines, at which point the incidence dropped to near zero. A Centers for Disease Control and Prevention website aimed at countering common misconceptions about vaccines argued, "Are we expected to believe that better sanitation caused incidence of each disease to drop, just at the time a vaccine for that disease was introduced?"
Other critics argue that the immunity granted by vaccines is only temporary and requires boosters, whereas those who survive the disease become permanently immune. As discussed below, the philosophies of some alternative medicine practitioners are incompatible with the idea that vaccines are effective.
Incomplete vaccine coverage increases the risk of disease for the entire population, including those who have been vaccinated, because it reduces herd immunity. For example, the measles vaccine is given to children between the ages of 9 and 12 months, and the short window between the disappearance of maternal antibody (before which the vaccine often fails to seroconvert) and natural infection means that vaccinated children are frequently still vulnerable. Herd immunity lessens this vulnerability if all the children are vaccinated. Increasing herd immunity during an outbreak or risk of outbreak is perhaps the most widely accepted justification for mass vaccination. When a new vaccine is introduced mass vaccination helps increase coverage rapidly.
If enough of a population is vaccinated, herd immunity takes effect, decreasing risk to people who cannot receive vaccines because they are too young or old, immunocompromised, or have severe allergies to the ingredients in the vaccine. The outcome for people with compromised immune systems who get infected is often worse than that of the general population.
Commonly used vaccines are a cost-effective and preventive way of promoting health, compared to the treatment of acute or chronic disease. In the US during the year 2001, routine childhood immunizations against seven diseases were estimated to save over $40 billion per birth-year cohort in overall social costs, including $10 billion in direct health costs, and the societal benefit-cost ratio for these vaccinations was estimated to be 16.5.
When a vaccination program successfully reduces the disease threat, it may reduce the perceived risk of disease as cultural memories of the effects of that disease fade. At this point, parents may feel they have nothing to lose by not vaccinating their children. If enough people hope to become free-riders, gaining the benefits of herd immunity without vaccination, vaccination levels may drop to a level where herd immunity is ineffective. According to Jennifer Reich, those parents who believe vaccination to be quite effective but might prefer their children to remain unvaccinated, are those who are the most likely to be convinced to change their mind, as long as they are approached properly.
While some anti-vaccinationists openly deny the improvements vaccination has made to public health, or succumb to conspiracy theories, it is much more common to cite concerns about safety. As with any medical treatment, there is a potential for vaccines to cause serious complications, such as severe allergic reactions, but unlike most other medical interventions, vaccines are given to healthy people and so a higher standard of safety is expected. While serious complications from vaccinations are possible, they are extremely rare and much less common than similar risks from the diseases they prevent. As the success of immunization programs increases and the incidence of disease decreases, public attention shifts away from the risks of disease to the risk of vaccination, and it becomes challenging for health authorities to preserve public support for vaccination programs.
The overwhelming success of certain vaccinations has made certain diseases rare and consequently this has led to incorrect heuristic thinking, in weighing risks against benefits, among people who are vaccine-hesitant. Once such diseases (e.g., Haemophilus influenzae B) decrease in prevalence, people may no longer appreciate how serious the illness is due to a lack of familiarity with it and become complacent. The lack of personal experience with these diseases reduces the perceived danger and thus reduces the perceived benefit of immunization. Conversely, certain illnesses (e.g., influenza) remain so common that vaccine-hesitant people mistakenly perceive the illness to be non-threatening despite clear evidence that the illness poses a significant threat to human health. Omission and disconfirmation biases also contribute to vaccine hesitancy.
Various concerns about immunization have been raised. They have been addressed and the concerns are not supported by evidence. Concerns about immunization safety often follow a pattern. First, some investigators suggest that a medical condition of increasing prevalence or unknown cause is an adverse effect of vaccination. The initial study and subsequent studies by the same group have inadequate methodology—typically a poorly controlled or uncontrolled case series. A premature announcement is made about the alleged adverse effect, resonating with individuals suffering from the condition, and underestimating the potential harm of forgoing vaccination to those whom the vaccine could protect. Other groups attempt to replicate the initial study but fail to get the same results. Finally, it takes several years to regain public confidence in the vaccine. Adverse effects ascribed to vaccines typically have an unknown origin, an increasing incidence, some biological plausibility, occurrences close to the time of vaccination, and dreaded outcomes. In almost all cases, the public health effect is limited by cultural boundaries: English speakers worry about one vaccine causing autism, while French speakers worry about another vaccine causing multiple sclerosis, and Nigerians worry that a third vaccine causes infertility.
The idea of a link between vaccines and autism has been extensively investigated and conclusively shown to be false. The scientific consensus is that there is no relationship, causal or otherwise, between vaccines and incidence of autism, and vaccine ingredients do not cause autism.
Nevertheless, the anti-vaccination movement continues to promote myths, conspiracy theories, and misinformation linking the two. A developing tactic appears to be the "promotion of irrelevant research [as] an active aggregation of several questionable or peripherally related research studies in an attempt to justify the science underlying a questionable claim."
Thiomersal (spelled "thimerosal" in the US) is an antifungal preservative used in small amounts in some multi-dose vaccines (where the same vial is opened and used for multiple patients) to prevent contamination of the vaccine. Despite thiomersal's efficacy, the use of thiomersal is controversial because it contains mercury (specifically ethylmercury). As a result, in 1999, the Centers for Disease Control (CDC) and the American Academy of Pediatrics (AAP) asked vaccine makers to remove thiomersal from vaccines as quickly as possible on the precautionary principle. Thiomersal is now absent from all common US and European vaccines, except for some preparations of influenza vaccine. Trace amounts remain in some vaccines due to production processes, at an approximate maximum of 1 microgramme, around 15% of the average daily mercury intake in the US for adults and 2.5% of the daily level considered tolerable by the WHO. The action sparked concern that thiomersal could have been responsible for autism. The idea is now considered disproven, as incidence rates for autism increased steadily even after thiomersal was removed from childhood vaccines. Currently there is no accepted scientific evidence that exposure to thiomersal is a factor in causing autism. Since 2000, parents in the United States have pursued legal compensation from a federal fund arguing that thiomersal caused autism in their children. A 2004 Institute of Medicine (IOM) committee favored rejecting any causal relationship between thiomersal-containing vaccines and autism. The concentration of thiomersal used in vaccines as an antimicrobial agent ranges from 0.001% (1 part in 100,000) to 0.01% (1 part in 10,000). A vaccine containing 0.01% thiomersal has 25 micrograms of mercury per 0.5 mL dose, roughly the same amount of elemental mercury found in a three-ounce can of tuna. There is robust peer-reviewed scientific evidence supporting the safety of thiomersal-containing vaccines.
In the UK, the MMR vaccine was the subject of controversy after the publication in The Lancet of a 1998 paper by Andrew Wakefield and others reporting case histories of 12 children mostly with autism spectrum disorders with onset soon after administration of the vaccine. At a 1998 press conference, Wakefield suggested that giving children the vaccines in three separate doses would be safer than a single vaccination. This suggestion was not supported by the paper, and several subsequent peer-reviewed studies have failed to show any association between the vaccine and autism. It later emerged that Wakefield had received funding from litigants against vaccine manufacturers and that he had not informed colleagues or medical authorities of his conflict of interest; had this been known, publication in The Lancet would not have taken place in the way that it did. Wakefield has been heavily criticized on scientific grounds and for triggering a decline in vaccination rates (vaccination rates in the UK dropped to 80% in the years following the study), as well as on ethical grounds for the way the research was conducted. In 2004, the MMR-and-autism interpretation of the paper was formally retracted by 10 of Wakefield's 12 coauthors, and in 2010 The Lancet's editors fully retracted the paper. Wakefield was struck off the UK medical register, with a statement identifying deliberate falsification in the research published in The Lancet, and is barred from practicing medicine in the UK.
The CDC, the IOM of the National Academy of Sciences, Australia's Department of Health, and the UK National Health Service have all concluded that there is no evidence of a link between the MMR vaccine and autism. A Cochrane review concluded that there is no credible link between the MMR vaccine and autism, that MMR has prevented diseases that still carry a heavy burden of death and complications, that the lack of confidence in MMR has damaged public health, and that the design and reporting of safety outcomes in MMR vaccine studies are largely inadequate. Additional reviews agree, with studies finding that vaccines are not linked to autism even in high risk populations with autistic siblings.
In 2009, The Sunday Times reported that Wakefield had manipulated patient data and misreported results in his 1998 paper, creating the appearance of a link with autism. A 2011 article in the British Medical Journal described how the data in the study had been falsified by Wakefield so that it would arrive at a predetermined conclusion. An accompanying editorial in the same journal described Wakefield's work as an "elaborate fraud" that led to lower vaccination rates, putting hundreds of thousands of children at risk and diverting energy and money away from research into the true cause of autism.
A special court convened in the United States to review claims under the National Vaccine Injury Compensation Program ruled on February 12, 2009 that parents of autistic children are not entitled to compensation in their contention that certain vaccines caused autism in their children.
Vaccine overload, a non-medical term, is the notion that giving many vaccines at once may overwhelm or weaken a child's immature immune system and lead to adverse effects. Despite scientific evidence that strongly contradicts this idea, some parents of autistic children believe that vaccine overload causes autism. The resulting controversy has caused many parents to delay or avoid immunizing their children. Such parental misperceptions are major obstacles towards immunization of children.
The concept of vaccine overload is flawed on several levels. Despite the increase in the number of vaccines over recent decades, improvements in vaccine design have reduced the immunologic load from vaccines; the total number of immunological components in the 14 vaccines administered to US children in 2009 is less than 10% of what it was in the 7 vaccines given in 1980. A study published in 2013 found no correlation between autism and the antigen number in the vaccines the children were administered up to the age of two. Of the 1,008 children in the study, one quarter of those diagnosed with autism were born between 1994 and 1999, when the routine vaccine schedule could contain more than 3,000 antigens (in a single shot of DTP vaccine). The vaccine schedule in 2012 contains several more vaccines, but the number of antigens the child is exposed to by the age of two is 315. Vaccines pose a very small immunologic load compared to the pathogens naturally encountered by a child in a typical year; common childhood conditions such as fevers and middle-ear infections pose a much greater challenge to the immune system than vaccines, and studies have shown that vaccinations, even multiple concurrent vaccinations, do not weaken the immune system or compromise overall immunity. The lack of evidence supporting the vaccine overload hypothesis, combined with these findings directly contradicting it, has led to the conclusion that currently recommended vaccine programs do not "overload" or weaken the immune system.
Any experiment based on withholding vaccines from children is considered unethical, and observational studies would likely be confounded by differences in the health care-seeking behaviors of under-vaccinated children. Thus, no study directly comparing rates of autism in vaccinated and unvaccinated children has been done. However, the concept of vaccine overload is biologically implausible, as vaccinated and unvaccinated children have the same immune response to non-vaccine-related infections, and autism is not an immune-mediated disease, so claims that vaccines could cause it by overloading the immune system go against current knowledge of the pathogenesis of autism. As such, the idea that vaccines cause autism has been effectively dismissed by the weight of current evidence.
There is evidence that schizophrenia is associated with prenatal exposure to rubella, influenza, and toxoplasmosis infection. For example, one study found a sevenfold increased risk of schizophrenia when mothers were exposed to influenza in the first trimester of gestation. This may have public health implications, as strategies for preventing infection include vaccination, simple hygiene, and, in the case of toxoplasmosis, antibiotics. Based on studies in animal models, theoretical concerns have been raised about a possible link between schizophrenia and maternal immune response activated by virus antigens; a 2009 review concluded that there was insufficient evidence to recommend routine use of trivalent influenza vaccine during the first trimester of pregnancy, but that the vaccine was still recommended outside the first trimester and in special circumstances such as pandemics or in women with certain other conditions. The CDC's Advisory Committee on Immunization Practices, the American College of Obstetricians and Gynecologists, and the American Academy of Family Physicians all recommend routine flu shots for pregnant women, for several reasons:
- their risk for serious influenza-related medical complications during the last two trimesters;
- their greater rates for flu-related hospitalizations compared to non-pregnant women;
- the possible transfer of maternal anti-influenza antibodies to children, protecting the children from the flu; and
- several studies that found no harm to pregnant women or their children from the vaccinations.
Despite this recommendation, only 16% of healthy pregnant US women surveyed in 2005 had been vaccinated against the flu.
Aluminum compounds are used as immunologic adjuvants to increase the effectiveness of many vaccines. The aluminum in vaccines simulates or causes small amounts of tissue damage, driving the body to respond more powerfully to what it sees as a serious infection and promoting the development of a lasting immune response. In some cases these compounds have been associated with redness, itching, and low-grade fever, but the use of aluminum in vaccines has not been associated with serious adverse events. In some cases, aluminum-containing vaccines are associated with macrophagic myofasciitis (MMF), localized microscopic lesions containing aluminum salts that persist for up to 8 years. However, recent case-controlled studies have found no specific clinical symptoms in individuals with biopsies showing MMF, and there is no evidence that aluminum-containing vaccines are a serious health risk or justify changes to immunization practice. Infants are exposed to greater quantities of aluminum in daily life in breastmilk and infant formula than in vaccines. In general, people are exposed to low levels of naturally occurring aluminum in nearly all foods and drinking water. The amount of aluminum present in vaccines is small, less than 1 milligram, and such low levels are not believed to be harmful to human health.
Vaccine hesitant people have also voiced strong concerns about the presence of formaldehyde in vaccines. Formaldehyde is used in very small concentrations to inactivate viruses and bacterial toxins used in vaccines. Very small amounts of residual formaldehyde can be present in vaccines but are far below values harmful to human health. The levels present in vaccines are minuscule when compared to naturally-occurring levels of formaldehyde in the human body and pose no significant risk of toxicity. The human body continuously produces formaldehyde naturally and contains 50–70 times the greatest amount of formaldehyde present in any vaccine. Furthermore, the human body is capable of breaking down naturally occurring formaldehyde as well as the small amount of formaldehyde present in vaccines. There is no evidence linking the infrequent exposures to small quantities of formaldehyde present in vaccines with cancer.
Sudden infant death syndrome
Sudden infant death syndrome (SIDS) is most common in infants around the time in life when they receive many vaccinations. Since the cause of SIDS has not been fully determined, this led to concerns about whether vaccines, in particular diphtheria-tetanus toxoid vaccines, were a possible causal factor. Several studies investigated this and found no evidence supporting a causal link between vaccination and SIDS. In 2003, the Institute of Medicine favored rejection of a causal link to DTwP vaccination and SIDS after reviewing the available evidence. Additional analyses of VAERS data also showed no relationship between vaccination and SIDS. In fact, evidence is mounting that vaccination may protect children against SIDS.
Swine flu vaccine
During the 2009 flu pandemic, significant controversy broke out regarding whether the 2009 H1N1 flu vaccine was safe in, among other countries, France. Numerous different French groups publicly criticized the vaccine as potentially dangerous.
Other safety concerns
Other safety concerns about vaccines have been promoted on the Internet, in informal meetings, in books, and at symposia. These include hypotheses that vaccination can cause epileptic seizures, allergies, multiple sclerosis, and autoimmune diseases such as type 1 diabetes, as well as hypotheses that vaccinations can transmit bovine spongiform encephalopathy, hepatitis C virus, and HIV. These hypotheses have been investigated, with the conclusion that currently used vaccines meet high safety standards and that criticism of vaccine safety in the popular press is not justified. Large well-controlled epidemiologic studies have been conducted and the results do not support the hypothesis that vaccines cause chronic diseases. Furthermore, some vaccines are probably more likely to prevent or modify than cause or exacerbate autoimmune diseases. Another common concern parents often have is about the pain associated with administering vaccines during a doctor's office visit. This may lead to parental requests to space out vaccinations; however, studies have shown a child's stress response is not different when receiving one vaccination or two. The act of spacing out vaccinations may actually lead to more stressful stimuli for the child.
In Pakistan, the CIA ran a fake vaccination clinic in an attempt to locate Osama bin Laden. As a direct consequence, there have been several attacks and deaths among vaccination workers. Several Islamist preachers and militant groups, including some factions of the Taliban, view vaccination as a plot to kill or sterilize Muslims. Efforts to eradicate polio have furthermore been disrupted by American drone strikes. This is part of the reason Pakistan and Afghanistan are the only countries where polio remained endemic as of 2015.
In India, a 3-minute doctored clip has been circulating[when?] among Muslims claiming that the MR-VAC vaccine against measles and rubella was a "Modi government-RSS conspiracy" to stop the population growth of Muslims. The clip was taken from a TV show that exposed the baseless rumors. Hundreds of madrassas in the state of Uttar Pradesh have refused permission to health department teams to administer vaccines because of rumors spread using WhatsApp.
Other vaccine myths
There are several other vaccination myths that contribute to parental concerns and vaccine hesitancy. These include the alleged superiority of natural infection when compared to vaccination, questioning whether the diseases vaccines prevent are dangerous, whether vaccines pose moral or religious dilemmas, suggesting that vaccines are not effective, proposing unproven or ineffective approaches as alternatives to vaccines, and conspiracy theories that center on mistrust of the government and medical institutions.
Vaccination during illness
Many parents are concerned about the safety of vaccination when their child is sick. Moderate to severe acute illness with or without a fever is indeed a precaution when considering vaccination. Vaccines remain effective during childhood illness. The reason vaccines may be withheld if a child is moderately to severely ill is because certain expected side effects of vaccination (e.g., fever or rash) may be confused with progression of the illness. It is safe to administer vaccines to well-appearing children who are mildly ill with the common cold.
Another common anti-vaccine myth is that natural infection produces better immune protection against contracting the illness in the future when compared to vaccination. In some cases, actual infection with the illness may produce lifelong immunity; however, natural disease carries a higher risk of harming a person's health than vaccines. For example, natural varicella infection carries a higher risk of bacterial superinfection with Group A streptococci.
The idea that the HPV vaccine is linked to increased sexual behavior is not supported by scientific evidence. A review of nearly 1,400 adolescent girls found no difference in teen pregnancy, incidence of sexually transmitted infection, or contraceptive counseling regardless of whether they received the HPV vaccine. Thousands of Americans die each year from cancers preventable by the vaccine.
Other concerns have been raised about the vaccine schedule recommended by the Advisory Committee on Immunization Practices (ACIP). The immunization schedule is designed to protect children against preventable diseases when they are most vulnerable. The practice of delaying or spacing out these vaccinations increases the amount of time the child is susceptible to these illnesses. Receiving vaccines on the recommended ACIP schedule is not linked to autism or developmental delay.
Events following reductions in vaccination
In several countries, reductions in the use of some vaccines were followed by increases in the diseases' morbidity and mortality. According to the Centers for Disease Control and Prevention, continued high levels of vaccine coverage are necessary to prevent resurgence of diseases that have been nearly eliminated. Pertussis remains a major health problem in developing countries, where mass vaccination is not practiced; the World Health Organization estimates it caused 294,000 deaths in 2002. Vaccine hesitancy has contributed to the resurgence of preventable disease. For example, in 2019, the number of measles cases increased by 30% worldwide and many cases occurred in countries that had nearly eliminated measles.
Stockholm, smallpox (1873–74)
An anti-vaccination campaign motivated by religious objections, concerns about effectiveness, and concerns about individual rights led to the vaccination rate in Stockholm dropping to just over 40%, compared to about 90% elsewhere in Sweden. A major smallpox epidemic began there in 1873. It led to a rise in vaccine uptake and an end of the epidemic.
During the Vietnam War, vaccination was necessary for soldiers to fight overseas. Because disease follows soldiers, they had to receive vaccines preventing cholera, influenza, measles, meningococcemia, Bubonic plague, poliovirus, smallpox, tetanus, diphtheria, typhoid, typhus, and yellow fever. However, the diseases mainly prevalent in Vietnam at this time were measles and polio. After arriving in Vietnam, the United States Military conducted the "Military Public Health Assistance Project". This public health program was a joint United States Military and Government of Vietnam concept to create or expand public medical facilities throughout South Vietnam. Local villages in Vietnam were inoculated. The United States military screened patients, dispensed medication, distributed clothing and food, and even passed out propaganda such as comic books.
UK, pertussis (1970s–80s)
In a 1974 report ascribing 36 reactions to whooping cough (pertussis) vaccine, a prominent public-health academic claimed that the vaccine was only marginally effective and questioned whether its benefits outweigh its risks, and extended television and press coverage caused a scare. Vaccine uptake in the UK decreased from 81% to 31%, and pertussis epidemics followed, leading to the deaths of some children. Mainstream medical opinion continued to support the effectiveness and safety of the vaccine; public confidence was restored after the publication of a national reassessment of vaccine efficacy. Vaccine uptake then increased to levels above 90%, and disease incidence declined dramatically.
Sweden, pertussis (1979–96)
In the vaccination moratorium period that occurred when Sweden suspended vaccination against whooping cough (pertussis) from 1979 to 1996, 60% of the country's children contracted the disease before the age of 10; close medical monitoring kept the death rate from whooping cough at about one per year.
Netherlands, measles (1999–2000)
An outbreak at a religious community and school in the Netherlands resulted in three deaths and 68 hospitalizations among 2,961 cases. The population in the several provinces affected had a high level of immunization, with the exception of one of the religious denominations, which traditionally does not accept vaccination. Ninety-five percent of those who contracted measles were unvaccinated.
UK and Ireland, measles (2000)
As a result of the MMR vaccine controversy, vaccination rates dropped sharply in the United Kingdom after 1996. From late 1999 until the summer of 2000, there was a measles outbreak in North Dublin, Ireland. At the time, the national immunization level had fallen below 80%, and in parts of North Dublin the level was around 60%. There were more than 100 hospital admissions from over 300 cases. Three children died and several more were gravely ill, some requiring mechanical ventilation to recover.
Nigeria, polio, measles, diphtheria (2001–)
In the early first decade of the 21st century, conservative religious leaders in northern Nigeria, suspicious of Western medicine, advised their followers not to have their children vaccinated with oral polio vaccine. The boycott was endorsed by the governor of Kano State, and immunization was suspended for several months. Subsequently, polio reappeared in a dozen formerly polio-free neighbors of Nigeria, and genetic tests showed the virus was the same one that originated in northern Nigeria. Nigeria had become a net exporter of the polio virus to its African neighbors. People in the northern states were also reported to be wary of other vaccinations, and Nigeria reported over 20,000 measles cases and nearly 600 deaths from measles from January through March 2005. In Northern Nigeria, it is a common belief that vaccination is a strategy created by the westerners to reduce the Northerners' population. As a result of this belief, a large number of Northerners reject vaccination. In 2006, Nigeria accounted for over half of all new polio cases worldwide. Outbreaks continued thereafter; for example, at least 200 children died in a late-2007 measles outbreak in Borno State.
United States, measles (2005–)
In 2000, measles was declared eliminated from the United States because internal transmission had been interrupted for one year; remaining reported cases were due to importation.
The Centers for Disease Control and Prevention (CDC) reported that the three biggest outbreaks of measles in 2013 were attributed to clusters of people who were unvaccinated due to their philosophical or religious beliefs. As of August 2013, three pockets of outbreak—New York City, North Carolina, and Texas—contributed to 64% of the 159 cases of measles reported in 16 states.
The number of cases in 2014 quadrupled to 644, including transmission by unvaccinated visitors to Disneyland in California. Some 97% of cases in the first half of the year were confirmed to be due directly or indirectly to importation (the remainder were unknown), and 49% from the Philippines. More than half of the victims (165 out of 288, or 57%) during that time were confirmed to be unvaccinated by choice; 30 (10%) were confirmed to have been vaccinated. The final count of measles in 2014 was 668 cases in 27 states.
From January 1 to June 26, 2015, 178 people from 24 states and the District of Columbia were reported to have measles. Most of these cases (117 cases [66%]) were part of a large multi-state outbreak linked to Disneyland in California, continued from 2014. Analysis by the CDC scientists showed that the measles virus type in this outbreak (B3) was identical to the virus type that caused the large measles outbreak in the Philippines in 2014. On July 2, 2015, the first confirmed death from measles in 12 years was recorded. An immunocompromised woman in Washington State was infected and later died of pneumonia due to measles.
By July, 2016, a three-month measles outbreak affecting at least 22 people was spread by unvaccinated employees of the Eloy, Arizona detention center, an Immigration and Customs Enforcement (ICE) facility owned by for-profit prison operator CoreCivic. Pinal County's health director presumed the outbreak likely originated with a migrant, but detainees had since received vaccinations. However convincing CoreCivic's employees to become vaccinated or demonstrate proof of immunity was much more difficult, he said.
In spring 2017, a measles outbreak occurred in Minnesota. As of June 16, 78 cases of measles had been confirmed in the state, 71 were unvaccinated and 65 were Somali-Americans. The outbreak has been attributed to low vaccination rates among Somali-American children, which can be traced back to 2008, when Somali parents began to express concern about disproportionately high numbers of Somali preschoolers in special education classes who were receiving services for autism spectrum disorder. Around the same time, disgraced former doctor Andrew Wakefield visited Minneapolis, teaming up with anti-vaccine groups to raise concerns that vaccines were the cause of autism, despite the fact that multiple studies have shown no connection between the MMR vaccine and autism.
From fall 2018 to early 2019, New York State experienced an outbreak of over 200 confirmed measles cases. Many of these cases were attributed to ultra-Orthodox Jewish communities with low vaccination rates in areas within Brooklyn and Rockland County. State Health Commissioner Howard Zucker stated that this was the worst outbreak of measles in his recent memory.
In January 2019, Washington state reported an outbreak of at least 73 confirmed cases of measles, most within Clark County, which has a higher rate of vaccination exemptions compared to the rest of the state. This led state governor Jay Inslee to declare a state of emergency, and the state's congress to introduce legislation to disallow vaccination exemption for personal or philosophical reasons.
Wales, measles (2013–)
In 2013, an outbreak of measles occurred in the Welsh city of Swansea. One death was reported. Some estimates indicate that while MMR uptake for two-year-olds was at 94% in Wales in 1995, it had fallen to as low as 67.5% in Swansea by 2003, meaning the region had a "vulnerable" age group. This has been linked to the MMR vaccine controversy, which caused a significant number of parents to fear allowing their children to receive the MMR vaccine. June 5, 2017, saw a new measles outbreak in Wales, at Lliswerry High School in the town of Newport.
United States, tetanus
Most cases of pediatric tetanus in the U.S. occur in unvaccinated children. In Oregon, in 2017, an unvaccinated boy had a scalp wound that his parents sutured themselves. Later the boy arrived at a hospital with tetanus. He spent 47 days in the Intensive Care Unit (ICU), and 57 total days in the hospital, at a cost of $811,929, not including the cost of airlifting him to the Oregon Health and Science University, Doernbecher Children's Hospital, or the subsequent two-and-a-half weeks of inpatient rehabilitation he required. Despite this, his parents declined the administration of subsequent tetanus boosters or other vaccinations. Due to privacy regulations, publicly identifying the payer of the costs was prohibited.
As of September 2017, a measles epidemic was ongoing across Europe, especially Eastern Europe. In Romania, there were about 9300 cases of measles, and 34 people—all of whom were unvaccinated—had died of measles. This was preceded by a 2008 controversy regarding the HPV vaccine. In 2012, doctor Christa Todea-Gross published a free downloadable book online, this book contained misinformation about vaccination from abroad translated into Romanian, which significantly stimulated the growth of the anti-vaccine movement. The government of Romania officially declared a measles epidemic in September 2016, and started an information campaign to encourage parents to have their children vaccinated. By February 2017, however, the stockpile of MMR vaccines was depleted, and doctors were overburdened. Around April, the vaccine stockpile had been restored. By March 2019, the death toll had risen to 62, with 15,981 cases reported.
Samoa, measles (2019)
The 2019 Samoa measles outbreak began in October 2019 and as of December 12, there were 4,995 confirmed cases of measles and 72 deaths, out of a Samoan population of 201,316. A state of emergency was declared on November 17, ordering all schools to be closed, barring children under 17 from public events, and making vaccination mandatory. UNICEF has sent 110,500 vaccines to Samoa. Tonga and Fiji have also declared states of emergency.
The outbreak has been attributed to a sharp drop in measles vaccination from the previous year, following an incident in 2018 when two infants died shortly after receiving measles vaccinations, which led the country to suspend its measles vaccination program. The reason for the two infants' deaths was incorrect preparation of the vaccine by two nurses who mixed vaccine powder with expired anesthetic. As of November 30, more than 50,000 people were vaccinated by the government of Samoa.
Vaccine hesitancy is challenging and optimal strategies for approaching it remain uncertain. Many interventions designed to address vaccine hesitancy have been based on the information deficit model. This model assumes that vaccine hesitancy is due to a person lacking the necessary information and attempts to provide them with that information to solve the problem. Despite many educational interventions attempting this approach, ample evidence indicates providing more information is often ineffective in changing a vaccine-hesitant person's views and may, in fact, have the opposite of the intended effect and reinforce their misconceptions.
Several communication strategies are recommended for use when interacting with vaccine-hesitant parents. These include establishing honest and respectful dialogue; acknowledging the risks of a vaccine but balancing them against the risk of disease; referring parents to reputable sources of vaccine information; and maintaining ongoing conversations with vaccine-hesitant families. The American Academy of Pediatrics recommends healthcare providers directly address parental concerns about vaccines when questioned about their efficacy and safety. Additional recommendations include asking permission to share information; maintaining a conversational tone (as opposed to lecturing); not spending excessive amounts of time debunking specific myths (this may have the opposite effect of strengthening the myth in the person's mind); focusing on the facts and simply identifying the myth as false; and keeping information as simple as possible (if the myth seems simpler than the truth, it may be easier for people to accept the simple myth). Storytelling and anecdote (e.g., about the decision to vaccinate one's own children) can be powerful communication tools for conversations about the value of vaccination. The perceived strength of the recommendation, when provided by a healthcare provider, also seems to influence uptake, with recommendations that are perceived to be stronger resulting in higher vaccination rates than perceived weaker recommendations.
Limited evidence suggests that a more paternalistic or presumptive approach ("Your son needs three shots today.") is more likely to result in patient acceptance of vaccines during a clinic visit than a participatory approach ("What do you want to do about shots?") but decreases patient satisfaction with the visit. A presumptive approach helps to establish that this is the normative choice. Similarly, one study found that the way in which physicians respond to parental vaccine resistance is important. Nearly half of initially vaccine-resistant parents accepted vaccinations if physicians persisted in their initial recommendation. The Centers for Disease Control and Prevention has released resources to aid healthcare providers in having more effective conversations with parents about vaccinations.
Parents may be hesitant to have their child vaccinated due to concerns about the pain of vaccination. There are several strategies that can be used to reduce the child's pain. Such strategies include distraction techniques (pinwheels); deep breathing techniques; breastfeeding the child; giving the child sweet-tasting solutions; quickly administering the vaccine without aspirating; keeping the child upright; providing tactile stimulation; applying numbing agents to the skin; and saving the most painful vaccine for last. As above, the number of vaccines offered in a particular encounter is related to the likelihood of parent vaccine refusal (the more vaccines offered, the higher the likelihood of vaccine deferral). The use of combination vaccines to provide protection against more diseases but with fewer injections may provide reassurance to parents. Similarly, reframing the conversation with less emphasis on the number of diseases the healthcare provider is immunizing against (e.g., "we will do two injections (combined vaccinations) and an oral vaccine") may be more acceptable to parents than "we're going to vaccinate against 7 diseases".
It is unclear whether interventions intended to educate parents about vaccines improve the rate of vaccination. It is also unclear whether citing the reasons of benefit to others and herd immunity improves parents' willingness to vaccinate their children. In one trial, an educational intervention designed to dispel common misconceptions about the influenza vaccine decreased parents' false beliefs about the vaccines but did not improve uptake of the influenza vaccine. In fact, parents with significant concerns about adverse effects from the vaccine were less likely to vaccinate their children with the influenza vaccine after receiving this education. Multicomponent initiatives which include targeting undervaccinated populations, improving the convenience of and access to vaccines, educational initiatives, and mandates may improve vaccination uptake.
It is recommended that healthcare providers advise parents against performing their own web search queries since many websites on the Internet contain significant misinformation. Many parents perform their own research online and are often confused, frustrated, and unsure of which sources of information are trustworthy. Additional recommendations include introducing parents to the importance of vaccination as far in advance of the initial well-child visit as possible; presenting parents with vaccine safety information while in their pediatrician's waiting room; and using prenatal open houses and postpartum maternity ward visits as opportunities to vaccinate.
Internet advertising, on Facebook and elsewhere, is purchased by both public health authorities and anti-vaccination groups. In the United States, the majority of anti-vaccine Facebook advertising in December 2018 and February 2019 had been paid for one of two groups: Robert F. Kennedy Jr.'s Children's Health Defense and Stop Mandatory Vaccination. The ads targeted women and young couples and generally highlighted the alleged risks of vaccines, while asking for donations. Several anti-vaccination advertising campaigns also targeted areas where measles outbreaks were underway during this period. The impact of Facebook's subsequent advertising policy changes has not been studied.
The World Health Organization published a paper in 2016 with the goal of aiding experts on how to respond to vaccine deniers in public. The WHO recommends for experts to view the general public as their target audience rather than the vaccine denier when debating in a public forum. The WHO also suggests for experts to make unmasking the techniques that the vaccine denier uses to spread misinformation as the goal of the conversation. The WHO asserts that this will make the public audience more resilient against anti-vaccine tactics.
Early attempts to prevent smallpox involved deliberate inoculation with the disease in hopes that a mild case would confer immunity. Originally called inoculation, this technique was later called variolation to avoid confusion with cowpox inoculation (vaccination) when that was introduced by Edward Jenner. Although variolation had a long history in China and India, it was first used in North America and England in 1721. Reverend Cotton Mather introduced variolation to Boston, Massachusetts, during the 1721 smallpox epidemic. Despite strong opposition in the community, Mather convinced Zabdiel Boylston to try it. Boylston first experimented on his 6-year-old son, his slave, and his slave's son; each subject contracted the disease and was sick for several days, until the sickness vanished and they were "no longer gravely ill". Boylston went on to variolate thousands of Massachusetts residents, and many places were named for him in gratitude as a result. Lady Mary Wortley Montagu introduced variolation to England. She had seen it used in Turkey and, in 1718, had her son successfully variolated in Constantinople under the supervision of Charles Maitland. When she returned to England in 1721, she had her daughter variolated by Maitland. This aroused considerable interest, and Sir Hans Sloane organized the variolation of some inmates in Newgate Prison. These were successful, and after a further short trial in 1722, two daughters of Caroline of Ansbach Princess of Wales were variolated without mishap. With this royal approval, the procedure became common when smallpox epidemics threatened.
Religious arguments against inoculation were soon advanced. For example, in a 1722 sermon entitled "The Dangerous and Sinful Practice of Inoculation", the English theologian Reverend Edmund Massey argued that diseases are sent by God to punish sin and that any attempt to prevent smallpox via inoculation is a "diabolical operation". It was customary at the time for popular preachers to publish sermons, which reached a wide audience. This was the case with Massey, whose sermon reached North America, where there was early religious opposition, particularly by John Williams. A greater source of opposition there was William Douglass, a medical graduate of Edinburgh University and a Fellow of the Royal Society, who had settled in Boston.:114–22
After Edward Jenner introduced the smallpox vaccine in 1798, variolation declined and was banned in some countries. As with variolation, there was some religious opposition to vaccination, although this was balanced to some extent by support from clergymen, such as Reverend Robert Ferryman, a friend of Jenner's, and Rowland Hill,:221 who not only preached in its favour but also performed vaccination themselves. There was also opposition from some variolators who saw the loss of a lucrative monopoly. William Rowley published illustrations of deformities allegedly produced by vaccination, lampooned in James Gillray's famous caricature depicted on this page, and Benjamin Moseley likened cowpox to syphilis, starting a controversy that would last into the 20th century.:203–05
There was legitimate concern from supporters of vaccination about its safety and efficacy, but this was overshadowed by general condemnation, particularly when legislation started to introduce compulsory vaccination. The reason for this was that vaccination was introduced before laboratory methods were developed to control its production and account for its failures. Vaccine was maintained initially through arm-to-arm transfer and later through production on the skin of animals, and bacteriological sterility was impossible. Further, identification methods for potential pathogens were not available until the late 19th to early 20th century. Diseases later shown to be caused by contaminated vaccine included erysipelas, tuberculosis, tetanus, and syphilis. This last, though rare—estimated at 750 cases in 100 million vaccinations—attracted particular attention. Much later, Charles Creighton, a leading medical opponent of vaccination, claimed that the vaccine itself was a cause of syphilis and devoted a book to the subject. As cases of smallpox started to occur in those who had been vaccinated earlier, supporters of vaccination pointed out that these were usually very mild and occurred years after the vaccination. In turn, opponents of vaccination pointed out that this contradicted Jenner's belief that vaccination conferred complete protection.:17–21 The views of opponents of vaccination that it was both dangerous and ineffective led to the development of determined anti-vaccination movements in England when legislation was introduced to make vaccination compulsory.
Because of its greater risks, variolation was banned in England by the 1840 Vaccination Act, which also introduced free voluntary vaccination for infants. Thereafter Parliament passed successive acts to enact and enforce compulsory vaccination. The 1853 act introduced compulsory vaccination, with fines for non-compliance and imprisonment for non-payment. The 1867 act extended the age requirement to 14 years and introduced repeated fines for repeated refusal for the same child. Initially, vaccination regulations were organised by the local Poor Law Guardians, and in towns where there was strong opposition to vaccination, sympathetic Guardians were elected who did not pursue prosecutions. This was changed by the 1871 act, which required Guardians to act. This significantly changed the relationship between the government and the public, and organized protests increased. In Keighley, Yorkshire, in 1876 the Guardians were arrested and briefly imprisoned in York Castle, prompting large demonstrations in support of the "Keighley Seven".:108–09 The protest movements crossed social boundaries. The financial burden of fines fell hardest on the working class, who would provide the largest numbers at public demonstrations. Societies and publications were organized by the middle classes, and support came from celebrities such as George Bernard Shaw and Alfred Russel Wallace, doctors such as Charles Creighton and Edgar Crookshank, and parliamentarians such as Jacob Bright and James Allanson Picton. By 1885, with over 3,000 prosecutions pending in Leicester, a mass rally there was attended by over 20,000 protesters.
Under increasing pressure, the government appointed a Royal Commission on Vaccination in 1889, which issued six reports between 1892 and 1896, with a detailed summary in 1898. Its recommendations were incorporated into the 1898 Vaccination Act, which still required compulsory vaccination but allowed exemption on the grounds of conscientious objection on presentation of a certificate signed by two magistrates. These were not easy to obtain in towns where magistrates supported compulsory vaccination, and after continued protests, a further act in 1907 allowed exemption on a simple signed declaration. Although this solved the immediate problem, the compulsory vaccination acts remained legally enforceable, and determined opponents lobbied for their repeal. No Compulsory Vaccination was one of the demands of the 1900 Labour Party General Election Manifesto. This was done as a matter of routine when the National Health Service was introduced in 1948, with "almost negligible" opposition from supporters of compulsory vaccination.
Vaccination in Wales was covered by English legislation, but the Scottish legal system was separate. Vaccination was not made compulsory there until 1863, and conscientious objection was allowed after vigorous protest only in 1907.:10–11
In the late 19th century, the city of Leicester in the UK received much attention because of the way smallpox was managed there. There was particularly strong opposition to compulsory vaccination, and medical authorities had to work within this framework. They developed a system that did not use vaccination but was based on the notification of cases, the strict isolation of patients and contacts, and the provision of isolation hospitals. This proved successful but required acceptance of compulsory isolation rather than vaccination. C. Killick Millard, initially a supporter of compulsory vaccination, was appointed Medical Officer of Health in 1901. He moderated his views on compulsion but encouraged contacts and his staff to accept vaccination. This approach, developed initially due to overwhelming opposition to government policy, became known as the Leicester Method. In time it became generally accepted as the most appropriate way to deal with smallpox outbreaks and was listed as one of the "important events in the history of smallpox control" by those most involved in the World Health Organization's successful Smallpox Eradication Campaign. The final stages of the campaign, generally referred to as "surveillance containment", owed much to the Leicester method.
In the US, President Thomas Jefferson took a close interest in vaccination, alongside Benjamin Waterhouse, chief physician at Boston. Jefferson encouraged the development of ways to transport vaccine material through the Southern states, which included measures to avoid damage by heat, a leading cause of ineffective batches. Smallpox outbreaks were contained by the latter half of the 19th century, a development widely attributed to the vaccination of a large portion of the population. Vaccination rates fell after this decline in smallpox cases, and the disease again became epidemic in the late 19th century.
After an 1879 visit to New York by prominent British anti-vaccinationist William Tebb, The Anti-Vaccination Society of America was founded. The New England Anti-Compulsory Vaccination League formed in 1882, and the Anti-Vaccination League of New York City in 1885. Tactics in the US largely followed those used in England. Vaccination in the US was regulated by individual states, in which there followed a progression of compulsion, opposition, and repeal similar to that in England. Although generally organized on a state-by-state basis, the vaccination controversy reached the US Supreme Court in 1905. There, in the case of Jacobson v. Massachusetts, the court ruled that states have the authority to require vaccination against smallpox during a smallpox epidemic.
John Pitcairn, the wealthy founder of the Pittsburgh Plate Glass Company (now PPG Industries), emerged as a major financier and leader of the American anti-vaccination movement. On March 5, 1907, in Harrisburg, Pennsylvania, he delivered an address to the Committee on Public Health and Sanitation of the Pennsylvania General Assembly criticizing vaccination. He later sponsored the National Anti-Vaccination Conference, which, held in Philadelphia in October 1908, led to the creation of The Anti-Vaccination League of America. When the league organized later that month, members chose Pitcairn as their first president.
On December 1, 1911, Pitcairn was appointed by Pennsylvania Governor John K. Tener to the Pennsylvania State Vaccination Commission, and subsequently authored a detailed report strongly opposing the commission's conclusions. He remained a staunch opponent of vaccination until his death in 1916.
In November 1904, in response to years of inadequate sanitation and disease, followed by a poorly explained public health campaign led by the renowned Brazilian public health official Oswaldo Cruz, citizens and military cadets in Rio de Janeiro arose in a Revolta da Vacina, or Vaccine Revolt. Riots broke out on the day a vaccination law took effect; vaccination symbolized the most feared and most tangible aspect of a public health plan that included other features, such as urban renewal, that many had opposed for years.
Later vaccines and antitoxins
Opposition to smallpox vaccination continued into the 20th century and was joined by controversy over new vaccines and the introduction of antitoxin treatment for diphtheria. Injection of horse serum into humans as used in antitoxin can cause hypersensitivity, commonly referred to as serum sickness. Moreover, the continued production of smallpox vaccine in animals and the production of antitoxins in horses prompted anti-vivisectionists to oppose vaccination.
Diphtheria antitoxin was serum from horses that had been immunized against diphtheria, and was used to treat human cases by providing passive immunity. In 1901, antitoxin from a horse named Jim was contaminated with tetanus and killed 13 children in St Louis, Missouri. This incident, together with nine deaths from tetanus from contaminated smallpox vaccine in Camden, New Jersey, led directly and quickly to the passing of the Biologics Control Act in 1902.
Robert Koch developed tuberculin in 1890. Inoculated into individuals who have had tuberculosis, it produces a hypersensitivity reaction, and is still used to detect those who have been infected. However, Koch used tuberculin as a vaccine. This caused serious reactions and deaths in individuals whose latent tuberculosis was reactivated by the tuberculin. This was a major setback for supporters of new vaccines.:30–31 Such incidents and others ensured that any untoward results concerning vaccination and related procedures received continued publicity, which grew as the number of new procedures increased.
In 1955, in a tragedy known as the Cutter incident, Cutter Laboratories produced 120,000 doses of the Salk polio vaccine that inadvertently contained some live polio virus along with inactivated virus. This vaccine caused 40,000 cases of polio, 53 cases of paralysis, and five deaths. The disease spread through the recipients' families, creating a polio epidemic that led to a further 113 cases of paralytic polio and another five deaths. It was one of the worst pharmaceutical disasters in US history.
Later 20th-century events included the 1982 broadcast of DPT: Vaccine Roulette, which sparked debate over the DPT vaccine, and the 1998 publication of a fraudulent academic article by Andrew Wakefield which sparked the MMR vaccine controversy. Also recently, the HPV vaccine has become controversial due to concerns that it may encourage promiscuity when given to 11- and 12-year-old girls.
Arguments against vaccines in the 21st century are often similar to those of 19th-century anti-vaccinationists.
Surveys have gathered information on whether people would be willing to take a potential COVID-19 vaccine. Researchers have estimated that 67% or 80% of people in the U.S. would accept a new vaccination against COVID-19.
Vaccine hesitancy is becoming an increasing concern, particularly in industrialized nations. For example, one study surveying parents in Europe found that 12–28% of surveyed parents expressed doubts about vaccinating their children. Several studies have assessed socioeconomic and cultural factors associated with vaccine hesitancy. Both high and low socioeconomic status as well as high and low education levels have all been associated with vaccine hesitancy in different populations. Other studies examining various populations around the world in different countries found that both high and low socioeconomic status are associated with vaccine hesitancy. Studies have demonstrated that children of parents who refused the pertussis vaccine, varicella vaccine, and pneumococcal vaccine are 23 times more likely to contract pertussis (whooping cough), nine times more likely to catch varicella (chickenpox), and six times more likely to be hospitalized with severe pneumonia from Streptococcus pneumoniae (pneumococcus).
Multiple major medical societies including the Infectious Diseases Society of America, the American Medical Association, and the American Academy of Pediatrics support the elimination of all nonmedical exemptions for childhood vaccines.
Compulsory vaccination policies have been controversial as long as they have existed, with opponents of mandatory vaccinations arguing that governments should not infringe on an individual's freedom to make medical decisions for themselves or their children, while proponents of compulsory vaccination cite the well-documented public health benefits of vaccination. Others argue that, for compulsory vaccination to effectively prevent disease, there must be not only available vaccines and a population willing to immunize, but also sufficient ability to decline vaccination on grounds of personal belief.
Vaccination policy involves complicated ethical issues, as unvaccinated individuals are more likely to contract and spread disease to people with weaker immune systems, such as young children and the elderly, and to other individuals in whom the vaccine has not been effective. However, mandatory vaccination policies raise ethical issues regarding parental rights and informed consent.
In the United States, vaccinations are not truly compulsory, but they are typically required in order for children to attend public schools.
Medical ethicist Arthur Caplan argues that children have a right to the best available medical care, including vaccines, regardless of parental feelings toward vaccines, saying "Arguments about medical freedom and choice are at odds with the human and constitutional rights of children. When parents won’t protect them, governments must."
A review of court cases from 1905 to 2016 found that, of the nine courts that have heard cases regarding whether not vaccinating a child constitutes neglect, seven have held vaccine refusal to be a form of child neglect.
To prevent the spread of disease by unvaccinated individuals, some schools and doctors' surgeries have prohibited unvaccinated children from being enrolled, even where not required by law. Refusal of doctors to treat unvaccinated children may cause harm to both the child and public health, and may be considered unethical, if the parents are unable to find another healthcare provider for the child. Opinion on this is divided, with the largest professional association, the American Academy of Pediatrics, saying that exclusion of unvaccinated children may be an option under narrowly defined circumstances.
Since most religions were started far before vaccinations were invented, scriptures do not specifically address the topic of vaccination. However, vaccination has been opposed on religious grounds ever since it was first introduced. Some Christian opponents argued, when vaccination was first becoming widespread, that if God had decreed that someone should die of smallpox, it would be a sin to thwart God's will via vaccination. Religious opposition continues to the present day, on various grounds, raising ethical difficulties when the number of unvaccinated children threatens harm to the entire population. Many governments allow parents to opt out of their children's otherwise mandatory vaccinations for religious reasons; some parents falsely claim religious beliefs to get vaccination exemptions.
Judaism supports vaccination. Among early Hasidic leaders, Rabbi Nachman of Breslov (1772–1810) was known for his criticism of the doctors and medical treatments of his day. However, when the first vaccines were successfully introduced, he stated: "Every parent should have his children vaccinated within the first three months of life. Failure to do so is tantamount to murder. Even if they live far from the city and have to travel during the great winter cold, they should have the child vaccinated before three months." Jewish and Islamic practitioners may have concerns about the use of gelatin in vaccines due to the substance being of porcine origin (from pigs). Jewish and Islamic scholars have determined that since the gelatin is cooked and not consumed as food, gelatin-containing vaccinations are acceptable. However, the Muslim Council of Britain argued against the use of intranasal influenza vaccine in 2019 due to the presence of gelatin in the vaccine and consider such vaccines to be non-halal (unclean).
Some Christians have objected to the use of cell cultures of some viral vaccines, and the virus of the rubella vaccine, on the grounds that they are derived from tissues taken from therapeutic abortions performed in the 1960s. The principle of double effect, originated by Thomas Aquinas, holds that actions with both good and bad consequences are morally acceptable in specific circumstances. The Vatican Curia has said that for vaccines originating from embryonic cells, Catholics have "a grave responsibility to use alternative vaccines and to make a conscientious objection", but concluded that it is acceptable for Catholics to use the existing vaccines until an alternative becomes available.
In the United States, some parents claim fake religious exemptions when their real motivation for avoiding vaccines is supposed safety concerns. For a number of years, there were only three states (Mississippi, West Virginia, and California) that did not provide exemptions based on religious beliefs. However, following the 2019 measles outbreaks, the states of Maine and New York also repealed their religious exemptions, and the state of Washington repealed that exemption with respect to the measles vaccination.
|This article is part of a series on|
Many forms of alternative medicine are based on philosophies that oppose vaccination (including germ theory denialism) and have practitioners who voice their opposition. As a consequence, the increase in popularity of alternative medicine in the 1970s planted the seed on the modern anti-vaccination movement. More specifically, some elements of the chiropractic community, some homeopaths, and naturopaths developed anti-vaccine rhetoric. The reasons for this negative vaccination view are complicated and rest at least in part on the early philosophies that shaped the foundation of these groups.
Historically, chiropractic strongly opposed vaccination based on its belief that all diseases were traceable to causes in the spine and therefore could not be affected by vaccines. Daniel D. Palmer (1845–1913), the founder of chiropractic, wrote: "It is the very height of absurdity to strive to 'protect' any person from smallpox or any other malady by inoculating them with a filthy animal poison." Vaccination remains controversial within the profession. Most chiropractic writings on vaccination focus on its negative aspects. A 1995 survey of US chiropractors found that about one third believed there was no scientific proof that immunization prevents disease. While the Canadian Chiropractic Association supports vaccination, a survey in Alberta in 2002 found that 25% of chiropractors advised patients for, and 27% advised against, vaccinations for patients or for their children.
Although most chiropractic colleges try to teach about vaccination in a manner consistent with scientific evidence, several have faculty who seem to stress negative views. A survey of a 1999–2000 cross-section of students of Canadian Memorial Chiropractic College (CMCC), which does not formally teach anti-vaccination views, reported that fourth-year students opposed vaccination more strongly than did first-year students, with 29.4% of fourth-year students opposing vaccination. A follow-up study on 2011–12 CMCC students found that pro-vaccination attitudes heavily predominated. Students reported support rates ranging from 84% to 90%. One of the study's authors proposed the change in attitude to be due to the lack of the previous influence of a "subgroup of some charismatic students who were enrolled at CMCC at the time, students who championed the Palmer postulates that advocated against the use of vaccination".
The American Chiropractic Association and the International Chiropractic Association support individual exemptions to compulsory vaccination laws. In March 2015, the Oregon Chiropractic Association invited Andrew Wakefield, chief author of a fraudulent research paper, to testify against Senate Bill 442, "a bill that would eliminate nonmedical exemptions from Oregon's school immunization law". The California Chiropractic Association lobbied against a 2015 bill ending belief exemptions for vaccines. They had also opposed a 2012 bill related to vaccination exemptions.
Several surveys have shown that some practitioners of homeopathy, particularly homeopaths without any medical training, advise patients against vaccination. For example, a survey of registered homeopaths in Austria found that only 28% considered immunization an important preventive measure, and 83% of homeopaths surveyed in Sydney, Australia, did not recommend vaccination. Many practitioners of naturopathy also oppose vaccination.
Homeopathic "vaccines" (nosodes) are ineffective because they do not contain any active ingredients and thus do not stimulate the immune system. They can be dangerous if they take the place of effective treatments. Some medical organizations have taken action against nosodes. In Canada, the labeling of homeopathic nosodes require the statement: "This product is neither a vaccine nor an alternative to vaccination."
Alternative medicine proponents gain from promoting vaccine conspiracy theories through the sale of ineffective and expensive medications, supplements, and procedures such as chelation therapy and hyperbaric oxygen therapy, sold as able to cure the 'damage' caused by vaccines. Homeopaths in particular gain through the promotion of water injections or 'nosodes' that they allege have a 'natural' vaccine-like effect. Additional bodies with a vested interest in promoting the "unsafeness" of vaccines may include lawyers and legal groups organizing court cases and class action lawsuits against vaccine providers.
Conversely, alternative medicine providers have accused the vaccine industry of misrepresenting the safety and effectiveness of vaccines, covering up and suppressing information, and influencing health policy decisions for financial gain. In the late 20th century, vaccines were a product with low profit margins, and the number of companies involved in vaccine manufacture declined. In addition to low profits and liability risks, manufacturers complained about low prices paid for vaccines by the CDC and other US government agencies. In the early 21st century, the vaccine market greatly improved with the approval of the vaccine Prevnar, along with a small number of other high-priced blockbuster vaccines, such as Gardasil and Pediarix, which each had sales revenues of over $1 billion in 2008. Despite high growth rates, vaccines represent a relatively small portion of overall pharmaceutical profits. As recently as 2010, the World Health Organization estimated vaccines to represent 2–3% of total sales for the pharmaceutical industry.
The United States has a very complex history with compulsory vaccination, particularly in enforcing compulsory vaccinations both domestically and abroad to protect American soldiers during times of war. There are hundreds of thousands of examples of soldier deaths that were not the result of combat wounds, but were instead from disease. Among wars with high death tolls from disease is the Civil War where an estimated 620,000 soldiers died from disease. American soldiers in other countries have spread diseases that ultimately disrupted entire societies and healthcare systems with famine and poverty.
The Spanish–American War began in April 1898 and ended in August 1898. During this time the United States gained control of Cuba, Puerto Rico, and the Philippines from Spain. As a military police power and as colonizers the United States took a very hands-on approach in administering healthcare particularly vaccinations to natives during the invasion and conquest of these countries. Although the Spanish–American War occurred during the era of "bacteriological revolution" where knowledge of disease was bolstered by germ theory, more than half of the soldier casualties in this war were from disease. Unknowingly, American soldiers acted as agents of disease transmission, fostering bacteria in their haphazardly made camps. These soldiers invaded Cuba, Puerto Rico, and the Philippines and connected parts of these countries that had never before been connected due to the countries sparse nature thereby beginning epidemics. The mobility of American soldiers around these countries encouraged a newfound mobility of disease that quickly infected natives.
Military personnel used Rudyard's Kipling's poem "The White Man's Burden" to explain their imperialistic actions in Cuba, the Philippines, and Puerto Rico and the need for the United States to help the "dark-skinned Barbarians" reach modern sanitary standards. American actions abroad before, during, and after the war emphasized a need for proper sanitation habits especially on behalf of the natives. Natives who refuse to oblige with American health standards and procedures risked fines or imprisonment. One penalty in Puerto Rico included a $10 fine for a failure to vaccinate and an additional $5 fine for any day you continue to be unvaccinated, refusal to pay resulted in ten or more days of imprisonment. If entire villages refused the army's current sanitation policy at any given time they risked being burnt to the ground in order to preserve the health and safety of soldiers from endemic smallpox and yellow fever. Vaccines were forcibly administered to the Puerto Ricans, Cubans, and Filipinos. Military personnel in Puerto Rico provided Public Health services that culminated in military orders that mandated vaccinations for children before they were six months old, as well as a general vaccination order. By the end of 1899 in Puerto Rico alone the U.S. military and other hired native vaccinators called practicantes, vaccinated an estimated 860,000 natives in a five-month period. This period began the United States' movement toward an expansion of medical practices that included "tropical medicine" in an attempt to protect the lives of soldiers abroad.
An analysis of tweets from July 2014 through September 2017 revealed an active campaign on Twitter by the Internet Research Agency (IRA), a Russian troll farm accused of interference in the 2016 U.S. elections, to sow discord about the safety of vaccines. The campaign used sophisticated Twitter bots to amplify highly polarizing pro-vaccine and anti-vaccine messages, containing the hashtag #VaccinateUS, posted by IRA trolls.
Confidence in vaccines varies over place and time and among different vaccines. The London School of Hygiene & Tropical Medicine's Vaccine Confidence Project in 2016 found that confidence was lower in Europe than in the rest of the world. Refusal of the MMR vaccine has increased in 12 European states since 2010. The project published a report in 2018 assessing vaccine hesitancy among the public in all the 28 EU member states and among general practitioners in ten of them. Younger adults in the survey had less confidence than older people. Confidence had risen in France, Greece, Italy, and Slovenia since 2015 but had fallen in the Czech Republic, Finland, Poland, and Sweden. 36% of the GPs surveyed in the Czech Republic and 25% of those in Slovakia did not agree that the MMR vaccine was safe. Most of the GPs did not recommend the seasonal influenza vaccine. Confidence in the population correlated with confidence among GPs. One study in the United States found that after vaccine-hesitant college students interviewed survivors of vaccine-preventable diseases, they were more likely to become pro-vaccine than a control group.
Parties opposed to the use of vaccines frequently refer to data obtained from the US Vaccine Adverse Event Reporting System (VAERS). This is a database of reports of issues associated with vaccines. When used appropriately VAERS is a useful tool for investigation, but since anyone can make a claim and have it entered into the VAERS, by itself it is not a reliable source of information. Dubious claims about vaccines against hepatitis B, HPV and other diseases have been propagated based on misuse of data from VAERS.
- "Ten health issues WHO will tackle this year". Who.int. Retrieved January 19, 2019.
- PM, Aristos Georgiou (January 15, 2019). "The anti-vax movement has been listed by WHO as one of its top 10 health threats for 2019". Retrieved January 16, 2019.
- Smith, MJ (November 2015). "Promoting Vaccine Confidence". Infectious Disease Clinics of North America (Review). 29 (4): 759–69. doi:10.1016/j.idc.2015.07.004. PMID 26337737.
- Larson, HJ; Jarrett, C; Eckersberger, E; Smith, DM; Paterson, P (April 2014). "Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: a systematic review of published literature, 2007–2012". Vaccine. 32 (19): 2150–59. doi:10.1016/j.vaccine.2014.01.081. PMID 24598724.
- "Communicating science-based messages on vaccines". Bulletin of the World Health Organization. 95 (10): 670–71. October 2017. doi:10.2471/BLT.17.021017. PMC 5689193. PMID 29147039.
- "Why do some people oppose vaccination?". Vox. Retrieved November 26, 2018.
- Ceccarelli L. "Defending science: How the art of rhetoric can help". The Conversation. Retrieved November 26, 2018.
- U.S. Department of Health and Human Services. "Vaccines.gov". Vaccines.gov. Retrieved August 5, 2018.
- Gerber JS, Offit PA (February 2009). "Vaccines and autism: a tale of shifting hypotheses". Clinical Infectious Diseases. 48 (4): 456–61. doi:10.1086/596476. PMC 2908388. PMID 19128068.
- "Frequently Asked Questions (FAQ)". Boston Children's Hospital. Archived from the original on October 17, 2013. Retrieved February 11, 2014.
- Phadke VK, Bednarczyk RA, Salmon DA, Omer SB (March 2016). "Association Between Vaccine Refusal and Vaccine Preventable Diseases in the United States: A Review of Measles and Pertussis". JAMA. 315 (11): 1149–58. doi:10.1001/jama.2016.1353. PMC 5007135. PMID 26978210.
- Wolfe RM, Sharp LK (August 2002). "Anti-vaccinationists past and present". BMJ. 325 (7361): 430–32. doi:10.1136/bmj.325.7361.430. PMC 1123944. PMID 12193361.
- Poland GA, Jacobson RM (January 2011). "The age-old struggle against the antivaccinationists". The New England Journal of Medicine. 364 (2): 97–99. doi:10.1056/NEJMp1010594. PMID 21226573. S2CID 39229852.
- Wallace A (October 19, 2009). "An epidemic of fear: how panicked parents skipping shots endangers us all". Wired. Retrieved October 21, 2009.
- Poland GA, Jacobson RM (March 2001). "Understanding those who do not understand: a brief review of the anti-vaccine movement". Vaccine. 19 (17–19): 2440–45. doi:10.1016/S0264-410X(00)00469-2. PMID 11257375.
- "The Long History of America's Anti-Vaccination Movement". DiscoverMagazine.com. Retrieved February 2, 2019.
- Young Z (November 21, 2018). "How anti-vax went viral". Retrieved February 2, 2019.
- "How the anti-vaxxers are winning in Italy". September 28, 2018. Retrieved February 2, 2019.
- Chang J (July 12, 2017). "'Civil liberties' at center of vaccination debate in Texas". Mystatesman. Austin American-Statesman.
- Elliman D, Bedford H (March 23, 2014). "In Britain, Vaccinate With Persuasion, not Coercion". The New York Times.
- "Anti-vaxxers have embraced social media. We're paying for fake news with real lives". June 28, 2017. Retrieved February 2, 2019.
- Bourree Lam, Vaccines Are Profitable, So What?. The Atlantic Feb. 10, 2015
- Christenson, Brith; Lundbergh, Per; Hedlund, Jonas; Örtqvist, Åke (March 2001). "Effects of a large-scale intervention with influenza and 23-valent pneumococcal vaccines in adults aged 65 years or older: a prospective study". The Lancet. 357 (9261): 1008–11. doi:10.1016/S0140-6736(00)04237-9. PMID 11293594. S2CID 8125882.
- Jacobson, RM; St Sauver, JL; Griffin, JM; MacLaughlin, KL; Finney Rutten, LJ (April 2020). "How health care providers should address vaccine hesitancy in the clinical setting: Evidence for presumptive language in making a strong recommendation". Human Vaccines & Immunotherapeutics: 1–5. doi:10.1080/21645515.2020.1735226. PMID 32242766.
- Fenner F, Henderson DA, Arita I, Ježek Z, Ladnyi ID (1988). Smallpox and its Eradication (PDF). Geneva: World Health Organization. ISBN 978-92-4-156110-5. Retrieved September 4, 2007.
- Sutter RW, Maher C (2006). "Mass vaccination campaigns for polio eradication: an essential strategy for success". Mass Vaccination: Global Aspects – Progress and Obstacles. Curr Top Microbiol Immunol. Current Topics in Microbiology and Immunology. 304. pp. 195–220. doi:10.1007/3-540-36583-4_11. ISBN 978-3-540-29382-8. PMID 16989271.
- Centers for Disease Control Prevention (CDC) (March 2002). "Progress toward elimination of Haemophilus influenzae type b invasive disease among infants and children – United States, 1998–2000". Morbidity and Mortality Weekly Report. 51 (11): 234–37. PMID 11925021.
- Park, Alice (June 2, 2008). "How safe are vaccines?". Time Magazine.
- "Some common misconceptions about vaccination and how to respond to them". National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention. Archived from the original on January 20, 2015. Retrieved September 28, 2012.
- Ernst E (October 2001). "Rise in popularity of complementary and alternative medicine: reasons and consequences for vaccination". Vaccine. 20 (Suppl 1): S90–93, discussion S89. doi:10.1016/S0264-410X(01)00290-0. PMID 11587822.
- Wane, Joanna. "The case for vaccination" (PDF). North & South. Retrieved July 3, 2015.
- Fine, P.; Eames, K.; Heymann, D. L. (March 22, 2011). "'Herd Immunity': A Rough Guide". Clinical Infectious Diseases. 52 (7): 911–16. doi:10.1093/cid/cir007. PMID 21427399.
- Heymann, D. L.; Aylward, R. B. (2006). "Mass Vaccination: When and Why". Mass Vaccination: Global Aspects – Progress and Obstacles. Current Topics in Microbiology and Immunology. 304. pp. 1–16. doi:10.1007/3-540-36583-4_1. ISBN 978-3-540-29382-8. PMID 16989261. S2CID 25259803.
- Bester JC (September 2017). "Measles Vaccination is Best for Children: The Argument for Relying on Herd Immunity Fails". Journal of Bioethical Inquiry. 14 (3): 375–84. doi:10.1007/s11673-017-9799-4. PMID 28815434. S2CID 3177668.
- "Immunization". CDC. August 30, 2018.
- Zhou F, Santoli J, Messonnier ML, Yusuf HR, Shefer A, Chu SY, Rodewald L, Harpaz R (December 2005). "Economic evaluation of the 7-vaccine routine childhood immunization schedule in the United States, 2001". Archives of Pediatrics & Adolescent Medicine. 159 (12): 1136–44. doi:10.1001/archpedi.159.12.1136. PMID 16330737.
- Fine PE, Clarkson JA (December 1986). "Individual versus public priorities in the determination of optimal vaccination policies". American Journal of Epidemiology. 124 (6): 1012–20. doi:10.1093/oxfordjournals.aje.a114471. PMID 3096132.
- Buttenheim AM, Asch DA (December 2013). "Making vaccine refusal less of a free ride". Human Vaccines & Immunotherapeutics. 9 (12): 2674–75. doi:10.4161/hv.26676. PMC 4162060. PMID 24088616.
- Reich, Jennifer (June 13, 2019). "I've talked to dozens of parents about why they don't vaccinate. Here's what they told me". Vox. Retrieved July 5, 2019.
- Wolfe RM, Sharp LK (August 2002). "Anti-vaccinationists past and present". BMJ. 325 (7361): 430–32. doi:10.1136/bmj.325.7361.430. PMC 1123944. PMID 12193361.
- The Lancet Infectious Diseases (April 2007). "Tackling negative perceptions towards vaccination". The Lancet Infectious Diseases. 7 (4): 235. doi:10.1016/S1473-3099(07)70057-9. PMID 17376373.
- "Possible Side-effects from Vaccines". Centers for Disease Control and Prevention. August 26, 2013. Retrieved January 3, 2014.
- Chen RT, Hibbs B (July 1998). "Vaccine Safety: Current and Future Challenges". Pediatric Annals. 27 (7): 445–55. doi:10.3928/0090-4481-19980701-11. PMID 9677616. Retrieved January 3, 2014.
- Bonhoeffer, Jan; Heininger, Ulrich (June 2007). "Adverse events following immunization: perception and evidence". Current Opinion in Infectious Diseases. 20 (3): 237–46. doi:10.1097/QCO.0b013e32811ebfb0. PMID 17471032. S2CID 40669829.
- Mooney C (June 2009). "Why does the vaccine/autism controversy live on?". Discover.
- Jacobson, RM; St Sauver, JL; Finney Rutten, LJ (November 2015). "Vaccine Hesitancy". Mayo Clinic Proceedings. 90 (11): 1562–68. doi:10.1016/j.mayocp.2015.09.006. PMID 26541249.
- Marshall, GS (2013). "Roots of vaccine hesitancy". S D Med. Spec no: 52–57. PMID 23444592.
- McClure, CC; Cataldi, JR; O'Leary, ST (August 2017). "Vaccine Hesitancy: Where We Are and Where We Are Going". Clinical Therapeutics. 39 (8): 1550–62. doi:10.1016/j.clinthera.2017.07.003. PMID 28774498.
- Leask J, Chapman S, Cooper Robbins SC. 'All manner of ills': The features of serious diseases attributed to vaccination. Vaccine. 2009. doi:10.1016/j.vaccine.2009.10.042. PMID 19879997.
- Goldacre B (2009). Bad Science. London: Fourth Estate. pp. 292–94. ISBN 978-0007284870.
- Taylor, Luke E.; Swerdfeger, Amy L.; Eslick, Guy D. (June 17, 2014). "Vaccines are not associated with autism: an evidence-based meta-analysis of case-control and cohort studies". Vaccine. 32 (29): 3623–29. doi:10.1016/j.vaccine.2014.04.085. ISSN 1873-2518. PMID 24814559.
- Smith, IM; MacDonald, NE (August 2017). "Countering evidence denial and the promotion of pseudoscience in autism spectrum disorder". Autism Research (Review). 10 (8): 1334–37. doi:10.1002/aur.1810. PMID 28544626.
- Boseley S (February 2, 2010). "Lancet retracts 'utterly false' MMR paper". The Guardian. Retrieved February 2, 2010.
- Taylor LE, Swerdfeger AL, Eslick GD (June 2014). "Vaccines are not associated with autism: an evidence-based meta-analysis of case-control and cohort studies". Vaccine. 32 (29): 3623–29. doi:10.1016/j.vaccine.2014.04.085. PMID 24814559.
- "Vaccines Do Not Cause Autism Concerns". Centers for Disease Control and Prevention. December 12, 2018. Retrieved February 7, 2019.
- "How autism myths came to fuel anti-vaccination movements". Popular Science. February 2019.
- Foster, Craig A.; Ortiz, Sarenna M. (2017). "Vaccines, Autism, and the Promotion of Irrelevant Research: A Science-Pseudoscience Analysis". Skeptical Inquirer. 41 (3): 44–48. Archived from the original on October 6, 2018. Retrieved October 6, 2018.
- Baker JP (February 2008). "Mercury, vaccines, and autism: one controversy, three histories". American Journal of Public Health. 98 (2): 244–53. doi:10.2105/AJPH.2007.113159. PMC 2376879. PMID 18172138.
- Offit PA (September 2007). "Thimerosal and vaccines – a cautionary tale". The New England Journal of Medicine. 357 (13): 1278–79. doi:10.1056/NEJMp078187. PMID 17898096. S2CID 36318722.
- Research, Center for Biologics Evaluation and (April 5, 2019). "Thimerosal and Vaccines". FDA. fda.gov.
- Bose-O'Reilly S, McCarty KM, Steckling N, Lettmeier B (September 2010). "Mercury exposure and children's health". Current Problems in Pediatric and Adolescent Health Care. 40 (8): 186–215. doi:10.1016/j.cppeds.2010.07.002. PMC 3096006. PMID 20816346.
- Gerber JS, Offit PA (February 2009). "Vaccines and autism: a tale of shifting hypotheses". Clinical Infectious Diseases. 48 (4): 456–61. doi:10.1086/596476. PMC 2908388. PMID 19128068. Lay summary – IDSA (January 30, 2009).
- Doja A, Roberts W (November 2006). "Immunizations and autism: a review of the literature". The Canadian Journal of Neurological Sciences. 33 (4): 341–46. doi:10.1017/s031716710000528x. PMID 17168158.
- Spencer, JP; Trondsen Pawlowski, RH; Thomas, S (June 2017). "Vaccine Adverse Events: Separating Myth from Reality". American Family Physician. 95 (12): 786–94. PMID 28671426.
- Sugarman SD (September 2007). "Cases in vaccine court – legal battles over vaccines and autism". The New England Journal of Medicine. 357 (13): 1275–77. doi:10.1056/NEJMp078168. PMID 17898095.
- Immunization Safety Review Committee (2004). Immunization Safety Review: Vaccines and Autism. The National Academies Press. doi:10.17226/10997. ISBN 978-0-309-09237-1. PMID 20669467.
- "Thimerosal and Vaccines". fda.gov. U.S. Food and Drug Administration. April 5, 2019.
- Wakefield AJ, Murch SH, Anthony A, Linnell J, Casson DM, Malik M, Berelowitz M, Dhillon AP, Thomson MA, Harvey P, Valentine A, Davies SE, Walker-Smith JA (February 1998). "Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children". Lancet. 351 (9103): 637–41. doi:10.1016/S0140-6736(97)11096-0. PMID 9500320. S2CID 439791. (Retracted)
- National Health Service (2015). "MMR vaccine". Retrieved July 4, 2018.
- Deer B (February 22, 2004). "Revealed: MMR research scandal". The Sunday Times. Retrieved September 23, 2007.
- Horton R (March 2004). "The lessons of MMR". Lancet. 363 (9411): 747–49. doi:10.1016/S0140-6736(04)15714-0. PMID 15016482. S2CID 5357597.
- "Doctors issue plea over MMR jab". BBC News. June 26, 2006. Retrieved November 23, 2007.
- Alazraki M (January 12, 2011). "The Autism Vaccine Fraud: Dr. Wakefield's Costly Lie to Society". DailyFinance, AOL Money & Finance. Archived from the original on October 27, 2011. Retrieved October 18, 2011.
- "MMR scare doctor 'paid children'". BBC News. July 16, 2007.
- Murch SH, Anthony A, Casson DH, Malik M, Berelowitz M, Dhillon AP, Thomson MA, Valentine A, Davies SE, Walker-Smith JA (March 2004). "Retraction of an interpretation". Lancet. 363 (9411): 750. doi:10.1016/S0140-6736(04)15715-2. PMID 15016483. S2CID 5128036.
- The Editors Of The Lancet (February 2010). "Retraction – Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children". Lancet. 375 (9713): 445. doi:10.1016/S0140-6736(10)60175-4. PMID 20137807. S2CID 26364726. Lay summary – BBC News (February 2, 2010).
- "General Medical Council, Fitness to Practise Panel Hearing, 24 May 2010, Andrew Wakefield, Determination of Serious Professional Misconduct" (PDF). General Medical Council. Archived from the original (PDF) on May 12, 2013. Retrieved September 18, 2011.
- Meikle, James; Boseley, Sarah (May 24, 2010). "MMR row doctor Andrew Wakefield struck off register". The Guardian. London. Archived from the original on May 27, 2010. Retrieved May 24, 2010.
- "Concerns about autism". Centers for Disease Control and Prevention. January 15, 2010.
- "MMR The facts". United Kingdom National Health Service. Archived from the original on June 15, 2007. Retrieved June 13, 2007.
- "Are Vaccines Safe?". health.gov.au. Australia Department of Health.
- Demicheli V, Rivetti A, Debalini MG, Di Pietrantonj C (February 2012). Demicheli V (ed.). "Vaccines for measles, mumps and rubella in children". The Cochrane Database of Systematic Reviews. 2 (2): CD004407. doi:10.1002/14651858.CD004407.pub3. PMC 6458016. PMID 22336803.
- DeStefano, Frank; Shimabukuro, Tom T. (April 15, 2019). "The MMR Vaccine and Autism". Annual Review of Virology. 6 (1): 585–600. doi:10.1146/annurev-virology-092818-015515. ISSN 2327-0578. PMC 6768751. PMID 30986133.
- Deer B (February 8, 2009). "MMR doctor Andrew Wakefield fixed data on autism". Sunday Times. Retrieved February 9, 2009.
- Deer B (January 2011). "How the case against the MMR vaccine was fixed". BMJ. 342: c5347. doi:10.1136/bmj.c5347. PMID 21209059.
- Godlee F, Smith J, Marcovitch H (January 2011). "Wakefield's article linking MMR vaccine and autism was fraudulent". BMJ. 342: c7452. doi:10.1136/bmj.c7452. PMID 21209060. S2CID 43640126.
- Vaccine court and autism:
- Hilton S, Petticrew M, Hunt K (May 2006). "'Combined vaccines are like a sudden onslaught to the body's immune system': parental concerns about vaccine 'overload' and 'immune-vulnerability'". Vaccine. 24 (20): 4321–27. doi:10.1016/j.vaccine.2006.03.003. PMID 16581162.
- Hurst L (October 30, 2009). "Vaccine phobia runs deep". Toronto Star. Retrieved November 4, 2009.
- Heininger U (September 2006). "An internet-based survey on parental attitudes towards immunization". Vaccine. 24 (37–39): 6351–55. doi:10.1016/j.vaccine.2006.05.029. PMID 16784799.
- Willingham, Emily (March 29, 2013). "Vaccines Not Linked To Autism. Again". Forbes. Retrieved April 4, 2013.
- DeStefano F, Price CS, Weintraub ES (August 2013). "Increasing exposure to antibody-stimulating proteins and polysaccharides in vaccines is not associated with risk of autism" (PDF). The Journal of Pediatrics. 163 (2): 561–77. CiteSeerX 10.1.1.371.2592. doi:10.1016/j.jpeds.2013.02.001. PMID 23545349.
- Immune challenges:
- Murphy TF (June 1996). "Branhamella catarrhalis: epidemiology, surface antigenic structure, and immune response" (PDF). Microbiological Reviews. 60 (2): 267–79. doi:10.1128/MMBR.60.2.267-279.1996. PMC 239443. PMID 8801433.
- Sloyer JL, Howie VM, Ploussard JH, Ammann AJ, Austrian R, Johnston RB (June 1974). "Immune response to acute otitis media in children. I. Serotypes isolated and serum and middle ear fluid antibody in pneumococcal otitis media" (PDF). Infection and Immunity. 9 (6): 1028–32. doi:10.1128/IAI.9.6.1028-1032.1974. PMC 414928. PMID 4151506.
- Vaccine burden:
- Miller E, Andrews N, Waight P, Taylor B (March 2003). "Bacterial infections, immune overload, and MMR vaccine. Measles, mumps, and rubella". Archives of Disease in Childhood. 88 (3): 222–23. doi:10.1136/adc.88.3.222. PMC 1719482. PMID 12598383.
- Hviid A, Wohlfahrt J, Stellfeld M, Melbye M (August 2005). "Childhood vaccination and nontargeted infectious disease hospitalization". JAMA. 294 (6): 699–705. doi:10.1001/jama.294.6.699. PMID 16091572.
- Gregson AL, Edelman R (November 2003). "Does antigenic overload exist? The role of multiple immunizations in infants". Immunology and Allergy Clinics of North America. 23 (4): 649–64. doi:10.1016/S0889-8561(03)00097-3. PMID 14753385.
- Offit, Paul A.; Hackett, Charles J. (2003). "Addressing Parents' Concerns: Do Vaccines Cause Allergic or Autoimmune Diseases?". Pediatrics. 111 (3): 653–59. doi:10.1542/peds.111.3.653. PMID 12612250.
- Schneeweiss B, Pfleiderer M, Keller-Stanislawski B (August 2008). "Vaccination safety update". Deutsches Ärzteblatt International. 105 (34–35): 590–95. doi:10.3238/arztebl.2008.0590. PMC 2680557. PMID 19471677.
- Deen JL, Clemens JD (November 2006). "Issues in the design and implementation of vaccine trials in less developed countries". Nature Reviews. Drug Discovery. 5 (11): 932–40. doi:10.1038/nrd2159. PMID 17080029. S2CID 413230.
- Fineberg AM, Ellman LM (May 2013). "Inflammatory cytokines and neurological and neurocognitive alterations in the course of schizophrenia". Biological Psychiatry. 73 (10): 951–66. doi:10.1016/j.biopsych.2013.01.001. PMC 3641168. PMID 23414821.
- Skowronski DM, De Serres G (July 2009). "Is routine influenza immunization warranted in early pregnancy?". Vaccine. 27 (35): 4754–70. doi:10.1016/j.vaccine.2009.03.079. PMID 19515466.
- Fiore AE, Shay DK, Haber P, Iskander JK, Uyeki TM, Mootrey G, Bresee JS, Cox NJ (July 2007). "Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2007". MMWR. Recommendations and Reports. 56 (RR-6): 1–54. PMID 17625497.
- Principi, N; Esposito, S (September 2018). "Aluminum in vaccines: Does it create a safety problem?". Vaccine. 36 (39): 5825–31. doi:10.1016/j.vaccine.2018.08.036. PMID 30139653.
- Baylor NW, Egan W, Richman P (May 2002). "Aluminum salts in vaccines – US perspective". Vaccine. 20 (Suppl 3): S18–23. doi:10.1016/S0264-410X(02)00166-4. PMID 12184360.
- Leslie M (July 2013). "Solution to vaccine mystery starts to crystallize". Science. 341 (6141): 26–27. Bibcode:2013Sci...341...26L. doi:10.1126/science.341.6141.26. PMID 23828925.
- François G, Duclos P, Margolis H, et al. (November 2005). "Vaccine safety controversies and the future of vaccination programs". The Pediatric Infectious Disease Journal. 24 (11): 953–61. doi:10.1097/01.inf.0000183853.16113.a6. PMID 16282928. S2CID 10484014.
- "Vaccine Ingredients". Vaccine Knowledge Project. Centre for Clinical Vaccinology and Tropical Medicine, Churchill Hospital, University of Oxford.
- "Common Ingredients Used in U.S. Licensed Vaccines". fda.gov. U.S. Food and Drug Administration. April 19, 2019.
- "Vaccine Ingredients-Formaldehyde". chop.edu/. Children's Hospital of Philadelphia. November 6, 2014.
- "Vaccine Ingredients". vaccines.gov/. U.S. Department of Health and Human Services.
- Moon, RY; Task Force on Sudden Infant Death Syndrome (November 2016). "SIDS and Other Sleep-Related Infant Deaths: Evidence Base for 2016 Updated Recommendations for a Safe Infant Sleeping Environment". Pediatrics. 138 (5): e20162940. doi:10.1542/peds.2016-2940. PMID 27940805.
- Task Force on Sudden Infant Death Syndrome (November 2016). "SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment". Pediatrics. 138 (5): e20162938. doi:10.1542/peds.2016-2938. PMID 27940804. Retrieved December 13, 2019.
- Institute of Medicine (US) Immunization Safety Review Committee; Stratton, K; Almario, DA; Wizemann, TM; McCormick, MC (2003). Immunization Safety Review: Vaccinations and Sudden Unexpected Death in Infancy (PDF). Washington D.C.: National Academies Press (US). PMID 25057654. Retrieved December 13, 2019.
- Vennemann, MM; Höffgen, M; Bajanowski, T; Hense, HW; Mitchell, EA (June 2007). "Do immunisations reduce the risk for SIDS? A meta-analysis". Vaccine. 25 (26): 4875–79. doi:10.1016/j.vaccine.2007.02.077. PMID 17400342.
- Poland GA, Jacobson RM, Ovsyannikova IG (May 2009). "Trends affecting the future of vaccine development and delivery: the role of demographics, regulatory science, the anti-vaccine movement, and vaccinomics". Vaccine. 27 (25–26): 3240–44. doi:10.1016/j.vaccine.2009.01.069. PMC 2693340. PMID 19200833.
- Ward JK (June 2016). "Rethinking the antivaccine movement concept: A case study of public criticism of the swine flu vaccine's safety in France". Social Science & Medicine. 159: 48–57. doi:10.1016/j.socscimed.2016.05.003. PMID 27173740.
- Mailand, MT; Frederiksen, JL (June 2017). "Vaccines and multiple sclerosis: a systematic review". Journal of Neurology. 264 (6): 1035–50. doi:10.1007/s00415-016-8263-4. PMID 27604618. S2CID 4005599.
- Rewers, M; Ludvigsson, J (June 2016). "Environmental risk factors for type 1 diabetes". Lancet. 387 (10035): 2340–48. doi:10.1016/S0140-6736(16)30507-4. PMC 5571740. PMID 27302273.
- Elwood, JM; Ameratunga, R (September 2018). "Autoimmune diseases after hepatitis B immunization in adults: Literature review and meta-analysis, with reference to 'autoimmune/autoinflammatory syndrome induced by adjuvants' (ASIA)". Vaccine (Systematic Review & Meta-Analysis). 36 (38): 5796–802. doi:10.1016/j.vaccine.2018.07.074. PMID 30100071.
- Edwards, Kathryn M.; Hackell, Jesse M. (August 29, 2016). "Countering Vaccine Hesitancy". Pediatrics. 138 (3): e20162146. doi:10.1542/peds.2016-2146. PMID 27573088. Lay summary – AAP News (August 29, 2016).
- Kennedy, Jonathan (October 2017). "How Drone Strikes and a Fake Vaccination Program Have Inhibited Polio Eradication in Pakistan: An Analysis of National Level Data". International Journal of Health Services: Planning, Administration, Evaluation. 47 (4): 807–25. doi:10.1177/0020731417722888. ISSN 1541-4469. PMID 28764582. S2CID 25844860.
- Jr, Donald G. McNeil (July 9, 2012). "C.I.A. Vaccine Ruse May Have Harmed the War on Polio". The New York Times. ISSN 0362-4331. Retrieved July 3, 2020.
- "Pakistan Raises Its Guard After 2 Polio Vaccinators Are Gunned Down". NPR.org.
- "Seven shot dead in Pakistan polio attack". BBC News. April 20, 2016 – via bbc.com.
- "Shot of life: saving vaccination drive from rumours and fake news". Hindustan Times. May 19, 2018.
- "Uttar Pradesh: WhatsApp rumours make 100s of UP madrassas reject vaccination". The Times of India.
- Gangarosa EJ, Galazka AM, Wolfe CR, Phillips LM, Gangarosa RE, Miller E, Chen RT (January 1998). "Impact of anti-vaccine movements on pertussis control: the untold story". Lancet. 351 (9099): 356–61. doi:10.1016/S0140-6736(97)04334-1. PMID 9652634. S2CID 35969647.
- Allen A (2002). "Bucking the herd". The Atlantic. 290 (2): 40–42. Retrieved November 7, 2007.
- "What would happen if we stopped vaccinations?". Centers for Disease Control and Prevention. June 12, 2007. Retrieved April 25, 2008.
- Centers for Disease Control and Prevention (2007). "Pertussis" (PDF). In Atkinson W, Hamborsky J, McIntyre L, Wolfe S (eds.). Epidemiology and Prevention of Vaccine-Preventable Diseases. Washington, DC: Public Health Foundation. ISBN 978-0-01-706605-3.
- Nelson MC, Rogers J (December 1992). "The right to die? Anti-vaccination activity and the 1874 smallpox epidemic in Stockholm". Social History of Medicine. 5 (3): 369–88. doi:10.1093/shm/5.3.369. PMID 11645870.
- Grabenstein, J. D.; Pittman, PR; Greenwood, JT; Engler, RJ (June 1, 2006). "Immunization to Protect the US Armed Forces: Heritage, Current Practice, and Prospects". Epidemiologic Reviews. 28 (1): 3–26. doi:10.1093/epirev/mxj003. PMID 16763072.
- Worthington B (March 17, 2011). "The Night the Viet Cong Stopped the War". History Net: Where History Comes Alive – World & US History Online. Retrieved November 18, 2015.
- Rahman TA, Al-Haj P (2008). Profiles of Malaysia's Foreign Ministers. Kuala Lumpur: Institute of Diplomacy and Foreign Relations (IDFR), Ministry of Foreign Affairs. ISBN 978-9832220268. OCLC 774064073.
- Centers for Disease Control and Prevention (April 2000). "Measles outbreak – Netherlands, April 1999–January 2000". Morbidity and Mortality Weekly Report. 49 (14): 299–303. PMID 10825086.
- Pepys MB (December 2007). "Science and serendipity". Clinical Medicine. 7 (6): 562–78. doi:10.7861/clinmedicine.7-6-562. PMC 4954362. PMID 18193704.
- Ireland measles outbreak:
- Clements, Christopher; Greenough, Paul; Shull, Diana (January 1, 2006). "How Vaccine Safety can Become Political – The Example of Polio in Nigeria". Current Drug Safety. 1 (1): 117–19. doi:10.2174/157488606775252575. PMID 18690921.
- Public Health Nigeria (October 2018). "Challenges of Immunization in Nigeria". PublichealthNg.com. Retrieved October 28, 2018.
- "Wild poliovirus 2000–2008" (PDF). Global Polio Eradication Initiative. February 5, 2008. Archived from the original (PDF) on September 27, 2007. Retrieved February 11, 2008.
- "'Hundreds' dead in measles outbreak". IRIN. December 14, 2007. Retrieved February 10, 2008.
- "Frequently Asked Questions about Measles in U.S". Centers for Disease Control and Prevention. August 28, 2018.
- Parker AA, Staggs W, Dayan GH, Ortega-Sánchez IR, Rota PA, Lowe L, Boardman P, Teclaw R, Graves C, LeBaron CW (August 2006). "Implications of a 2005 measles outbreak in Indiana for sustained elimination of measles in the United States". The New England Journal of Medicine. 355 (5): 447–55. doi:10.1056/NEJMoa060775. PMID 16885548. S2CID 34529542.
- Jaslow, Ryan (September 12, 2013). "CDC: Vaccine "philosophical differences" driving up U.S. measles rates". CBS News. Retrieved September 19, 2013.
- Centers for Disease Control Prevention (CDC) (September 2013). "National, state, and local area vaccination coverage among children aged 19–35 months – United States, 2012". Morbidity and Mortality Weekly Report. 62 (36): 733–40. PMC 4585572. PMID 24025754.
- Rañoa R, Zarracina J (January 15, 2015). "The spread of Disneyland measles outbreak". Los Angeles Times.
- Glenza J (January 19, 2015). "Measles outbreak worsens in US after unvaccinated woman visits Disneyland". The Guardian. Retrieved June 1, 2015.
- Gastañaduy PA, Redd SB, Fiebelkorn AP, Rota JS, Rota PA, Bellini WJ, Seward JF, Wallace GS (June 2014). "Measles – United States, January 1–May 23, 2014". Morbidity and Mortality Weekly Report. 63 (22): 496–99. PMC 5779360. PMID 24898167.
- CDC (June 30, 2015). "Measles Cases and Outbreaks". Retrieved July 2, 2015.
- Press Release (July 2, 2015). "Measles led to death of Clallam Co. woman; first in US in a dozen years". Washington Department of Health.
- Arizona measles outbreak: immigration workers blamed for refusing vaccines, The Guardian, July 8, 2016. Retrieved March 10, 2019.
- "Measles – Minnesota Dept. of Health". Health.state.mn.us.
- Sun LH (June 1, 2017). "Measles outbreak in Minnesota surpasses last year's total for the entire country". The Washington Post.
- Howard J (May 8, 2017). "Anti-vaccine groups blamed in Minnesota measles outbreak". CNN. Retrieved May 26, 2017.
- "Minnesota measles outbreak follows anti-vaccination campaign". New Scientist (3125) (published May 13, 2017). May 10, 2017. Retrieved May 26, 2017.
- Zdechlik M (May 3, 2017). "Unfounded Autism Fears Are Fueling Minnesota's Measles Outbreak". NPR.org. Retrieved May 26, 2017.
- Howard J. "Anti-vaccine groups blamed in Minnesota measles outbreak". CNN. Retrieved November 13, 2018.
- Sohn E (May 3, 2017). "Understanding The History Behind Communities' Vaccine Fears". NPR. Retrieved February 15, 2019.
- Dyer, Owen (May 16, 2017). "Measles outbreak in Somali American community follows anti-vaccine talks". BMJ. 357: j2378. doi:10.1136/bmj.j2378. PMID 28512183. S2CID 27124692.
- Sun, Lena H. (May 5, 2017). "Anti-vaccine activists spark a state's worst measles outbreak in decades". The Washington Post. Retrieved February 17, 2019.
- Otterman S (January 17, 2019). "New York Confronts Its Worst Measles Outbreak in Decades". The New York Times. ISSN 0362-4331. Retrieved January 19, 2019.
- Howard J. "NY tackles 'largest measles outbreak' in state's recent history". CNN. Retrieved January 19, 2019.
- Goldstein-Street, Jake (January 28, 2019). "Amid measles outbreak, legislation proposed to ban vaccine exemptions". The Seattle Times. Retrieved January 28, 2019.
- "Washington state is averaging more than one measles case per day in 2019". NBC News.
- "Amid Measles Outbreak, Anti-Vaxx Parents Have Put Others' Babies At Risk". MSN.
- Belluz, Julia (January 27, 2019). "Washington declared a public health emergency over measles. Thank vaccine-refusing parents". Vox.
- ""Dangerous" anti-vaxx warning issued by Washington officials as cases in measles outbreak continue to rise". Newsweek. January 28, 2019.
- "Public health emergency declared over measles in anti-vax hotspot near Portland, Oregon". Cbsnews.com. Retrieved February 5, 2019.
- "Swansea measles epidemic officially over". BBC News. July 3, 2013. Retrieved October 8, 2014.
Large numbers of children in the 10–18 age group were not given the MMR vaccine as babies, the result of a scare that caused panic among parents. It followed research by Dr Andrew Wakefield in the late 1990s that linked the vaccine with autism and bowel disease. His report, which was published in The Lancet medical journal, was later discredited, with health officials insisting the vaccine was completely safe.
- "Swansea measles epidemic: Worries over MMR uptake after outbreak". BBC News. July 10, 2013. Retrieved October 8, 2014.
- "600 children get MMR jab after measles outbreak in Newport". BBC News. BBC. June 22, 2017.
- Fair E, Murphy TV, Golaz A, Wharton M (January 2002). "Philosophic objection to vaccination as a risk for tetanus among children younger than 15 years". Pediatrics. 109 (1): E2. doi:10.1542/peds.109.1.e2. PMID 11773570.
- An unvaccinated child contracted tetanus. It took two months and more than $800K to save him., Washington Post, Amy Wang, March 8, 2019. Retrieved March 10, 2019.
- Unvaccinated boy nearly died from tetanus. The cost of his care was almost $1 million., NBC News, Linda Carroll, March 8, 2019. Retrieved March 10, 2019.
- Ovidiu Covaciu (November 5, 2017). "How the Romanian anti-vaccine movement threatens Europe". European Skeptics Congress. European Council of Skeptical Organisations. Retrieved November 6, 2017.
- "Centrul Național de Supraveghere şi Control al Bolilor Transmisibile – Informări săptămanale". cnscbt.ro. Retrieved March 7, 2019.
- "Australia – Oceania :: Samoa – The World Factbook". cia.gov – Central Intelligence Agency (July 2018 est.). Retrieved December 6, 2019.
- "Measles death toll rises to 68 in Samoa". RNZ. December 8, 2019. Retrieved December 8, 2019.
- "Latest update: 4,357 measles cases have been reported since the outbreak with 140 recorded in the last 24 hours. mainly children under four years old".
- Beat, Pacific (November 26, 2019). "Samoa makes measles vaccinations compulsory after outbreak kills 32". ABC News. Retrieved November 26, 2019.
- "Samoa declares state of emergency over deadly measles outbreak". abc.net.au. November 17, 2019. Retrieved November 26, 2019.
- "Samoa measles outbreak worsens". November 23, 2019. Retrieved November 26, 2019.
- France-Presse, Agence (November 28, 2019). "Samoa measles outbreak: WHO blames anti-vaccine scare as death toll hits 39". The Guardian. Retrieved November 30, 2019.
- Beat, Pacific (August 2, 2019). "'Her body was turning black': Samoan nurses jailed for infant vaccination deaths". ABC News. Retrieved November 29, 2019.
- Dubé, E; Gagnon, D; MacDonald, NE; SAGE Working Group on Vaccine Hesitancy. (August 2015). "Strategies intended to address vaccine hesitancy: Review of published reviews". Vaccine (Review). 33 (34): 4191–4203. doi:10.1016/j.vaccine.2015.04.041. PMID 25896385.
- Brelsford, D; Knutzen, E; Neher, JO; Safranek, S (December 2017). "Clinical Inquiries: Which interventions are effective in managing parental vaccine refusal?" (PDF). Journal of Family Practice. 66 (12): E12-14. PMID 29202149.
- "Provider Resources for Vaccine Conversations with Parents". cdc.gov. Centers for Disease Control and Prevention. May 28, 2019.
- Jarrett, C; Wilson, R; O'Leary, M; Eckersberger, E; Larson, HJ; SAGE Working Group on Vaccine Hesitancy. (August 2015). "Strategies for addressing vaccine hesitancy – A systematic review". Vaccine. 33 (34): 4180–90. doi:10.1016/j.vaccine.2015.04.040. PMID 25896377.
- Jamison, A.M.; Broniatowski, D. A.; Dredze, M. (November 13, 2019). "Vaccine-related advertising in the Facebook Ad Archive". Vaccine. 38 (3): 512–20. doi:10.1016/j.vaccine.2019.10.066. PMC 6954281. PMID 31732327 – via Sciencedirect.
- Sun, Lena H. (November 15, 2019). "Majority of anti-vaccine ads on Facebook were funded by two groups". Washington Post. Archived from the original on November 17, 2019. Retrieved November 16, 2019.
- How to respond to vocal vaccine deniers in public: World Health Organization (2016). https://www.who.int/immunization/sage/meetings/2016/october/8_Best-practice-guidance-respond-vocal-vaccine-deniers-public.pdf
- Allen A (2007). Vaccine: The Controversial Story of Medicine's Greatest Lifesaver. New York: W. W. Norton & Company, Inc. pp. 25–36. ISBN 978-0-393-05911-3.
Early religious opposition:
- White AD (1896). "Theological opposition to inoculation, vaccination, and the use of anæsthetics". A History of the Warfare of Science with Theology in Christendom. New York: Appleton.
- Bazin H (September 2001). "The ethics of vaccine usage in society: lessons from the past". Endeavour. 25 (3): 104–08. doi:10.1016/S0160-9327(00)01376-4. PMID 11725304.
- Noble M (December 2005). "Ethics in the trenches: a multifaceted analysis of the stem cell debate". Stem Cell Reviews. 1 (4): 345–76. CiteSeerX 10.1.1.465.2410. doi:10.1385/SCR:1:4:345. PMID 17142878. S2CID 21775014.
- Williams G (2010). Angel Of Death; the story of smallpox. Basingstoke, UK: Palgrave Macmillan. pp. 87–94. ISBN 978-0-230-27471-6.
- Bazin H (October 2003). "A brief history of the prevention of infectious diseases by immunisations". Comparative Immunology, Microbiology and Infectious Diseases. 26 (5–6): 293–308. doi:10.1016/S0147-9571(03)00016-X. PMID 12818618.
- Ellner PD (1998). "Smallpox: gone but not forgotten". Infection. 26 (5): 263–69. doi:10.1007/BF02962244. PMID 9795781. S2CID 23658644.
- Baxby D (2001). Smallpox Vaccine, Ahead of its Time. Berkeley, UK: the Jenner Museum. pp. 12–21. ISBN 0-9528695-1-9.
- Bazin H (2000). The Eradication of Smallpox. London: Academic Press. p. 122. ISBN 0-12-083475-8.
- Creighton C (1887). The Natural History of Cowpox and Vaccinal Syphilis. London: Cassell.
- Williamson S (2007). The Vaccination Controversy; the rise, reign and decline of compulsory vaccination. Liverpool: Liverpool University Press. ISBN 978-1846310867.
- Porter D, Porter R (July 1988). "The politics of prevention: anti-vaccinationism and public health in nineteenth-century England". Medical History. 32 (3): 231–52. doi:10.1017/s0025727300048225. PMC 1139881. PMID 3063903.
- Durbach N (April 2000). "'They might as well brand us': working-class resistance to compulsory vaccination in Victorian England". Social History of Medicine. 13 (1): 45–62. doi:10.1093/shm/13.1.45. PMID 11624425.
- Baxby, Derrick (1999). "The End of Smallpox". History Today. 49 (3): 14–16. PMID 21384695.
- (Royal Commission) (1898). Vaccination and its Results; a Report based on the Evidence taken by the Royal Commission. London: New Sydenham Society.
- "Labour Party Manifesto 1900". Voice of Anti-Capitalism in Guildford. April 20, 2014. Retrieved July 2, 2015.
- Millard CK (December 1948). "The end of compulsory vaccination". British Medical Journal. 2 (4589): 1073–75. doi:10.1136/bmj.2.4589.1073. PMC 2092290. PMID 18121624.
- Mooney, Graham (2015). Intrusive Interventions: Public Health, Domestic Space, and Infectious Disease Surveillance in England, 1840–1914. Rochester, NY: University of Rochester Press. ISBN 978-1580465274. Retrieved April 2, 2016.
- Fraser SM (July 1980). "Leicester and smallpox: the Leicester method". Medical History. 24 (3): 315–32. doi:10.1017/s0025727300040345. PMC 1082657. PMID 6997656.
- Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID (1988). Smallpox and its Eradication. Geneva: World Health Organization. pp. 247, 275. ISBN 978-9241561105.
- Henderson DA (2009). Smallpox; the death of a disease. Amherst, NY: Prometheus Books. pp. 90–92. ISBN 978-1-59102-722-5.
- Public health. In: Plotkin SA, Orenstein WA. Vaccines. 3rd ed. Philadelphia: 1999. ISBN 0-7216-7443-7.
- Wolfe RM, Sharp LK (August 2002). "Anti-vaccinationists past and present". BMJ. 325 (7361): 430–32. doi:10.1136/bmj.325.7361.430. PMC 1123944. PMID 12193361.
In 1879, after a visit to New York by William Tebb, the leading British anti-vaccinationist, the Anti-Vaccination Society of America was founded. Subsequently, the New England Anti-Compulsory Vaccination League was formed in 1882 and the Anti-Vaccination League of New York City in 1885.
- "History of Anti-vaccination Movements". College of Physicians of Philadelphia. March 8, 2012. Retrieved February 11, 2015.
The Anti Vaccination Society of America was founded in 1879, following a visit to America by leading British anti-vaccinationist William Tebb. Two other leagues, the New England Anti Compulsory Vaccination League (1882) and the Anti-Vaccination League of New York City (1885) followed. ...
- Kaufman M (1967). "The American anti-vaccinationists and their arguments". Bulletin of the History of Medicine. 41 (5): 463–78. PMID 4865041.
- Hopkins DR (2002). The Greatest Killer; smallpox in history. Chicago: University of Chicago Press. pp. 83–84. ISBN 978-0226351667.
- Mariner WK, Annas GJ, Glantz LH (April 2005). "Jacobson v Massachusetts: it's not your great-great-grandfather's public health law". American Journal of Public Health. 95 (4): 581–90. doi:10.2105/AJPH.2004.055160. PMC 1449224. PMID 15798113.
- Pitcairn J (1907). Vaccination. Anti-Vaccination League of Pennsylvania. OCLC 454411147.
- Higgins CM (1920). "Life sketch of John Pitcairn by a Philadelphia friend". Horrors of Vaccination Exposed and Illustrated. Brooklyn, NY: C.M. Higgins. pp. 73–75. OCLC 447437840.
- Meade T (1989). "'Living worse and costing more': resistance and riot in Rio de Janeiro, 1890–1917". J Lat Am Stud. 21 (2): 241–66. doi:10.1017/S0022216X00014784.
- Ciok, Amy E. "Horses and the diphtheria antitoxin." Academic Medicine 75.4 (2000): 396.
- Lilienfeld DE (2008). "The first pharmacoepidemiologic investigations: national drug safety policy in the United States, 1901–1902". Perspectives in Biology and Medicine. 51 (2): 188–98. doi:10.1353/pbm.0.0010. PMID 18453724. S2CID 30767303.
- Gradman C (2009). Laboratory Disease; Robert Koch's medical bacteriology. Baltimore: Johns Hopkins University Press. pp. 133–36. ISBN 978-0-8018-9313-1.
- Brock, Thomas. Robert Koch: A life in medicine and bacteriology. ASM Press: Washington DC, 1999. Print.
- Offit PA (April 2005). "The Cutter incident, 50 years later". The New England Journal of Medicine. 352 (14): 1411–12. doi:10.1056/NEJMp048180. PMID 15814877.
- "Scientist: autism paper had catastrophic effects". NPR. February 7, 2010.
- Goldacre B (August 30, 2008). "The MMR hoax". The Guardian. London. Archived from the original on February 6, 2015. Retrieved August 30, 2008. Alt URL
- Knox, Richard (September 19, 2011). "HPV Vaccine: The Science Behind The Controversy". NPR. Retrieved September 30, 2015.
- Chatterjee A, O'Keefe C (May 2010). "Current controversies in the USA regarding vaccine safety". Expert Review of Vaccines. 9 (5): 497–502. doi:10.1586/erv.10.36. PMID 20450324. S2CID 24443783.
- Malik, Amyn A; McFadden, SarahAnn M; Elharake, Jad; Omer, Saad B (2020). "Determinants of COVID-19 vaccine acceptance in the US". EClinicalMedicine, The Lancet: 100495. doi:10.1016/j.eclinm.2020.100495. ISSN 2589-5370.
- Linda Thunström, Madison Ashworth, David Finnoff, and Stephen C. Newbold. 2020. Hesitancy towards a COVID-19 vaccine and prospects for herd immunity. Covid Economics 35: 7 July 2020
- Attwell, K; Wiley, KE; Waddington, C; Leask, J; Snelling, T (October 2018). "Midwives' attitudes, beliefs and concerns about childhood vaccination: A review of the global literature". Vaccine. 36 (44): 6531–39. doi:10.1016/j.vaccine.2018.02.028. PMID 29483029.
- Pearce A, Law C, Elliman D, Cole TJ, Bedford H (April 2008). "Factors associated with uptake of measles, mumps, and rubella vaccine (MMR) and use of single antigen vaccines in a contemporary UK cohort: prospective cohort study". BMJ. 336 (7647): 754–57. doi:10.1136/bmj.39489.590671.25. PMC 2287222. PMID 18309964.
- Yang YT, Delamater PL, Leslie TF, Mello MM (January 2016). "Sociodemographic Predictors of Vaccination Exemptions on the Basis of Personal Belief in California". American Journal of Public Health. 106 (1): 172–77. doi:10.2105/AJPH.2015.302926. PMC 4695929. PMID 26562114.
- Ogilvie G, Anderson M, Marra F, McNeil S, Pielak K, Dawar M, McIvor M, Ehlen T, Dobson S, Money D, Patrick DM, Naus M (May 2010). "A population-based evaluation of a publicly funded, school-based HPV vaccine program in British Columbia, Canada: parental factors associated with HPV vaccine receipt". PLOS Medicine. 7 (5): e1000270. doi:10.1371/journal.pmed.1000270. PMC 2864299. PMID 20454567.
- Amit Aharon A, Nehama H, Rishpon S, Baron-Epel O (April 2017). "Parents with high levels of communicative and critical health literacy are less likely to vaccinate their children". Patient Education and Counseling. 100 (4): 768–75. doi:10.1016/j.pec.2016.11.016. PMID 27914735.
- Kim SS, Frimpong JA, Rivers PA, Kronenfeld JJ (February 2007). "Effects of maternal and provider characteristics on up-to-date immunization status of children aged 19 to 35 months". American Journal of Public Health. 97 (2): 259–66. doi:10.2105/AJPH.2005.076661. PMC 1781415. PMID 17194865.
- Colgrove J, Bayer R (April 2005). "Manifold restraints: liberty, public health, and the legacy of Jacobson v Massachusetts". American Journal of Public Health. 95 (4): 571–76. doi:10.2105/AJPH.2004.055145. PMC 1449222. PMID 15798111.
- Salmon DA, Teret SP, MacIntyre CR, Salisbury D, Burgess MA, Halsey NA (February 2006). "Compulsory vaccination and conscientious or philosophical exemptions: past, present, and future". Lancet. 367 (9508): 436–42. doi:10.1016/s0140-6736(06)68144-0. PMID 16458770. S2CID 19344405.
- Moodley, Keymanthri; Hardie, Kate; Selgelid, Michael J.; Waldman, Ronald J.; Strebel, Peter; Rees, Helen; Durrheim, David N. (February 7, 2013). "Ethical considerations for vaccination programmes in acute humanitarian emergencies". Bulletin of the World Health Organization. 91 (4): 290–97. doi:10.2471/BLT.12.113480. PMC 3629456. PMID 23599553.
- Caplan AL. "Do Children Have Vaccination Rights?". Medscape Business of Medicine.
- "Anti-vaccine misinformation denies children's rights". April 18, 2018.
- Parasidis E, Opel DJ (January 2017). "Parental Refusal of Childhood Vaccines and Medical Neglect Laws". American Journal of Public Health. 107 (1): 68–71. doi:10.2105/AJPH.2016.303500. PMC 5308147. PMID 27854538.
- "Should Pediatricians Refuse Unvaccinated Kids?". The Huffington Post. Retrieved July 4, 2015.
- Bachai, Sabrina (June 24, 2014). "NYC Schools Are Now Allowed To Ban Unvaccinated Kids, Rules Federal Judge". Medical Daily. Retrieved July 4, 2015.
- Halperin, Beth; Melnychuk, Ryan; Downie, Jocelyn; Macdonald, Noni (December 2007). "When is it permissible to dismiss a family who refuses vaccines? Legal, ethical and public health perspectives". Paediatrics & Child Health. 12 (10): 843–45. doi:10.1093/pch/12.10.843. PMC 2532570. PMID 19043497.
- May T, Silverman RD (2005). "Free-riding, fairness and the rights of minority groups in exemption from mandatory childhood vaccination". Human Vaccines. 1 (1): 12–15. doi:10.4161/hv.1.1.1425. PMID 17038833. S2CID 39321188.
- LeBlanc S (October 17, 2007). "Parents use religion to avoid vaccines". USA Today. Retrieved November 24, 2007.
- "Statement on Vaccinations from the OU and Rabbinical Council of America." Orthodox Union. 14 November 2018. 21 May 2019.
- Avaneha Barzel p. 31 #34
- Plotkin SA, Buser F (1985). "History of RA27/3 rubella vaccine". Reviews of Infectious Diseases. 7 (Suppl 1): S77–78. doi:10.1093/clinids/7.supplement_1.s77. PMID 3890107.
- Grabenstein JD (1999). "Moral considerations with certain viral vaccines" (PDF). Christ Pharm. 2 (2): 3–6. Archived from the original (PDF) on July 18, 2011. Retrieved May 11, 2009.
- Pontifical Academy for Life (2005). "Moral reflections on vaccines prepared from cells derived from aborted human foetuses". Medicina e Morale. Archived from the original on May 7, 2006. Retrieved December 3, 2008.
- "Parents Fake Religion To Avoid Vaccines". CBS News. AP. October 17, 2007.
- "State Vaccination Exemptions for Children Entering Public Schools". Vaccines.procon.org.
- Beinart, Peter (August 2019). "What the Measles Epidemic Really Says About America". The Atlantic. Retrieved July 8, 2019.
- Busse JW, Morgan L, Campbell JB (June 2005). "Chiropractic antivaccination arguments". Journal of Manipulative and Physiological Therapeutics. 28 (5): 367–73. doi:10.1016/j.jmpt.2005.04.011. PMID 15965414.
- Campbell JB, Busse JW, Injeyan HS (April 2000). "Chiropractors and vaccination: A historical perspective". Pediatrics. 105 (4): E43. doi:10.1542/peds.105.4.e43. PMID 10742364.
- Russell ML, Injeyan HS, Verhoef MJ, Eliasziw M (December 2004). "Beliefs and behaviours: understanding chiropractors and immunization". Vaccine. 23 (3): 372–79. doi:10.1016/j.vaccine.2004.05.027. PMID 15530683.
- Busse JW, Wilson K, Campbell JB (November 2008). "Attitudes towards vaccination among chiropractic and naturopathic students". Vaccine. 26 (49): 6237–43. doi:10.1016/j.vaccine.2008.07.020. PMID 18674581.
- Lameris M, Schmidt C, Gleberzon B, Ogrady J (September 2013). "Attitudes toward vaccination: A cross-sectional survey of students at the Canadian Memorial Chiropractic College". The Journal of the Canadian Chiropractic Association. 57 (3): 214–20. PMC 3743647. PMID 23997247.
- Yoo S (February 24, 2015), "Vaccine researcher Wakefield to testify in Oregon", Statesman Journal, retrieved March 3, 2015
- Yoo S (February 26, 2015), "Meeting on vaccine mandate bill canceled", Statesman Journal, retrieved March 3, 2015
- Mason M (March 5, 2015). "Chiropractors lobby against bill ending belief exemptions for vaccines". Los Angeles Times. Retrieved March 6, 2015.
- Schmidt K, Ernst E (March 2003). "MMR vaccination advice over the Internet". Vaccine. 21 (11–12): 1044–47. doi:10.1016/S0264-410X(02)00628-X. PMID 12559777.
- Crislip M (November 5, 2010). "Homeopathic Vaccines".
- Stop Nosodes/Bad Science Watch (August 2015). "Nosode Use in Canada".
- Kerr MA (2009). "Movement impact" (PDF). The Autism Spectrum Disorders / vaccine link debate: a health social movement. University of Pittsburgh. pp. 194–203. Archived from the original (PDF) on July 18, 2011. Retrieved February 25, 2010.
- Weeks, Carly. "Health experts question lack of crackdown on 'homeopathic vaccines'". The Globe and Mail. Retrieved July 4, 2015.
- Sheridan C (June 2009). "Vaccine market boosters". Nature Biotechnology. 27 (6): 499–501. doi:10.1038/nbt0609-499. PMID 19513043. S2CID 205268563.
- Allen A (2007). "Epilogue: our best shots". Vaccine: the Controversial Story of Medicine's Greatest Lifesafer. W.W. Norton. pp. 421–42. ISBN 978-0-393-05911-3.
- Willrich M (2010). Pox: An American History. New York: Penguin Group. pp. 117–65. ISBN 978-1101476222.
- Broniatowski DA, Jamison AM, Qi S, AlKulaib L, Chen T, Benton A, Quinn SC, Dredze M (October 2018). "Weaponized Health Communication: Twitter Bots and Russian Trolls Amplify the Vaccine Debate". American Journal of Public Health. 108 (10): 1378–84. doi:10.2105/AJPH.2018.304567. PMC 6137759. PMID 30138075.
- Glenza J (August 23, 2018). "Russian trolls 'spreading discord' over vaccine safety online". The Guardian. Retrieved August 23, 2018.
- "The State of Vaccine Confidence in the EU: 2018". Vaccine Confidence Project. London School of Hygiene & Tropical Medicine. Retrieved December 2, 2018.
- Johnson, Deborah K.; Mello, Emily J.; Walker, Trent D.; Hood, Spencer J.; Jensen, Jamie L.; Poole, Brian D. (May 12, 2019). "Combating Vaccine Hesitancy with Vaccine-Preventable Disease Familiarization: An Interview and Curriculum Intervention for College Students". Vaccines. 7 (2): 39. doi:10.3390/vaccines7020039. PMC 6631173. PMID 31083632.
- Hall, Harriet. "Diving into the VAERS Dumpster". CSI. Center for Inquiry. Retrieved December 15, 2018.
- Largent, Mark A. (2012). Vaccine: The Debate in Modern America. Johns Hopkins University Press. ISBN 978-1421406077.
- Bedford H, Elliman D (January 2000). "Concerns about immunisation". BMJ. 320 (7229): 240–43. doi:10.1136/bmj.320.7229.240. PMC 1117437. PMID 10642238.
- Davies P, Chapman S, Leask J (July 2002). "Antivaccination activists on the world wide web". Archives of Disease in Childhood. 87 (1): 22–25. doi:10.1136/adc.87.1.22. PMC 1751143. PMID 12089115.
- Richardson PD, Mohammed SF, Mason RG, Steiner M, Kane R (2004). "Dynamics of platelet interaction with surfaces in steady flow conditions". Transactions of the American Society for Artificial Internal Organs. 25 (7473): 147–51. doi:10.1136/bmj.329.7473.1049. PMC 524574. PMID 524574.
- Friedlander E (2007). "The anti-immunization activists: a pattern of deception". Retrieved November 13, 2007.
- Hanratty B, Holt T, Duffell E, Patterson W, Ramsay M, White JM, Jin L, Litton P (October 2000). "UK measles outbreak in non-immune anthroposophic communities: the implications for the elimination of measles from Europe". Epidemiology and Infection. 125 (2): 377–83. doi:10.1017/S0950268899004525. PMC 2869610. PMID 11117961.
- Herlihy SM, Hagood EA, Offit PA (2012). Your Baby's Best Shot: Why Vaccines Are Safe and Save Lives. Rowman & Littlefield Publishers. ISBN 978-1442215788.
- Miller CL (February 1985). "Deaths from measles in England and Wales, 1970–83". British Medical Journal. 290 (6466): 443–44. doi:10.1136/bmj.290.6466.443. PMC 1417782. PMID 3918622.
- Myers MG, Pineda D (2008). Do Vaccines Cause That?! A Guide for Evaluating Vaccine Safety Concerns. Galveston, TX: Immunizations for Public Health (i4ph). ISBN 978-0-9769027-1-3.
- Naono, Atsuko (2006). "Vaccination Propaganda: The Politics of Communicating Colonial Medicine in Nineteenth-Century Burma" (PDF). SOAS Bulletin of Burma Research. 4 (1): 30–44.
- Offit, Paul A. (2008). Autism's False Prophets: Bad Science, Risky Medicine, and the Search for a Cure. Columbia University Press. ISBN 978-0-231-14636-4.
- Offit, Paul A. (2012). Deadly Choices: How the Anti-Vaccine Movement Threatens Us All. Basic Books. ISBN 978-0465029624.
- Orenstein WA, Hinman AR (October 1999). "The immunization system in the United States – the role of school immunization laws". Vaccine. 17 (Suppl 3): S19–24. doi:10.1016/S0264-410X(99)00290-X. PMID 10559531.
- Spier RE (November 1998). "Ethical aspects of vaccines and vaccination". Vaccine. 16 (19): 1788–94. doi:10.1016/S0264-410X(98)00169-8. PMC 7173252. PMID 9795382.
- Vermeersch E (October 1999). "Individual rights versus societal duties". Vaccine. 17 (Suppl 3): S14–17. doi:10.1016/s0264-410x(99)00289-3. PMID 10627239.
- Wolfe RM, Sharp LK, Lipsky MS (June 2002). "Content and design attributes of antivaccination web sites". JAMA. 287 (24): 3245–48. doi:10.1001/jama.287.24.3245. PMID 12076221.
- "Six common misconceptions about immunization". World Health Organization. February 16, 2006. Retrieved November 2, 2006.
- Lewandowsky et al. Anti-Vax Psychology Study Report – Mooney, Chris (October 2, 2013). "If You Distrust Vaccines, You're More Likely to Think NASA Faked the Moon Landings". Mother Jones. Retrieved February 2, 2016.
- National Academies of Sciences, Engineering, and Medicine 2020. Vaccine Accessand Hesitancy: Part One of a Workshop Series: Proceedings of a Workshop inBrief. Washington, DC: The National Academies Press.https://doi.org/10.17226/25895.
|Wikiquote has quotations related to: Vaccine hesitancy|