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The United States - and many other parts of the globe - have taken great strides to eliminate deadly disease. Yet, it seems like diseases such as measles tend to randomly appear back in the news. Recently, we've seen states such as Washington declare a state of an emergency due to an outbreak of measles.

Despite the facts about vaccinations, there are still loud opposing voices. If the country takes pride in keeping our people safe - we need to collectively do a better job at informing people the truth about vaccinations. This debate should of been settled years ago - but here we are.

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The U.S Center of Disease Control proudly boasts vaccines as "the greatest success stories in public health." The country has virtually eradicated diseases such as polio and smallpox. While small, isolated outbreaks can be contained - it seems like a growing number of vaccine skeptics are contributing to one of the worst measles outbreaks since 1992.

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Vaccines are one of the greatest success stories in public health. Through use of vaccines, we have eradicated smallpox and nearly eliminated wild polio virus. The number of people who experience the devastating effects of preventable infectious diseases like measles, diphtheria, and whooping cough is at an all-time low. To ensure the continued success of vaccines in the United States, it's crucial to make sure that vaccines are safe.

Before vaccines are approved by the Food and Drug Administration (FDA), they are tested extensively by scientists to ensure they are effective and safe. Vaccines are the best defense we have against infectious diseases; however, no vaccine is actually 100% safe or effective for everyone because each person's body reacts to vaccines differently. [ 1, 2, 3]

As infectious diseases become less common, we hear less about the serious consequences of preventable illnesses like diphtheria and tetanus and more about the risks associated with vaccines. It's good to be informed about health choices, but the reality is that Americans have never been healthier than we are today and vaccines have never been safer than they are today. The benefits of vaccines far outweigh the risks. As science continues to advance, we strive to develop safer vaccines and improve delivery to protect ourselves against disease more effectively. This overview focuses on vaccine research, how vaccines are licensed, and how we make sure vaccines are safe. [ 1, 2, 3]

National Childhood Vaccine Injury Act

During the mid-1970s, there was an increased focus on personal health and more people became concerned about vaccine safety. Several lawsuits were filed against vaccine manufacturers and healthcare providers by people who believed they had been injured by the diphtheria, pertussis, tetanus (DPT) vaccine. [ 4] Damages were awarded despite the lack of scientific evidence to support vaccine injury claims. [ 4] As a result of these decisions, liability and prices soared, and several vaccine manufacturers halted production. A vaccine shortage resulted and public health officials became concerned about the return of epidemic disease. To reduce liability and respond to public health concerns, Congress passed the National Childhood Vaccine Injury Act (NCVIA) in 1986. This act was influential in many ways. [ 4, 5]

The National Vaccine Program Office (NVPO) was established to coordinate immunization-related activities between all Department of Health and Human Services (DHHS) agencies including the Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), National Institutes of Health (NIH), and the Health Resources and Services Administration (HRSA).

The NCVIA requires health care providers who administer vaccines to provide a vaccine information statement (VIS) to the person getting the vaccine or his or her guardian. A VIS must be given with every vaccination including each dose in a multi-dose series. Each VIS contains a brief description of the disease as well as the risks and benefits of the vaccine. CDC develops VISs and distributes them to state and local health departments as well as individual providers.

The NCVIA also requires health care providers to report certain adverse events (health effects occurring after immunization that may or may not be related to the vaccine) following vaccination to the Vaccine Adverse Event Reporting System (VAERS).

Under the NCVIA, the National Vaccine Injury Compensation Program (NVICP) was created to compensate those injured by vaccines on a "no fault" basis.

The NCVIA established a committee from the Institute of Medicine (IOM) to review the literature on vaccine reactions. This group concluded that there are limitations in our knowledge of the risks associated with vaccines. The group looked at 76 health problems to see if they were caused by vaccines. Of those, 50 (66%) had no or inadequate research to form a conclusion. [6, 7] Specifically, the IOM identified the following problems:

1. Limited understanding of biological processes that underlie adverse events.

2. Incomplete and inconsistent information from individual reports.

3. Poorly constructed research studies (not enough people enrolled for the period of time).

4. Inadequate systems to track vaccine side effects.

5. Few experimental studies were published in the medical literature.

Significant progress has been made over the past few years to monitor side effects and conduct research relevant to vaccine safety.

Monitoring Vaccine Safety: Pre-Licensure

Before vaccines are licensed by the FDA, they are tested extensively in the laboratory and with human subjects to ensure their safety. First, researchers use computers to predict how the vaccine will interact with the human immune system. Then researchers test the vaccine on animals including mice, guinea pigs, rabbits, and monkeys.

After the vaccine completes these laboratory tests successfully, the FDA approves its use in clinical studies on human subjects. Participation in these studies is completely voluntary. Many individuals choose to contribute their time and energy for the advancement of science. Before they participate in research, all participants must demonstrate that they understand the purpose of the study and its potential risks. Volunteers agree to receive the vaccine and undergo any medical testing necessary to assess its safety and efficacy. [ 7]

Vaccine licensing is a lengthy process that may take 10 years or longer. The FDA requires that vaccines undergo three phases of clinical trials with human subjects before they can be licensed for use in the general public:

Phase one trials are small, involving only 20 to 100 volunteers, and last only a few months. The purpose of phase one trials is to evaluate basic safety and identify very common reactions.

Phase two trials are larger and involve several hundred participants. These studies last anywhere from several months to two years and collect additional information on safety and efficacy. Data gained from phase two trials can be used to determine the composition of the vaccine, how many doses are necessary, and a profile of common reactions.

Unless the vaccine is ineffective or causes health problems, the trials are expanded to phase three, which involves several hundred to several thousand volunteers. Typically these trials last several years. Because the vaccinated group can be compared to those who have not received the vaccine, researchers are able to identify true reactions. [1, 3, 7, 8, 9]

If the clinical trials demonstrate that the vaccine is safe and effective, the manufacturer applies to the FDA for two licenses: one for the vaccine (product license), and one for the production plant (establishment license). During the application process, the FDA reviews the clinical trial data and proposed product labeling. In addition, the FDA inspects the plant and goes over manufacturing protocols to ensure vaccines are produced in a safe and consistent manner. Only after the FDA is satisfied that the vaccine is safe is it licensed for use in the general population. [ 8]

Monitoring Vaccine Safety: Post-Licensing

After a vaccine is licensed for public use, its safety is monitored continually. The FDA requires all manufacturers to submit samples from each vaccine lot prior to its release. In addition, the manufacturers must provide the FDA with their test results for vaccine safety, potency, and purity. Each lot must be tested because vaccines are sensitive to environmental factors like temperature, and can be contaminated during production. The FDA rarely has recalled vaccine lots, for concerns such as mislabeling, contamination during production, and potential manufacturing problems at a production plant. [ 8]

While clinical trials provide important information on vaccine safety, the data are somewhat limited because of the relatively small number (hundreds to thousands) of study participants. Rare side effects and delayed reactions may not be evident until the vaccine is administered to millions of people. Therefore, the federal government established a surveillance system to monitor adverse events following vaccination. This project is known as the Vaccine Adverse Event Reporting System (VAERS). In addition, large-linked databases containing information on millions of individuals have been created to study rare vaccine adverse events. [ 1, 3]

Learn more about systems used to monitor vaccine safety:
Vaccine Adverse Event Reporting System (VAERS) Vaccine Safety Datalink (VSD) Clinical Immunization Safety Assessment (CISA) Project National Vaccine Injury Compensation Programexternal icon
Improvements in Vaccine Safety

In the last decades, numerous changes in vaccine production and administration have reduced the number of side effects and resulted in safer vaccines.

A more purified acellular pertussis (aP) vaccine has been licensed for use and has replaced the whole cell pertussis vaccine used in DTP (diphtheria, tetanus, pertussis vaccine). Several studies have evaluated the safety and efficacy of DTaP as compared to DTP and concluded DTaP is effective in preventing disease, and mild and serious side effects occurred less frequently when the DTaP vaccine was given. [3]

Changes in the schedule of polio vaccines also have resulted in fewer reports of serious adverse events. In 1997, the Advisory Committee on Immunization Practices recommended a change in the vaccination schedule to include sequential administration of inactivated polio vaccine (IPV) and oral polio vaccine (OPV). [10] This sequential schedule was expected to produce a high level of individual protection against the disease caused by wild polio virus, while reducing by 50 to 70% vaccine-associated paralytic polio (VAPP) that occurs in 8-10 people a year who receive OPV. [10] Today, only IPV is on the recommended childhood immunization schedule.

The Future of Vaccine Safety

The importance of vaccine safety will continue to grow throughout the 21st century. The development and licensure of new vaccines will add to the already robust immunization schedule. Scientists may also perfect new ways of administering immunizations including edible vaccines and needleless injections. However they are formulated or delivered, vaccines will remain the most effective tool we possess for preventing disease and improving public health in the future.

References

1. Chen RT, Hibbs B. Vaccine safety: Current and future challengesexternal icon . Pediatric Annals 1998;27(7):445-455.

2. Ellenberg SS, Chen RT. The complicated task of monitoring vaccine safetyexternal icon . Public Health Reports 1997;112(1):10-20.

3. Centers for Disease Control and Prevention. (1997) "Epidemiology and prevention of vaccine-preventable diseases, vaccine safety" (chapter 15). Washington DC: Government Printing Office.

4. Freed GL, Katz SL, Clark SJ. Safety of vaccinations: Miss America, the media, and public healthexternal icon . Journal of the American Medical Association 1996;276(23):1869-1872.

5. Brink EW, Hinman AR. The vaccine injury compensation act: The new law and you. Contemporary Pediatrics 1989;6(3):28-32, 35-36, 39, 42.

6. Howson CP, Howe CJ, Finchere HV, eds. Institute of Medicine. Adverse effects of pertussis and rubella vaccinesexternal icon : A report of the Committee to Review the Adverse Consequences or Pertussis and Rubella Vaccines. Washington, DC: National Academy Press, 1991.

7. Stratton KR, Howe CJ, Johnsion RB, eds. Adverse events associated with childhood vaccines; Evidence bearing on causalityexternal icon . Washington, DC; National Academy Press, 1994.

8. Understanding Vaccines;external icon . Bethesda, MD; National Institutes of Health, 2008.

9. Food and Drug Administration (FDA)external icon .

10. Advisory Committee on Immunization Practice (ACIP). Poliomyelitis prevention in the United States: Introduction of a sequential vaccination schedule of inactivated poliovirus vaccine followed by oral poliovirus vaccine.MMWR 1997;46(RR-3);1-25.

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Vaccines are one of the greatest success stories in public health. Through use of vaccines, we have eradicated smallpox and nearly eliminated wild polio virus. The number of people who experience the devastating effects of preventable infectious diseases like measles, diphtheria, and whooping cough is at an all-time low.

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According to a study, anti-vaccination propaganda dates back to the 18th century. For many theological reasons, some in the church would detest mandatory vaccinations, particularly in England, with some claiming vaccines are, "an attempt to oppose God’s punishments upon man for his sins" (Hussain, Azhar et al. “The Anti-vaccination Movement: A Regression in Modern Medicine”  Cureus vol. 10,7 e2919. 3 Jul. 2018, doi:10.7759/cureus.2919).

The same study notes that anti-vaccination efforts have resurfaced due to a "former British doctor and researcher, Andrew Wakefield" who reignited a debunked theory that, "the measles, mumps, and rubella (MMR) vaccine and development of autism in young children."

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Monitoring Editor: Alexander Muacevic and John R Adler

Abstract

There have been recent trends of parents in Western countries refusing to vaccinate their children due to numerous reasons and perceived fears. While opposition to vaccines is as old as the vaccines themselves, there has been a recent surge in the opposition to vaccines in general, specifically against the MMR (measles, mumps, and rubella) vaccine, most notably since the rise in prominence of the notorious British ex-physician, Andrew Wakefield, and his works. This has caused multiple measles outbreaks in Western countries where the measles virus was previously considered eliminated. This paper evaluates and reviews the origins of the anti-vaccination movement, the reasons behind the recent strengthening of the movement, role of the internet in the spread of anti-vaccination ideas, and the repercussions in terms of public health and safety.

Keywords: vaccination, mmr vaccine, measles outbreak, virus, anti-vaccine movement

Introduction and background

Vaccines are one of the most important measures of preventative medicine to protect the population from diseases and infections. They have contributed to decreasing rates of common childhood diseases and, in some cases, have even wiped out some diseases that were common in years past, such as smallpox, rinderpest, and have nearly eradicated malaria and polio [ 1]. In fact, according to the World Health Organization's Polio Global Eradication Initiative, the inactivated polio vaccine (IPV) will be used as a backbone for eradicating poliovirus in the next decade. However, there has been a recent rise in anti-vaccination sentiments surrounding beliefs that vaccines cause more harm than benefits to the health of the children who receive them. The premise of the anti-vaccination movement can also be contributed to the demonization of vaccinations by news and entertainment outlets. Voices such as Jenny McCarthy's have proven to be influential, sweeping fear and distrust into parents' minds by parading as "autism experts". Social media and television talk show hosts, such as Oprah Winfrey, played a big role in this miseducation by giving credence to the campaign. This has caused vaccination rates to sustain a surprising drop in some Western countries [ 2]. The decrease in vaccinations has led to recent outbreaks of diseases that were thought to be "eliminated", such as measles. Still, other reasons for the anti-vaccination movement can be due to personal reasons, such as religious or secular views. A drop in immunizations poses a threat to the herd immunity the medical world has worked hard to achieve. Global communities are now more connected than ever, which translates to a higher probability of the transmission of pathogens. The only thing that can protect populations against a rapidly spreading disease is the disease's resistance created by herd immunity when the majority are immune after vaccinations. Given the highly contagious nature of diseases like measles, vaccination rates of 96% to 99% are necessary to preserve herd immunity and prevent future outbreaks [ 3].

Review

Origins of the anti-vaccination movement

Fear of vaccines and myths against them are not a new phenomenon. Opposition to vaccines goes as far back as the 18th century when, for example, Reverend Edmund Massey in England called the vaccines "diabolical operations" in his 1772 sermon, "The Dangerous and Sinful Practice of Inoculation" [ 4]. He decried these vaccines as an attempt to oppose God's punishments upon man for his sins [ 5]. Similar religious opposition was seen in the "New World" even earlier, such as in the writings of Reverend John Williams in Massachusetts, who also cited similar reasons for his opposition to vaccines claiming that they were the devil's work [ 6]. However, opposition against vaccines was not only manifested in theological arguments; many also objected to them for political and legal reasons. After the passage of laws in Britain in the mid-19th century making it mandatory for parents to vaccinate their children, anti-vaccine activists formed the Anti-Vaccination League in London. The league emphasized that its mission was to protect the liberties of the people which were being "invaded" by Parliament and its compulsory vaccination laws [ 7]. Eventually, the pressure exerted by the league and its supporters compelled the British Parliament to pass an act in 1898, which removed penalties for not abiding by vaccination laws and allowed parents who did not believe vaccination was beneficial or safe to not have their children vaccinated [ 8]. Since the rise and spread of the use of vaccines, opposition to vaccines has never completely gone away, vocalized intermittently in different parts of the world due to arguments based in theology, skepticism, and legal obstacles [ 9].

Anti-vaccination propaganda

While pushback against the measles vaccine due to fears of its connection to autism is the most recent example that comes to mind, there have been other instances of outbreaks of previously "extinct" diseases in modern times. One example is the refusal of some British parents to vaccinate their children in the 1970s and 1980s against pertussis in response to the publication of a report in 1974 that credited 36 negative neurological reactions to the whole-cell pertussis vaccine [ 10]. This caused a decrease in the pertussis vaccine uptake in the United Kingdom (UK) from 81% in 1974 to 31% in 1980, eventually resulting in a pertussis outbreak in the UK, putting severe strain and pressure on the National Health System [ 11- 12]. Vaccine uptake levels were elevated to normal levels after the publication of a national reassessment of vaccine efficacy that reaffirmed the vaccine's benefits, as well as financial incentives for general practitioners who achieved the target of vaccine coverage [ 13]. Disease incidence declined dramatically as a result.

The anti-vaccination movement was most strongly rejuvenated in recent years by the publication of a paper in The Lancet by a former British doctor and researcher, Andrew Wakefield, which suggested credence to the debunked-claim of a connection between the measles, mumps, and rubella (MMR) vaccine and development of autism in young children [ 14]. Several studies published later disproved a causal association between the MMR vaccine and autism [ 15- 18]. Wakefield drew severe criticism for his flawed and unethical research methods, which he used to draw his data and conclusions [ 19]. A journalistic investigation also revealed that there was a conflict of interest with regard to Wakefield's publication because he had received funding from litigants against vaccine manufacturers, which he obviously did not disclose to either his co-workers nor medical authorities [ 20]. For all of the aforementioned reasons, The Lancet retracted the study, and its editor declared it "utterly false" [ 21]. As a result, three months later, he was also struck off the UK Medical Registry, barring him from practicing medicine in the UK. The verdict declared that he had "abused his position of trust" and "brought the medical profession into disrepute" in the studies he carried out [ 22].

Repercussions of declining vaccination rates

The damage, however, was already done and the myth was spread to many different parts of the world, especially Western Europe and North America. In the UK, for example, the MMR vaccination rate dropped from 92% in 1996 to 84% in 2002. In 2003, the rate was as low as 61% in some parts of London, far below the rate needed to avoid an epidemic of measles [ 23]. In Ireland, in 1999-2000, the national immunization level had fallen below 80%, and in part of North Dublin, the level was around 60% [ 24]. In the US, the controversy following the publication of the study led to a decline of about 2% in terms of parents obtaining the MMR vaccine for their children in 1999 and 2000. Even after later studies explicitly and thoroughly debunked the alleged MMR-autism link, the drop in vaccination rates persisted [ 25].

As a result, multiple breakouts of measles have occurred throughout different parts of the Western world, infecting dozens of patients and even causing deaths. In the UK in 1998, 56 people contracted measles; in 2006, this number increased to 449 in the first five months of the year, with the first death since 1992 [ 26]. In 2008, measles was declared endemic in the UK for the first time in 14 years [ 27]. In Ireland, an outbreak occurred in 2000 and 1,500 cases and three deaths were reported. The outbreak was reported to have occurred as a direct result of a drop in vaccination rates following the MMR controversy [ 28]. In France, more than 22,000 cases of measles were reported from 2008 - 2011 [ 29]. The United States has not been an exception, with outbreaks occurring most recently in 2008, 2011, and 2013 [ 30- 32].

Perhaps the most infamous example of a measles outbreak in the United States occurred in 2014-2015. The outbreak was believed to originate from the Disneyland Resort in Anaheim, California and resulted in an estimated 125 people contracting the disease [ 33]. It was estimated that MMR vaccination rates among the exposed population in which secondary cases have occurred might be as low as 50% and likely no higher than 86% [ 34]. Physicians in the region were criticized for deviating from the CDC's (Center for Disease Control and Prevention) recommended vaccination schedule and/or discouraging vaccination. As a result, California passed Senate Bill 277, a mandatory vaccination law in June 2015, banning personal and religious exemptions to abstain from vaccinations [ 35].

Technology and its effects on anti-vaccination movement

Access to medical information online has dramatically changed the dynamics of the healthcare industry and patient-physician interactions. Medical knowledge that was previously bound to textbooks and journals, or held primarily by medical professionals, is now accessible to the layman, which has shifted the power from doctors as exclusive managers of a patient's care to the patients themselves [ 36]. This has led to the recent establishment of shared decision-making between patients and healthcare physicians [ 37]. While this is beneficial in some ways, the dissemination of false and misleading information found on the internet can also lead to negative consequences, such as parents not giving consent to having their children vaccinated. When it comes to vaccines, the false information is plentiful and easy to find. An analysis of YouTube videos about immunization found that 32% opposed vaccination and that these had higher ratings and more views than pro-vaccine videos [ 38]. An analysis of MySpace blogs about HPV immunization found that 43% portrayed the immunization in a negative light; these blogs referenced vaccine-critical organizations and cited inaccurate data [ 39]. A similar study of Canadian internet users tracked the sharing of influenza vaccine information on social media networks, such as Facebook, Twitter, YouTube, and Digg. Of the top search results during the study period, 60% promoted anti-vaccination sentiments [ 40]. A study that examined the content of the first 100 anti-vaccination sites found after searching for "vaccination" and "immunization" on Google concluded that 43% of websites were anti-vaccination (including all of the first 10) [ 41].

Online anti-vaccination authors use numerous tactics to further their agendas. These tactics include, but are not limited to, skewing science, shifting hypotheses, censoring opposition, attacking critics, claiming to be "pro-safe vaccines", and not "anti-vaccine", claiming that vaccines are toxic or unnatural, and more [ 42]. Not only are these tactics deceitful and dishonest, they are also effective on many parents. A study that evaluated how effectively users assessed the accuracy of medical information about vaccines online concluded that 59% of student participants thought retrieved sites were entirely accurate; however, out of the 40 sites they were given, only 18 were actually accurate, while 22 were inaccurate. These sites were not evidence-based and argued vaccines were inherently dangerous without any merit-based argument. More than half of participants (53%) left the exercise with significant misconceptions about vaccines [ 43]. Research has also shown that viewing an anti-vaccine website for merely 5 - 10 minutes increased perceptions of vaccination risks and decreased perceptions of the risks of vaccine omission, compared to visiting a control site [ 44]. The study also found that the anti-vaccine sentiments obtained from viewing the websites still persisted five months later, causing the children of these parents to obtain fewer vaccinations than recommended [ 45]. The role of the online access to false anti-vaccination information just cannot be understated in examining the rise and spread of the anti-vaccination movement.

Ethical and legal issues regarding vaccination

Opposition to the MMR vaccine among parents leads to an ethical dilemma that can be analyzed using both medical ethics and moral principles. Medical ethics call for health professionals to abide by a code of bioethics upholding autonomy, non-maleficence, beneficence, and justice. The most relevant in mandating vaccinations are autonomy and non-maleficence [ 46]. Patients are entitled to the right to refuse vaccination using "our children, our choice" based on their autonomy, while health care providers are morally obligated to treat everyone with non-maleficence and avoiding harm to society at all costs.

At the individual level, religion is a common reason to refuse vaccination. The MMR vaccine specifically has been the cause of instigating debate among the Hindu, Protestant, Orthodox Jewish, and Jehovah's Witness communities. Specific religious views on vaccines in general, however, are not normally the cause for debate but instead the components of the MMR vaccine [ 47]. The MMR vaccine, combined with the rubella vaccine, was originally derived from the cells of aborted fetal tissue. Hindu, Protestant, Muslim, and Jewish communities are generally opposed to abortion for moral reasons based on religious teachings; thus, individuals from these beliefs may cite religious reasons for filing vaccine exemptions. Further, the MMR vaccine contains porcine gelatin as a stabilizer, a means for ensuring effective storage. The porcine ingredients are unlike gelatins used for oral consumption and purified down to small peptides, commonly used in medicine capsules as well [ 48]. As there is a wide range of practice preferences in every religion, some individuals belonging to religions, such as Judaism, Islam, and Hinduism (to name a few), may be opposed to injecting a porcine product into their body along with the vaccine [ 47]. Further, other religious views, such as the ones held by Dutch-Protestant Christian congregations, consider vaccinations "inappropriate meddling in the work of God". These groups, therefore, believe that we should not change the predestined fate of someone who becomes ill [ 49].

While exercising autonomy and refusing vaccination is valid for sensitive personal issues, it will cause more harm than good if a certain percentage of the population does not get vaccines causing the immunization rate to fall below the herd immunity threshold. This threshold varies in every disease. The development of vaccines is considered one of the greatest strides made in medicine due to the enormous benefits to an entire population. From an ethics perspective, achieving herd immunity and minimizing the amount of "freeloaders" is in the best interest of society as a whole [ 48- 49].

Further, studies liken the decision to object to vaccinations to military service drafts. For the conscientious objectors, military duty and receiving a vaccine hold the same costs: liberty, personal risk, and utility in terms of time [ 41]. Naturally, the costs of military duty are more taxing and demand more from an individual than receiving a vaccine. In terms of herd immunity and depending on the severity of impending diseases, these costs are ones that they should incur for the benefit of themselves as well as society.

At the forefront of the legal complications lies the state-regulated vaccinations for all children attending school. Anti-vaccination proponents argue that this is an infringement upon autonomy; however, public health policymakers justify their actions using rule utilitarianism. Rule utilitarianism is the ideology that a rule for society should be established that has the best outcome for the greatest amount of people in the society. In addition to this, John Stuart Mill's essay, "On Liberty", explains the Harm Principle that is often used to justify mandated infectious disease control methods, including vaccines [ 50]. The Harm Principle justifies interfering with autonomy and individual liberties, against their will, if it is done so as to prevent harm to others. An example of this was seen in California in 2014-2015 after an outbreak of measles led to the passing of Senate Bill 277 calling for state-mandated vaccinations for everyone - no personal exemptions. The root of the problem, however, was most likely to be contributed to Wakefield's fraudulent findings striking the fear of a vaccination-autism link in parents, which led to an all-time low rate of people receiving the MMR vaccine. The hoax has been called the most damaging medical hoax in 100 years after bringing about outbreaks of diseases otherwise eradicated [ 8- 9, 11].

In the times that we have achieved herd immunity, there remain two questions then. Can legal exemptions still be justified? And should these exemptions be limited to religious reasons or should they include secular reasoning as well [ 21, 25]? Most scientists and medical experts suggest that exemptions should only even be considered if society is well within the limits for herd immunity. As for the religious versus secular debate, it is difficult to ignore secular objections as most of them are rooted in spiritual or holistic personal views [ 6, 47]. Since herd immunity is cumulative, the ability to waive immunizations is concluded to be difficult but not impossible. If the waivers are given to a small number of individuals who sincerely need them rather than ones who are inconvenienced by them, waivers may be ethically and legally sound.

Conclusions

The rise of anti-vaccination movements in parts of the Western world poses a dire threat to people's health and the collective herd immunity. People of all ages have fallen victim to recent outbreaks of measles, one of the most notable "eliminated" diseases that made a comeback as a direct consequence of not reaching the immunization threshold for MMR vaccines. These outbreaks not only put a strain on national healthcare systems but also cause fatal casualties. Therefore, it is of the utmost importance that all stakeholders in the medical world - physicians, researchers, educators, and governments - unite to curb the influence of the anti-vaccination movement targeting parents. Research has shown that even parents favorable to vaccination can be confused by the ongoing debate, leading them to question their choices. Many parents lack basic knowledge of how vaccines work, as well as access to accurate information explaining the importance of the process. Furthermore, those with the greatest need for knowledge about vaccination seem most vulnerable to this information. Further, we must effectively combat the wrongful demonization of vaccinations through social media and news media platforms. A qualitative study that explored how parents respond to competing media messages about vaccine safety concluded that personal experiences, value systems, and level of trust in health professionals are essential to parental decision making about immunization. Therefore, to combat the anti-vaccination movement, there must be a strong emphasis on helping parents develop trust in health professionals and relevant authorities, educating them on the facts and figures, debunking the myths peddled by the anti-vaccination movements, and even introducing legislation that promotes vaccination, if not mandating it.

Acknowledgments

We would like to thank Dr. Alice Anne Brunn, Ph.D., Associate Professor of Psychiatry and Ethics, and Chairman of Behavioral Sciences and Ethics Department, as well as Dr. Xenia Sotiriou, Ph.D., Assistant Professor of Behavior Science and Ethics at St. Matthew's University School of Medicine.

Notes

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

Footnotes

The authors have declared that no competing interests exist.

References

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7. Strauss M. Available from; [Jun;2018 ]. 2014. 19th-Century Documents Show How Little The Anti-Vaxxers Have Changed. [ Google Scholar]

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12. Gangarosa EJ, Galazka AM, Wolfe CR, et al. Lancet. Vol. 351. London, England: Lancet; 1998. Impact of anti-vaccine movements on pertussis control: the untold story; pp. 356-361. [[ PubMed] Google Scholar]

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Articles from Cureus are provided here courtesy of Cureus Inc.

# data[].attributes.attachment_link.title
The Anti-vaccination Movement: A Regression in Modern Medicine

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There have been recent trends of parents in Western countries refusing to vaccinate their children due to numerous reasons and perceived fears. While opposition to vaccines is as old as the vaccines themselves, there has been a recent surge in the opposition ...

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Elizabeth Earl from The Atlantic writes, "Today's anti-vaccination movement is not the first. Riots, pamphlets, and an outcry in 19th-century England set the stage for contemporary misinformation campaigns."

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Today's anti-vaccination movement is not the first. Riots, pamphlets, and an outcry in 19th-century England set the stage for contemporary misinformation campaigns.

The dewy chill over Leicester, England, in March 1885 did not deter thousands of protesters from gathering outside nearby York Castle to protest the imprisonment of seven activists. Organizers claimed as many as 100,000 people attended, although historians estimate it was closer to 20,000.

The cause they rallied against? Vaccination.

This movement has faded from popular memory, obscured by the controversy of more recent anti-vaccination efforts, which gained momentum in the 1990s. However, the effects of the Victorian anti-vaccination movement still echo in the debate over the personal belief exemption, which was banned in California in June.

On the day the Leicester protesters gathered, vaccination was mandatory in England. Nearly a century before, Edward Jenner, a Scottish physician, had invented a method of protecting people against the raging threat of smallpox. The treatment was called variolation, and it involved voluntary infection with a similar disease. Patients were given cowpox to protect them against the much deadlier smallpox, much the way parents long exposed their children to chicken pox to protect them from getting sicker from the illness later in life. (Today pediatricians recommend the chicken pox vaccine instead.)

After germ theory was expanded upon and researchers developed vaccines, the British government outlawed variolation, which still carried some risk of killing the person it was meant to protect, in the Vaccination Act of 1840. Safer vaccines, which contain a weakened form of a particular disease, replaced variolation, which was a controlled exposure to a disease by injecting a healthy person with some of the infected pus or fluid of an ill person. To encourage widespread vaccination, the law made it compulsory for infants during their first three months of life and then extended the age to children up to 14 years old in 1867, imposing fines on those who did not comply. At first, many local authorities did not enforce the fines, but by 1871, the law was changed to punish officials if they did not enforce the requirement. The working class was outraged at the imposition of fines. Activists raised an outcry, claiming the government was infringing on citizens' private affairs and decisions.
Many of the concerns of the 19th century, such as the role of government in personal choices, have reemerged.
Over the course of a decade, multiple prominent scientists threw their support behind the anti-vaccination movement as well.

"Every day the vaccination laws remain in force parents are being punished, infants are being killed," wrote Alfred Russel Wallace, a prominent scientist and natural selection theorist, in a vitriolic monograph against mandatory vaccination in 1898. He accused doctors and politicians of pushing for vaccination based on personal interest without being sure that the vaccinations were safe. Wallace cited statistics from a report by the Registrar-General of deaths from vaccination from 1881 to 1895, showing that an average of 52 individuals a year died from cowpox or other complications after vaccination. Wallace pointed to the deaths to assert that vaccination was useless and caused unnecessary deaths.

Pro-vaccinationists cited other statistics from London, where the number of deaths from smallpox fell significantly between the 18th and 19th centuries, after the discovery of vaccination. The National Vaccine Establishment figures claiming that nearly 4,000 people died in the city each year from smallpox before the discovery of vaccination, which Wallace and other anti-vaxers claimed was a grossly inflated figure. The Statistical Society of London noted in its journal in 1852 that "smallpox has greatly prevailed," saying that vaccination was insufficient but that the registrars of the various counties were optimistic that it could work in the future. British government chose not to answer, staying silent behind the law as protests mounted.

Epidemic disease was a fact of life at the time. Smallpox claimed more than 400,000 lives per year throughout the 19th century, according to the World Health Organization. Nadja Durbach, a professor of history at the University of Utah and the author of Bodily Matters: The Anti-Vaccination Movement in England, 1853-1907, says a major difference between the 19th century movement and today's is that anti-vaxers in the past were more aware of the consequences of their choice: Disease was still rampant. Despite the existence of vaccines, thousands still died of infectious disease every year. Today, in most developed countries, large-scale epidemics are confined to the annals of history or to flash-in-the-pan flare-ups such as MERS in South Korea.

By the time of the Leicester protest, public opinion was souring toward vaccination. The injections were not completely without risk, with a percentage of those who received the vaccination becoming ill, and riots broke out in towns such as Ipswich, Henley, and Mitford, according to a 2002 paper in the British Medical Journal. The Anti-Compulsory Vaccination League launched in London in 1867 amid the publication of multiple journals that produced anti-vaccination propaganda. Another chapter cropped up later in the century in New York City to spread the "warning" about vaccines to the United States.

Under this pressure, the British government introduced a key concept in 1898: A "conscientious objector" exemption. The clause allowed parents to opt out of compulsory vaccination as long as they acknowledged they understood the choice. Similar to today's religious exemptions in 47 U.S. states and the personal belief exemptions in 18 states, according to the National Conference of State Legislatures, the parents signed paperwork certifying that they knew and accepted the risks associated with not vaccinating.

Modern vaccination activists come from a different world than those in the 19th century. While anti-vaxers today are largely upper middle class, the crowd opposing vaccination in the 19th century was largely composed of lower- and working-class British citizens, according to Durbach.

"They felt that they were the particular targets, as a class group, for vaccination and for prosecution under the compulsory laws," she says. "This was part of a larger expression of their sense of themselves as second-class citizens who thus lacked control over their bodies in the way that the middle and upper classes did not."
Unless the root issues are addressed, the anti-vaccination movement will continue to resurface with different faces.
By the close of the 19th century and the dawn of the 20th, the protests had come to a head. The anti-vaccination sentiment had spread to the U.S., garnering support in urban centers such as New York City and Boston.

The British government ceded its stringent line to the protests of the people. The law was amended yet again in 1907 to make the exemptions easier to obtain-because of an extensive approval process, many parents could not obtain the necessary paperwork to claim the exemption before the child was more than four months old, past the deadline.

The U.S. government, however, took a harder tack. In the 1905 Supreme Court ruling in the case of Jacobson v. Massachusetts, the court upheld the state government's right to mandate vaccination. The Massachusetts Anti-Compulsory Vaccination Society lobbied hard for the court to rule in favor of the plaintiff, but all they won from the decision was the provision that individuals cannot be forcibly vaccinated.

The protests quieted after these two decisions, but small pockets of unease have now bubbled up again. Durbach said that unless the root issues are addressed-the boundaries of personal freedom versus social obligations-the movement will continue to resurface with different faces.

"The argument about personal freedom is important," Durbach says, "but we willingly surrender these freedoms when we believe it is for the public good and our own safety."

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Today's anti-vaccination movement is not the first. Riots, pamphlets, and an outcry in 19th-century England set the stage for contemporary misinformation campaigns. The dewy chill over Leicester, England, in March 1885 did not deter thousands of protesters from gathering outside nearby York Castle to protest the imprisonment of seven activists.

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The Somali-American community in Minnesota saw an outbreak of measles last year. VICE News interviewed members of the community who refused to vaccinate their children. The video explains how exploiting fears and spreading misconceptions can contribute to more people believing anecdotes rather than science. They even interview a "vaccine skeptic" who has helped fuel fire to the debate.

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Anti-Vaxxers And Fear Caused Minnesota's Measles Outbreak (HBO)

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"What happens when your personal liberty infringes on public safety?

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"What happens when your personal liberty infringes on public safety?

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Here is a great video explaining how states like Texas have seen more children receiving "exemptions" for vaccines. As more anti-vaccination groups use propaganda techniques such as fear-mongering or testimonials, more parents are choosing to not vaccinate their children.

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Anti-Vaxxers In Texas Would Rather Have Liberty Than Safety (HBO)

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"Anti-vaccine groups use standard propaganda methods to manipulate folks into thinking that vaccines are dangerous and don’t work and that your child would be better off getting sick with a vaccine-preventable disease, like polio or measles."

According to Vaxopedia, a website devoted to providing factual information about vaccines, they state the following:

One or more of these three basic themes is repeated over and over again in most anti-vaccine arguments, posts, or stories:

1. Make you think vaccines are dangerous by overstating the side effects and risks of getting vaccinated. And never mentioning any of the many benefits of vaccines.

2. Make you think it’s no big deal to get measles or polio, by underestimating the risks of vaccine-preventable diseases and overstating the benefits of natural immunity over the protection you can get from vaccines. And never ever mention that the reason you aren’t likely to get polio is because most people are vaccinated (hiding in the herd strategy).

3. Make you think that vaccines don’t even work. They even push the false idea that there are still big outbreaks of measles in China, that the smallpox vaccine didn’t eradicate smallpox, that herd immunity isn’t real, that DDT caused polio, and that vaccine-preventable diseases have never been controlled or eradicated – we just changed the names to something else. After seeing the smallpox photo above, do you really think that anyone would fail to recognize a kid with smallpox?

Source: https://vaxopedia.org/2017/10/20/the-3-components-of-anti-vaccine-propaganda/

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John Oliver gives a very funny perspective on the overview of vaccines, the hesitation towards them, and the fight to curb propaganda. He also mentions how a former doctor, Andrew Wakefield  (mentioned above), spread disinformation lost his medical license due to distorting data.

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Vaccines: Last Week Tonight with John Oliver (HBO)