Early last week, news broke that the initial findings of Pfizer’s coronavirus vaccine showed a 90% efficacy rate against COVID-191. Although this brings new hope that life may soon resemble the normalcy, we all so crave, the scientific community is treading lightly as the full data is not available and even then, such data will require rigorous cross-examination.
However, after the logistical and manufacturing hurdles with creating millions of doses, the general public need to be willing to accept the vaccine. This has the potential to be somewhat a difficult task given the revival of various anti-vaccination movements. Global studies which aimed to map vaccine confidence are unearthing hotspots of hesitancy, presenting that confidence is remaining low, but improving across Europe, compared to that of other continents2. This poses an additional social and community challenge to improve confidence in vaccines, especially a COVID-19 one.
Confidence and the usage of a vaccine is shown to be intimately linked, as study by the Vaccine Confidence Project, at the London School of Hygiene and Tropical Medicine, found that individuals being confident in the importance and efficacy of a vaccine has the “strongest associations with vaccine uptake” when compared with other factors2.
Coming to terms with the existence of a community which aims to dismantle trust between scientists and society is difficult, but it is important to note that anti-vaccination groups have persisted and existed throughout history. Looking at the motivations, core values and drivers of those who sow distrust in a well-studied avenue of science might be the key to improving confidence and finally, the uptake of any vaccine.
A century old practice…
The idea to use vaccines to manage infectious diseases has been around for at least a century and has been documented, as early as 1714, in parts of the Ottoman Empire, Europe and China3. Long before the 18th century, it is thought that these practises were carried out in parts of Africa and India when people were faced with an outbreak of various infectious diseases which include small pox4.
In the eighteenth century, smallpox (Figure 15) accounted for about 10% of all deaths and was especially aggressive within adolescents. Not only was the virus in question, easily spread and contagious, those who survived were left with physical disfigurements and could even go blind6. Since 1664 there were more than 320,000 recorded deaths from smallpox within London presenting the a need for a suitable treatment or preventative measure7.
Edward Jenner, a physician at the time, noticed that individuals which were exposed to infectious material from cowpox also presented immunity to smallpox. After a series of experiments presented that individuals could be protected from smallpox in this way, he showed his findings to the medical establishment who consequently accepted them. Jenner was the first individual to coin the term “vaccination” and to popularise it as a way to prevent disease outbreaks within the Western Hemisphere8.
The Vaccination and the Contagious Disease Acts of 1840-1867 in the UK which followed provided free vaccination of smallpox and later, made the vaccine compulsory to infants and teenagers. Penalties were issued to guardians and parents that did not abide. These laws were met with great resistance as they extended government powers into personal liberties due to the mounting public health crisis caused by small-pox9.
Mirroring: Past and Present Resistance
Resistance of vaccination was widespread in the UK shortly after the introduction of compulsory vaccination. A large number of anti-vaccination books, journals and images of what people perceived vaccination to be (Figure 210) came into circulation8. Interestingly such pictures, which can be perceived as propaganda to encourage anti-vaccination movements, present doctors and even Edward Jenner himself, as feeding this hideous cow-like beast, representing vaccination, young children. However it is important to note that such resistance was not isolated to the UK, but was rampant within other parts of Europe and even the USA at the time8,11.
Similarly, opposition to vaccination can be seen even within this century even whilst grappling with a pandemic that a vaccine hopes to provide an exit. Interestingly, a study published in BMJ, presented that the arguments from both present day and 19th century anti-vaccination groups show “uncanny similarities” presenting the “core-beliefs” and attitudes associated with vaccination have not changed8. These attitudes include but are not limited to, that vaccines cause illness, are ineffective and only provide temporary immunity towards disease.
Interestingly, the language aiming to discourage others to use vaccines have changed significantly. In an article published by Nature, the director of the Vaccine Confidence Project, Heidi Larson, commented that modern anti-vaccination movements are gaining following through the use of “personalised, emotive” language which aims to “appeal to the heart” instead of mainly using fear-based tactics as shown through history12.
In the end, the Vaccination Act of 1898 removed the penalties when guardians did not vaccinate their children against smallpox. Additionally, it included a clause which allowed parents, who believed vaccines were not effective or safe, to obtain an exception certificate.
However, such exception comes at a societal cost
Freedom to refuse, at what cost?
Many of the arguments which anti-vaccination groups of the past and present have used to refuse mandated vaccines was to demand the freedom to choose whether they wanted to be inoculated or not.
This presents an unique ethical dilemma where bodily autonomy and wide societal benefits are at odds with one another.
Autonomy of body is an essential liberty which must be respected on every level. However, to achieve herd immunity through the means of vaccination large amounts of the population need to take up said vaccine. For example, for a population to acquire herd immunity through the use of a COVD-19 vaccine more than 60% of a population needs to be inncolutated13. Surpassing the manufacturing and logistics problems of creating millions of doses, the population need to be confident and willing to use this vaccine.
Ultimately, vaccine usage is not only in the interest of personal health, but to that of the community too
Social media and anti-vaxxers: Toxic relations
The tactics of anti-vaccine literature have since evolved in the 20th century due to technological advancement. Such literature has the potential to be distributed in a wide variety of formats over various social media platforms. However, it is important to note that today, such media being circulated can be just as, if not, more damaging as it can reach communities who are undecided on the importance of vaccination.
A paper published in Nature found that although anti-vaccine groups on social media were smaller in size, compared to that of pro-vaccine groups they have the tendency to become “highly entangled” with users who were “undecided about vaccination”14. Worryingly, such groups are entangling themselves with school associations which may still deciding their stance on policy, presenting the influence and power that anti-vaccination groups have on the health of a community.
Therefore, overlooking the importance that the social media presence anti-vaccination communities use will be fatal if we are to dispel the myths and disinformation these groups make15. This presents that social media companies have just as much of a responsibility as the scientific community.
As of October 2020, Facebook has since banned adverts that discourage people from getting the seasonal flu vaccine. However, it has still allowed an anti-vaccine ‘discussion’ to be found, especially within Facebook group pages16. It is unclear how this policy will impact anti-vaccination groups and thinking.
Anti-vaccination groups may be smaller in size currently however, extrapolation and modelling studies have suggested that the current rate at which these groups are becoming popularised may cause the size of anti-vaccination groups to exceed pro-vaccine groups within ten years.14
Such findings present there is immeasurable work to done against the rising tide of anti-vaccination groups. Scientists, pharmaceutical companies and finally policy makers have a duty to the wider community to restore the trust eroded by these groups by being transparent with how vaccines are made and what kind of regulatory procedures need to be passed in order for a vaccine to come to market.
Finally, there is hope by better understanding the motivations of past anti-vaccination movements that researchers and communities alike can open a healthy, insightful dialogue on the many benefits of vaccination.
1. Thomas, K., Gelles, D. & Zimmer, C. Pfizer’s Early Data Shows Vaccine Is More Than 90% Effective. The New York Times (2020).
2. Figueiredo, A. de, Simas, C., Karafillakis, E., Paterson, P. & Larson, H. J. Mapping global trends in vaccine confidence and investigating barriers to vaccine uptake: a large-scale retrospective temporal modelling study. The Lancet 396, 898–908 (2020).
3. Boylston, A. The origins of inoculation. J. R. Soc. Med. 105, 309–313 (2012).
4. Riedel, S. Edward Jenner and the history of smallpox and vaccination. Proc. Bayl. Univ. Med. Cent. 18, 21–25 (2005).
5. Kupferschmidt, K. How Canadian researchers reconstituted an extinct poxvirus for $100,000 using mail-order DNA. Science (2017) doi:10.1126/science.aan7069.
6. Smith, K. A. Edward Jenner and the Small Pox Vaccine. Front. Immunol. 2, (2011).
7. Krylova, O. & Earn, D. J. D. Patterns of smallpox mortality in London, England, over three centuries. bioRxiv 771220 (2019) doi:10.1101/771220.
8. Wolfe, R. M. & Sharp, L. K. Anti-vaccinationists past and present. BMJ 325, 430–432 (2002).
9. Porter, D. & Porter, R. The politics of prevention: anti-vaccinationism and public health in nineteenth-century England. Med. Hist. 32, 231–252 (1988).
10. Unknown. Vaccination | British Museum.
11. Siddiqui, M., Salmon, D. A. & Omer, S. B. Epidemiology of vaccine hesitancy in the United States. Hum. Vaccines Immunother. 9, 2643–2648 (2013).
12. Ball, P. Anti-vaccine movement could undermine efforts to end coronavirus pandemic, researchers warn. Nature 581, 251–251 (2020).
13. Anderson, R. M., Hollingsworth, T. D., Baggaley, R. F., Maddren, R. & Vegvari, C. COVID-19 spread in the UK: the end of the beginning? The Lancet 396, 587–590 (2020).
14. Johnson, N. F. et al. The online competition between pro- and anti-vaccination views. Nature 582, 230–233 (2020).
15. Evrony, A. & Caplan, A. The overlooked dangers of anti-vaccination groups’ social media presence. Hum. Vaccines Immunother. 13, 1475–1476 (2017).
16. Paul, K. & agencies. Facebook to ban ads discouraging vaccination. The Guardian (2020).
17. Riedel, S. Edward Jenner and the history of smallpox and vaccination. Proc. Bayl. Univ. Med. Cent. 18, 21–25 (2005).