In addition, our society is poorly educated on risk and probability thinking such that we fail to
grasp the undeniable notion that harm cannot be completely prevented and some risks remain
irreducible or uncertain, and yet to do nothing offers greater harm to the public good. As an
example, during the 1980's in the US, lawsuits over alleged serious and fatal side effects of the
whole cell pertussis vaccine caused manufacturers to substantially increase the cost of pertussis
vaccine in response to increased financial liability. Due to this situation, several manufacturers
simply stopped producing pertussis vaccine, resulting in a crisis that culminated in the federal
government developing a vaccine injury compensation program to protect manufacturers and
prevent the loss of the nations’ ability to manufacture and distribute pertussis vaccine [6-8].
Another trend of concern is the failure of public health officials to educate both the public and
providers on the benefits of vaccines, and the failure of health systems to develop safety
monitoring systems to answer patient concerns with convincing data. In addition, in an era of
increasing numbers of vaccines, we may, on occasion, fail to intelligently deploy vaccines - using a
‘one size fits all’ approach - mostly due to an inability to deliver vaccine to the highest risk groups
(often for political or other reasons). Finally, our own observation has been a surprising number
of health care workers at all levels, who themselves do not understand vaccine safety and efficacy,
and are not champions of vaccines.
The genesis of many of the concerns commonly expressed by anti-vaccine groups include the
idea that immunobiologics are ‘foreign’ material injected into the body of otherwise healthy
persons, in order to lower the probability of future harm. In parallel with this concern is that an
increasing number of antigens and injections, by virtue solely of the number of vaccines, are
though to somehow carry additional risks not true of the individual vaccines by themselves, such
as vague concern over an increased risk of cancer or of auto-immune illnesses. The Center for
Disease Control and Prevention has developed a booklet examining the most common objections
that anti-vaccine advocates express regarding vaccines [9]. These include the idea that the disease
had already begun to disappear prior to the use of vaccines; concerns that the majority of people
who get a vaccine-preventable disease were previously immunized, that there are ‘hot’ lots of
vaccines particularly associated with a greater frequency and/or severity of adverse events and
deaths than other lots; that vaccines cause illnesses and deaths; that vaccine-preventable disease
have been eliminated already; that multiple vaccines ‘overload’ the immune system; that vaccines
are not ‘natural’ with a preference for disease-induced immunity, and finally any variety of
political/economic conspiracy theories regarding manufacturer profits, minority issues, and even
genocide issues.
The concerns expressed above are widely, in one form or another, promulgated on anti-
vaccine internet web sites. Anti-vaccine groups have taken advantage not only of the internet to
increase their presence in the debate, but also exaggerate, publicize and dramaticize cases of
vaccine reactions to the media and the public. At the current time we were able to identify well
over 300 anti-vaccine internet sites from a single simple search. An inadequate scientific
knowledge base within the media, and an irresponsible tendency toward the sensational
contributes and plays into public fears and concerns as the media and the anti-vaccine groups
engage one another without regard to scientific knowledge, facts, or credentials, leading to the
coining of the term ‘scientific terrorism’. In addition, anti-vaccine groups have been successful in
finding outspoken and articulate spokespersons for their cause. Members of the public, in turn,
develop concern about vaccines and vaccine programs when an authority (i.e. the government)
mandates them, and where the loss of philosophical or religious exemptions is threatened. Finally,
in the face of such concerns, the decreased advocacy by some health care workers for vaccines
contributes to an increase in societal concerns relative to vaccine risks and benefits and vaccine
coverage rates.
An example of the effects described above is illustrated by a recent nationally representative
telephone survey of 1600 US parents of children <6 years old [10]. The results of those
interviews revealed that 25% of parents believed that a child’s immune system was ‘weakened’ by
too many vaccines. Twenty-three percent believed that children got more immunizations than
was good for their health, and 15% did not want the next child to get at least one of the currently
recommended vaccines. Further evidence of this phenomenon is that the number of reports to the
Vaccine Adverse Even Reporting System (VAERS) is now about 11,000 per year, exceeding the
reported incidence of most childhood vaccine-preventable diseases combined [11]. Of course, as
individual concerns arise, the number of reports rises, without regard to differentiating adverse
events caused by a vaccine, versus those associated coincidentally with the timing of vaccine
administration.
As another example, for some years questions about the possible association between vaccines
and auto-immune disorders have been raised - in the absence of data suggesting merit in this
hypothesis [13]. Since 1994, vocal anti-vaccine groups in France began advocating a countrywide
shut-down of hepatitis B immunization programs among pre-adolescents, due to concerns that the
vaccine was causing demyelination syndromes, particularly multiple sclerosis among this age
group. As a result of increasing pressure from these groups, and their effective engagement of the
public and the courts in these concerns, the government of France suspended all hepatitis B
immunization programs among adolescents on October 1, 1998. This occurred despite expert
advice from the WHO and others, as well as studies demonstrating that no evidence existed
suggesting such an association in studies conducted in France, the UK, and in the US [14]. When
science began to prevail over anecdote, and it became clear that such concerns were unfounded
[15-17] the program was again reinstated by the government. Nonetheless, acceptance of the
hepatitis B vaccine in France had predictably fallen, despite evidence contrary to the hypothesis
that there is a causal association between hepatitis B immunization and multiple sclerosis.
Finally, concerns over possible associations between measles vaccine and both autism and
inflammatory bowel disease have arisen in UK, again in the absence of plausible evidence
suggesting causation [18]. Unfortunately, measles vaccine uptake will predictably suffer with
untold harm to many children.
Also, as we have discussed elsewhere [20], the perception of risk or probability of harm in this
‘pyramid model’ among the population arises from a ‘dilution of benefit’. As the widespread use
of a vaccine diminishes or eliminates the risk of a disease, the public’s perception of the vaccines’
value paradoxically diminishes - because the public no longer observes the disease or its
aftermath, and hence perceives little or no benefit. The very success of the vaccine causes its
benefit to be diluted or less valued once the disease is no longer considered a high-level threat or
risk. Paradoxically, the more effective a vaccine is the more powerful the dilution of benefit
effects appears to be. Chen has propped a model that attempts to define these stages of an
immunization program starting with the introduction of a new vaccines, where such programs go
from the pre-vaccine stage to the stage of increasing vaccine coverage, loss of confidence in the
vaccine (due to real or perceived side effects), resumption of vaccine confidence, eradication of
disease, and finally cessation of vaccine use [12].
Other factors also may promote an anti-vaccine ethos in the culture. Mandatory federal
programs with punitive consequences for failure to comply, as opposed to ‘promotive’
immunization programs, may increase vaccine non-acceptance [22]. Evidence for this is simply
the large number of ‘anti-vaccine’ groups who frequently cite this issue. Additionally, federal
attempts to institute childhood immunization registries in each county and each state add to
concerns about the role of government in individual health matters, particularly the right of the
government to ‘coerce individuals to have themselves of their children vaccinated [22]’.
Streefland et al. comment that ‘the imminent expansion of vaccination schedules with more
vaccines and vaccine combinations,...will stress parents’ perception that, in vaccination practice,
‘experts’ are making fundamental decisions about their children’s health, without consultation or
providing the option to exempt [22]’.
On an individual level, it is also instructive to examine how individuals made decisions
regarding vaccines. Such decisions are often made on the basis of common ‘rules of thumb’, or
heuristics. The availability heuristic occurs when we assume that the ease with which we can
recall something (such as dramatic media reports of a dreadful side effect to a theoretical vaccine)
represents the probability with which such side effects really do, in fact, take place, or the
representativeness heuristic (judging probabilities according to similarity of circumstances) [23].
For this reason, the public may be easily misled, lose confidence, and make faulty decisions, about
a vaccine where there are unbalanced reports of vaccine adverse events.
Another theory, the extended parallel process model, states that people are unlikely to
undertake a risk control measure unless they feel that they can effectively control the risk and that
it is personally relevant and serious. Finally, other factors found to be involved in the individual
decision as to whether to receive a vaccine includes such issues as omission bias [24] ( a bad
outcome is worse if it occurred due to an active choice to do something rather than as a
consequence of not doing something,...), free-loading (as long as everyone else gets the vaccine,
there’s no reason for me to get it,...), altruism (I should get vaccines to protect others too,...),
bandwagoning (I get vaccines because it seems like everyone else does,...), risk perception (I get
vaccines because the risk of not getting them is so much worse,...), and adverse event avoidance
(I don’t get vaccines because there might be a side effect,...) [25]. Interestingly enough, social
research suggests that the highest rates of vaccine coverage are achieved in a milieu of
bandwagoning, where everyone else if apparently getting the vaccine and it seems to be the
expectation that everyone does this good and right thing for themselves and their children. Others
have named this phenomenon ‘passive acceptance’ and attribute high vaccine coverage rates to
this situation where ‘people have their children vaccinated because everybody does so and it
seems the normal thing to do’ [22].
Since we have much to gain, individually and as a society, by protecting ourselves against
infectious diseases, we must be prepared to engage in the hard work of engaging the public and
demonstrating the safety and benefits of vaccines. We must also do this in a manner that protects
individual rights of autonomy and freedom of choice, including what we might see as the
misguided choice of not receiving vaccines. Efforts at developing promotive, rather than
prescriptive immunization programs are likely to achieve better long-term results in a free society
where trust in government and public health recommendations must be maintained. For this
reason, as we have promoted, our own view is that the role of the government is to inform,
educate, recommend, and even provide incentives for immunization - and not to mandate without
exclusion acceptance among the civilian population [20]. Informed refusal must remain an
acceptable choice in a free democracy, and the culture of informed consent, with both religious
and philosophical exemption must be maintained. We recognize the difficult balancing act in
determining the right of the state to control an infectious disease, and the right of the individual to
choose. This might be negotiated by considering (with informed refusal) universal immunization
against those disease that pose unacceptable risks to others in the community.
Finally, much more in the way of research must be funded and carried out in understanding
vaccine safety, and in particular social research designed to understand how individuals make
vaccine decisions [22, 25]. As we move into the 21st century, new technologies such as the
Human Genome Project and gene expression array systems, may offer the ability to easily
individually screen individuals for gene-mediated risks of adverse reactions to vaccines, and
predict who might suffer harm from a vaccine. Until then, health care providers must be informed
advocates for vaccines and offer the public and the media balanced scientific facts, credibility, and
an understandable assessment of the risks and benefits of their immunization choices.
[2] Black, FL, Pinheiro FD, Hierholzer WJ, Lee RV. Epidemiology of infectious disease: the
example of measles. In: Health and Disease in Tribal Societies. Amsterdam: Elsevier, 1997:115-
35.
[3] Centers for Disease Control (CDC). Achievements in public health, 1900-1999 impact of
vaccines universally recommended for children - United States, 1990-1999. MMWR
1999;48:243-8.
[4] Breen LA. Cotton Mather, the ‘angelical ministry’, and inoculation. J Hist Med Allied Sci
1991;46:333-57.
[5] Barquest N, Domingo P. Smallpox: the triumph over the most terrible of the ministers of
death. Ann Intern Med 1997;127:635-42.
[6] Brink EW, Hinman AR. The vaccine injury compensation act: the new law and you.
Contemp Pediatr 1989;6:82-42.
[7] Puryear-Lloyd MA, Ball LK, Benor D. Should the vaccine injury compensation program be
expanded to cover adults. Public Health Rep 1998;113:236-42.
[8] Eickhoff TC. An Idea Whose Time Has Come. Public Health Rep 1998;113:243-54.
[9] Six common misconceptions about vaccinations,....and to respond to them. Minn Dept Health
Dis Cont Newsltr 1996;13-5.
[10] Gellin BG, Maiback EW, and Marcuse IK. Do parents understand immunizations.
Pediatrics 2000;106:1097-1102.
[11] Chen RT. Vaccine risks: real, perceived and unknown. Vaccine 1999;17:S41-6.
[12] Gangarosa EJ, Galazka AM, Wolfe CR, et al. Impact of anti-vaccine movements on
pertussis control: the untold story. Lancet 1998;351:356-61.
[13] Shoenfeld Y, Aron-Maor A. Vaccination and autoimmunity - ‘vaccinosis’ a dangerous
liaison? J Autoimmun 2000;14:1-10.
[14] Hall A, Ikane M, Roure C, Meheus A. Multiple sclerosis and hepatitis B vaccine? Vaccine
1999;17:2473-5.
[15] Tosti ME, Traversa G, Bianco E, Mele A. Multiple sclerosis and vaccination against
hepatitis B: analysis of risk benefit profile. Ital J Gastroenterol Hepatol 1999;31:388-91.
[16] Halsey NA, Duclos P, Van Damme P, Margolis H. Viral Hepatitis Prevention Board.
Hepatitis B vaccine and central nervous system demyelinating disease. Pediatr Infect Dis J
1999;18:23-24.
[17] Monteyne P, Andre FE. Is there a causal link between hepatitis B vaccination and multiple
sclerosis? Vaccine 2000;18:1994-2001.
[18] Chen RT, DeStefano F. Vaccine adverse events: causal or coincidental. Lancet
1998;351:611-2.
[19] Fine PEM, Clarkson, JA. Individual versus public priorities in the determination of optimal
vaccination policies. Am J Epidemiol 1986;124:1012-20.
[20] Poland GA, Jacobson RM. Vaccine safety: injecting a dose of common sense. Mayo Clin
Proc 2000;75:135-9.
[21] Chen RT. Safety of vaccines. In: Plotkin SA, Orenstein WA, editors. Vaccines.
Philadelphia, PA: W.B. Saunders Company, 1999:1144-63.
[22] Streefland P, Chowdhury AMR, Ramos-Jimenez P. Patterns of vaccination acceptance. Soc
Sci Med 1999;49:1705-16.
[23] Tversky A, Kahneman D. The framing decisions and the psychology of choice. Science
1981;211:453-8.
[24] Asch DA, Baron J, Hershey JC, Kunreuther H, Meszaros J, Ritov I, Sprance M. Omission
bias and pertussis vaccination. Med Decis Making 1994;14:118-23.
[25] Bostrom A. Vaccine risk communication: Lessons from risk perception, decision making
and environmental risk communication research. Risk: Health Safety Environ 1997;8:173-200.
1. Introduction
Vaccines and the ability to prevent morbidity and mortality due to infectious disease have been
on of the greatest public health success stories [1]. On a global level, it is one of the few cost-
effective medical measures that result in population-level broad benefit across the age spectrum.
Despite this, there is evidence in Western Europe, the US, Japan, Australia, and other countries of
a growing anti-vaccine movement. This movement has resulted in major disruptions and even
cessation of vaccine programs, with resultant increased morbidity and mortality. Of interest is an
examination of the factors that seem to contribute to the current trend of anti-vaccine sentiment.
In this paper we will examine the current anti-vaccine movement and provide case studies
involving pertussis and hepatitis B vaccines. We will then discuss the implications for public
health vaccine policy. Finally, we will propose a framework for understanding how individuals
make decisions about receipt of vaccines. This will be discussed in order to stimulate discussion
and debate about how best to design public health policies aimed at improving immunization
coverage rates.
2. Background
Infectious diseases have plagued mankind since the beginning of time. In fact, infectious
diseases have been suggested as a major factor shaping the history of man [2]. It is therefore a
considerable scientific and public health triumph to realize that mortality due to vaccine-
preventable disease is at an all time low [3]. In addition, once deadly or debilitating diseases such
as smallpox, polio, and haemophilus influenzae type b have either been eradicated or significantly
reduced in most developed countries through the universal use of safe and effective vaccines. In
the case of smallpox as one example, this occurred despite tremendous opposition at the onset of
smallpox vaccination programs [4-5]. As infectious disease epidemics have waned and fear of
death or disability due to infection has lessened, increasing concerns over possible vaccine side
effects and safety have arisen. While history suggest that this sequence of events is predictable,
the skilled use of the media and the internet in today’s global communication network have
allowed immense influence of the ‘anti-vaccine’ groups, further fueling public and media concerns
over vaccine safety. In addition, this has led to concerns and objections over federal mandates to
receive vaccines as a condition for school and military entry. In measurable ways the anti-vaccine
movement has impacted state and national public health policy, and jeopardize individual and
societal health. The issue then, is that even as we eradicate disease, we are now faced with anti-
vaccine movement and wide-spread cultural concerns that may make eradication of disease
impossible. For this reason, vaccine providers and advocates will increasingly be faced with being
able to articulate the value of vaccines to anti-vaccine groups, persons with legitimate questions
and concerns, and other groups such as hospital boards, legislative bodies, schools, and others.
3. Current cultural context and concerns
Many would argue that we have become a culture characterized by intolerance of any risk
(particularly of co-mission as opposed to omission), such that when harm does occur someone is
to blame. We have also become an information society where information, accurate or inaccurate,
is widely available, utilized, and promulgated across the world via the internet. Influenced by
these trends, many of the anti-vaccine groups also demonstrate an anti-authority stance (with
implications for state or federal mandates for vaccines). This plays into widespread feelings on
the part of many American who now view their government with varying levels of mistrust (some
legitimate, some not) further fueling concerns over ‘governmental’ recommendations regarding
vaccine use, and governmental reassurances regarding vaccine safety.
4. Genesis of concerns
We must first acknowledge that vaccines can and do cause harm and may even theoretically
carry unknown risks. Vaccines are immunobiologics, and all immunobiologics have been
associated with adverse effects, from the frequent occurrence of brief and mild local inflammation
following tetanus toxoid injection to the rare occurrence of paralytic polio following vaccination
with the oral polio vaccine (OPV). Inescapable, however, is that it is impossible to fully know all
the possible risks of a given vaccine until it is widely used in the population.
5. Case study: pertussis and hepatitis B vaccines
During the 1970's, anti-vaccine groups increasingly voiced media-intense concerns about
perceived ill effects due to the whole cell pertussis vaccines, while the disease itself caused
millions of cases and hundreds of thousands of deaths, globally. The results of these concerns
was widespread cessation of pertussis vaccine use in Sweden, Japan, UK, the Russian Federation,
Italy, former West Germany, Ireland and Australia. A review of the association between the anti-
vaccine movement in each country and the resulting decease in pertussis immunization coverage
rates, led to documented increases in pertussis infection 10-100 times higher than in neighboring
countries without disruption of pertussis immunization [12]. Indeed, strong evidence, using
standard epidemiologic criteria for causality, revealed a casual relation between anti-vaccine
movements against pertussis vaccine and pertussis epidemics. These countries have now
reinstated pertussis immunization programs - but only after considerable and avoidable morbidity
and mortality. In comparison, countries such as USA, Hungary, former East Germany, and
Poland with sustained use of pertussis vaccines, did not experience pertussis epidemics.
6. Understanding societal and individual decision-making regarding immunization
As others have demonstrated, as the incidence of vaccine-preventable disease decreases due to
efficacious vaccines, vaccine adverse events become more noticeable and highly publicized [19].
As a result, loss of confidence in the vaccine may occur, with the result that outbreaks once again
occur. Fortunately, this usually leads to resumption in confidence of the vaccine [11].
So how then, does loss of confidence occur - at least at the population or societal level? We
have proposed that a ‘pyramid effect’ is operative in the way societal decisions are made about
vaccine safety and acceptance in society [20]. The base of the pyramid can be imagined to
resemble the benefit of a widespread public health policy such as the use of a vaccine to prevent a
common disease that causes harm. It is broad in its effects. The vaccine benefits the vast majority
of the public. The peak of the pyramid represents harm or risk. In all cases is has an effect on
very, very few individuals, however, its effects are perceived as severe, acute, and major in harm.
The majority benefits from the vaccine but never or rarely is aware of the benefit (i.e. the gradual
cessation of an epidemic). A few are actually harmed, or perceive harm, but perceive it intensely,
acutely, and substantially. For this reason the societal (and media) voices are unbalanced. The
vast majority who benefit from an immunization program are passive participants. The minority
who experience or perceive harm may become passionate and vociferous opponents. In many
cases, they may become the only individuals who voice their opinions, thus causing societal sense
that the vaccine leads to more harm than good.
7. Conclusion
In recent years, concerns about vaccine safety have hampered efforts at increasing
immunization rates among individuals and important subsets of the population. As we have
demonstrated within this paper, the controversy and alarm caused by anti-vaccine groups has a
demonstrable detrimental effect on population-level vaccine coverage rates. This, in turn,
increases the burden of human suffering, increases health care costs, consumes resources
otherwise useful for a productive economy, and finally, compounds the problem by putting other
individuals and groups at risk.
References
[1] Centers for Disease Control. Ten great public health achievements - United States 1900-
1999. MMWR 1999;1-2.