View source for Vaccine hesitancy

{{short description|Reluctance or refusal to be vaccinated or have one's children vaccinated}}
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{{Use mdy dates |date=January 2017}}
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[[File:Anti-vaccination protest near Leicester clock tower, October 2021.jpg|thumb|upright=1.5|An anti-vaccination activist with a misleading claim that children can be effectively protected from disease solely by [[natural immunity]]]]
{{Vaccination|expanded=issues}}
{{Alternative medicine sidebar|conspiracy}}
'''Vaccine hesitancy''' is a delay in acceptance, or refusal of [[vaccine]]s despite availability and supporting evidence. The term covers refusals to vaccinate, delaying vaccines, accepting vaccines but remaining uncertain about their use, or using certain vaccines but not others.<ref>{{cite journal | title = Vaccine hesitancy: a generation at risk | journal = The Lancet. Child & Adolescent Health | volume = 3 | issue = 5 | pages = 281 | date = May 2019 | pmid = 30981382 | doi = 10.1016/S2352-4642(19)30092-6 | s2cid = 115201206 | doi-access = free | vauthors = ((The Editors)) }}</ref><ref name="Smith2015">{{cite journal | vauthors = Smith MJ | title = Promoting Vaccine Confidence | journal = Infectious Disease Clinics of North America | volume = 29 | issue = 4 | pages = 759–769 | date = December 2015 | pmid = 26337737 | doi = 10.1016/j.idc.2015.07.004 | type = Review }}</ref><ref name="Larson2014">{{cite journal | vauthors = Larson HJ, Jarrett C, Eckersberger E, Smith DM, Paterson P | title = Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: a systematic review of published literature, 2007-2012 | journal = Vaccine | volume = 32 | issue = 19 | pages = 2150–2159 | date = April 2014 | pmid = 24598724 | doi = 10.1016/j.vaccine.2014.01.081 }}</ref><ref>{{cite journal | vauthors = Cataldi JR, O'Leary ST | title = Parental vaccine hesitancy: scope, causes, and potential responses | journal = Current Opinion in Infectious Diseases | volume = 34 | issue = 5 | pages = 519–526 | date = October 2021 | pmid = 34524202 | doi = 10.1097/QCO.0000000000000774 | s2cid = 237437018 }}</ref> Although [[adverse effect]]s associated with vaccines are occasionally observed,<ref name="COVID-19 mRNA vaccines">{{cite journal | vauthors = Yasmin F, Najeeb H, Naeem U, Moeed A, Atif AR, Asghar MS, Nimri N, Saleem M, Bandyopadhyay D, Krittanawong C, Fadelallah Eljack MM, Tahir MJ, Waqar F | title = Adverse events following COVID-19 mRNA vaccines: A systematic review of cardiovascular complication, thrombosis, and thrombocytopenia | journal = Immunity, Inflammation and Disease | volume = 11 | issue = 3 | pages = e807 | date = March 2023 | pmid = 36988252 | pmc = 10022421 | doi = 10.1002/iid3.807 | doi-access = free }}</ref> the [[scientific consensus]] that vaccines are generally safe and effective is overwhelming.<ref>{{cite journal | vauthors =  | title = Communicating science-based messages on vaccines | journal = Bulletin of the World Health Organization | volume = 95 | issue = 10 | pages = 670–671 | date = October 2017 | pmid = 29147039 | pmc = 5689193 | doi = 10.2471/BLT.17.021017 }}</ref><ref>{{cite news|title=Why do some people oppose vaccination?|work=Vox|url=https://www.vox.com/2018/8/21/17588104/vaccine-opposition-anti-vaxxer|access-date=2018-11-26}}</ref><ref>{{cite news| vauthors = Ceccarelli L |title=Defending science: How the art of rhetoric can help|language=en|work=The Conversation|url=http://theconversation.com/defending-science-how-the-art-of-rhetoric-can-help-68210|access-date=2018-11-26}}</ref><ref>{{cite web|last=U.S. Department of Health and Human Services|title=Vaccines.gov|url=https://www.vaccines.gov/basics/safety/index.html|access-date=2018-08-05|website=Vaccines.gov|language=en-us}}</ref> Vaccine hesitancy often results in disease [[outbreak]]s and deaths from [[vaccine-preventable diseases]].<ref>{{cite web|title=Frequently Asked Questions (FAQ)|url=http://www.childrenshospital.org/centers-and-services/division-of-infectious-diseases/faq-resurgence-of-measles|archive-url=https://web.archive.org/web/20131017113035/http://www.childrenshospital.org/centers-and-services/division-of-infectious-diseases/faq-resurgence-of-measles|archive-date=October 17, 2013|access-date=February 11, 2014|website=[[Boston Children's Hospital]]}}</ref><ref name="Phadke_2016">{{cite journal | vauthors = Phadke VK, Bednarczyk RA, Salmon DA, Omer SB | title = Association Between Vaccine Refusal and Vaccine-Preventable Diseases in the United States: A Review of Measles and Pertussis | journal = JAMA | volume = 315 | issue = 11 | pages = 1149–1158 | date = March 2016 | pmid = 26978210 | pmc = 5007135 | doi = 10.1001/jama.2016.1353 }}</ref><ref name="wolfesharp">{{cite journal |vauthors=Wolfe RM, Sharp LK |date=August 2002 |title=Anti-vaccinationists past and present |journal=BMJ |volume=325 |issue=7361 |pages=430–432 |doi=10.1136/bmj.325.7361.430 |pmc=1123944 |pmid=12193361}}</ref><ref name="AgeOld">{{cite journal | vauthors = Poland GA, Jacobson RM | title = The age-old struggle against the antivaccinationists | journal = The New England Journal of Medicine | volume = 364 | issue = 2 | pages = 97–99 | date = January 2011 | pmid = 21226573 | doi = 10.1056/NEJMp1010594 | s2cid = 39229852 }}</ref><ref>{{cite magazine| vauthors = Wallace A|date=2009-10-19|title=An epidemic of fear: how panicked parents skipping shots endangers us all|url=https://www.wired.com/magazine/2009/10/ff_waronscience/all/1|magazine=Wired|access-date=2009-10-21}}</ref><ref>{{cite journal | vauthors = Poland GA, Jacobson RM | title = Understanding those who do not understand: a brief review of the anti-vaccine movement | journal = Vaccine | volume = 19 | issue = 17–19 | pages = 2440–2445 | date = March 2001 | pmid = 11257375 | doi = 10.1016/S0264-410X(00)00469-2 | s2cid = 1978650 }}</ref> Therefore, the [[World Health Organization]] characterizes vaccine hesitancy as one of the top ten global health threats.<ref>{{cite web|title=Ten threats to global health in 2019|url=http://www.who.int/emergencies/ten-threats-to-global-health-in-2019|url-status=dead|archive-url=https://web.archive.org/web/20190627025209/http://www.who.int/emergencies/ten-threats-to-global-health-in-2019|archive-date=2019-06-27|access-date=2020-12-09|website=Who.int|language=en}}</ref><ref>{{cite news | vauthors = Georgiou A |date=2019-01-15|title=The anti-vax movement has been listed by WHO as one of its top 10 health threats for 2019|language=en|url=https://www.newsweek.com/world-health-organization-who-un-global-health-air-pollution-anti-vaxxers-1292493|access-date=2019-01-16}}</ref>

Vaccine hesitancy is complex and context-specific, varying across time, place and vaccines.<ref>{{cite web |date=1 October 2014|title=Report of the SAGE working group on vaccine hesitancy |url= https://www.who.int/immunization/sage/meetings/2014/october/1_Report_WORKING_GROUP_vaccine_hesitancy_final.pdf | archive-url = https://web.archive.org/web/20180722231735/https://www.who.int/immunization/sage/meetings/2014/october/1_Report_WORKING_GROUP_vaccine_hesitancy_final.pdf | archive-date = 22 July 2018 |website=WHO}}</ref> It can be influenced by factors such as lack of proper scientifically based knowledge and understanding about how vaccines are made or work, as well as psychological factors including [[fear of needles]]<ref name="Smith2015" /> and distrust of public authorities, 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).<ref name="Larson2014" /> It has existed since the invention of vaccination and pre-dates the coining of the terms "vaccine" and "vaccination" by nearly eighty years.<ref name="Gerber"/>

"'''Anti-vaccinationism'''" refers to total opposition to vaccination. Anti-vaccinationists have been known as "'''anti-vaxxers'''" or "'''anti-vax'''".<ref>{{cite web | vauthors = Hinsliff G |date=16 November 2020 |title=It's the 'vaccine hesitant', not anti-vaxxers, who are troubling public health experts |website=[[TheGuardian.com]] |url=https://www.theguardian.com/commentisfree/2020/nov/16/vaccine-hesitant-anti-vaxxers-public-health-experts-covid}}</ref> The specific hypotheses raised by anti-vaccination advocates have been found to change over time.<ref name="Gerber"/> [[Anti-vaccine activism]] has been increasingly connected to political and economic goals.<ref name="Carpiano">{{cite journal | vauthors = Carpiano RM, Callaghan T, DiResta R, Brewer NT, Clinton C, Galvani AP, Lakshmanan R, Parmet WE, Omer SB, Buttenheim AM, Benjamin RM, Caplan A, Elharake JA, Flowers LC, Maldonado YA, Mello MM, Opel DJ, Salmon DA, Schwartz JL, Sharfstein JM, Hotez PJ | title = Confronting the evolution and expansion of anti-vaccine activism in the USA in the COVID-19 era | journal = Lancet | volume = 401 | issue = 10380 | pages = 967–970 | date = March 2023 | pmid = 36871571 | pmc = 9981160 | doi = 10.1016/S0140-6736(23)00136-8 }}</ref><ref name="Herasimenka">{{cite journal | vauthors = Herasimenka A, Au Y, George A, Joynes-Burgess K, Knuutila A, Bright J, Howard PN | title = The political economy of digital profiteering: communication resource mobilization by anti-vaccination actors | journal = The Journal of Communication | volume = 73 | issue = 2 | pages = 126–137 | date = April 2023 | pmid = 37016634 | pmc = 10066223 | doi = 10.1093/joc/jqac043 }}</ref>
Although myths, [[conspiracy theory|conspiracy theories]], [[Vaccine misinformation|misinformation]] and [[disinformation attack|disinformation]] spread by the anti-vaccination movement and [[Fringe science|fringe]] doctors leads to vaccine hesitancy and public debates around the medical, ethical, and legal issues related to vaccines, there is no serious hesitancy or debate within mainstream medical and scientific circles about the benefits of vaccination.<ref name="Dubé">{{cite journal | vauthors = Dubé È, Ward JK, Verger P, MacDonald NE | title = Vaccine Hesitancy, Acceptance, and Anti-Vaccination: Trends and Future Prospects for Public Health | journal = Annual Review of Public Health | volume = 42 | issue = 1 | pages = 175–191 | date = April 2021 | pmid = 33798403 | doi = 10.1146/annurev-publhealth-090419-102240 | quote = "the scientific and medical consensus on the benefits of vaccination is clear and unambiguous" | s2cid = 232774243 | doi-access = free }}</ref>

Proposed laws that mandate vaccination, such as [[California Senate Bill 277]] and Australia's [[No Jab No Pay]], have been opposed by [[List of anti-vaccination groups|anti-vaccination activists and organizations]].<ref>{{cite news |url=http://discovermagazine.com/2018/dec/fostering-fear |title=The Long History of America's Anti-Vaccination Movement |access-date=2019-02-02 |website=DiscoverMagazine.com}}</ref><ref>{{cite news |url=https://www.politico.eu/article/how-anti-vax-went-viral/ |title=How anti-vax went viral | vauthors = Young Z |date=2018-11-21 |access-date=2019-02-02 }}</ref><ref>{{cite news |url=https://www.independent.co.uk/news/world/europe/anti-vaxxers-italy-vaccine-measles-epidemic-europe-us-vaccination-global-health-security-agenda-a8560021.html |title=How the anti-vaxxers are winning in Italy |date=2018-09-28 |access-date=2019-02-02 |language=en}}</ref> Opposition to [[vaccine policy|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.<ref name="wolfesharp" /><ref>{{cite web |url=https://www.mystatesman.com/news/state--regional-govt--politics/civil-liberties-center-vaccination-debate-texas/lWzq91qhSyAKcY8MiaWnYM/ |title='Civil liberties' at center of vaccination debate in Texas | vauthors = Chang J |date=12 July 2017 |website=Mystatesman |publisher=[[Austin American-Statesman]] |access-date=July 28, 2018 |archive-date=July 13, 2017 |archive-url=https://web.archive.org/web/20170713075809/https://www.mystatesman.com/news/state--regional-govt--politics/civil-liberties-center-vaccination-debate-texas/lWzq91qhSyAKcY8MiaWnYM/ |url-status=dead }}</ref><ref>{{cite web |url=https://www.nytimes.com/roomfordebate/2014/03/23/making-vaccination-mandatory-for-all-children/in-britain-vaccinate-with-persuasion-not-coercion |title=In Britain, Vaccinate With Persuasion, not Coercion | vauthors = Elliman D, Bedford H |date=23 March 2014 |website=The New York Times }}</ref><ref>{{cite news |url=https://health.spectator.co.uk/anti-vaxxers-have-embraced-social-media-were-paying-for-fake-news-with-real-lives/ |title=Anti-vaxxers have embraced social media. We're paying for fake news with real lives |date=2017-06-28 |access-date=2019-02-02 |language=en-GB |archive-date=April 5, 2019 |archive-url=https://web.archive.org/web/20190405124330/https://health.spectator.co.uk/anti-vaxxers-have-embraced-social-media-were-paying-for-fake-news-with-real-lives/ |url-status=dead }}</ref><ref>{{cite web | vauthors = Lam B | url = https://www.theatlantic.com/business/archive/2015/02/vaccines-are-profitable-so-what/385214/ | title = Vaccines Are Profitable, So What? | work = The Atlantic | date = 10 February 2015 }}</ref>
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==Effectiveness==
[[File:Measles US 1938-2019.png|thumb|upright=1.5 |right |Rates of measles fell sharply when universal immunization was introduced]]

[[Scientific evidence]] for the effectiveness of large-scale vaccination campaigns is well established.<ref>{{cite journal | vauthors = Christenson B, Lundbergh P, Hedlund J, Ortqvist A | title = Effects of a large-scale intervention with influenza and 23-valent pneumococcal vaccines in adults aged 65 years or older: a prospective study | journal = Lancet | volume = 357 | issue = 9261 | pages = 1008–1011 | date = March 2001 | pmid = 11293594 | doi = 10.1016/S0140-6736(00)04237-9 | s2cid = 8125882 }}</ref> It is estimated that two to three million deaths are prevented each year worldwide by vaccination, and it is thought that an additional 1.5 million deaths could be prevented each year if all recommended vaccines were used.<ref name="Jacobson2020">{{cite journal | vauthors = Jacobson RM, St Sauver JL, Griffin JM, MacLaughlin KL, Finney Rutten LJ | title = How health care providers should address vaccine hesitancy in the clinical setting: Evidence for presumptive language in making a strong recommendation | journal = Human Vaccines & Immunotherapeutics | volume = 16 | issue = 9 | pages = 2131–2135 | date = September 2020 | pmid = 32242766 | pmc = 7553710 | doi = 10.1080/21645515.2020.1735226 | doi-access = free }}</ref> Vaccination campaigns helped eradicate [[smallpox]], which once killed as many as one in seven children in Europe,<ref name="Fenner">{{cite book |url=http://whqlibdoc.who.int/smallpox/9241561106.pdf |title=Smallpox and its Eradication |vauthors=Fenner F, Henderson DA, Arita I, Ježek Z, Ladnyi ID |publisher=World Health Organization |year=1988 |isbn=978-92-4-156110-5 |location=Geneva |access-date=2007-09-04}}</ref> and have nearly [[poliomyelitis eradication|eradicated polio]].<ref>{{cite book | vauthors = Sutter RW, Maher C | title = Mass Vaccination: Global Aspects — Progress and Obstacles | chapter = Mass vaccination campaigns for polio eradication: an essential strategy for success | series = Current Topics in Microbiology and Immunology | volume = 304 | pages = 195–220 | year = 2006 | pmid = 16989271 | doi = 10.1007/3-540-36583-4_11 | isbn = 978-3-540-29382-8 }}</ref> 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.<ref>{{cite journal | title = Progress toward elimination of Haemophilus influenzae type b invasive disease among infants and children--United States, 1998-2000 | journal = MMWR. Morbidity and Mortality Weekly Report | volume = 51 | issue = 11 | pages = 234–237 | date = March 2002 | pmid = 11925021 | url = https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5111a4.htm | author1 = Centers for Disease Control and Prevention (CDC) }}</ref> 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.<ref>{{cite news |url=http://www.time.com/time/health/article/0,8599,1808438-1,00.html |archive-url=https://web.archive.org/web/20080528022614/http://www.time.com/time/health/article/0,8599,1808438-1,00.html |url-status=dead |archive-date=May 28, 2008 |title=How safe are vaccines? | vauthors = Park A |date=June 2, 2008 |work=Time Magazine |url-access=subscription}}</ref>

There is anti-vaccine literature that argues that reductions in infectious disease result from 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 the incidence of each disease to drop, just at the time a vaccine for that disease was introduced?"<ref name="CDC: common misconceptions">{{cite web |url=https://www.cdc.gov/vaccines/vac-gen/6mishome.htm |title=Some common misconceptions about vaccination and how to respond to them |publisher=[[National Center for Immunization and Respiratory Diseases]], Centers for Disease Control and Prevention |archive-url=https://web.archive.org/web/20150120055820/http://www.cdc.gov/vaccines/vac-gen/6mishome.htm |archive-date=January 20, 2015 |access-date=September 28, 2012}}</ref>

Another rallying cry of the anti-vaccine movement is to call for randomized [[clinical trials]] in which an experimental group of children are vaccinated while a [[control group]] are unvaccinated.  Such a study would never be approved because it would require deliberately denying children standard medical care, rendering the study unethical.  Studies have been done that compare vaccinated to unvaccinated people, but the studies are typically not randomized.  Moreover, literature already exists that demonstrates the safety of vaccines using other experimental methods.<ref>{{cite book | vauthors = Novella S, Novella B, Santa Maria C, Novella J, Bernstein E |title=The Skeptics' Guide to the Universe: How to Know What's Really Real in a World Increasingly Full of Fake |publisher=Grand Central Publishing |date=2018 |page=185 |isbn=9781538760512}}</ref>

Other critics argue that the immunity granted by vaccines is only temporary and requires boosters, whereas those who survive the disease become permanently immune.<ref name="wolfesharp" /> As discussed below, the philosophies of some [[#Alternative medicine|alternative medicine]] practitioners are incompatible with the idea that vaccines are effective.<ref name="Ernst">{{cite journal |vauthors=Ernst E |date=October 2001 |title=Rise in popularity of complementary and alternative medicine: reasons and consequences for vaccination |journal=Vaccine |volume=20 |issue=Suppl 1 |pages=S90-3; discussion S89 |doi=10.1016/S0264-410X(01)00290-0 |pmid=11587822}}</ref>

===Population health===

[[File:Charlotte Cleverley-Bisman.jpg|thumb|[[Charlotte Cleverley-Bisman]] is a child known as the face of a New Zealand campaign to encourage vaccination against meningococcal disease after contracting and surviving severe meningococcal sepsis.<ref>{{cite news | vauthors = Johnston M |date=3 July 2006 |url=http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10389468 |title=Vaccine campaign beating meningococcal epidemic |work=[[The New Zealand Herald]] |location=Auckland}}</ref> She had all four limbs partially amputated at age seven months due to [[meningococcal disease]],<ref>{{cite web | vauthors = Wane J |url=http://www.biocsl.co.nz/docs/957/642/NorthSouth_case-for-accination.pdf |title=The case for vaccination |website=North & South |access-date=July 3, 2015}}</ref> which is preventable in children too young to vaccinate through widespread population vaccination sufficient to develop herd immunity<ref name="pmid21427399">{{cite journal | vauthors = Fine P, Eames K, Heymann DL | title = "Herd immunity": a rough guide | journal = Clinical Infectious Diseases | volume = 52 | issue = 7 | pages = 911–916 | date = April 2011 | pmid = 21427399 | doi = 10.1093/cid/cir007 | doi-access = free }}</ref>]]

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 9–12 months old, and the window between the disappearance of maternal antibody and [[seroconversion]] means that vaccinated children are frequently still vulnerable. Strong herd immunity reduces this vulnerability. Increasing herd immunity during an outbreak or when there is a risk of an outbreak is perhaps the most widely accepted justification for mass vaccination. When a new vaccine is introduced, mass vaccination can help increase coverage rapidly.<ref>{{cite book | vauthors = Heymann DL, Aylward RB | chapter = Mass Vaccination: When and Why | title = Mass Vaccination: Global Aspects — Progress and Obstacles | volume = 304 | pages = 1–16 | year = 2006 | pmid = 16989261 | doi = 10.1007/3-540-36583-4_1 | isbn = 978-3-540-29382-8 | series = Current Topics in Microbiology and Immunology | s2cid = 25259803 }}</ref>

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.<ref>{{cite journal | vauthors = Bester JC | title = Measles Vaccination is Best for Children: The Argument for Relying on Herd Immunity Fails | journal = Journal of Bioethical Inquiry | volume = 14 | issue = 3 | pages = 375–384 | date = September 2017 | pmid = 28815434 | doi = 10.1007/s11673-017-9799-4 | s2cid = 3177668 }}</ref> The outcome for people with compromised immune systems who get infected is often worse than that of the general population.<ref>{{cite web |url=https://www.cdc.gov/features/ReasonsToVaccinate |title=Immunization |date=2018-08-30 |publisher=CDC}}</ref>

===Cost-effectiveness===
Commonly used vaccines are a cost-effective and preventive way of promoting health, compared to the treatment of acute or chronic disease. In 2001, the United States spent approximately $2.8 billion to promote and implement routine [[vaccination schedule|childhood immunizations]] against seven diseases. The societal benefits of those vaccinations were estimated to be $46.6 billion, yielding a benefit-cost ratio of 16.5.<ref>{{cite journal | vauthors = Zhou F, Santoli J, Messonnier ML, Yusuf HR, Shefer A, Chu SY, Rodewald L, Harpaz R | title = Economic evaluation of the 7-vaccine routine childhood immunization schedule in the United States, 2001 | journal = Archives of Pediatrics & Adolescent Medicine | volume = 159 | issue = 12 | pages = 1136–1144 | date = December 2005 | pmid = 16330737 | doi = 10.1001/archpedi.159.12.1136 | doi-access =  }}</ref>

===Necessity===
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.<ref>{{cite journal | vauthors = Fine PE, Clarkson JA | title = Individual versus public priorities in the determination of optimal vaccination policies | journal = American Journal of Epidemiology | volume = 124 | issue = 6 | pages = 1012–1020 | date = December 1986 | pmid = 3096132 | doi = 10.1093/oxfordjournals.aje.a114471 }}</ref> If enough people hope to become [[free rider problem|free-riders]], gaining the benefits of herd immunity without vaccination, vaccination levels may drop to a level where herd immunity is ineffective.<ref>{{cite journal | vauthors = Buttenheim AM, Asch DA | title = Making vaccine refusal less of a free ride | journal = Human Vaccines & Immunotherapeutics | volume = 9 | issue = 12 | pages = 2674–2675 | date = December 2013 | pmid = 24088616 | pmc = 4162060 | doi = 10.4161/hv.26676 }}</ref> 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.<ref>{{cite web | vauthors = Reich J |author-link=Jennifer Reich |url=https://www.vox.com/first-person/2019/5/8/18535944/jessica-biel-measles-2019-outbreak-anti-vax |title=I've talked to dozens of parents about why they don't vaccinate. Here's what they told me. |date=June 13, 2019 |website=Vox |access-date=July 5, 2019}}</ref>

==Safety concerns==
While some anti-vaccinationists openly deny the improvements vaccination has made to public health or believe in [[conspiracy theories]],<ref name="wolfesharp"/> it is much more common to cite concerns about safety.<ref name="LancetID">{{cite journal | title = Tackling negative perceptions towards vaccination | journal = The Lancet. Infectious Diseases | volume = 7 | issue = 4 | pages = 235 | date = April 2007 | pmid = 17376373 | doi = 10.1016/S1473-3099(07)70057-9 | vauthors = ((The Editors)) }}</ref> As with any medical treatment, there is a potential for vaccines to cause serious complications, such as severe allergic reactions,<ref>{{cite web |url=https://www.cdc.gov/vaccines/vac-gen/side-effects.htm#mmr |title=Possible Side-effects from Vaccines |date=August 26, 2013 |publisher=Centers for Disease Control and Prevention |access-date=January 3, 2014}}</ref> but unlike most other medical interventions, vaccines are given to healthy people and so a higher standard of safety is demanded.<ref>{{cite journal | vauthors = Chen RT, Hibbs B | title = Vaccine safety: current and future challenges | journal = Pediatric Annals | volume = 27 | issue = 7 | pages = 445–455 | date = July 1998 | pmid = 9677616 | doi = 10.3928/0090-4481-19980701-11 }}</ref> While serious complications from vaccinations are possible, they are extremely rare and much less common than similar risks from the diseases they prevent.<ref name="CDC: common misconceptions" /> 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,<ref name="BH">{{cite journal |vauthors=Bonhoeffer J, Heininger U |date=June 2007 |title=Adverse events following immunization: perception and evidence |journal=Current Opinion in Infectious Diseases |volume=20 |issue=3 |pages=237–246 |doi=10.1097/QCO.0b013e32811ebfb0 |pmid=17471032 |s2cid=40669829}}</ref> and it becomes challenging for health authorities to preserve public support for vaccination programs.<ref>{{cite journal | vauthors = Mooney C |date=June 2009 |title=Why does the vaccine/autism controversy live on? |url=http://discovermagazine.com/2009/jun/06-why-does-vaccine-autism-controversy-live-on |journal=Discover}}</ref>

The overwhelming success of certain vaccinations has made certain diseases rare, and, consequently, has led to incorrect [[Heuristics in judgment and decision-making|heuristic thinking]] in weighing risks against benefits among people who are vaccine-hesitant.<ref name="Jacobson2015">{{cite journal | vauthors = Jacobson RM, St Sauver JL, Finney Rutten LJ | title = Vaccine Hesitancy | journal = Mayo Clinic Proceedings | volume = 90 | issue = 11 | pages = 1562–1568 | date = November 2015 | pmid = 26541249 | doi = 10.1016/j.mayocp.2015.09.006 | doi-access = free }}</ref> Once such diseases (e.g., ''[[Haemophilus influenzae serotype b|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.<ref name="Jacobson2015" /> The lack of personal experience with these diseases reduces the perceived danger and thus reduces the perceived benefit of immunization.<ref name="Marshall2013" /> 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.<ref name="Jacobson2015" /> [[Omission bias|Omission]] and [[disconfirmation bias]]es also contribute to vaccine hesitancy.<ref name="Jacobson2015" /><ref name="McClure2017" />

Various concerns about immunization have been raised. They have been addressed and the concerns are not supported by evidence.<ref name="Marshall2013">{{cite journal | vauthors = Marshall GS | title = Roots of vaccine hesitancy | journal = South Dakota Medicine | volume = Spec no | pages = 52–57 | date = 2013 | pmid = 23444592 }}</ref> 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 an inadequate methodology, typically a poorly controlled or uncontrolled [[case series]]. A premature announcement is made about the alleged adverse effect, resonating with individuals who have 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.<ref name="BH" /> Adverse effects ascribed to vaccines typically have an unknown origin, an increasing [[Incidence (epidemiology)|incidence]], some [[biological plausibility]], occurrences close to the time of vaccination, and dreaded outcomes.<ref>{{cite journal | vauthors = Leask J, Chapman S, Cooper Robbins SC | title = "All manner of ills": The features of serious diseases attributed to vaccination | journal = Vaccine | volume = 28 | issue = 17 | pages = 3066–3070 | date = April 2010 | pmid = 19879997 | doi = 10.1016/j.vaccine.2009.10.042 }}</ref> 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.<ref>{{cite book |title=Bad Science | vauthors = Goldacre B |publisher=Fourth Estate |year=2009 |isbn=978-0007284870 |location=London |pages=292–94 }}</ref>

=== Ingredients concerns ===

==== Thiomersal ====
{{Main|Thiomersal and vaccines}}

[[Thiomersal]] (called "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.<ref name="Baker">{{cite journal | vauthors = Baker JP | title = Mercury, vaccines, and autism: one controversy, three histories | journal = American Journal of Public Health | volume = 98 | issue = 2 | pages = 244–253 | date = February 2008 | pmid = 18172138 | pmc = 2376879 | doi = 10.2105/AJPH.2007.113159 }}</ref> Despite thiomersal's efficacy, the use of thiomersal is controversial because it can be metabolized or degraded in the body to [[ethylmercury]] (C<sub>2</sub>H<sub>5</sub>Hg<sup>+</sup>) and [[thiosalicylate]].<ref name=T-in-vaccines>{{cite web |date=June 3, 2008 |url=https://www.fda.gov/cber/vaccine/thimerosal.htm |archive-url=https://web.archive.org/web/20080726010009/https://www.fda.gov/cber/vaccine/thimerosal.htm |archive-date=July 26, 2008|url-status=dead |access-date=July 25, 2008 |title=Thimerosal in vaccines |publisher=Center for Biologics Evaluation and Research, U.S. Food and Drug Administration}}</ref><ref name=cber2019 /> As a result, in 1999, the [[Centers for Disease Control and Prevention|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]].<ref name="Offit">{{cite journal | vauthors = Offit PA | title = Thimerosal and vaccines--a cautionary tale | journal = The New England Journal of Medicine | volume = 357 | issue = 13 | pages = 1278–1279 | date = September 2007 | pmid = 17898096 | doi = 10.1056/NEJMp078187 | s2cid = 36318722 | doi-access = free | author-link = Paul Offit }}</ref> Trace amounts remain in some vaccines due to production processes, at an approximate maximum of one 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 [[World Health Organization|WHO]].<ref name=cber2019>{{cite journal |author=Center for Biologics Evaluation and Research |date=April 5, 2019 |title=Thimerosal and Vaccines |url=https://www.fda.gov/vaccines-blood-biologics/safety-availability-biologics/thimerosal-and-vaccines |archive-url=https://web.archive.org/web/20190506153627/https://www.fda.gov/vaccines-blood-biologics/safety-availability-biologics/thimerosal-and-vaccines |url-status=dead |archive-date=May 6, 2019 |journal=FDA |publisher=fda.gov}}</ref><ref>{{cite journal | vauthors = Bose-O'Reilly S, McCarty KM, Steckling N, Lettmeier B | title = Mercury exposure and children's health | journal = Current Problems in Pediatric and Adolescent Health Care | volume = 40 | issue = 8 | pages = 186–215 | date = September 2010 | pmid = 20816346 | pmc = 3096006 | doi = 10.1016/j.cppeds.2010.07.002 }}</ref> The action sparked concern that thiomersal could have been responsible for autism.<ref name="Offit" /> The idea is now considered disproven, as incidence rates for autism increased steadily even after thiomersal was removed from childhood vaccines.<ref name="Gerber" /> Currently there is no accepted scientific evidence that exposure to thiomersal is a factor in causing autism.<ref>{{cite journal | vauthors = Doja A, Roberts W | title = Immunizations and autism: a review of the literature | journal = The Canadian Journal of Neurological Sciences. Le Journal Canadien des Sciences Neurologiques | volume = 33 | issue = 4 | pages = 341–346 | date = November 2006 | pmid = 17168158 | doi = 10.1017/s031716710000528x | doi-access = free }}</ref><ref name="Spencer2017">{{cite journal | vauthors = Spencer JP, Trondsen Pawlowski RH, Thomas S | title = Vaccine Adverse Events: Separating Myth from Reality | journal = American Family Physician | volume = 95 | issue = 12 | pages = 786–794 | date = June 2017 | pmid = 28671426 | url = https://www.aafp.org/afp/2017/0615/p786.html }}</ref> Since 2000, parents in the United States have pursued legal compensation from a federal fund arguing that thiomersal caused autism in their children.<ref name="Sugarman">{{cite journal | vauthors = Sugarman SD | title = Cases in vaccine court--legal battles over vaccines and autism | journal = The New England Journal of Medicine | volume = 357 | issue = 13 | pages = 1275–1277 | date = September 2007 | pmid = 17898095 | doi = 10.1056/NEJMp078168 | doi-access = free }}</ref> A 2004 [[Institute of Medicine]] (IOM) committee favored rejecting any causal relationship between thiomersal-containing vaccines and autism.<ref name="ISRC">{{cite book |url=http://www.nap.edu/catalog.php?record_id=10997 |title=Immunization Safety Review: Vaccines and Autism |last=Immunization Safety Review Committee |publisher=The National Academies Press |year=2004 |isbn=978-0-309-09237-1 |doi=10.17226/10997 |pmid=20669467}}</ref> 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).<ref name="FDAThiomersalTuna" /> 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 {{convert|3|oz|g|adj=on|spell=in}} can of [[tuna]].<ref name="FDAThiomersalTuna">{{cite web |url=https://www.fda.gov/vaccines-blood-biologics/safety-availability-biologics/thimerosal-and-vaccines#pres |title=Thimerosal and Vaccines |date=April 5, 2019 |website=fda.gov |publisher=U.S. Food and Drug Administration}}</ref> There is robust peer-reviewed scientific evidence supporting the safety of thiomersal-containing vaccines.<ref name="FDAThiomersalTuna" />

==== Aluminium ====
Aluminum compounds are used as [[immunologic adjuvant]]s to increase the effectiveness of many vaccines.<ref name="Principi2018">{{cite journal |vauthors=Principi N, Esposito S |date=September 2018 |title=Aluminum in vaccines: Does it create a safety problem? |journal=Vaccine |volume=36 |issue=39 |pages=5825–5831 |doi=10.1016/j.vaccine.2018.08.036 |pmid=30139653 |s2cid=52073320}}</ref> 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.<ref name="Baylor">{{cite journal |vauthors=Baylor NW, Egan W, Richman P |date=May 2002 |title=Aluminum salts in vaccines--US perspective |journal=Vaccine |volume=20 |issue=Suppl 3 |pages=S18–S23 |doi=10.1016/S0264-410X(02)00166-4 |pmid=12184360}}</ref><ref>{{cite journal |vauthors=Leslie M |date=July 2013 |title=Solution to vaccine mystery starts to crystallize |journal=Science |volume=341 |issue=6141 |pages=26–27 |bibcode=2013Sci...341...26L |doi=10.1126/science.341.6141.26 |pmid=23828925}}</ref> In some cases these compounds have been associated with redness, itching, and low-grade fever,<ref name="Baylor" /> but the use of aluminum in vaccines has not been associated with serious adverse events.<ref name="Principi2018" /><ref name="Francois">{{cite journal |vauthors=François G, Duclos P, Margolis H, Lavanchy D, Siegrist CA, Meheus A, Lambert PH, Emiroğlu N, Badur S, Van Damme P |date=November 2005 |title=Vaccine safety controversies and the future of vaccination programs |journal=The Pediatric Infectious Disease Journal |volume=24 |issue=11 |pages=953–961 |doi=10.1097/01.inf.0000183853.16113.a6 |pmid=16282928 |s2cid=10484014}}</ref> In some cases, aluminum-containing vaccines are associated with [[macrophagic myofasciitis]] (MMF), localized microscopic [[lesion]]s 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.<ref name="Principi2018" /><ref name="Francois" /> 

Infants are exposed to greater quantities of aluminum in daily life in breastmilk and infant formula than in vaccines.<ref name="Smith2015" /> In general, people are exposed to low levels of naturally occurring aluminum in nearly all foods and drinking water.<ref name="OxfordVaccineIngredients">{{cite web |title=Vaccine Ingredients |url=http://vk.ovg.ox.ac.uk/vaccine-ingredients#aluminium |website=Vaccine Knowledge Project |publisher=Centre for Clinical Vaccinology and Tropical Medicine, Churchill Hospital, University of Oxford}}</ref> The amount of aluminum present in vaccines is small, less than one milligram, and such low levels are not believed to be harmful to human health.<ref name="OxfordVaccineIngredients" />

Overall while the state of knowledge on adjuvant safety is uncertain and no drug is perfectly safe, serious adverse effects from adjuvants are extremely rare.<ref name="Petrovsky_2015">{{cite journal |vauthors=Petrovsky N |date=November 2015 |title=Comparative Safety of Vaccine Adjuvants: A Summary of Current Evidence and Future Needs |journal=Drug Safety |volume=38 |issue=11 |pages=1059–1074 |doi=10.1007/s40264-015-0350-4 |pmc=4615573 |pmid=26446142}}</ref>

==== Formaldehyde ====
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.<ref name="FDAVaccineIngredient">{{cite web |date=April 19, 2019 |title=Common Ingredients Used in U.S. Licensed Vaccines |url=https://www.fda.gov/vaccines-blood-biologics/safety-availability-biologics/common-ingredients-us-licensed-vaccines |archive-url=https://web.archive.org/web/20190526071550/https://www.fda.gov/vaccines-blood-biologics/safety-availability-biologics/common-ingredients-us-licensed-vaccines |url-status=dead |archive-date=May 26, 2019 |website=fda.gov |publisher=U.S. Food and Drug Administration}}</ref> Very small amounts of residual formaldehyde can be present in vaccines but are far below values harmful to human health.<ref name="CHOPformaldehyde">{{cite web |date=November 6, 2014 |title=Vaccine Ingredients-Formaldehyde |url=https://www.chop.edu/centers-programs/vaccine-education-center/vaccine-ingredients/formaldehyde |website=chop.edu/ |publisher=Children's Hospital of Philadelphia}}</ref><ref name="Vaccineingredients">{{cite web |date=April 26, 2021 |title=Vaccine Ingredients |url=https://www.vaccines.gov/basics/vaccine_ingredients |website=vaccines.gov/ |publisher=U.S. Department of Health and Human Services}}</ref> 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.<ref name="FDAVaccineIngredient" /> The human body continuously produces formaldehyde naturally and contains 50–70 times the greatest amount of formaldehyde present in any vaccine.<ref name="FDAVaccineIngredient" /> Furthermore, the human body is capable of breaking down naturally occurring formaldehyde as well as the small amount of formaldehyde present in vaccines.<ref name="FDAVaccineIngredient" /> There is no evidence linking the infrequent exposures to small quantities of formaldehyde present in vaccines with [[cancer]].<ref name="FDAVaccineIngredient" />

=== MMR vaccine ===
{{Main|MMR vaccine and autism}}

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 twelve children mostly with [[autism spectrum|autism spectrum disorders]] with onset soon after administration of the vaccine.<ref>{{cite journal | vauthors = 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 | title = Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children | journal = Lancet | volume = 351 | issue = 9103 | pages = 637–641 | date = February 1998 | pmid = 9500320 | doi = 10.1016/S0140-6736(97)11096-0 | s2cid = 439791 | author-link1 = Andrew Wakefield }}{{Retracted|doi=10.1016/S0140-6736(10)60175-4|pmid=20137807|http://retractionwatch.com/the-retraction-watch-leaderboard/top-10-most-highly-cited-retracted-papers/ ''Retraction Watch''|http://retractionwatch.com/2015/02/03/frauds-long-tail-measles-outbreak-shows-important-look-downstream-retractions/ ''Retraction Watch''|intentional=yes}}</ref> 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.<ref name="NHS">{{cite web |url=https://www.nhs.uk/conditions/vaccinations/mmr-vaccine/ |title=MMR vaccine |last=National Health Service |year=2015 |access-date=4 July 2018}}</ref> 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]]: Wakefield reportedly stood to earn up to $43 million per year selling diagnostic kits.<ref name="WakefieldCapitalize">{{cite news | vauthors = Stein R |date=11 January 2011 |title=Wakefield tried to capitalize on autism-vaccine link, report says |url=http://voices.washingtonpost.com/checkup/2011/01/wakefield_tried_to_capitalize.html |url-status=dead |archive-url=https://web.archive.org/web/20120630205839/http://voices.washingtonpost.com/checkup/2011/01/wakefield_tried_to_capitalize.html |archive-date=2012-06-30 |access-date=12 January 2011 |newspaper=[[The Washington Post]]}}</ref><ref>{{cite news |url=https://www.thetimes.com/article/revealed-mmr-research-scandal-7bpvmphmdrn |title=Revealed: MMR research scandal | vauthors = Deer B |authorlink=Brian Deer |date=2004-02-22 |work=The Sunday Times |access-date=2025-01-23}}</ref> Had this been known, publication in ''The Lancet'' would not have taken place in the way that it did.<ref>{{cite journal | vauthors = Horton R | title = The lessons of MMR | journal = Lancet | volume = 363 | issue = 9411 | pages = 747–749 | date = March 2004 | pmid = 15016482 | doi = 10.1016/S0140-6736(04)15714-0 | s2cid = 5357597 }}</ref> Wakefield has been heavily criticized on scientific and ethical grounds for the way the research was conducted<ref name="paid_children">{{cite news |url=http://news.bbc.co.uk/2/hi/health/6289166.stm |title=MMR scare doctor 'paid children' |date=2007-07-16 |work=BBC News}}</ref> and for triggering a decline in vaccination rates, which fell in the UK to 80% in the years following the study.<ref>{{cite news |url=http://news.bbc.co.uk/2/hi/health/5118166.stm |title=Doctors issue plea over MMR jab |date=2006-06-26 |work=BBC News |access-date=2007-11-23}}</ref><ref name="Alazraki11">{{cite news |date=January 12, 2011 |title=The Autism Vaccine Fraud: Dr. Wakefield's Costly Lie to Society |url=http://www.dailyfinance.com/2011/01/12/autism-vaccine-fraud-wakefield-cost-money-deaths/ |url-status=dead |archive-url=https://web.archive.org/web/20111027104603/http://www.dailyfinance.com/2011/01/12/autism-vaccine-fraud-wakefield-cost-money-deaths/ |archive-date=October 27, 2011 |access-date=October 18, 2011 |work=DailyFinance, AOL Money & Finance |vauthors=Alazraki M |df=mdy-all}}</ref> In 2004, the MMR-and-autism interpretation of the paper was formally retracted by ten of its thirteen coauthors,<ref>{{cite journal | vauthors = Murch SH, Anthony A, Casson DH, Malik M, Berelowitz M, Dhillon AP, Thomson MA, Valentine A, Davies SE, Walker-Smith JA | title = Retraction of an interpretation | journal = Lancet | volume = 363 | issue = 9411 | pages = 750 | date = March 2004 | pmid = 15016483 | doi = 10.1016/S0140-6736(04)15715-2 | s2cid = 5128036 }}</ref> and in 2010 ''The Lancet''{{'}}s editors fully retracted the paper.<ref>{{cite journal | vauthors = ((The Editors Of The Lancet)) | title = Retraction--Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children | journal = Lancet | volume = 375 | issue = 9713 | pages = 445 | date = February 2010 | pmid = 20137807 | doi = 10.1016/S0140-6736(10)60175-4 | s2cid = 26364726 }}</ref><ref name="Triggle_2/2/2010">{{cite web | vauthors = Triggle N | title=Lancet accepts MMR study 'false' | website=BBC News | date=February 2, 2010 | url=http://news.bbc.co.uk/2/low/health/8493753.stm | access-date=February 28, 2022}}</ref> Wakefield was struck off the [[General Medical Council#Registering doctors in the UK|UK medical register]], with a statement identifying deliberate falsification in the research published in ''The Lancet'',<ref name="gmc-uk_Wakefield_SPM">{{cite web |url=http://www.gmc-uk.org/Wakefield_SPM_and_SANCTION.pdf_32595267.pdf |title=General Medical Council, Fitness to Practise Panel Hearing, 24 May 2010, Andrew Wakefield, Determination of Serious Professional Misconduct |publisher=General Medical Council |url-status=dead |archive-url=https://web.archive.org/web/20130512115524/http://www.gmc-uk.org/Wakefield_SPM_and_SANCTION.pdf_32595267.pdf |archive-date=May 12, 2013 |access-date=September 18, 2011}}</ref> and is barred from practicing medicine in the UK.<ref name="MeikleBoseley">{{cite news |url=https://www.theguardian.com/society/2010/may/24/mmr-doctor-andrew-wakefield-struck-off |title=MMR row doctor Andrew Wakefield struck off register | vauthors = Meikle J, Boseley S |date=May 24, 2010 |work=The Guardian |access-date=May 24, 2010 |url-status=live |archive-url=https://web.archive.org/web/20100527003931/http://www.guardian.co.uk/society/2010/may/24/mmr-doctor-andrew-wakefield-struck-off |archive-date=May 27, 2010 |location=London}}</ref>

The CDC, the IOM of the [[United States National Academy of Sciences|National Academy of Sciences]], Australia's [[Department of Health (Australia)|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.<ref name="ISRC" /><ref>{{cite web |url=http://cdc.gov/vaccinesafety/Concerns/Autism/Index.html |title=Concerns about autism |date=2010-01-15 |publisher=Centers for Disease Control and Prevention}}</ref><ref>{{cite web |url=http://www.mmrthefacts.nhs.uk/ |title=MMR The facts |publisher=United Kingdom [[National Health Service]] |url-status=dead |archive-url=https://web.archive.org/web/20070615000359/http://www.mmrthefacts.nhs.uk/ |archive-date=June 15, 2007 |access-date=June 13, 2007}}</ref><ref name="AustraliaVaccines">{{cite web |title=Are Vaccines Safe? |url=https://www.health.gov.au/health-topics/immunisation/about-immunisation/are-vaccines-safe#no-established-link-between-vaccines-and-autism |website=health.gov.au |date=October 24, 2017 |publisher=Australia Department of Health}}</ref> 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.<ref name="pmid22336803">{{cite journal | vauthors = Demicheli V, Rivetti A, Debalini MG, Di Pietrantonj C | title = Vaccines for measles, mumps and rubella in children | journal = The Cochrane Database of Systematic Reviews | volume = 2012 | issue = 2 | pages = CD004407 | date = February 2012 | pmid = 22336803 | pmc = 6458016 | doi = 10.1002/14651858.CD004407.pub3 | veditors = Demicheli V }}</ref>{{Update inline|reason=Updated version https://www.ncbi.nlm.nih.gov/pubmed/32309885|date = October 2024}} Additional reviews agree, with studies finding that vaccines are not linked to autism even in high risk populations with autistic siblings.<ref>{{cite journal | vauthors = DeStefano F, Shimabukuro TT | title = The MMR Vaccine and Autism | journal = Annual Review of Virology | volume = 6 | issue = 1 | pages = 585–600 | date = September 2019 | pmid = 30986133 | pmc = 6768751 | doi = 10.1146/annurev-virology-092818-015515 }}</ref>

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.<ref>{{cite news |url=http://www.timesonline.co.uk/tol/life_and_style/health/article5683671.ece |archive-url=https://web.archive.org/web/20090208234919/http://www.timesonline.co.uk/tol/life_and_style/health/article5683671.ece |url-status=dead |archive-date=February 8, 2009 |title=MMR doctor Andrew Wakefield fixed data on autism | vauthors = Deer B |date=2009-02-08 |work=Sunday Times |access-date=2009-02-09}}</ref> A 2011 article in the [[BMJ|''British Medical Journal'']] described how the data in the study had been falsified by Wakefield so that it would arrive at a predetermined conclusion.<ref>{{cite journal | vauthors = Deer B | title = How the case against the MMR vaccine was fixed | journal = BMJ | volume = 342 | pages = c5347 | date = January 2011 | pmid = 21209059 | doi = 10.1136/bmj.c5347 | s2cid = 46683674 | doi-access =  }}</ref> 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.<ref>{{cite journal | vauthors = Godlee F, Smith J, Marcovitch H | title = Wakefield's article linking MMR vaccine and autism was fraudulent | journal = BMJ | volume = 342 | pages = c7452 | date = January 2011 | pmid = 21209060 | doi = 10.1136/bmj.c7452 | s2cid = 43640126 }}</ref>

A special court convened in the United States to review claims under the [[Vaccine court|National Vaccine Injury Compensation Program]] ruled on February 12, 2009, that the evidence "failed to demonstrate that thimerosal-containing vaccines can contribute to causing immune dysfunction, or that the MMR vaccine can contribute to causing either autism or gastrointestinal dysfunction", and that parents of autistic children were therefore not entitled to compensation in their contention that certain vaccines caused autism in their children.<ref>Vaccine court and autism:
* {{cite news |url=http://www.cnn.com/2009/HEALTH/02/12/autism.vaccines/index.html | vauthors = Miriam F |title=Vaccine didn't cause autism, court rules |date=2009-02-12 |publisher=CNN |access-date=2009-02-12}}
* {{cite court |litigants=Theresa Cedillo and Michael Cedillo, as parents and natural guardians of Michelle Cedillo vs. Secretary of Health and Human Services |vol=98-916V |court=United States Court of Federal Claims |date=2009-02-12 |url=https://www.uscfc.uscourts.gov/sites/default/files/vaccine_files/Hastings-Cedillo.pdf}}</ref>

===Vaccine overload===
''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.<ref name="Hilton" /> Despite scientific evidence that strongly contradicts this idea,<ref name="Gerber" /> there are still parents of autistic children that believe that vaccine overload causes autism.<ref>{{cite news |url=https://www.thestar.com/news/article/718829 |title=Vaccine phobia runs deep | vauthors = Hurst L |date=2009-10-30 |work=Toronto Star |access-date=2009-11-04}}</ref> The resulting controversy has caused many parents to delay or avoid immunizing their children.<ref name="Hilton">{{cite journal | vauthors = Hilton S, Petticrew M, Hunt K | title = 'Combined vaccines are like a sudden onslaught to the body's immune system': parental concerns about vaccine 'overload' and 'immune-vulnerability' | journal = Vaccine | volume = 24 | issue = 20 | pages = 4321–4327 | date = May 2006 | pmid = 16581162 | doi = 10.1016/j.vaccine.2006.03.003 }}</ref> Such parental misperceptions are major obstacles towards immunization of children.<ref>{{cite journal | vauthors = Heininger U | title = An internet-based survey on parental attitudes towards immunization | journal = Vaccine | volume = 24 | issue = 37–39 | pages = 6351–6355 | date = September 2006 | pmid = 16784799 | doi = 10.1016/j.vaccine.2006.05.029 }}</ref>

The concept of vaccine overload is flawed on several levels.<ref name="Gerber" /> 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 ten percent of what it was in the seven vaccines given in 1980.<ref name="Gerber">{{cite journal | vauthors = Gerber JS, Offit PA | title = Vaccines and autism: a tale of shifting hypotheses | journal = Clinical Infectious Diseases | volume = 48 | issue = 4 | pages = 456–461 | date = February 2009 | pmid = 19128068 | pmc = 2908388 | doi = 10.1086/596476 | author-link2 = Paul Offit }}</ref> 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. There were 1,008 children in the study, one quarter of whom were diagnosed with autism, and the whole cohort was 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.<ref>{{cite web | vauthors = Willingham E |author-link=Emily Willingham |url=https://www.forbes.com/sites/emilywillingham/2013/03/29/vaccines-not-linked-to-autism-again/ |title=Vaccines Not Linked To Autism. Again |date=March 29, 2013 |website=Forbes |access-date=April 4, 2013}}</ref><ref>{{cite journal | vauthors = DeStefano F, Price CS, Weintraub ES | title = Increasing exposure to antibody-stimulating proteins and polysaccharides in vaccines is not associated with risk of autism | journal = The Journal of Pediatrics | volume = 163 | issue = 2 | pages = 561–567 | date = August 2013 | pmid = 23545349 | doi = 10.1016/j.jpeds.2013.02.001 | url = http://www.jpeds.com/webfiles/images/journals/ympd/JPEDSDeStefano.pdf | access-date = April 4, 2013 | url-status = dead | citeseerx = 10.1.1.371.2592 | archive-url = https://web.archive.org/web/20140923222908/http://www.jpeds.com/webfiles/images/journals/ympd/JPEDSDeStefano.pdf | archive-date = September 23, 2014 | author-link = Frank DeStefano }}</ref> Vaccines pose a very small immunologic load compared to the pathogens naturally encountered by a child in a typical year;<ref name="Gerber" /> common childhood conditions such as fevers and [[otitis media|middle-ear infections]] pose a much greater challenge to the immune system than vaccines,<ref>Immune challenges:
* {{cite journal | vauthors = Murphy TF | title = Branhamella catarrhalis: epidemiology, surface antigenic structure, and immune response | journal = Microbiological Reviews | volume = 60 | issue = 2 | pages = 267–279 | date = June 1996 | pmid = 8801433 | pmc = 239443 | doi = 10.1128/MMBR.60.2.267-279.1996 }}
* {{cite journal | vauthors = Sloyer JL, Howie VM, Ploussard JH, Ammann AJ, Austrian R, Johnston RB | title = Immune response to acute otitis media in children. I. Serotypes isolated and serum and middle ear fluid antibody in pneumococcal otitis media | journal = Infection and Immunity | volume = 9 | issue = 6 | pages = 1028–1032 | date = June 1974 | pmid = 4151506 | pmc = 414928 | doi = 10.1128/IAI.9.6.1028-1032.1974 }}</ref> and studies have shown that vaccinations, even multiple concurrent vaccinations, do not weaken the immune system<ref name="Gerber" /> or compromise overall immunity.<ref>Vaccine burden:
* {{cite journal | vauthors = Miller E, Andrews N, Waight P, Taylor B | title = Bacterial infections, immune overload, and MMR vaccine. Measles, mumps, and rubella | journal = Archives of Disease in Childhood | volume = 88 | issue = 3 | pages = 222–223 | date = March 2003 | pmid = 12598383 | pmc = 1719482 | doi = 10.1136/adc.88.3.222 }}
* {{cite journal | vauthors = Hviid A, Wohlfahrt J, Stellfeld M, Melbye M | title = Childhood vaccination and nontargeted infectious disease hospitalization | journal = JAMA | volume = 294 | issue = 6 | pages = 699–705 | date = August 2005 | pmid = 16091572 | doi = 10.1001/jama.294.6.699 | doi-access =  }}</ref> 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.<ref name="BH" /><ref>{{cite journal | vauthors = Gregson AL, Edelman R | title = Does antigenic overload exist? The role of multiple immunizations in infants | journal = Immunology and Allergy Clinics of North America | volume = 23 | issue = 4 | pages = 649–664 | date = November 2003 | pmid = 14753385 | doi = 10.1016/S0889-8561(03)00097-3 }}</ref><ref name="Hackett-Offit" /><ref name="Schneeweiss" />

Any experiment based on withholding vaccines from children is considered unethical,<ref>{{cite journal | vauthors = Deen JL, Clemens JD | title = Issues in the design and implementation of vaccine trials in less developed countries | journal = Nature Reviews. Drug Discovery | volume = 5 | issue = 11 | pages = 932–940 | date = November 2006 | pmid = 17080029 | doi = 10.1038/nrd2159 | s2cid = 413230 | doi-access = free }}</ref> and observational studies would likely be [[Confounding|confounded]] by differences in the healthcare-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.<ref name="Gerber" />

===Prenatal infection===
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, [[antibiotic]]s.<ref>{{cite journal | vauthors = Fineberg AM, Ellman LM | title = Inflammatory cytokines and neurological and neurocognitive alterations in the course of schizophrenia | journal = Biological Psychiatry | volume = 73 | issue = 10 | pages = 951–966 | date = May 2013 | pmid = 23414821 | pmc = 3641168 | doi = 10.1016/j.biopsych.2013.01.001 }}</ref> 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 [[influenza vaccine|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.<ref>{{cite journal | vauthors = Skowronski DM, De Serres G | title = Is routine influenza immunization warranted in early pregnancy? | journal = Vaccine | volume = 27 | issue = 35 | pages = 4754–4770 | date = July 2009 | pmid = 19515466 | doi = 10.1016/j.vaccine.2009.03.079 }}</ref> The CDC's [[Advisory Committee on Immunization Practices]], the [[American Congress of Obstetricians and Gynecologists|American College of Obstetricians and Gynecologists]], and the [[American Academy of Family Physicians]] all recommend routine flu shots for pregnant women, for several reasons:<ref name="ACIP2007" />
*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.<ref name="ACIP2007">{{cite journal | vauthors = Fiore AE, Shay DK, Haber P, Iskander JK, Uyeki TM, Mootrey G, Bresee JS, Cox NJ | title = Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2007 | journal = MMWR. Recommendations and Reports | volume = 56 | issue = RR-6 | pages = 1–54 | date = July 2007 | pmid = 17625497 | url = https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5606a1.htm }}</ref>

===Sudden infant death syndrome===
[[Sudden infant death syndrome]] (SIDS) is most common in infants around the time in life when they receive many vaccinations.<ref name="PediatricsSIDS2016">{{cite journal | vauthors = Moon RY | title = SIDS and Other Sleep-Related Infant Deaths: Evidence Base for 2016 Updated Recommendations for a Safe Infant Sleeping Environment | journal = Pediatrics | volume = 138 | issue = 5 | pages = e20162940 | date = November 2016 | pmid = 27940805 | doi = 10.1542/peds.2016-2940 | doi-access = free }}</ref> 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.<ref name="PediatricsSIDS2016"/> Several studies investigated this and found no evidence supporting a causal link between vaccination and SIDS.<ref name="PediatricsSIDS2016"/> In 2003, the [[Institute of Medicine]] favored rejection of a causal link to [[DTP vaccine|DTwP]] vaccination and SIDS after reviewing the available evidence.<ref>{{cite book | vauthors = Stratton K, Almario DA, Wizemann TM, McCormick MC | collaboration = Institute of Medicine (US) Immunization Safety Review Committee |title=Immunization Safety Review: Vaccinations and Sudden Unexpected Death in Infancy |date=2003 |publisher=National Academies Press (US) |location=Washington D.C. |pmid=25057654 |url=https://www.ncbi.nlm.nih.gov/books/NBK221466/pdf/Bookshelf_NBK221466.pdf|access-date=13 December 2019}}</ref> Additional analyses of [[VAERS]] data also showed no relationship between vaccination and SIDS.<ref name="PediatricsSIDS2016"/> Studies have shown a negative correlation between SIDs and vaccination. That is vaccinated children are less likely to die but no causal link has been found. One suggestion is that infants who are less likely to develop SIDS are more likely to be presented for vaccination.<ref name="PediatricsSIDS2016"/><ref name="Vennemann2007">{{cite journal | vauthors = Vennemann MM, Höffgen M, Bajanowski T, Hense HW, Mitchell EA | title = Do immunisations reduce the risk for SIDS? A meta-analysis | journal = Vaccine | volume = 25 | issue = 26 | pages = 4875–4879 | date = June 2007 | pmid = 17400342 | doi = 10.1016/j.vaccine.2007.02.077 }}</ref>

===Anthrax vaccines===
In the mid-1990s media reports on vaccines discussed the [[Gulf War Syndrome]], a multi-symptomatic disorder affecting returning US military veterans of the [[Gulf War|1990–1991 Persian Gulf War]]. Among the first articles of the online magazine [[Slate (magazine)|''Slate'']] was one by [[Atul Gawande]] in which the required immunizations received by soldiers, including an [[Anthrax vaccines|anthrax vaccination]], were named as one of the likely culprits for the symptoms associated with the Gulf War Syndrome. In the late 1990s ''Slate'' published an article on the "brewing rebellion" in the military against anthrax immunization because of "the availability to soldiers of vaccine misinformation on the Internet". ''Slate'' continued to report on concerns about the required anthrax and [[smallpox]] immunization for US troops after the [[September&nbsp;11 attacks]] and articles on the subject also appeared on the [[Salon (website)|''Salon'']] website.<ref name="hausman">{{cite book |title=Anti/Vax: Reframing the Vaccination Controversy | vauthors = Hausman BL |publisher=Cornell University Press |year=2019 |isbn=9781501735639 |pages=28, 39–42}}</ref> The [[2001 anthrax attacks]] heightened concerns about [[bioterrorism]] and the [[Federal government of the United States]] stepped up its efforts to store and create more vaccines for American citizens.<ref name=hausman/> In 2002, [[Mother Jones (magazine)|''Mother Jones'']] published an article that was highly skeptical of the anthrax and smallpox immunization required by the [[United States Armed Forces]].<ref name=hausman/> With the [[2003 invasion of Iraq]] a wider controversy ensued in the media about requiring US troops to be vaccinated against anthrax.<ref name=hausman/> From 2003 to 2008 a series of court cases were brought to oppose the compulsory anthrax vaccination of US troops.<ref name=hausman/>

===Swine flu vaccine===
[[File:President Ford receives a swine flu inoculation - NARA - 7064718.jpg|thumb|upright=1.3|U.S. President [[Gerald Ford]] receiving his vaccine for the swine flu]]

The US [[Swine influenza|swine flu]] immunization campaign in response to the [[1976 swine flu outbreak]] has become known as "the swine flu fiasco" because the outbreak did not lead to a [[pandemic]] as US President [[Gerald Ford]] had feared and the hastily rolled out vaccine was found to increase the number of [[Guillain–Barré Syndrome]] cases two weeks after immunization. Government officials stopped the mass immunization campaign due to great anxiety about the safety of the swine flu vaccine. The general public was left with greater fear of the [[vaccination|vaccination campaign]] than the virus itself, and vaccination policies, in general, were challenged.<ref name = "Chatterjee_2013">{{cite book | vauthors = Chatterjee A |title=Vaccinophobia and Vaccine Controversies of the 21st Century |publisher=Springer Science & Business Media |year=2013 |pages=8 |isbn=9781461474388}}</ref>{{rp|8}}

During the [[2009 flu pandemic]], significant controversy broke out regarding whether the [[2009 flu pandemic vaccine|2009 H1N1 flu vaccine]] was safe in, among other countries, [[France]]. Numerous different French groups publicly criticized the vaccine as potentially dangerous.<ref>{{cite journal | vauthors = Ward JK | title = Rethinking the antivaccine movement concept: A case study of public criticism of the swine flu vaccine's safety in France | journal = Social Science & Medicine | volume = 159 | pages = 48–57 | date = June 2016 | pmid = 27173740 | doi = 10.1016/j.socscimed.2016.05.003 }}</ref> Because of similarities between the 2009 [[Pandemic H1N1/09 virus|influenza A subtype H1N1 virus]] and the 1976 influenza A/NJ virus many countries established surveillance systems for vaccine-related adverse effects on human health. A possible link between the 2009 H1N1 flu vaccine and Guillain–Barré Syndrome cases was studied in Europe and the United States.<ref name = "Chatterjee_2013" />{{rp|325}}

===Blood transfusion===
After the introduction of [[COVID-19 vaccine]]s, vaccine hesitant people have at times demanded that they get donor blood from donors that have not received the vaccine. In the US and Canada, blood centers do not keep data on whether a donor has been COVID-19 infected or vaccinated, and in August 2021 it was estimated that 60-70% of US blood donors had COVID-19 antibodies.<ref name="Skeptical of coronavirus shots">{{cite news | vauthors = Aleccia JN |title=Skeptical of coronavirus shots, some patients demand blood transfusions only from the unvaccinated |url=https://www.washingtonpost.com/health/skeptical-of-coronavirus-shots-some-patients-demand-blood-transfusions-only-from-the-unvaccinated/2021/08/20/17635a9e-003f-11ec-ba7e-2cf966e88e93_story.html |access-date=9 December 2022 |newspaper=[[Washington Post]] |date=21 August 2021}}</ref><ref name="Doctors seeing resistance to blood transfusions">{{cite news | vauthors = Lee J |title=Doctors seeing resistance to blood transfusions over unfounded COVID vaccine concerns |url=https://www.cbc.ca/news/canada/calgary/alberta-blood-transfusions-resistance-covid-1.6613841 |access-date=9 December 2022 |work=[[CBC.ca]]|date=13 October 2022}}</ref> Research director [[Timothy Caulfield]] said that "This really highlights, I think, how powerful misinformation can be. It can really have an impact in a way that can be dangerous ... There is no evidence to support these concerns."<ref name="Covid misinformation ignites" /> The ''[[British Journal of Haematology]]'' called the trend "alarming" in 2021.<ref name="BJHaem on C19 and blood-transfusions, 2021" /> The chief medical officer of [[Blood Emergency Readiness Corps|ImpactLife]] said the same year that accepting such a demand "would be an operational can of worms for a medically unjustifiable request".<ref name="KFF on C19 and blood-transfusions, 2021">{{cite web |last1=Aleccia |first1=JoNel |title=‘Tainted’ Blood: Covid Skeptics Request Blood Transfusions From Unvaccinated Donors |url=https://kffhealthnews.org/news/article/tainted-blood-covid-skeptics-request-blood-transfusions-from-unvaccinated-donors/ |publisher=[[Kaiser Family Foundation|KFF]] |access-date=29 March 2025 |date=17 August 2021}}</ref>

As of August 2021, such demands were rare in the US.<ref name="Skeptical of coronavirus shots" /> As of 2024, the numbers are increasing.<ref name="CAP on C19 and blood tranfusions">{{cite web |last1=Urgun |first1=Kamran |last2=Mathur |first2=Gagan |title=Post-COVID-19 Blood Supply Challenges: Requests for Blood from… |url=https://www.cap.org/member-resources/articles/post-covid-19-blood-supply-challenges-requests-for-blood-from-unvaccinated-donors |publisher=[[College of American Pathologists]] |access-date=29 March 2025 |language=en-us |date=30 October 2024}}</ref> Doctors in Alberta, Canada, warned in November 2022 that the demands were becoming more common.<ref name="Covid misinformation ignites">{{cite web | vauthors = Robinson R |title=Covid misinformation ignites a battle over blood in a Canadian province |url=https://www.codastory.com/waronscience/covid-misinformation-ignites-a-battle-over-blood-in-a-canadian-province/ |website=[[Coda Media]] |access-date=9 December 2022 |date=16 November 2022}}</ref> The [[Association for the Advancement of Blood & Biotherapies]] (AABB) and the [[Canadian Blood Services]] have both issued guidance on how to respond to such demands.<ref name="BJHaem on C19 and blood-transfusions, 2021">{{cite journal |last1=Jacobs |first1=Jeremy W. |last2=Bibb |first2=Lorin A. |last3=Savani |first3=Bipin N. |last4=Booth |first4=Garrett S. |title=Refusing blood transfusions from COVID-19-vaccinated donors: are we repeating history? |journal=[[British Journal of Haematology]] |date=2022 |volume=196 |issue=3 |pages=585–588 |doi=10.1111/bjh.17842 |url=https://onlinelibrary.wiley.com/doi/10.1111/bjh.17842 |language=en |issn=1365-2141|pmc=8653055 }}</ref>

In Italy and [[Sue Grey (lawyer)#Baby W case|New Zealand]], parents have gone to court to stop their children's urgent heart surgery, unless COVID-19 vaccine free blood was provided. In both cases the parents were ruled against, though they stated that they could provide willing donors they found acceptable.<ref name="Italian parents lose appeal">{{cite news | vauthors = Barbarani S |title=Italian parents lose appeal over unvaccinated blood transfusion for child's surgery |url=https://www.independent.co.uk/news/world/europe/italy-unvaccinated-blood-child-heart-surgery-b2010414.html |access-date=9 December 2022 |work=[[The Independent]] |date=8 February 2022 |language=en}}</ref><ref>{{cite web |title=Blood donor case: Baby who had heart op against parents' wishes is 'doing well' |url=https://www.stuff.co.nz/national/health/300760872/blood-donor-case-baby-who-had-heart-op-against-parents-wishes-is-doing-well |website=[[Stuff (website)|Stuff]] |access-date=9 December 2022 |language=en |date=9 December 2022}}</ref><ref name="Donor blood case might deter">{{cite web | vauthors = Sommerville T |title=Donor blood case might deter some from taking kids to doctor - ethics professor |url=https://www.stuff.co.nz/national/130711032/donor-blood-case-might-deter-some-from-taking-kids-to-doctor--ethics-professor?rm=a&cx_rm-ctrl=true |website=[[Stuff (website)|Stuff]] |access-date=9 December 2022 |language=en |date=8 December 2022}}</ref> The [[New Zealand Blood Service]] does not label blood according to the donor's COVID-19 vaccine history,<ref name="Parents refuse use of 'vaccine-tainted' donor blood">{{cite news |title=Parents refuse use of 'vaccine-tainted' donor blood for baby's operation |url=https://www.jpost.com/international/article-724046 |access-date=11 December 2022 |work=[[The Jerusalem Post]] |date=4 December 2022}}</ref> and as of 2022, about 90% of New Zealand's population over twelve years of age has had two COVID-19 vaccinations.<ref name="New Zealand court takes guardianship">{{cite news | vauthors = Magramo K |title=New Zealand court takes guardianship of baby after parents refuse vaccinated blood for heart surgery |url=https://edition.cnn.com/2022/12/07/asia/new-zealand-covid-vaccine-donor-blood-baby-scn-intl-hnk/index.html |access-date=9 December 2022 |work=CNN |date=7 December 2022 |language=en}}</ref> In another Italian case, a blood transfusion for a sick 90-year-old man was refused by his two daughters, due to vaccine hesitancy concerns.<ref name="Italian parents lose appeal" /> Another New Zealand couple stated that they were trying to arrange their child to have her next heart surgery in India, to avoid her being given blood from COVID-19 vaccinated donors.<ref name="Second set of parents seeks">{{cite news | vauthors = Earley M |title=Second set of parents seeks 'unvaccinated' blood for baby's heart surgery |url=https://www.stuff.co.nz/national/health/130748678/second-set-of-parents-seeks-unvaccinated-blood-for-babys-heart-surgery |access-date=13 December 2022 |work=Stuff |date=13 December 2022 |language=en}}</ref>

===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 seizure]]s, [[allergy|allergies]], [[multiple sclerosis]], and [[autoimmune disease]]s such as [[diabetes mellitus type 1|type{{spaces}}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.<ref name="Marshall2013" /><ref name="Schneeweiss">{{cite journal | vauthors = Schneeweiss B, Pfleiderer M, Keller-Stanislawski B | title = Vaccination safety update | journal = Deutsches Ärzteblatt International | volume = 105 | issue = 34–35 | pages = 590–595 | date = August 2008 | pmid = 19471677 | pmc = 2680557 | doi = 10.3238/arztebl.2008.0590 }}</ref><ref name="Mailand2017">{{cite journal | vauthors = Mailand MT, Frederiksen JL | title = Vaccines and multiple sclerosis: a systematic review | journal = Journal of Neurology | volume = 264 | issue = 6 | pages = 1035–1050 | date = June 2017 | pmid = 27604618 | doi = 10.1007/s00415-016-8263-4 | s2cid = 4005599 }}</ref><ref name="Rewers2016">{{cite journal | vauthors = Rewers M, Ludvigsson J | title = Environmental risk factors for type 1 diabetes | journal = Lancet | volume = 387 | issue = 10035 | pages = 2340–2348 | date = June 2016 | pmid = 27302273 | pmc = 5571740 | doi = 10.1016/S0140-6736(16)30507-4 }}</ref> 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.<ref name="Hackett-Offit">{{cite journal | vauthors = Offit PA, Hackett CJ | title = Addressing parents' concerns: do vaccines cause allergic or autoimmune diseases? | journal = Pediatrics | volume = 111 | issue = 3 | pages = 653–659 | date = March 2003 | pmid = 12612250 | doi = 10.1542/peds.111.3.653 | s2cid = 10695185 | doi-access =  | author-link1 = Paul Offit }}</ref><ref name="Elwood2018">{{cite journal | vauthors = Elwood JM, Ameratunga R | title = Autoimmune diseases after hepatitis B immunization in adults: Literature review and meta-analysis, with reference to 'autoimmune/autoinflammatory syndrome induced by adjuvants' (ASIA) | journal = Vaccine | volume = 36 | issue = 38 | pages = 5796–5802 | date = September 2018 | pmid = 30100071 | doi = 10.1016/j.vaccine.2018.07.074 | type = Systematic Review & Meta-Analysis | s2cid = 51967163 }}</ref> 

Another common concern parents often have is about the pain associated with administering vaccines during a doctor's office visit.<ref name="Edwards2016" /> 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.<ref name="Smith2015" />

==Vaccine myths and misinformation==
Several vaccination myths 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.<ref name="Jacobson2020" />

Nevertheless, despite a major measles outbreak in the United States Southwest which began February 2025 in an area of Texas with low measles immunization rates—perhaps due in part to vaccine misinformation—in March of 2025, the U.S. [[National Institutes of Health]] and the [[Centers for Disease Control and Prevention]], under the direction of Secretary of Health and Human Services [[Robert F. Kennedy Jr.]], abruptly cancelled funding for over 40 research grants studying vaccine hesitancy.<ref>{{Cite news |last=Stein |first=Rob |date=March 12, 2025 |title=NIH cuts funding for vaccine-hesitancy research. mRNA research may be next |url=https://www.npr.org/2025/03/12/nx-s1-5325863/nih-trump-vaccine-hesitancy-mrna-research |access-date= |work=NPR |language=en}}</ref>
===Autism===
{{Main|Vaccines and autism}}

<!--summary at Vaccines and autism/Summary-->
The idea of a link between vaccines and autism has been extensively investigated and conclusively shown to be false.<ref name="Vaccines are not associated with au">{{cite journal |vauthors=Taylor LE, Swerdfeger AL, Eslick GD |date=June 2014 |title=Vaccines are not associated with autism: an evidence-based meta-analysis of case-control and cohort studies |journal=Vaccine |volume=32 |issue=29 |pages=3623–3629 |doi=10.1016/j.vaccine.2014.04.085 |pmid=24814559}}</ref><ref name="Smith2017">{{cite journal |vauthors=Smith IM, MacDonald NE |date=August 2017 |title=Countering evidence denial and the promotion of pseudoscience in autism spectrum disorder |journal=Autism Research |type=Review |volume=10 |issue=8 |pages=1334–1337 |doi=10.1002/aur.1810 |pmid=28544626 |s2cid=205456548}}</ref> The [[scientific consensus]] is that there is no relationship, causal or otherwise, between vaccines and incidence of autism,<ref name="BH" /><ref>{{cite news |date=February 2, 2010 |title=Lancet retracts 'utterly false' MMR paper |url=https://www.theguardian.com/society/2010/feb/02/lancet-retracts-mmr-paper |access-date=February 2, 2010 |work=The Guardian |vauthors=Boseley S}}</ref><ref name="Vaccines are not associated with au" /> and vaccine ingredients do not cause autism.<ref>{{cite web |date=2018-12-12 |title=Vaccines Do Not Cause Autism Concerns |url=https://www.cdc.gov/vaccinesafety/concerns/autism.html |access-date=2019-02-07 |website=Centers for Disease Control and Prevention |language=en-us}}</ref>

Nevertheless, the anti-vaccination movement continues to promote myths, [[conspiracy theory|conspiracy theories]], and misinformation linking the two.<ref>{{cite journal |date=February 2019 |title=How autism myths came to fuel anti-vaccination movements |url=https://www.popsci.com/timeline-autism-myth-anti-vaccine |journal=Popular Science |language=en}}</ref> 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", to quote the ''[[Skeptical Inquirer]]''.<ref>{{cite journal |vauthors=Foster CA, Ortiz SM |date=2017 |title=Vaccines, Autism, and the Promotion of Irrelevant Research: A Science-Pseudoscience Analysis |url=https://www.csicop.org/si/show/vaccines_autism_and_the_promotion_of_irrelevant_research_a_science-pseudosc |url-status=dead |journal=[[Skeptical Inquirer]] |volume=41 |issue=3 |pages=44–48 |archive-url=https://web.archive.org/web/20181006204019/https://www.csicop.org/si/show/vaccines_autism_and_the_promotion_of_irrelevant_research_a_science-pseudosc |archive-date=2018-10-06 |access-date=6 October 2018}}</ref>

===Vaccination during illness===
Many parents are concerned about the safety of vaccination when their child is sick.<ref name="Smith2015" /> Moderate to severe acute illness with or without a fever is indeed a precaution when considering vaccination.<ref name="Smith2015" /> Vaccines remain effective during childhood illness.<ref name="Smith2015" /> 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 the progression of the illness.<ref name="Smith2015" /> It is safe to administer vaccines to well-appearing children who are mildly ill with the [[common cold]].<ref name="Smith2015" />

===Natural infection===
Another common anti-vaccine myth is that the [[immune system]] produces a better immune protection in response to natural infection when compared to vaccination.<ref name="Smith2015" /> However, strength and duration of immune protection gained varies by both disease and vaccine, with some vaccines giving better protection than natural infection.  For example, the [[HPV vaccine]] generates better immune protection than natural infection due to the vaccine containing higher concentrations of a viral coat protein, while also not containing proteins the [[HPV]] viruses use to inhibit immune response.<ref name="CNN_2020-10-20">{{cite news |date=2020-10-20 |title=A vaccine can provide better immunity than an actual infection. Here's why. |url=https://edition.cnn.com/2020/10/02/health/vaccine-better-immunity-than-infection-wellness-partner/index.html |newspaper=[[CNN]] |quote=For instance, the human papillomavirus (HPV) vaccine elicits a stronger immune response than infection by the virus itself. One reason for this is that the vaccine contains high concentrations of a viral coat protein, more than what would occur in a natural infection. This triggers strongly neutralizing antibodies, making the vaccine very effective at preventing infection. The natural immunity against HPV is especially weak, as the virus uses various tactics to evade the host immune system. Many viruses, including HPV, have proteins that block the immune response or simply lie low to avoid detection. Indeed, a vaccine that provides accessible antigens in the absence of these other proteins may allow us to control the response in a way that a natural infection does not. |vauthors=Shivkumar M}}</ref>

While it is true that infection with certain illnesses may produce lifelong [[Immunity (medical)|immunity]], many natural infections do not produce lifelong immunity, while carrying a higher risk of harming a person's health than vaccines.<ref name="Smith2015" /> For example, natural [[varicella]] infection carries a higher risk of bacterial superinfection with [[Group A streptococci]].<ref name="Smith2015" />

Natural [[measles]] infection carries a high risk of many serious, and sometimes life-long, complications, all of which can be avoided by vaccination. Those infected with measles rarely have a symptomatic reinfection.<ref>{{cite journal |author1=Centers for Disease Control (CDC) |date=May 1982 |title=Recommendation of the Immunization Practices Advisory Committee (ACIP). Measles prevention |url=https://www.cdc.gov/mmwr/preview/mmwrhtml/00001090.htm |journal=MMWR. Morbidity and Mortality Weekly Report |volume=31 |issue=17 |pages=217–224, 229–231 |pmid=6804783}}</ref>

Most people survive measles, though in some cases, complications may occur. Among those that experience complications, about 1 in 4 individuals will be hospitalized and 1–2 in 1000 will die. Complications are more likely in children under age 5 and adults over age 20.<ref>{{cite web |date=25 February 2019 |title=Measles Complications |url=https://www.cdc.gov/measles/about/complications.html |access-date=14 May 2019 |website=[[Centers for Disease Control and Prevention]] (CDC)}}</ref> [[Pneumonia]] is the most common fatal complication of measles infection and accounts for 56–86% of measles-related deaths.<ref>{{cite journal |vauthors=Di Pietrantonj C, Rivetti A, Marchione P, Debalini MG, Demicheli V |date=November 2021 |title=Vaccines for measles, mumps, rubella, and varicella in children |journal=The Cochrane Database of Systematic Reviews |volume=2021 |issue=11 |pages=CD004407 |doi=10.1002/14651858.CD004407.pub5 |pmc=8607336 |pmid=34806766}}</ref>

Possible consequences of measles virus infection include [[laryngotracheobronchitis]], [[sensorineural hearing loss]],<ref name="Cohen2014">{{cite journal |vauthors=Cohen BE, Durstenfeld A, Roehm PC |date=July 2014 |title=Viral causes of hearing loss: a review for hearing health professionals |journal=Trends in Hearing |volume=18 |pages=2331216514541361 |doi=10.1177/2331216514541361 |pmc=4222184 |pmid=25080364}}</ref> and—in about 1 in 10,000 to 1 in 300,000 cases<ref name="Noyce2012">{{cite journal |vauthors=Noyce RS, Richardson CD |date=September 2012 |title=Nectin 4 is the epithelial cell receptor for measles virus |journal=Trends in Microbiology |volume=20 |issue=9 |pages=429–439 |doi=10.1016/j.tim.2012.05.006 |pmid=22721863}}</ref>—[[Subacute sclerosing panencephalitis|panencephalitis]], which is usually fatal.<ref name="ninds.nih.gov">{{cite web |title=NINDS Subacute Sclerosing Panencephalitis Information Page |url=http://www.ninds.nih.gov/disorders/subacute_panencephalitis/subacute_panencephalitis.htm |url-status=live |archive-url=https://web.archive.org/web/20141017073411/http://www.ninds.nih.gov/disorders/subacute_panencephalitis/subacute_panencephalitis.htm |archive-date=2014-10-17 |access-date=2018-03-26}} "NINDS Subacute Sclerosing Panencephalitis Information Page"</ref> Acute measles encephalitis is another serious risk of measles virus infection. It typically occurs two days to one week after the measles [[exanthem|rash]] breaks out and begins with very high fever, severe headache, [[convulsion]]s and altered mentation. A person with measles encephalitis may become [[coma]]tose, and death or brain injury may occur.<ref>{{MerckManual|14|193|b|}}</ref>

The measles virus can deplete previously acquired [[Immunological memory|immune memory]] by killing cells that make antibodies, and thus weakens the immune system which can cause deaths from other diseases.<ref name="Amnesia">{{cite web |date=18 May 2019 |title=Measles and Immune Amnesia |url=https://asm.org/Articles/2019/May/Measles-and-Immune-Amnesia |url-status=live |archive-url=https://archive.today/20200118042959/https://asm.org/Articles/2019/May/Measles-and-Immune-Amnesia |archive-date=18 January 2020 |access-date=18 January 2020 |website=asm.org |publisher=American Society for Microbiology |vauthors=Griffin AH}}</ref><ref name="Mina 2019">{{cite journal |vauthors=Mina MJ, Kula T, Leng Y, Li M, de Vries RD, Knip M, Siljander H, Rewers M, Choy DF, Wilson MS, Larman HB, Nelson AN, Griffin DE, de Swart RL, Elledge SJ |date=November 2019 |title=Measles virus infection diminishes preexisting antibodies that offer protection from other pathogens |journal=Science |volume=366 |issue=6465 |pages=599–606 |bibcode=2019Sci...366..599M |doi=10.1126/science.aay6485 |pmc=8590458 |pmid=31672891 |doi-access=free}}</ref><ref name="Nature">{{cite journal |vauthors=Guglielmi G |date=October 2019 |title=Measles erases immune 'memory' for other diseases |journal=Nature |doi=10.1038/d41586-019-03324-7 |pmid=33122832 |s2cid=208489179}}</ref> [[immunosuppression|Suppression of the immune system]] by measles lasts about two years and has been epidemiologically implicated in up to 90% of childhood deaths in [[Third World|third world]] countries, and historically may have caused rather more deaths in the United States, the UK and Denmark than were directly caused by measles.<ref name="pmid25954009">{{cite journal |vauthors=Mina MJ, Metcalf CJ, de Swart RL, Osterhaus AD, Grenfell BT |date=May 2015 |title=Long-term measles-induced immunomodulation increases overall childhood infectious disease mortality |journal=Science |volume=348 |issue=6235 |pages=694–699 |bibcode=2015Sci...348..694M |doi=10.1126/science.aaa3662 |pmc=4823017 |pmid=25954009 |doi-access=free}}</ref> Although the measles vaccine contains an attenuated strain, it does not deplete immune memory.<ref name="Mina 2019" />

===HPV vaccine===
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, the incidence of [[sexually transmitted infection]], or [[contraceptive]] counseling regardless of whether they received the HPV vaccine.<ref name="Smith2015" /> Thousands of Americans die each year from cancers preventable by the vaccine.<ref name="Smith2015" />

There remains a disproportionate rate of HPV-related cancers amongst [[Latinx|LatinX]] populations, leading researchers to explore how messaging may be made more effective to address vaccine hesitancy.<ref>{{cite journal |vauthors=Reno JE, Dempsey AF |date=April 2023 |title=Promoting HPV vaccination among Latinx: an application of the extended parallel processing model |journal=Journal of Behavioral Medicine |volume=46 |issue=1–2 |pages=324–334 |doi=10.1007/s10865-022-00293-7 |pmid=35178652 |s2cid=246905792}}</ref>

===Vaccine schedule===
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.<ref name="Smith2015" /> Receiving vaccines on the schedule recommended by the ACIP is not linked to autism or developmental delay.<ref name="Smith2015" />

=== Information warfare ===
An analysis of [[Twitter#Tweets|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 [[Russian interference in the 2016 United States elections|interference in the 2016 U.S. elections]], to sow discord about the safety of vaccines.<ref name="WeaponizedHealthCommunication">{{cite journal |vauthors=Broniatowski DA, Jamison AM, Qi S, AlKulaib L, Chen T, Benton A, Quinn SC, Dredze M |date=October 2018 |title=Weaponized Health Communication: Twitter Bots and Russian Trolls Amplify the Vaccine Debate |journal=American Journal of Public Health |volume=108 |issue=10 |pages=1378–1384 |doi=10.2105/AJPH.2018.304567 |pmc=6137759 |pmid=30138075}}</ref><ref>{{cite news |date=23 August 2018 |title=Russian trolls 'spreading discord' over vaccine safety online |url=https://www.theguardian.com/society/2018/aug/23/russian-trolls-spread-vaccine-misinformation-on-twitter |access-date=23 August 2018 |work=The Guardian |vauthors=Glenza J}}</ref> The campaign used sophisticated [[Twitter bots]] to amplify polarizing pro-vaccine and anti-vaccine messages, containing the hashtag #VaccinateUS, posted by IRA trolls.<ref name="WeaponizedHealthCommunication" />

Throughout 2020 and 2021, the [[ChinaAngVirus disinformation campaign|United States ran a propaganda campaign]] to spread disinformation about the [[Sinovac Biotech|Sinovac]] Chinese COVID-19 vaccine, including using fake social media accounts to spread the disinformation that the Sinovac vaccine contained pork-derived ingredients and was therefore ''[[haram]]'' under [[Sharia|Islamic law]].<ref name=":632">{{Cite news |last1=Bing |first1=Chris |last2=Schechtman |first2=Joel |date=June 14, 2024 |title=Pentagon Ran Secret Anti-Vax Campaign to Undermine China during Pandemic |url=https://www.reuters.com/investigates/special-report/usa-covid-propaganda/ |work=[[Reuters]]|archive-url=https://web.archive.org/web/20240623141032/https://www.reuters.com/investigates/special-report/usa-covid-propaganda/|archive-date=23 June 2024|url-status=live}}</ref> The campaign primarily targeted people in the [[Philippines]] and used a social media [[hashtag]] for "China is the virus" in [[Tagalog language|Tagalog]].<ref name=":632" />

==Alternative medicine==
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 seeds of the modern anti-vaccination movement.<ref>{{cite web |date=August 2019 |title=What the Measles Epidemic Really Says About America |url=https://www.theatlantic.com/magazine/archive/2019/08/measles-as-metaphor/592756/ |access-date=July 8, 2019 |website=The Atlantic |vauthors=Beinart P}}</ref> More specifically, some elements of the [[chiropractic]] community, some [[homeopathy|homeopaths]], and [[naturopathy|naturopaths]] developed anti-vaccine rhetoric.<ref name="Ernst" /> 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.<ref name="Ernst" />

===Chiropractic===
{{main|Anti-vaccinationism in chiropractic}}

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 David Palmer|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."<ref name="Busse">{{cite journal |vauthors=Busse JW, Morgan L, Campbell JB |date=June 2005 |title=Chiropractic antivaccination arguments |journal=Journal of Manipulative and Physiological Therapeutics |volume=28 |issue=5 |pages=367–373 |doi=10.1016/j.jmpt.2005.04.011 |pmid=15965414}}</ref> Vaccination remains controversial within the profession.<ref name="Campbell">{{cite journal |vauthors=Campbell JB, Busse JW, Injeyan HS |date=April 2000 |title=Chiropractors and vaccination: A historical perspective |journal=Pediatrics |volume=105 |issue=4 |pages=E43 |doi=10.1542/peds.105.4.e43 |pmid=10742364 |s2cid=14561867 |doi-access=}}</ref> Most chiropractic writings on vaccination focus on its negative aspects.<ref name="Busse" /> A 1995 survey of US chiropractors found that about one third believed there was no scientific proof that immunization prevents disease.<ref name="Campbell" /> While the Canadian Chiropractic Association supports vaccination,<ref name="Busse" /> 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.<ref>{{cite journal |vauthors=Russell ML, Injeyan HS, Verhoef MJ, Eliasziw M |date=December 2004 |title=Beliefs and behaviours: understanding chiropractors and immunization |journal=Vaccine |volume=23 |issue=3 |pages=372–379 |doi=10.1016/j.vaccine.2004.05.027 |pmid=15530683}}</ref>

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.<ref name="Campbell" /> 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.<ref>{{cite journal |vauthors=Busse JW, Wilson K, Campbell JB |date=November 2008 |title=Attitudes towards vaccination among chiropractic and naturopathic students |journal=Vaccine |volume=26 |issue=49 |pages=6237–6243 |doi=10.1016/j.vaccine.2008.07.020 |pmid=18674581}}</ref> 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".<ref>{{cite journal |vauthors=Lameris M, Schmidt C, Gleberzon B, Ogrady J |date=September 2013 |title=Attitudes toward vaccination: A cross-sectional survey of students at the Canadian Memorial Chiropractic College |journal=The Journal of the Canadian Chiropractic Association |volume=57 |issue=3 |pages=214–220 |pmc=3743647 |pmid=23997247}}</ref>

====Policy positions====
The [[American Chiropractic Association]] and the International Chiropractic Association support individual exemptions to compulsory vaccination laws.<ref name="Campbell" /> In March 2015, the Oregon Chiropractic Association invited [[Andrew Wakefield]], chief author of a [[MMR vaccine controversy|fraudulent research paper]], to testify against Senate Bill 442,<ref name="Yoo">{{Citation |title=Vaccine researcher Wakefield to testify in Oregon |vauthors=Yoo S |date=February 24, 2015 |work=[[Statesman Journal]] |url=http://www.statesmanjournal.com/story/news/health/2015/02/24/andrew-wakefield-vaccine-oregon/23967797/ |access-date=March 3, 2015}}</ref> "a bill that would eliminate nonmedical exemptions from Oregon's school immunization law".<ref name="Yoo_canceled">{{Citation |title=Meeting on vaccine mandate bill canceled |vauthors=Yoo S |date=February 26, 2015 |work=Statesman Journal |url=http://www.statesmanjournal.com/story/news/health/2015/02/25/meeting-vaccine-mandate-bill-canceled/24020213/ |access-date=March 3, 2015}}</ref> 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.<ref name="Mason">
{{cite web |date=March 5, 2015 |title=Chiropractors lobby against bill ending belief exemptions for vaccines |url=https://www.latimes.com/local/political/la-me-pc-vaccine-bill-chiropractors-20150305-story.html |access-date=March 6, 2015 |work=Los Angeles Times |vauthors=Mason M}}
</ref>

===Homeopathy===
{{See also|Homeopathy Plus!}}

Several surveys have shown that some practitioners of [[homeopathy]], particularly homeopaths without any medical training, advise patients against vaccination.<ref>{{cite journal |vauthors=Schmidt K, Ernst E |date=March 2003 |title=MMR vaccination advice over the Internet |journal=Vaccine |volume=21 |issue=11–12 |pages=1044–1047 |doi=10.1016/S0264-410X(02)00628-X |pmid=12559777}}</ref> 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.<ref name="Ernst" /> Many practitioners of [[naturopathy]] also oppose vaccination.<ref name="Ernst" />

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.<ref name="SciMed">{{cite web |author-link=Mark Crislip |date=November 5, 2010 |title=Homeopathic Vaccines |url=http://www.sciencebasedmedicine.org/?p=8003 |vauthors=Crislip M}}</ref> 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."<ref name="StopNosodes">{{cite web |last=Stop Nosodes/[[Bad Science Watch]] |date=August 2015 |title=Nosode Use in Canada |url=http://www.stopnosodes.org/the-problem/the-extent-of-nosode-use-in-canada/ |url-status=usurped |archive-url=https://web.archive.org/web/20161026005548/http://www.stopnosodes.org/the-problem/the-extent-of-nosode-use-in-canada/ |archive-date=October 26, 2016 |access-date=October 20, 2015}}</ref>

=== Financial motives ===
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 medicine|hyperbaric oxygen therapy]], sold as able to cure the 'damage' caused by vaccines.<ref>{{cite book |title=The Autism Spectrum Disorders / vaccine link debate: a health social movement |vauthors=Kerr MA |publisher=University of Pittsburgh |year=2009 |pages=194–203 |chapter=Movement impact |access-date=2010-02-25 |chapter-url=http://etd.library.pitt.edu/ETD/available/etd-04302009-115908/unrestricted/Kerr_FINAL.pdf |archive-url=https://web.archive.org/web/20110718173710/http://etd.library.pitt.edu/ETD/available/etd-04302009-115908/unrestricted/Kerr_FINAL.pdf |archive-date=July 18, 2011}}</ref> Homeopaths in particular gain through the promotion of water injections or 'nosodes' that they allege have a 'natural' vaccine-like effect.<ref>{{cite news |title=Health experts question lack of crackdown on 'homeopathic vaccines' |url=https://www.theglobeandmail.com/news/national/health-experts-question-lack-of-crackdown-on-homeopathic-vaccines/article23019800/ |access-date=July 4, 2015 |website=The Globe and Mail |vauthors=Weeks C}}</ref> 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.<ref name="wolfesharp" /> In the late 20th century, vaccines were a product with low [[profit margin]]s,<ref name="Sheridan">{{cite journal |vauthors=Sheridan C |date=June 2009 |title=Vaccine market boosters |journal=Nature Biotechnology |volume=27 |issue=6 |pages=499–501 |doi=10.1038/nbt0609-499 |pmid=19513043 |s2cid=205268563}}</ref> 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.<ref>{{cite book |title=Vaccine: the Controversial Story of Medicine's Greatest Lifesaver |vauthors=Allen A |publisher=W.W. Norton |year=2007 |isbn=978-0-393-05911-3 |pages=421–42 |chapter=Epilogue: our best shots |chapter-url=https://archive.org/details/vaccinecontrover00arth}}</ref> In the early 21st century, the vaccine market greatly improved with the approval of the vaccine [[Pneumococcal conjugate vaccine|Prevnar]], along with a small number of other high-priced [[Pharmaceutical drug#Blockbuster drug|blockbuster vaccines]], such as [[Gardasil]] and [[Pediarix]], which each had sales revenues of over $1 billion in 2008.<ref name="Sheridan" /> 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]].<ref>{{cite web |title=Global Vaccine Market Features and Trends |url=https://www.who.int/influenza_vaccines_plan/resources/session_10_kaddar.pdf |vauthors=Kaddar M}}</ref>

== Psychological factors ==
The rise in vaccine hesitancy has led to research on the psychology of those who actively oppose vaccines. The largest psychological factors leading to anti-vaccination attitudes are [[Conspiracy theory|conspiratorial thinking]], [[Reactance (psychology)|reactance]], disgust regarding blood or needles, and individualistic or hierarchical worldviews. In contrast, demographic variables are not significant.<ref>{{cite journal | vauthors = Hornsey MJ, Harris EA, Fielding KS | title = The psychological roots of anti-vaccination attitudes: A 24-nation investigation | journal = Health Psychology | volume = 37 | issue = 4 | pages = 307–315 | date = April 2018 | pmid = 29389158 | doi = 10.1037/hea0000586 | s2cid = 3965857 }}</ref>

Researchers have also investigated the psychological roots of vaccine hesitancy with regard to specific vaccines. For instance, a 2021 study published in ''[[Nature Communications]]'' investigated psychological characteristics associated with COVID-19 vaccine hesitancy and resistance in Ireland and the UK. The study found that vaccine hesitant or resistant respondents in the two countries varied across socio-demographic and health-related variables, however, they were similar in range of psychological factors. Such respondents were less likely to obtain information about the pandemic from authoritative and traditional media sources and demonstrated similar skepticism towards these sources compared to respondents who accepted the vaccine.<ref>{{cite journal | vauthors = Murphy J, Vallières F, Bentall RP, Shevlin M, McBride O, Hartman TK, McKay R, Bennett K, Mason L, Gibson-Miller J, Levita L, Martinez AP, Stocks TV, Karatzias T, Hyland P | title = Psychological characteristics associated with COVID-19 vaccine hesitancy and resistance in Ireland and the United Kingdom | journal = Nature Communications | volume = 12 | issue = 1 | pages = 29 | date = January 2021 | pmid = 33397962 | pmc = 7782692 | doi = 10.1038/s41467-020-20226-9 | bibcode = 2021NatCo..12...29M }}</ref>

=== Fear of needles ===
[[Blood-injection-injury phobia]] and general [[fear of needles]] and injections can lead people to avoid vaccinations. One survey conducted in January and February 2021 estimated this was responsible for 10% of the COVID-19 vaccine hesitancy in the UK at the time.<ref name="Freeman">{{cite news| vauthors = Freeman D |date=16 June 2021|title=Needle phobia could be the cause of 10% of COVID vaccine hesitancy in the UK – new research|website=[[The Conversation (website)|The Conversation]]|url=https://theconversation.com/needle-phobia-could-be-the-cause-of-10-of-covid-vaccine-hesitancy-in-the-uk-new-research-162678}}</ref><ref name="Freeman_2021">{{cite journal | vauthors = Freeman D, Loe BS, Yu LM, Freeman J, Chadwick A, Vaccari C, Shanyinde M, Harris V, Waite F, Rosebrock L, Petit A, Vanderslott S, Lewandowsky S, Larkin M, Innocenti S, Pollard AJ, McShane H, Lambe S | title = Effects of different types of written vaccination information on COVID-19 vaccine hesitancy in the UK (OCEANS-III): a single-blind, parallel-group, randomised controlled trial | journal = The Lancet. Public Health | volume = 6 | issue = 6 | pages = e416–e427 | date = June 2021 | pmid = 33991482 | pmc = 8116130 | doi = 10.1016/S2468-2667(21)00096-7 }}</ref> A 2012 survey of American parents found that a fear of needles was the most common reason for adolescents to forgo their second dose of a [[HPV vaccine]].<ref name="Baxter">{{cite web| vauthors = Baxter A |date=11 Jun 2021|title=Over half of adults unvaccinated for COVID-19 fear needles – here's what's proven to help|url=https://theconversation.com/over-half-of-adults-unvaccinated-for-covid-19-fear-needles-heres-whats-proven-to-help-161636|website=[[The Conversation (website)|The Conversation]]}}</ref><ref name="Clark_2016">{{cite journal | vauthors = Clark SJ, Cowan AE, Filipp SL, Fisher AM, Stokley S | title = Understanding Non-Completion of the Human Papillomavirus Vaccine Series: Parent-Reported Reasons for Why Adolescents Might Not Receive Additional Doses, United States, 2012 | journal = Public Health Reports | volume = 131 | issue = 3 | pages = 390–395 | date = 1 May 2016 | pmid = 27252558 | pmc = 4869083 | doi = 10.1177/003335491613100304 }}</ref>

Various [[Fear of needles#Treatment, mitigation, and alternatives|treatments for fear of needles]] can help overcome this problem, from offering pain reduction at the time of injection to long-term behavioral therapy.<ref name="Baxter" /> Tensing the stomach muscles can help avoid [[fainting]], swearing can reduce perceived pain, and distraction can also improve the perceived experience, such as by pretending to cough, performing a visual task, watching a video, or playing a video game.<ref name="Baxter" />
To avoid dissuading people who have a needle phobia, vaccine update researchers recommend against using pictures of needles, people getting an injection, or faces displaying negative emotions (like a crying baby) in promotional materials. Instead, they recommend medically accurate photos depicting smiling, diverse people with bandages, vaccination cards, or a rolled-up sleeve; depicting vials instead of needles; and depicting the people who develop and test vaccines.<ref name="Seale_2021">{{cite web| vauthors = Seale H, Kaufman J |date=8 April 2021|title=Pictures of COVID injections can scare the pants off people with needle phobias. Use these instead|url=https://theconversation.com/pictures-of-covid-injections-can-scare-the-pants-off-people-with-needle-phobias-use-these-instead-157963|website=[[The Conversation (website)|The Conversation]]}}</ref> Development of vaccines that can be administered orally or with a [[jet injector]] can also avoid triggering the fear of needles.<ref name="Apostolopoulos_2020">{{cite web| vauthors = Apostolopoulos V, Husaric M, de Courten M |date=30 September 2020|title=A COVID-19 vaccine may come without a needle, the latest vaccine to protect without jabbing|url=https://theconversation.com/a-covid-19-vaccine-may-come-without-a-needle-the-latest-vaccine-to-protect-without-jabbing-146564|website=[[The Conversation (website)|The Conversation]]}}</ref>

== Social factors ==
Beyond misinformation, social and economic conditions also influence how many people take vaccines. Factors such as income, [[socioeconomic status]], ethnicity, age, and education can determine the uptake of vaccines and their impact, especially among vulnerable communities.<ref>{{Cite journal |last1=Vardavas |first1=Constantine |last2=Nikitara |first2=Katerina |last3=Aslanoglou |first3=Katerina |last4=Lagou |first4=Ioanna |last5=Marou |first5=Valia |last6=Phalkey |first6=Revati |last7=Leonardi-Bee |first7=Jo |last8=Fernandez |first8=Esteve |last9=Vivilaki |first9=Victoria |last10=Kamekis |first10=Apostolos |last11=Symvoulakis |first11=Emmanouil |last12=Noori |first12=Teymur |last13=Wuerz |first13=Andrea |last14=Suk |first14=Jonathan E. |last15=Deogan |first15=Charlotte |date=October 2023 |title=Social determinants of health and vaccine uptake during the first wave of the COVID-19 pandemic: A systematic review |journal=Preventive Medicine Reports |language=en |volume=35 |pages=102319 |doi=10.1016/j.pmedr.2023.102319 |pmc=10410576 |pmid=37564118}}</ref>

Social factors like whether one lives with others may affect vaccine uptake. For example, older individuals who live alone are much more likely not to take up vaccines compared to those living with other people.<ref>{{Cite journal |last1=Jain |first1=Anu |last2=van Hoek |first2=A.J. |last3=Boccia |first3=Delia |last4=Thomas |first4=Sara L. |date=7 April 2017 |title=Lower vaccine uptake amongst older individuals living alone: A systematic review and meta-analysis of social determinants of vaccine uptake |journal=Vaccine |language=en |volume=35 |issue=18 |pages=2315–2328 |doi=10.1016/j.vaccine.2017.03.013|pmid=28343775 |doi-access=free }}</ref> Other factors may be racial, with minority groups being affected by low vaccine uptake.<ref>{{Cite journal |last1=Yang |first1=Lawrence H. |last2=Link |first2=Bruce G. |last3=Susser |first3=Ezra S. |date=2021-12-01 |title=Examining Power Relations to Understand and Address Social Determinants of Vaccine Uptake |url=https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2784107 |journal=JAMA Psychiatry |language=en |volume=78 |issue=12 |pages=1303–1304 |doi=10.1001/jamapsychiatry.2021.2497 |pmid=34495319 |issn=2168-622X|url-access=subscription }}</ref>

People with [[Immunodeficiency|weaker immune systems]] or [[Chronic condition|chronic illness]] are more likely to take up a vaccine if recommended by their physicians.<ref>{{Cite journal |last1=Doornekamp |first1=Laura |last2=van Leeuwen |first2=Leanne |last3=van Gorp |first3=Eric |last4=Voeten |first4=Helene |last5=Goeijenbier |first5=Marco |date=2020-08-27 |title=Determinants of Vaccination Uptake in Risk Populations: A Comprehensive Literature Review |journal=Vaccines |language=en |volume=8 |issue=3 |pages=480 |doi=10.3390/vaccines8030480 |doi-access=free |issn=2076-393X |pmc=7563537 |pmid=32867126}}</ref>

== Other reasons ==

=== Unethical human experimentation and medical racism ===
Some people in groups experiencing [[medical racism]] are less willing to trust doctors and modern medicine due to real historical incidents of [[unethical human experimentation]] and [[involuntary sterilization]]. Famous examples include [[Unethical human experimentation#International drug trials|drug trials in Africa]] without informed consent, the [[Guatemala syphilis experiments]],<ref>{{cite journal |vauthors=Lin C, Tu P, Terry TC |date=January 2022 |title=Moving the needle on racial disparity: COVID-19 vaccine trust and hesitancy |journal=Vaccine |volume=40 |issue=1 |pages=5–8 |doi=10.1016/j.vaccine.2021.11.010 |pmc=8604693 |pmid=34839990}}</ref><ref>{{cite journal |vauthors=Rodriguez MA, García R |date=December 2013 |title=First, do no harm: the US sexually transmitted disease experiments in Guatemala |journal=American Journal of Public Health |volume=103 |issue=12 |pages=2122–2126 |doi=10.2105/AJPH.2013.301520 |pmc=3828982 |pmid=24134370}}</ref> the [[Tuskegee Syphilis Study]], the culturing of cells from [[Henrietta Lacks]] without consent, and [[Nazi human experimentation]].

To overcome this type of distrust, experts recommend including representative samples of majority and minority populations in drug trials, including minority groups in study design, being diligent about informed consent, and being transparent about the process of drug design and testing.<ref>{{cite web |date=28 Dec 2020 |title=Fueled by a History of Mistreatment, Black Americans Distrust the New COVID-19 Vaccines |url=https://time.com/5925074/black-americans-covid-19-vaccine-distrust/ |vauthors=Kum D |magazine=Time}}</ref>

=== Malpractice and fraud ===

==== CIA fake vaccination clinic ====
{{main|CIA Vaccination Cover in Pakistan}}
In Pakistan, the [[Central Intelligence Agency|CIA]] ran a fake vaccination clinic in an attempt to locate [[Osama bin Laden]].<ref name="Kennedy_2017">{{cite journal |vauthors=Kennedy J |date=October 2017 |title=How Drone Strikes and a Fake Vaccination Program Have Inhibited Polio Eradication in Pakistan: An Analysis of National Level Data |url=http://qmro.qmul.ac.uk/xmlui/handle/123456789/25135 |journal=International Journal of Health Services |volume=47 |issue=4 |pages=807–825 |doi=10.1177/0020731417722888 |pmid=28764582 |s2cid=25844860}}</ref><ref>{{cite news |date=2012-07-09 |title=C.I.A. Vaccine Ruse May Have Harmed the War on Polio |url=https://www.nytimes.com/2012/07/10/health/cia-vaccine-ruse-in-pakistan-may-have-harmed-polio-fight.html |access-date=2020-07-03 |work=The New York Times |language=en-US |issn=0362-4331 |vauthors=McNeil Jr DG}}</ref> 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.<ref>{{cite news |date=January 23, 2018 |title=Pakistan Raises Its Guard After 2 Polio Vaccinators Are Gunned Down |url=https://www.npr.org/sections/goatsandsoda/2018/01/23/580002283/pakistan-raises-its-guard-after-two-polio-vaccinators-are-gunned-down |newspaper=NPR |vauthors=Aizenman N}}</ref> Efforts to eradicate polio have furthermore been disrupted by [[Drone strikes in Pakistan|American drone strikes]].<ref name="Kennedy_2017" /> Pakistan is among the only countries where polio remained endemic as of 2015.<ref name="Iqbal 2021">{{cite web |date=1 February 2021 |title=How the CIA's fake Hepatitis B vaccine program in Pakistan helped fuel vaccine distrust |url=https://www.vox.com/first-person/22256595/vaccine-covid-pakistan-cia-program |access-date=19 February 2023 |website=Vox |vauthors=Iqbal H}}</ref>

==== Fake COVID-19 vaccines ====
In July 2021, Indian police arrested 14 people for administering doses of [[Saline (medicine)|saline solution]] instead of the [[Oxford–AstraZeneca COVID-19 vaccine|AstraZeneca vaccine]] at nearly a dozen private vaccination sites in Mumbai. The organizers, including medical professionals, charged between $10 and $17 for each dose, and more than 2,600 people paid to receive what they thought was the vaccine.<ref>{{cite news |date=2021-07-04 |title=Indian police investigate whether scammers gave thousands of shots of salt water instead of vaccine. |url=https://www.nytimes.com/2021/07/04/world/asia/india-covid-vaccine-scam.html |url-access=limited |archive-url=https://ghostarchive.org/archive/20211228/https://www.nytimes.com/2021/07/04/world/asia/india-covid-vaccine-scam.html |archive-date=2021-12-28 |access-date=2021-07-07 |work=The New York Times |language=en-US |issn=0362-4331 |vauthors=Kumar H}}{{cbignore}}</ref><ref>{{cite news |title=Thousands Given Fake Vaccines Through Scam In India |url=https://www.npr.org/2021/07/09/1014512227/thousands-given-fake-vaccines-through-scam-in-india |access-date=2021-07-10 |website=NPR.org |language=en}}</ref> The [[Government of India|federal government]] downplayed the scandal, claiming these cases were isolated. [[McAfee]] stated India was among the top countries to have been targeted by fake apps to lure people with a promise of vaccines.<ref>{{cite web |date=1 July 2021 |title=India: Fake vaccines undermine fight against COVID |url=https://www.dw.com/en/india-fake-vaccines-undermine-fight-against-covid/a-58122010 |access-date=2021-07-10 |website=Deutsche Welle |language=en-GB |vauthors=Krishnan M}}</ref>

In [[Bhopal]], slum residents were misled into thinking they would get an approved [[COVID-19]] vaccine, but instead were actually part of an experimental clinical trial for the domestic vaccine [[Covaxin]]. Only 50% of participants in the trials received a vaccine with the rest receiving a [[placebo]]. One participant stated, "...I didn't know that there was a possibility you could get a water shot."<ref>{{cite web |date=February 26, 2021 |title=More than a dozen slum residents in an Indian city say they didn't know they were part of a clinical vaccine trial |url=https://www.cnn.com/2021/02/25/asia/india-vaccine-trials-covid-ethics-intl-dst-hnk/index.html |access-date=2021-07-11 |website=CNN |vauthors=Mitra E, Hollingsworth J}}</ref><ref>{{cite web |date=2021-01-14 |title=How Covaxin Trial Participants in Bhopal Were Misled |url=https://science.thewire.in/health/peoples-hospital-bhopal-covaxin-clinical-trials-exploitation-ethics-ground-report/ |access-date=2021-07-11 |website=The Wire Science |language=en-GB |vauthors=Bhuyan A}}</ref>

=== Religion ===
{{Main|Vaccination and religion}}

Since most religions predate the invention of vaccines, scriptures do not specifically address the topic of vaccination.<ref name="Smith2015" /> However, vaccination has been opposed by some on religious grounds ever since it was first introduced. When vaccination was first becoming widespread, some Christian opponents argued that preventing smallpox deaths would be thwarting God's will and that such prevention is sinful.<ref name="Early">Early religious opposition:

* {{cite book |title=A History of the Warfare of Science with Theology in Christendom |vauthors=White AD |publisher=Appleton |year=1896 |location=New York |chapter=Theological opposition to inoculation, vaccination, and the use of anæsthetics |access-date=July 22, 2007 |chapter-url=http://abob.libs.uga.edu/bobk/whitem10.html |archive-url=https://web.archive.org/web/20080917184044/http://abob.libs.uga.edu/bobk/whitem10.html |archive-date=September 17, 2008 |url-status=dead}}
* {{cite journal |vauthors=Bazin H |date=September 2001 |title=The ethics of vaccine usage in society: lessons from the past |journal=Endeavour |volume=25 |issue=3 |pages=104–108 |doi=10.1016/S0160-9327(00)01376-4 |pmid=11725304}}
* {{cite journal |vauthors=Noble M |date=December 2005 |title=Ethics in the trenches: a multifaceted analysis of the stem cell debate |journal=Stem Cell Reviews |volume=1 |issue=4 |pages=345–376 |citeseerx=10.1.1.465.2410 |doi=10.1385/SCR:1:4:345 |pmid=17142878 |s2cid=21775014}}</ref> Opposition from some religious groups continues to the present day, on various grounds, raising ethical difficulties when the number of unvaccinated children threatens harm to the entire population.<ref name="May">{{cite journal |vauthors=May T, Silverman RD |year=2005 |title=Free-riding, fairness and the rights of minority groups in exemption from mandatory childhood vaccination |journal=Human Vaccines |volume=1 |issue=1 |pages=12–15 |doi=10.4161/hv.1.1.1425 |pmid=17038833 |s2cid=39321188 |doi-access=free}}</ref> 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.<ref>{{cite news |date=2007-10-17 |title=Parents use religion to avoid vaccines |url=https://www.usatoday.com/news/nation/2007-10-17-19819928_x.htm |access-date=2007-11-24 |work=USA Today |vauthors=LeBlanc S}}</ref>

Many Jewish community leaders support vaccination.<ref>{{cite web |date=14 November 2018 |title=Statement on Vaccinations from the OU and Rabbinical Council of America. |url=https://www.ou.org/news/statement-vaccinations-ou-rabbinical-council-america/ |access-date=21 May 2019 |work=Orthodox Union}}</ref> 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."<ref>Avaneha Barzel p. 31 #34</ref>

Although [[gelatin]] can be derived from many animals, Jewish and [[Islamic]] scholars have determined that since the gelatin is cooked and not consumed as food, vaccinations containing gelatin are acceptable.<ref name="Smith2015" /> However, in 2015 and again in 2020, the possible use of [[porcine]]-based gelatin in vaccines raised religious concerns among Muslims and Orthodox Jews about the [[halal]] or [[kosher]] status of several vaccinations against [[COVID-19]].<ref>{{cite news |date=20 December 2020 |title=Concern among Muslims over halal status of COVID-19 vaccine |url=https://abcnews.go.com/Health/wireStory/concern-muslims-halal-status-covid-19-vaccine-74826269 |access-date=30 December 2020 |work=ABC News |language=en |agency=Associated Press (AP) |vauthors=Milko V}}</ref> The [[Muslim Council of Britain]] raised concern about the UK's intranasal influenza vaccine deployment in 2019 due to the presence of gelatin in the vaccine. The MCB subsequently clarified that it never advised against the vaccine, it did not have any religious authority to issue a [[fatwa]] on the matter, and that vaccines containing porcine gelatin are generally not considered [[haram]] if alternatives are unavailable (the injectable flu vaccine was also offered in Scotland, but not England).<ref>{{cite web |date=2019-07-29 |title=Position on Flu Vaccines {{!}} Muslim Council of Britain |url=https://mcb.org.uk/position-on-flu-vaccines/ |access-date=2024-02-09 |language=en-GB}}</ref>

In India, in 2018, a three-minute doctored clip circulated among Muslims claiming that the MR-VAC vaccine against measles and rubella was a "[[Narendra Modi|Modi]] government-[[Rashtriya Swayamsevak Sangh|RSS]] conspiracy" to stop the population growth of Muslims. The clip was taken from a TV show that exposed the baseless rumors.<ref>{{cite web |date=May 19, 2018 |title=Shot of life: saving vaccination drive from rumours and fake news |url=https://www.hindustantimes.com/india-news/shot-of-life-saving-vaccination-drive-from-rumours-and-fake-news/story-WHgsXRDorzKxpjPWpdCx7M.html |website=Hindustan Times}}</ref> Hundreds of [[madrassas]] in the state of Uttar Pradesh refused permission to health department teams to administer vaccines because of rumors spread using [[WhatsApp]].<ref>{{cite news |date=December 21, 2018 |title=Uttar Pradesh: WhatsApp rumours make 100s of UP madrassas reject vaccination |url=https://timesofindia.indiatimes.com/city/meerut/madrassas-in-west-up-say-no-to-measles-rubella-vaccination/articleshow/67184011.cms |website=The Times of India}}</ref>

Some Christians have objected to the use of cell cultures of some viral vaccines, and the virus of the [[rubella]] vaccine,<ref name="pmid3890107">{{cite journal |vauthors=Plotkin SA, Buser F |year=1985 |title=History of RA27/3 rubella vaccine |journal=Reviews of Infectious Diseases |volume=7 |issue=Suppl 1 |pages=S77–S78 |doi=10.1093/clinids/7.supplement_1.s77 |pmid=3890107}}</ref> 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.<ref>{{cite journal |vauthors=Grabenstein JD |year=1999 |title=Moral considerations with certain viral vaccines |url=http://www.immunizationinfo.org/files/nnii/files/Moral_Considerations_With_Certain_Viral_Vaccines.pdf |url-status=dead |journal=Christ Pharm |volume=2 |issue=2 |pages=3–6 |archive-url=https://web.archive.org/web/20110718001330/http://www.immunizationinfo.org/files/nnii/files/Moral_Considerations_With_Certain_Viral_Vaccines.pdf |archive-date=July 18, 2011 |access-date=2009-05-11 |df=mdy-all}}</ref> The Vatican Curia has said that for vaccines originating from embryonic cells, [[Catholic]]s 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.<ref name="Vatican">{{cite journal |last=Pontifical Academy for Life |year=2005 |title=Moral reflections on vaccines prepared from cells derived from aborted human foetuses |url=http://www.academiavita.org/template.jsp?sez=Documenti&pag=testo/vacc/vacc&lang=english |url-status=dead |journal=Medicina e Morale |archive-url=https://web.archive.org/web/20060507072740/http://www.academiavita.org/template.jsp?sez=Documenti&pag=testo%2Fvacc%2Fvacc&lang=english |archive-date=May 7, 2006 |access-date=2008-12-03 |df=mdy-all}}</ref>

In the United States, some parents falsely claim religious exemptions when their real motivation for avoiding vaccines is supposed safety concerns.<ref name="cbs-fake">{{cite news |date=17 October 2007 |title=Parents Fake Religion To Avoid Vaccines |url=https://www.cbsnews.com/news/parents-fake-religion-to-avoid-vaccines/ |website=CBS News |agency=AP}}</ref> For a number of years, only Mississippi, West Virginia, and California did not provide religious exemptions. Following the [[2019 measles outbreaks]], Maine and New York repealed their religious exemptions, and the state of Washington did so for the measles vaccination.<ref>{{cite web |title=State Vaccination Exemptions for Children Entering Public Schools |url=http://vaccines.procon.org/view.resource.php?resourceID=003597 |website=Vaccines.procon.org| date=November 8, 2024 }}</ref>

According to a March 2021 poll conducted by The Associated Press/[[NORC at the University of Chicago|NORC]], vaccine skepticism is more widespread among white evangelicals than most other blocs of Americans. Forty percent of white evangelical Protestants said they were not likely to get vaccinated against COVID-19.  That compares with 25% of all Americans, 28% of white mainline Protestants and 27% of nonwhite Protestants.<ref>{{cite web |date=2021-04-05 |title=Vaccine skepticism runs deep among white evangelicals in US |url=https://apnews.com/article/coronavirus-vaccine-skepticism-white-evangelicals-us-32898166bbb673ad87842af24c8daefb |access-date=2021-04-07 |website=AP News}}</ref>

==Countermeasures==

Vaccine hesitancy is challenging and optimal strategies for approaching it remain uncertain.<ref name="Dubé2015">{{cite journal | vauthors = Dubé E, Gagnon D, MacDonald NE | title = Strategies intended to address vaccine hesitancy: Review of published reviews | journal = Vaccine | volume = 33 | issue = 34 | pages = 4191–4203 | date = August 2015 | pmid = 25896385 | doi = 10.1016/j.vaccine.2015.04.041 | type = Review | doi-access = free }}</ref><ref name="Dubé" />

Multicomponent initiatives which include targeting undervaccinated populations, improving the convenience of and access to vaccines, educational initiatives, and mandates may improve vaccination uptake.<ref name="Brelsford2017" /><ref name="Jarrett2015">{{cite journal | vauthors = Jarrett C, Wilson R, O'Leary M, Eckersberger E, Larson HJ | title = Strategies for addressing vaccine hesitancy - A systematic review | journal = Vaccine | volume = 33 | issue = 34 | pages = 4180–4190 | date = August 2015 | pmid = 25896377 | doi = 10.1016/j.vaccine.2015.04.040 | doi-access = free }}</ref>

The World Health Organization (WHO) published a paper in 2016 intending to aid 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.<ref>{{cite web|title=How to respond to vocal vaccine deniers in public|publisher=World Health Organization|year=2016|url=https://www.who.int/immunization/sage/meetings/2016/october/8_Best-practice-guidance-respond-vocal-vaccine-deniers-public.pdf}}</ref>

===Providing information===
Many interventions designed to address vaccine hesitancy have been based on the [[information deficit model]].<ref name="McClure2017" /> 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.<ref name="McClure2017" /> 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.<ref name="Jacobson2020" /><ref name="McClure2017" />

It is unclear whether interventions intended to educate parents about vaccines improve the rate of vaccination.<ref name="Brelsford2017">{{cite journal | vauthors = Brelsford D, Knutzen E, Neher JO, Safranek S | title = Clinical Inquiries: Which interventions are effective in managing parental vaccine refusal? | journal = The Journal of Family Practice | volume = 66 | issue = 12 | pages = E12–E14 | date = December 2017 | pmid = 29202149 | url = https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/Document/November-2017/JFP06612e12.PDF | access-date = June 8, 2019 | url-status = dead | archive-url = https://web.archive.org/web/20190608003118/https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/Document/November-2017/JFP06612e12.PDF | archive-date = June 8, 2019 }}</ref> It is also unclear whether citing the reasons of benefit to others and [[herd immunity]] improves parents' willingness to vaccinate their children.<ref name="Brelsford2017" /> 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.<ref name="Brelsford2017" /> 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.<ref name="Brelsford2017" />

===Communication strategies===
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.<ref name="Smith2015" /> The [[American Academy of Pediatrics]] recommends healthcare providers directly address parental concerns about vaccines when questioned about their efficacy and safety.<ref name="Edwards2016" /> 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).<ref name="McClure2017" /> 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.<ref name="McClure2017" /> A New Zealand-based General Practitioner has used a comic, ''[[Jenny & the Eddies]]'', both to educate children about vaccines and address his patients' concerns through open, trusting, and non-threatening conversations, concluding [that] "I always listen to what people have to say on any matter. That includes vaccine hesitancy. That's a very important opening stage to improving the therapeutic relationship. If I'm going to change anyone's attitude, first I need to listen to them and be open-minded."<ref name="Using books to help in NZ">{{cite news | vauthors = McKenzie P |title=Covid-19: Doctor using comics to confront vaccine conspiracy theories |url=https://www.stuff.co.nz/national/health/300212725/covid19-doctor-using-comics-to-confront-vaccine-conspiracy-theories |access-date=23 March 2021 |publisher=[[Stuff (website)|Stuff (New Zealand)]] |date=24 January 2021}}</ref> 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.<ref name="Jacobson2020" />

===Provider presumption and persistence===
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.<ref name="Brelsford2017" /> A presumptive approach helps to establish that this is the normative choice.<ref name="McClure2017">{{cite journal | vauthors = McClure CC, Cataldi JR, O'Leary ST | title = Vaccine Hesitancy: Where We Are and Where We Are Going | journal = Clinical Therapeutics | volume = 39 | issue = 8 | pages = 1550–1562 | date = August 2017 | pmid = 28774498 | doi = 10.1016/j.clinthera.2017.07.003 | doi-access = free }}</ref> Similarly, one study found that the way in which physicians respond to parental vaccine resistance is important.<ref name="Smith2015" /> Nearly half of initially vaccine-resistant parents accepted vaccinations if physicians persisted in their initial recommendation.<ref name="McClure2017" /> The [[Centers for Disease Control and Prevention]] has released resources to aid healthcare providers in having more effective conversations with parents about vaccinations.<ref name="CDCVaccineConversationResources">{{cite web |url=https://www.cdc.gov/vaccines/hcp/conversations/index.html |title=Provider Resources for Vaccine Conversations with Parents |date=May 28, 2019 |website=cdc.gov |publisher=Centers for Disease Control and Prevention}}</ref>

===Pain mitigation for children===
Parents may be hesitant to have their children vaccinated due to concerns about the pain of vaccination. Several strategies can be used to reduce the child's pain.<ref name="Edwards2016" /> Such strategies include distraction techniques ([[Pinwheel (toy)|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 [[anesthetic|numbing agents]] to the skin; and saving the most painful vaccine for last.<ref name="Edwards2016" /> As above, the number of vaccines offered in a particular encounter is related to the likelihood of parental vaccine refusal (the more vaccines offered, the higher the likelihood of vaccine deferral).<ref name="Smith2015" /> The use of combination vaccines to protect against more diseases but with fewer injections may provide reassurance to parents.<ref name="Smith2015" /> 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 seven diseases".<ref name="Smith2015" />

===Cultural sensitivity===

[[Cultural sensitivity]] is important to reducing vaccine hesitancy. For example, pollster [[Frank Luntz]] discovered that for [[Conservatism in the United States|conservative Americans]], family is by far the "most powerful motivator" to get a vaccine (over country, economy, community, or friends).<ref name="Kenen">{{cite news | vauthors = Kenen J |title=Vaccine-skeptical Trump country poses challenge to immunization push |url=https://www.politico.com/news/2021/03/08/coronavirus-vaccine-rural-america-473940 |work=Politico |date=March 8, 2021}}</ref> Luntz "also found a very pronounced preference for the word 'vaccine' over 'jab.{{' "}}<ref name="Kenen" />

===Avoiding online misinformation===
It is recommended that healthcare providers advise parents against performing their own web search queries since many websites on the Internet contain significant misinformation.<ref name="Smith2015" /> Many parents perform their own research online and are often confused, frustrated, and unsure of which sources of information are trustworthy.<ref name="McClure2017" /> 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.<ref name="Smith2015" />

Internet advertising, especially on [[Advertising on social networks|social networking websites]], 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: [[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.<ref name="journ">{{cite journal | vauthors = Jamison AM, Broniatowski DA, Dredze M, Wood-Doughty Z, Khan D, Quinn SC | title = Vaccine-related advertising in the Facebook Ad Archive | journal = Vaccine | volume = 38 | issue = 3 | pages = 512–520 | date = January 2020 | pmid = 31732327 | pmc = 6954281 | doi = 10.1016/j.vaccine.2019.10.066 }}</ref><ref name="study">{{cite news |url=https://www.washingtonpost.com/health/2019/11/15/majority-anti-vaccine-ads-facebook-were-funded-by-two-groups/ |title=Majority of anti-vaccine ads on Facebook were funded by two groups | vauthors = Sun LH |date=2019-11-15 |newspaper=The Washington Post |access-date=2019-11-16 |url-status=live |archive-url=https://web.archive.org/web/20191117003403/https://www.washingtonpost.com/health/2019/11/15/majority-anti-vaccine-ads-facebook-were-funded-by-two-groups/ |archive-date=2019-11-17}}</ref>

=== Incentive programs ===
Several countries have implemented programs to counter vaccine hesitancy, including raffles, lotteries, rewards and mandates.<ref>{{cite news|url=https://www.economist.com/asia/2021/06/12/politicians-in-the-philippines-are-holding-raffles-to-boost-vaccination | title=Politicians in the Philippines are holding raffles to boost vaccination | newspaper=The Economist | date=12 June 2021}}</ref><ref>{{cite web|url=https://www.aljazeera.com/news/2021/6/14/win-a-cow-avoid-covid-philippines-tempts-vaccine-hesitant | title=Win a cow, avoid COVID: Philippines tempts vaccine hesitant | website= Al Jazeera | date=14 June 2021}}</ref><ref>{{cite web|url=https://www.scientificamerican.com/article/from-1-million-lotteries-to-free-beer-do-covid-vaccination-incentives-work/ | title=From $1-Million Lotteries to Free Beer: Do COVID Vaccination Incentives Work? | website=Scientific American |date=June 17, 2021 | vauthors = Lewis T }}</ref><ref>{{cite web|url=https://abcnews.go.com/Health/wireStory/jab-win-condo-hong-kong-vaccine-incentives-78330532 | title=Get a jab, win a condo: Hong Kong tries vaccine incentives | website=ABC News | date=17 June 2021 | author=ZEN SOO}}</ref> In the US [[State of Washington]], authorities have given the green light to licensed [[cannabis dispensaries]] to offer free [[Joint (cannabis)|joints]] as incentives to get [[COVID-19 vaccination]] in an effort dubbed "Joints for Jabs".<ref>{{cite news|url=https://www.telegraph.co.uk/global-health/science-and-disease/joints-jabs-washington-state-allows-free-cannabis-covid-19-vaccination/ |archive-url=https://ghostarchive.org/archive/20220111/https://www.telegraph.co.uk/global-health/science-and-disease/joints-jabs-washington-state-allows-free-cannabis-covid-19-vaccination/ |archive-date=January 11, 2022 |url-access=subscription |url-status=live | title='Joints for jabs': US state offers free cannabis as vaccine incentive | website=The Telegraph | date=8 June 2021  | vauthors = Farmer B }}{{cbignore}}</ref>

=== Vaccine mandates ===
Mandatory vaccination is one set of policy measures to address vaccine hesitancy by imposing penalties or burdens on those who fail to vaccinate. An example of this kind of measure is Australia's vaccine mandates around childhood vaccination, the [[No Jab No Pay]] policy. This policy linked financial payments to children's vaccine status and, while studies have found significant improvements in vaccination compliance, years later there were still issues of vaccine hesitancy.<ref>{{cite journal | vauthors = Hull BP, Beard FH, Hendry AJ, Dey A, Macartney K | title = "No jab, no pay": catch-up vaccination activity during its first two years | journal = The Medical Journal of Australia | volume = 213 | issue = 8 | pages = 364–369 | date = October 2020 | pmid = 32951230 | pmc = 7692886 | doi = 10.5694/mja2.50780 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Li A, Toll M | title = Removing conscientious objection: The impact of 'No Jab No Pay' and 'No Jab No Play' vaccine policies in Australia | journal = Preventive Medicine | volume = 145 | pages = 106406 | date = April 2021 | pmid = 33388333 | doi = 10.1016/j.ypmed.2020.106406 | s2cid = 230489130 }}</ref> In 2021, Australian airline [[Qantas]] issued plans to mandate [[COVID-19 vaccination]] for their work force.<ref>{{cite news | vauthors = Williams J, Seale H |title=If you're going to mandate COVID vaccination at your workplace, here's how to do it ethically |url=https://theconversation.com/if-youre-going-to-mandate-covid-vaccination-at-your-workplace-heres-how-to-do-it-ethically-166110 |agency=The Conversation |date=August 18, 2021}}</ref>

==Geographical distribution==
[[File:Share that agrees that vaccines are important for children to have (Wellcome Trust (2019)), OWID.svg|thumb|upright=1.5|Share that agrees that vaccines are important for children to have (2018)]]

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.<ref name="Attwell2018">{{cite journal | vauthors = Attwell K, Wiley KE, Waddington C, Leask J, Snelling T | title = Midwives' attitudes, beliefs and concerns about childhood vaccination: A review of the global literature | journal = Vaccine | volume = 36 | issue = 44 | pages = 6531–6539 | date = October 2018 | pmid = 29483029 | doi = 10.1016/j.vaccine.2018.02.028 | s2cid = 3591014 }}</ref> 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.<ref name="Edwards2016" /><ref>{{cite journal | vauthors = Pearce A, Law C, Elliman D, Cole TJ, Bedford H | title = 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 | journal = BMJ | volume = 336 | issue = 7647 | pages = 754–757 | date = April 2008 | pmid = 18309964 | pmc = 2287222 | doi = 10.1136/bmj.39489.590671.25 }}</ref><ref>{{cite journal | vauthors = Yang YT, Delamater PL, Leslie TF, Mello MM | title = Sociodemographic Predictors of Vaccination Exemptions on the Basis of Personal Belief in California | journal = American Journal of Public Health | volume = 106 | issue = 1 | pages = 172–177 | date = January 2016 | pmid = 26562114 | pmc = 4695929 | doi = 10.2105/AJPH.2015.302926 }}</ref><ref name="sciencedirect.com">{{cite journal | vauthors = Toll M, Li A | title = Vaccine sentiments and under-vaccination: Attitudes and behaviour around Measles, Mumps, and Rubella vaccine (MMR) in an Australian cohort | journal = Vaccine | volume = 39 | issue = 4 | pages = 751–759 | date = January 2021 | pmid = 33218781 | doi = 10.1016/j.vaccine.2020.11.021 | s2cid = 227100012 }}</ref><ref>{{cite journal | vauthors = Ogilvie G, Anderson M, Marra F, McNeil S, Pielak K, Dawar M, McIvor M, Ehlen T, Dobson S, Money D, Patrick DM, Naus M | title = A population-based evaluation of a publicly funded, school-based HPV vaccine program in British Columbia, Canada: parental factors associated with HPV vaccine receipt | journal = PLOS Medicine | volume = 7 | issue = 5 | pages = e1000270 | date = May 2010 | pmid = 20454567 | pmc = 2864299 | doi = 10.1371/journal.pmed.1000270 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Amit Aharon A, Nehama H, Rishpon S, Baron-Epel O | title = Parents with high levels of communicative and critical health literacy are less likely to vaccinate their children | journal = Patient Education and Counseling | volume = 100 | issue = 4 | pages = 768–775 | date = April 2017 | pmid = 27914735 | doi = 10.1016/j.pec.2016.11.016 }}</ref><ref>{{cite journal | vauthors = Kim SS, Frimpong JA, Rivers PA, Kronenfeld JJ | title = Effects of maternal and provider characteristics on up-to-date immunization status of children aged 19 to 35 months | journal = American Journal of Public Health | volume = 97 | issue = 2 | pages = 259–266 | date = February 2007 | pmid = 17194865 | pmc = 1781415 | doi = 10.2105/AJPH.2005.076661 }}</ref> Other studies examining various populations around the world in different countries found that both high and low socioeconomic status are associated with vaccine hesitancy.<ref name="Larson2014" />

=== Migrant populations ===
Migrants and refugees arriving and living in Europe face various difficulties in getting vaccinated and many of them are not fully vaccinated. People arriving from Africa, Eastern Europe, the Eastern Mediterranean, and Asia are more likely to be under-vaccinated (partial or delayed vaccination). Also, recently arrived [[refugee]]s, [[Migrant worker|migrants]] and [[Asylum seeker|seekers of asylum]] were less likely to be fully vaccinated than other people from the same groups. Those with little contact to healthcare services, no citizenship and lower income are also more likely to be under-vaccinated.<ref name="NIHR Evidence_2022">{{cite journal |date=2022-12-20 |title=How to increase vaccination uptake among migrant communities |url=https://evidence.nihr.ac.uk/alert/how-to-increase-vaccination-uptake-migrant-communities/ |journal=NIHR Evidence |language=en |doi=10.3310/nihrevidence_55367|s2cid=254969959 |url-access=subscription }}</ref><ref name="Crawshaw_2022">{{cite journal | vauthors = Crawshaw AF, Farah Y, Deal A, Rustage K, Hayward SE, Carter J, Knights F, Goldsmith LP, Campos-Matos I, Wurie F, Majeed A, Bedford H, Forster AS, Hargreaves S | title = Defining the determinants of vaccine uptake and undervaccination in migrant populations in Europe to improve routine and COVID-19 vaccine uptake: a systematic review | journal = The Lancet. Infectious Diseases | volume = 22 | issue = 9 | pages = e254–e266 | date = September 2022 | pmid = 35429463 | pmc = 9007555 | doi = 10.1016/S1473-3099(22)00066-4 }}</ref>

Vaccination barriers for migrants include language/literacy barriers, lack of understanding of the need for or their entitlement to vaccines, concerns about the side-effects, health professionals lack of knowledge of vaccination guidelines for migrants, and practical/legal issues, for example, having no fixed address. Vaccines uptake of migrants can be increased by customised communications, clear policies, community-guided interventions (such as vaccine advocates), and vaccine offers in local accessible settings.<ref name="NIHR Evidence_2022" /><ref name="Crawshaw_2022" />

=== Australia ===
An Australian study that examined the factors associated with vaccine attitudes and uptake separately found that under-vaccination correlated with lower socioeconomic status but not with negative attitudes towards vaccines. The researchers suggested that practical barriers are more likely to explain under-vaccination among individuals with lower socioeconomic status.<ref name="sciencedirect.com" /> A 2012 Australian study found that 52% of parents had concerns about the safety of vaccines.<ref>{{cite journal | vauthors = My C, Danchin M, Willaby HW, Pemberton S, Leask J | title = Parental attitudes, beliefs, behaviours and concerns towards childhood vaccinations in Australia: A national online survey | journal = Australian Family Physician | volume = 46 | issue = 3 | pages = 145–151 | date = March 2017 | pmid = 28260278 | url = https://pubmed.ncbi.nlm.nih.gov/28260278 }}</ref>

During the [[COVID-19 pandemic]], [[COVID-19 vaccine]] hesitancy reportedly was spreading in remote [[Indigenous Australians|Indigenous]] communities, where people are typically poorer and less educated.<ref>{{cite web | url=https://www.abc.net.au/news/2021-08-31/border-residents-claim-followed-by-police/100420196 | title=Residents claim to be followed by police in vital cross-border shopping, medical trips - ABC News | website=[[Australian Broadcasting Corporation]] }}</ref>

=== Europe ===
Confidence in vaccines varies over place and time and among different vaccines. The [[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 twelve 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.<ref>{{cite web |title=The State of Vaccine Confidence in the EU: 2018 |url=https://www.vaccineconfidence.org/research/the-state-of-vaccine-confidence-in-the-eu-2018/ |access-date=2 December 2018 |website=Vaccine Confidence Project |publisher=London School of Hygiene & Tropical Medicine}}</ref>

==Policy implications==
{{Further|Vaccination policy}}

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.<ref name="Edwards2016" />

===Individual liberty===
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.<ref name="wolfesharp" /><ref>{{cite journal | vauthors = Colgrove J, Bayer R | title = Manifold restraints: liberty, public health, and the legacy of Jacobson v Massachusetts | journal = American Journal of Public Health | volume = 95 | issue = 4 | pages = 571–576 | date = April 2005 | pmid = 15798111 | pmc = 1449222 | doi = 10.2105/AJPH.2004.055145 | author-link1 = James Colgrove }}</ref> 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.<ref>{{cite journal | vauthors = Salmon DA, Teret SP, MacIntyre CR, Salisbury D, Burgess MA, Halsey NA | title = Compulsory vaccination and conscientious or philosophical exemptions: past, present, and future | journal = Lancet | volume = 367 | issue = 9508 | pages = 436–442 | date = February 2006 | pmid = 16458770 | doi = 10.1016/s0140-6736(06)68144-0 | s2cid = 19344405 }}</ref>

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]].<ref>{{cite journal | vauthors = Moodley K, Hardie K, Selgelid MJ, Waldman RJ, Strebel P, Rees H, Durrheim DN | title = Ethical considerations for vaccination programmes in acute humanitarian emergencies | journal = Bulletin of the World Health Organization | volume = 91 | issue = 4 | pages = 290–297 | date = April 2013 | pmid = 23599553 | pmc = 3629456 | doi = 10.2471/BLT.12.113480 | url = https://www.who.int/bulletin/volumes/91/4/12-113480/en/ | url-status = dead | author-link3 = Michael Selgelid | author-link6 = Helen Rees | archive-url = https://web.archive.org/web/20140912112515/http://www.who.int/bulletin/volumes/91/4/12-113480/en/ | archive-date = September 12, 2014 }}</ref>

In the United States, vaccinations are not truly compulsory, but they are typically required in order for children to attend public schools. As of January 2021, five states{{snd}}Mississippi, West Virginia, [[California Senate Bill 277|California]], [[2020 Maine Question 1|Maine]], and New York{{snd}}have eliminated religious and philosophical exemptions to required school immunizations.<ref>{{cite web |title=States With Religious and Philosophical Exemptions From School Immunization Requirements |url=https://www.ncsl.org/research/health/school-immunization-exemption-state-laws.aspx |website=National Conference of State Legislatures |access-date=2 January 2021 |archive-url=https://archive.today/20201022191725/https://www.ncsl.org/research/health/school-immunization-exemption-state-laws.aspx |archive-date=22 October 2020}}</ref>

===Children's rights===
{{Further|Mature minor doctrine|Gillick competence}}

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."<ref>{{cite journal | vauthors = Caplan AL |title=Do Children Have Vaccination Rights? |url=https://www.medscape.com/viewarticle/902956 |journal=Medscape Business of Medicine }}</ref><ref>{{cite web |url=https://www.seattletimes.com/opinion/anti-vaccine-misinformation-denies-childrens-rights/ |title=Anti-vaccine misinformation denies children's rights |date=2018-04-18}}</ref>

A review of American 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]].<ref>{{cite journal | vauthors = Parasidis E, Opel DJ | title = Parental Refusal of Childhood Vaccines and Medical Neglect Laws | journal = American Journal of Public Health | volume = 107 | issue = 1 | pages = 68–71 | date = January 2017 | pmid = 27854538 | pmc = 5308147 | doi = 10.2105/AJPH.2016.303500 }}</ref>

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.<ref>{{cite web |url=http://live.huffingtonpost.com/r/segment/should-pediatricians-refuse-unvaccinated-kids/53285f162b8c2a24f700070f |title=Should Pediatricians Refuse Unvaccinated Kids? |website=The Huffington Post |access-date=July 4, 2015}}</ref><ref>{{cite web |url=http://www.medicaldaily.com/nyc-schools-are-now-allowed-ban-unvaccinated-kids-rules-federal-judge-289614 |title=NYC Schools Are Now Allowed To Ban Unvaccinated Kids, Rules Federal Judge | vauthors = Bachai S |date=24 June 2014 |website=Medical Daily |access-date=4 July 2015}}</ref> 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.<ref>{{cite journal | vauthors = Halperin B, Melnychuk R, Downie J, Macdonald N | title = When is it permissible to dismiss a family who refuses vaccines? Legal, ethical and public health perspectives | journal = Paediatrics & Child Health | volume = 12 | issue = 10 | pages = 843–845 | date = December 2007 | pmid = 19043497 | pmc = 2532570 | doi = 10.1093/pch/12.10.843 | author-link4 = Noni MacDonald }}</ref> 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.<ref name="Edwards2016">{{cite journal | vauthors = Edwards KM, Hackell JM | title = Countering Vaccine Hesitancy | journal = Pediatrics | volume = 138 | issue = 3 | pages = e20162146 | date = September 2016 | pmid = 27573088 | doi = 10.1542/peds.2016-2146 | doi-access = free }}</ref>

==History==
===Variolation===
[[File:The cow pock.jpg|thumb |upright=1.25 |An anti-vaccination caricature by [[James Gillray]], ''The Cow-Pock{{snd}}or{{snd}}The Wonderful Effects of the New Inoculation!'' (1802)]]

Early attempts to prevent smallpox involved deliberate [[inoculation]] with the milder form of the disease (Variola Minor) in the expectation that a mild case would confer immunity and avoid Variola Major. 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. [[Cotton Mather|Reverend Cotton Mather]] introduced variolation to Boston, Massachusetts, during the 1721 smallpox epidemic.<ref name="VaccineControversy">{{cite book |url=https://archive.org/details/vaccinecontrover00arth |title=Vaccine: The Controversial Story of Medicine's Greatest Lifesaver |vauthors=Allen A |publisher=W. W. Norton & Company, Inc. |year=2007 |isbn=978-0-393-05911-3 |location=New York |pages=25–36}}</ref> Despite strong opposition in the community,<ref name="Early" /> 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<!--Is "miraculously vanished" a direct quote?--> and they were "no longer gravely ill".<ref name="VaccineControversy" /> 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 (physician)|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.<ref name="williams">{{cite book |title=Angel Of Death; the story of smallpox |vauthors=Williams G |publisher=Palgrave Macmillan |year=2010 |isbn=978-0-230-27471-6 |location=Basingstoke, UK |pages=87–94}}</ref>

[[Vaccination and religion|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".<ref name="Early" /> 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 (New England minister)|John Williams]]. A greater source of opposition there was [[William Douglass (physician)|William Douglass]], a medical graduate of [[Edinburgh University]] and a [[Fellow of the Royal Society]], who had settled in Boston.<ref name="williams" />{{rp |114–22}}

===Smallpox vaccination===
[[File:Edward Jenner2.jpg|thumb|Edward Jenner]]

After [[Edward Jenner]] introduced the [[smallpox vaccine]] in 1798, variolation declined and was banned in some countries.<ref>{{cite journal |vauthors=Bazin H |date=October 2003 |title=A brief history of the prevention of infectious diseases by immunisations |journal=Comparative Immunology, Microbiology and Infectious Diseases |volume=26 |issue=5–6 |pages=293–308 |doi=10.1016/S0147-9571(03)00016-X |pmid=12818618}}</ref><ref>{{cite journal |vauthors=Ellner PD |year=1998 |title=Smallpox: gone but not forgotten |journal=Infection |volume=26 |issue=5 |pages=263–269 |doi=10.1007/BF02962244 |pmid=9795781 |s2cid=23658644 |doi-access=free}}</ref> 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 (preacher)|Rowland Hill]],<ref name="williams" />{{rp |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.<ref name="williams" />{{rp |203–05}}
[[File:Gloucester smallpox epidemic, 1896; Henry Wicklin, aged 6 Wellcome V0031456.jpg|thumb|Henry Wicklin, age 6, affected by [[smallpox]]. Smallpox was eradicated worldwide as a result of mandatory vaccinations]]
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.<ref name="baxby2001">{{cite book |author-link=Derrick Baxby |title=Smallpox Vaccine, Ahead of its Time |vauthors=Baxby D |publisher=the Jenner Museum |year=2001 |isbn=0-9528695-1-9 |location=Berkeley, UK |pages=12–21}}</ref> 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{{snd}}estimated at 750 cases in 100 million vaccinations<ref name="bazin2000">{{cite book |title=The Eradication of Smallpox |vauthors=Bazin H |publisher=Academic Press |year=2000 |isbn=0-12-083475-8 |location=London |page=122}}</ref>{{snd}}attracted particular attention. Much later, [[Charles Creighton (physician)|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.<ref name="creighton">{{cite book |title=The Natural History of Cowpox and Vaccinal Syphilis |vauthors=Creighton C |publisher=Cassell |year=1887 |location=London}}</ref> 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.<ref name="baxby2001" />{{rp |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.<ref name="williamson">{{cite book |title=The Vaccination Controversy; the rise, reign and decline of compulsory vaccination |vauthors=Williamson S |publisher=Liverpool University Press |year=2007 |isbn=978-1846310867 |location=Liverpool}}</ref>

====England====
[[File:Diphtheria is Deadly Art.IWMPST14182.jpg|thumb |upright |In a postwar poster the [[Department of Health (United Kingdom)|Ministry of Health]] urged British residents to immunize children against diphtheria]]

Because of its greater risks, [[variolation]] was banned in England by the [[Vaccination Act 1840]] ([[3 & 4 Vict.]] c. 29), which also introduced free voluntary vaccination for infants. Thereafter Parliament passed successive acts to enact and enforce compulsory vaccination.<ref name="porter">{{cite journal |vauthors=Porter D, Porter R |date=July 1988 |title=The politics of prevention: anti-vaccinationism and public health in nineteenth-century England |journal=Medical History |volume=32 |issue=3 |pages=231–252 |doi=10.1017/s0025727300048225 |pmc=1139881 |pmid=3063903}}</ref> The Vaccination Act 1853 ([[16 & 17 Vict.]] c. 100) introduced compulsory vaccination, with fines for non-compliance and imprisonment for non-payment. The Vaccination Act 1867 ([[30 & 31 Vict.]] c. 84) 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 Vaccination Act 1871 ([[34 & 35 Vict.]] c. 98), which required guardians to act. This significantly changed the relationship between the government and the public, and organized protests increased.<ref name="porter" /> In Keighley, Yorkshire, in 1876 the guardians were arrested and briefly imprisoned in York Castle, prompting large demonstrations in support of the "Keighley Seven".<ref name="williamson" />{{rp |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.<ref>{{cite journal |vauthors=Durbach N |date=April 2000 |title='They might as well brand us': working-class resistance to compulsory vaccination in Victorian England |journal=Social History of Medicine |volume=13 |issue=1 |pages=45–62 |doi=10.1093/shm/13.1.45 |pmid=11624425}}</ref> 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]].<ref name="porter" /> By 1885, with over 3,000 prosecutions pending in Leicester, a mass rally there was attended by over 20,000 protesters.<ref name="baxby1999">{{cite journal |vauthors=Baxby D |year=1999 |title=The end of smallpox |journal=History Today |volume=49 |issue=3 |pages=14–16 |pmid=21384695}}</ref>

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.<ref>{{cite book |last=(Royal Commission) |title=Vaccination and its Results; a Report based on the Evidence taken by the Royal Commission |publisher=New Sydenham Society |year=1898 |location=London}}</ref> Its recommendations were incorporated into the [[Vaccination Act 1898]] ([[61 & 62 Vict.]] c. 49), which still required compulsory vaccination but allowed exemption on the grounds of conscientious objection on presentation of a certificate signed by two magistrates.<ref name="wolfesharp" /><ref name="porter" /> 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.<ref name="baxby1999" /> 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 United Kingdom general election|1900 Labour Party General Election Manifesto]].<ref>{{cite web |date=2014-04-20 |title=Labour Party Manifesto 1900 |url=https://suacs.wordpress.com/2014/04/20/labour-party-manifesto-1900/ |access-date=July 2, 2015 |website=Voice of Anti-Capitalism in Guildford}}</ref> 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.<ref name="millard1948">{{cite journal |vauthors=Millard CK |date=December 1948 |title=The end of compulsory vaccination |journal=British Medical Journal |volume=2 |issue=4589 |pages=1073–1075 |doi=10.1136/bmj.2.4589.1073 |pmc=2092290 |pmid=18121624}}</ref>

Vaccination in Wales was covered by English legislation, but the [[Scottish legal system]] was separate. Vaccination was not made compulsory there until 1863, and a conscientious objection was allowed after vigorous protest only in 1907.<ref name="baxby2001" />{{rp |10–11}}

In the late 19th century, Leicester in the UK received much attention because of how 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.<ref>{{cite book |url=http://www.urpress.com/store/viewItem.asp?idProduct=14810 |title=Intrusive Interventions: Public Health, Domestic Space, and Infectious Disease Surveillance in England, 1840–1914 |vauthors=Mooney G |date=2015 |publisher=University of Rochester Press |isbn=978-1580465274 |location=Rochester, NY |access-date=2 April 2016}}</ref> 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.<ref name="millard1948" /><ref name="fraser">{{cite journal |vauthors=Fraser SM |date=July 1980 |title=Leicester and smallpox: the Leicester method |journal=Medical History |volume=24 |issue=3 |pages=315–332 |doi=10.1017/s0025727300040345 |pmc=1082657 |pmid=6997656}}</ref> 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.<ref>{{cite book |title=Smallpox and its Eradication |vauthors=Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID |publisher=World Health Organization |year=1988 |isbn=978-9241561105 |location=Geneva |pages=247, 275}}</ref><ref>{{cite book |title=Smallpox; the death of a disease |vauthors=Henderson DA |publisher=Prometheus Books |year=2009 |isbn=978-1-59102-722-5 |location=Amherst, NY |pages=90–92}}</ref>

====United States====
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.<ref>{{cite book |url=https://www.ncbi.nlm.nih.gov/books/NBK7291/ |title=Vaccines |vauthors=Henderson DA, Moss B |date=1999 |publisher=W. B. Saunders |isbn=0-7216-7443-7 |veditors=Plotkin SA, Orenstein WA |edition=3rd |location=Philadelphia |chapter=Public health |chapter-url=https://www.ncbi.nlm.nih.gov/books/NBK7293/}}</ref>

After an 1879 visit to New York by prominent British anti-vaccinationist [[William Tebb]], The Anti-Vaccination Society of America was founded.<ref>{{cite journal |vauthors=Wolfe RM, Sharp LK |date=August 2002 |title=Anti-vaccinationists past and present |journal=BMJ |volume=325 |issue=7361 |pages=430–432 |doi=10.1136/bmj.325.7361.430 |pmc=1123944 |pmid=12193361 |quote=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.}}</ref><ref name="history">{{cite news |date=March 8, 2012 |title=History of Anti-vaccination Movements |url=http://www.historyofvaccines.org/content/articles/history-anti-vaccination-movements |access-date=2015-02-11 |publisher=[[College of Physicians of Philadelphia]] |quote=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.{{spaces}}...}}</ref> The New England Anti-Compulsory Vaccination League formed in 1882, and the Anti-Vaccination League of New York City in 1885.<ref name="history" /> Tactics in the US largely followed those used in England.<ref>{{cite journal |vauthors=Kaufman M |year=1967 |title=The American anti-vaccinationists and their arguments |journal=Bulletin of the History of Medicine |volume=41 |issue=5 |pages=463–478 |pmid=4865041}}</ref> 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.<ref>{{cite book |author-link=Donald Hopkins |url=https://archive.org/details/greatestkillersm0000hopk |title=The Greatest Killer; smallpox in history |vauthors=Hopkins DR |publisher=University of Chicago Press |year=2002 |isbn=978-0226351667 |location=Chicago |pages=[https://archive.org/details/greatestkillersm0000hopk/page/83 83–84] |url-access=registration}}</ref> 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.<ref>{{cite journal |vauthors=Mariner WK, Annas GJ, Glantz LH |date=April 2005 |title=Jacobson v Massachusetts: it's not your great-great-grandfather's public health law |journal=American Journal of Public Health |volume=95 |issue=4 |pages=581–590 |doi=10.2105/AJPH.2004.055160 |pmc=1449224 |pmid=15798113}}</ref>

[[John Pitcairn, Jr.|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.<ref name="vaccination_address">{{cite book |url=https://archive.org/details/vaccination00pitcgoog |title=Vaccination |vauthors=Pitcairn J |publisher=Anti-Vaccination League of Pennsylvania |year=1907 |oclc=454411147}}</ref> 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.<ref name="Horrors">{{cite book |title=Horrors of Vaccination Exposed and Illustrated |vauthors=Higgins CM |publisher=C.M. Higgins |year=1920 |location=Brooklyn, NY |pages=73–75 |chapter=Life sketch of John Pitcairn by a Philadelphia friend |oclc=447437840 |chapter-url=https://archive.org/details/horrorsvaccinat00higggoog}}</ref>

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.<ref name="Horrors" /> He remained a staunch opponent of vaccination until his death in 1916.

====Brazil====
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.<ref>{{cite journal |vauthors=Meade T |year=1989 |title='Living worse and costing more': resistance and riot in Rio de Janeiro, 1890–1917 |journal=J Lat Am Stud |volume=21 |issue=2 |pages=241–66 |doi=10.1017/S0022216X00014784 |s2cid=145241097}}</ref>

===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 the smallpox vaccine in animals and the production of antitoxins in horses prompted [[anti-vivisectionist]]s to oppose vaccination.<ref>Ciok, Amy E. "Horses and the diphtheria antitoxin." ''Academic Medicine'' 75.4 (2000): 396.</ref>

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 (horse)|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.<ref>{{cite journal |vauthors=Lilienfeld DE |year=2008 |title=The first pharmacoepidemiologic investigations: national drug safety policy in the United States, 1901-1902 |journal=Perspectives in Biology and Medicine |volume=51 |issue=2 |pages=188–198 |doi=10.1353/pbm.0.0010 |pmid=18453724 |s2cid=30767303}}</ref> The [[Bundaberg tragedy]] of 1928 saw a diphtheria antitoxin contaminated with the ''[[Staph. aureus]]'' bacterium kill 12 children in [[Bundaberg]], Australia, resulting in the suspension of local immunisation programs.<ref>{{cite journal |vauthors=Akers H, Porter S |year=2008 |title=Bundaberg's Gethsemane: the tragedy of the inoculated children |url=https://espace.library.uq.edu.au/view/UQ:152716/UQ_PV_152716.pdf |journal=Royal Historical Society of Queensland Journal |volume=20 |pages=261–278 |number=7}}</ref>

[[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.<ref>{{cite book |title=Laboratory Disease; Robert Koch's medical bacteriology |vauthors=Gradman C |publisher=Johns Hopkins University Press |year=2009 |isbn=978-0-8018-9313-1 |location=Baltimore |pages=133–36}}</ref> This was a major setback for supporters of new vaccines.<ref name="baxby2001" />{{rp |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.<ref>Brock, Thomas. ''Robert Koch: A life in medicine and bacteriology''. ASM Press: Washington DC, 1999. Print.</ref>

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 poliovirus 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.<ref>{{cite journal |author-link=Paul Offit |vauthors=Offit PA |date=April 2005 |title=The Cutter incident, 50 years later |journal=The New England Journal of Medicine |volume=352 |issue=14 |pages=1411–1412 |doi=10.1056/NEJMp048180 |pmid=15814877}}</ref>

Later 20th-century events included the 1982 broadcast of ''DPT: Vaccine Roulette'', which sparked debate over the [[DPT vaccine]],<ref>{{cite news |date=2010-02-07 |title=Scientist: autism paper had catastrophic effects |url=https://www.npr.org/templates/story/story.php?storyId=123472234 |publisher=NPR}}</ref> and the 1998 publication of a fraudulent academic article by [[Andrew Wakefield]]<ref name="Goldacre-2008">{{cite news |date=August 30, 2008 |title=The MMR hoax |url=https://www.theguardian.com/society/2008/aug/30/mmr.health.media |archive-url=https://web.archive.org/web/20150206073230/http://www.theguardian.com/society/2008/aug/30/mmr.health.media |archive-date=February 6, 2015 |access-date=2008-08-30 |work=The Guardian |location=London |vauthors=Goldacre B}} [http://www.badscience.net/2008/08/the-medias-mmr-hoax/ Alt URL]</ref> 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.<ref>{{cite news |date=September 19, 2011 |title=HPV Vaccine: The Science Behind The Controversy |url=https://www.npr.org/2011/09/19/140543977/hpv-vaccine-the-science-behind-the-controversy |access-date=September 30, 2015 |newspaper=NPR.org |publisher=NPR |vauthors=Knox R}}</ref><ref>{{cite journal |vauthors=Chatterjee A, O'Keefe C |date=May 2010 |title=Current controversies in the USA regarding vaccine safety |journal=Expert Review of Vaccines |volume=9 |issue=5 |pages=497–502 |doi=10.1586/erv.10.36 |pmid=20450324 |s2cid=24443783}}</ref>

Arguments against vaccines in the 21st century are often similar to those of 19th-century anti-vaccinationists.<ref name="wolfesharp" /> Around 2014, anti-vaccine rhetoric shifted from being mostly scientific and medical arguments, such as the idea that vaccines were harming children, to political arguments, such as what David Broniatowski of [[George Washington University]] has called a "don't-tell-me-what-to-do freedom movement." At the same time, according to [[Renée DiResta]], a researcher at the [[Stanford Internet Observatory]], anti-vaxxers began networking with [[Tea Party movement|Tea Party]] and [[Second Amendment to the United States Constitution|Second Amendment]] activists in a "weird [[Libertarianism|libertarian]] crossover". This happened partly due to anti-vaccine medical arguments failing to stop the passage of [[California Senate Bill 277|SB277]] in California.<ref name="Velasquez-Manoff_2022">{{cite news |date=2022-05-25 |title=The Anti-Vaccine Movement's New Frontier |url=https://www.nytimes.com/2022/05/25/magazine/anti-vaccine-movement.html |access-date=2022-06-02 |work=The New York Times |language=en-US |issn=0362-4331 |vauthors=Velasquez-Manoff M}}</ref>

====COVID-19====
{{See also|COVID-19 vaccine misinformation and hesitancy|COVID-19 vaccine hesitancy in the United States|COVID-19 protests in the United Kingdom}}
[[File:202003- Cumulative county COVID-19 death rates - by share of votes for Donald Trump.svg |thumb|After the December 2020 introduction of COVID vaccines, a partisan gap in death rates developed, indicating the effects of vaccine skepticism.<ref name="NYTimes_20240311">{{cite news |date=March 11, 2024 |title=The Fourth Anniversary of the Covid Pandemic |url=https://www.nytimes.com/2024/03/11/briefing/covid-pandemic-anniversary.html |url-status=live |archive-url=https://archive.today/20240311124758/https://www.nytimes.com/2024/03/11/briefing/covid-pandemic-anniversary.html |archive-date=March 11, 2024 |newspaper=The New York Times |vauthors=Leonhardt D}} "Data excludes Alaska. Sources: C.D.C. Wonder; Edison Research. (Chart) By The New York Times. Source credits chart to Ashley Wu.</ref> As of March 2024, more than 30 percent of Republicans had not received a Covid vaccine, compared with less than 10 percent of Democrats.<ref name="NYTimes_20240311" />]]
[[File:Antivax protest in London 2.jpg|thumb|A protest against COVID-19 vaccination in [[London]], United Kingdom]]
In mid-2020, surveys on whether people would be willing to take a potential [[COVID-19 vaccine]] estimated that 67% or 80% of people in the US would accept a new vaccination against COVID-19.<ref name="malik">{{cite journal |vauthors=Malik AA, McFadden SM, Elharake J, Omer SB |date=September 2020 |title=Determinants of COVID-19 vaccine acceptance in the US |journal=eClinicalMedicine |volume=26 |pages=100495 |doi=10.1016/j.eclinm.2020.100495 |pmc=7423333 |pmid=32838242 |doi-access=free}}</ref><ref>{{cite journal |vauthors=Thunstrom L, Ashworth M, Finnoff D, Newbold S |date=7 July 2020 |title=Hesitancy towards a COVID-19 vaccine and prospects for herd immunity. |url=https://cepr.org/system/files/publication-files/101387-covid_economics_issue_35.pdf |journal=Covid Economics |publisher=The Centre for Economic Policy Research (CEPR) |issue=35 |pages=1–50 |access-date=7 July 2020}}</ref>

In the United Kingdom, a 16 November 2020 [[YouGov]] poll showed that 42% said they were very likely to take the vaccine and 25% were fairly likely (67% likely overall); 11% would be very unlikely and 10% fairly unlikely (21% unlikely overall) and 12% are unsure.<ref name="McDonnell_YouGov">{{cite web |date=16 November 2020 |title=How many Britons are willing to take a coronavirus vaccine? |url=https://yougov.co.uk/topics/health/articles-reports/2020/11/16/how-many-britons-are-willing-take-coronavirus-vacc |access-date=10 December 2020 |website=YouGov |language=en-gb |vauthors=McDonnell A}}</ref> There have been a number of reasons expressed why people might not wish to take COVID-19 vaccines, such as concerns over safety, self-perception of being "low risk", or questioning the [[Tozinameran|Pfizer-BioNTech vaccine]] in particular. 8% of those reluctant to take it say it is because they oppose vaccinations overall; this amounts to just 2% of the British public.<ref name="McDonnell_YouGov" />

A December 2020 [[Ipsos]]/[[World Economic Forum]] 15-country poll asked online respondents whether they agreed with the statement: "If a vaccine for COVID-19 were available, I would get it." Rates of agreement were smallest in France (40%), Russia (43%) and South Africa (53%). In the United States, 69% of those polled agreed with the statement; rates were even higher in Britain (77%) and China (80%).<ref>{{cite news |date=29 December 2020 |title=Less than half of French want Covid vaccine: poll |url=https://news.yahoo.com/less-half-french-want-covid-173848670.html |access-date=31 December 2020 |work=Yahoo News |agency=AFP}}</ref><ref>{{cite web |title=U.S. and U.K. are optimistic indicators for COVID-19 vaccination uptake |url=https://www.ipsos.com/en/global-attitudes-covid-19-vaccine-december-2020 |url-status=dead |archive-url=https://web.archive.org/web/20210718141218/https://www.ipsos.com/en/global-attitudes-covid-19-vaccine-december-2020 |archive-date=July 18, 2021 |access-date=31 December 2020 |website=Ipsos |language=en}}</ref>

A March 2021 NPR/PBS NewsHour/Marist poll found the difference between white and black Americans to be within the margin of error, but 47% of [[Donald Trump|Trump]] supporters said they would refuse a COVID-19 vaccine, compared to 30% of all adults.<ref>{{cite news |date=March 12, 2021 |title=Little Difference In Vaccine Hesitancy Among White And Black Americans, Poll Finds |url=https://www.npr.org/sections/coronavirus-live-updates/2021/03/12/976172586/little-difference-in-vaccine-hesitancy-among-white-and-black-americans-poll-find |newspaper=NPR |vauthors=Summers J}}</ref>

In May 2021, a report titled "Global attitudes towards a COVID-19 vaccine" from the Institute of Global Health Innovation and Imperial College London, which included detailed survey data from March to May 2021 including survey data from 15 countries Australia, Canada, Denmark, France, Germany, Israel, Italy, Japan, Norway, Singapore, South Korea, Spain, Sweden, the UK, and the US. It found that in 13 of the 15 countries more than 50% of people were confident in COVID-19 vaccines. In the UK 87% of survey respondents said they trusted the vaccines, which showed a significant increase in confidence following earlier less reliable polls. The survey also found trust in different vaccine brands varied, with the Pfizer–BioNTech COVID-19 vaccine being the most trusted across all age groups in most countries and particularly the most trusted for under 65s.<ref>{{cite journal |vauthors=Mahase E |date=June 2021 |title=Covid-19: UK has highest vaccine confidence and Japan and South Korea the lowest, survey finds |journal=BMJ |volume=373 |pages=n1439 |doi=10.1136/bmj.n1439 |pmid=34088703 |doi-access=free}}</ref><ref>{{cite web |author1=Institute of Global Health Innovation |date=May 2021 |title=Global attitudes towards a COVID-19 vaccine |url=https://www.imperial.ac.uk/media/imperial-college/institute-of-global-health-innovation/GlobalVaccineInsights_ICL-YouGov-Covid-19-Behaviour-Tracker_20210520_v2.pdf |access-date=14 June 2021 |website=Imperial College London |publisher=Covid Data Hub}}</ref>

A January 2022 report from ''[[Time (magazine)|Time]]'' magazine noted that the anti-vaccine movement "has repositioned itself as an opposition to mandates and government overreach."<ref>{{cite magazine |date=2022-01-26 |title=How the Anti-Vax Movement Is Taking Over the Right |url=https://time.com/6141699/anti-vaccine-mandate-movement-rally/ |access-date=2022-07-16 |magazine=[[Time (magazine)|Time]] |language=en |vauthors=Bergengruen V}}</ref> A May 2022 report from ''[[The New York Times]]'' noted that "A wave of parents has been radicalized by Covid-era misinformation to reject ordinary childhood immunizations—with potentially lethal consequences."<ref name="Velasquez-Manoff_2022" />

=== Events following reductions in vaccination ===
[[File:GAVI Global Alliance Save Childrens Lives pledging conference (5827417113).jpg|thumb |Campaigners in [[London]] for expanded vaccination in the developing world]]

In several countries, reductions in the use of some vaccines were followed by increases in the diseases' morbidity and mortality.<ref name="Gangarosa_pertussis">{{cite journal |vauthors=Gangarosa EJ, Galazka AM, Wolfe CR, Phillips LM, Gangarosa RE, Miller E, Chen RT |date=January 1998 |title=Impact of anti-vaccine movements on pertussis control: the untold story |journal=Lancet |volume=351 |issue=9099 |pages=356–361 |doi=10.1016/S0140-6736(97)04334-1 |pmid=9652634 |s2cid=35969647}}</ref><ref name="Allen_herd">{{cite journal |vauthors=Allen A |year=2002 |title=Bucking the herd |url=http://immunize.org/exemptions/allen.htm |journal=The Atlantic |volume=290 |issue=2 |pages=40–42 |access-date=2007-11-07 |archive-date=March 15, 2016 |archive-url=https://web.archive.org/web/20160315030117/http://www.immunize.org/exemptions/allen.htm |url-status=dead }}</ref> According to the [[Centers for Disease Control and Prevention]], continued high levels of vaccine coverage are necessary to prevent a resurgence of diseases that have been nearly eliminated.<ref name="CDC_stop">{{cite web |date=2007-06-12 |title=What would happen if we stopped vaccinations? |url=https://www.cdc.gov/vaccines/vac-gen/whatifstop.htm |access-date=2008-04-25 |publisher=Centers for Disease Control and Prevention}}</ref> 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.<ref>{{cite book |last=Centers for Disease Control and Prevention |title=Epidemiology and Prevention of Vaccine-Preventable Diseases |publisher=Public Health Foundation |year=2007 |isbn=978-0-01-706605-3 |veditors=Atkinson W, Hamborsky J, McIntyre L, Wolfe S |location=Washington, DC |chapter=Pertussis |chapter-url=https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/pert.pdf}}</ref> Vaccine hesitancy has contributed to the resurgence of preventable disease. For example, in 2019, the number of measles cases increased by thirty percent worldwide and many cases occurred in countries that had nearly eliminated measles.<ref name="Jacobson2020" />

==== 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.<ref>{{cite journal |vauthors=Nelson MC, Rogers J |date=December 1992 |title=The right to die? Anti-vaccination activity and the 1874 smallpox epidemic in Stockholm |journal=Social History of Medicine |volume=5 |issue=3 |pages=369–388 |doi=10.1093/shm/5.3.369 |pmid=11645870}}</ref>

==== UK, pertussis (1970s–80s) ====
In a 1974 report ascribing 36 reactions to [[pertussis|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. The 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.<ref name="Gangarosa_pertussis" />

==== 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.<ref name="Allen_herd" />

==== Netherlands, measles (1999–2000) ====<!--I'm uncertain whether religious behaviour is in the same category – this is more like a control experiment (as sometimes demanded by anti-vaccinationists) If we define a-v as actively trying to stop others from being vaccinated this group probably falls outside it, and therefore should move to the vaccination article AKM.-->
An outbreak at a religious community and school in the Netherlands resulted in three deaths and 68 hospitalizations among 2,961 cases.<ref name="Centers for Disease Control and Prevention (CDC)_2000">{{cite journal |author1=Centers for Disease Control and Prevention (CDC) |date=April 2000 |title=Measles outbreak--Netherlands, April 1999-January 2000 |url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4914a2.htm |journal=MMWR. Morbidity and Mortality Weekly Report |volume=49 |issue=14 |pages=299–303 |pmid=10825086}}</ref> The population in the several provinces affected had a high level of immunization, with the exception of [[Vaccination and religion|one of the religious denominations]], which traditionally does not accept vaccination. Ninety-five percent of those who contracted measles were unvaccinated.<ref name="Centers for Disease Control and Prevention (CDC)_2000" />

==== UK and Ireland, measles (2000) ====
As a result of the [[MMR vaccine controversy]], vaccination rates dropped sharply in the United Kingdom after 1996.<ref name="Pepys">{{cite journal |vauthors=Pepys MB |date=December 2007 |title=Science and serendipity |journal=Clinical Medicine |volume=7 |issue=6 |pages=562–578 |doi=10.7861/clinmedicine.7-6-562 |pmc=4954362 |pmid=18193704}}</ref> From late 1999 until the summer of 2000, there was a [[measles]] outbreak in [[Northside, Dublin|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.<ref>Ireland measles outbreak:

* {{cite news |date=May 30, 2000 |title=Measles outbreak feared |url=http://news.bbc.co.uk/2/hi/health/769381.stm |work=BBC News}}
* {{cite journal |vauthors=McBrien J, Murphy J, Gill D, Cronin M, O'Donovan C, Cafferkey MT |date=July 2003 |title=Measles outbreak in Dublin, 2000 |journal=The Pediatric Infectious Disease Journal |volume=22 |issue=7 |pages=580–584 |doi=10.1097/00006454-200307000-00002 |pmid=12867830}}</ref>

==== Nigeria, polio, measles, diphtheria (2001–) ====
In the early first decade of the 21st century, conservative religious leaders in northern Nigeria, suspicious of [[Medicine|Western medicine]], advised their followers not to have their children vaccinated with the 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 poliovirus 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.<ref name="Clements">{{cite journal |vauthors=Clements CJ, Greenough P, Shull D |date=January 2006 |title=How vaccine safety can become political--the example of polio in Nigeria |journal=Current Drug Safety |volume=1 |issue=1 |pages=117–119 |doi=10.2174/157488606775252575 |pmid=18690921}}</ref> 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.<ref>{{cite news |last=Public Health Nigeria |date=October 2018 |title=Challenges of Immunization in Nigeria |url=https://publichealthng.com/immunization-nigeria-challenges-benefits-prevention/ |url-status=dead |archive-url=https://web.archive.org/web/20181029113729/https://publichealthng.com/immunization-nigeria-challenges-benefits-prevention/ |archive-date=October 29, 2018 |access-date=2018-10-28 |publisher=PublichealthNg.com}}</ref> In 2006, Nigeria accounted for over half of all new polio cases worldwide.<ref>{{cite web |date=2008-02-05 |title=Wild poliovirus 2000–2008 |url=http://www.polioeradication.org/content/general/casecount.pdf |archive-url=https://web.archive.org/web/20070927204139/http://www.polioeradication.org/content/general/casecount.pdf <!--bot retrieved archive--> |archive-date=2007-09-27 |access-date=2008-02-11 |publisher=Global Polio Eradication Initiative}}</ref> Outbreaks continued thereafter; for example, at least 200 children died in a late-2007 measles outbreak in [[Borno State]].<ref>{{cite news |date=2007-12-14 |title='Hundreds' dead in measles outbreak |url=http://irinnews.org/Report.aspx?ReportId=75883 |url-status=dead |archive-url=https://web.archive.org/web/20120208011542/http://irinnews.org/Report.aspx?ReportId=75883 |archive-date=February 8, 2012 |access-date=2008-02-10 |agency=IRIN}}</ref>

==== United States, measles (2005–) ====
In 2000, measles was declared eliminated from the United States because the internal transmission had been interrupted for one year; the remaining reported cases were due to importation.<ref>{{cite web |date=2018-08-28 |title=Frequently Asked Questions about Measles in U.S |url=https://www.cdc.gov/measles/about/faqs.html |publisher=Centers for Disease Control and Prevention}}</ref>

A 2005 measles outbreak in the US state of Indiana was attributed to parents who had refused to have their children vaccinated.<ref name="parker">{{cite journal |vauthors=Parker AA, Staggs W, Dayan GH, Ortega-Sánchez IR, Rota PA, Lowe L, Boardman P, Teclaw R, Graves C, LeBaron CW |date=August 2006 |title=Implications of a 2005 measles outbreak in Indiana for sustained elimination of measles in the United States |journal=The New England Journal of Medicine |volume=355 |issue=5 |pages=447–455 |doi=10.1056/NEJMoa060775 |pmid=16885548 |s2cid=34529542 |doi-access=free}}</ref>
[[File:US Measles Cases 2015-07-02.jpg|thumb|upright=1.5]]

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{{snd}}New York City, North Carolina, and Texas{{snd}}contributed to 64% of the 159 cases of measles reported in 16 states.<ref>{{cite news |date=September 12, 2013 |title=CDC: Vaccine "philosophical differences" driving up U.S. measles rates |url=https://www.cbsnews.com/news/cdc-vaccine-philosophical-differences-driving-up-us-measles-rates/ |access-date=September 19, 2013 |work=CBS News |vauthors=Jaslow R}}</ref><ref>{{cite journal |author1=Centers for Disease Control and Prevention (CDC) |date=September 2013 |title=National, state, and local area vaccination coverage among children aged 19-35 months - United States, 2012 |url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6236a1.htm |journal=MMWR. Morbidity and Mortality Weekly Report |volume=62 |issue=36 |pages=733–740 |pmc=4585572 |pmid=24025754}}</ref>

The number of cases in 2014 quadrupled to 644,<ref>{{cite news |date=January 15, 2015 |title=The spread of Disneyland measles outbreak |url=https://www.latimes.com/visuals/graphics/la-me-g-spread-of-disneyland-measles-outbreak-20150113-htmlstory.html |work=Los Angeles Times |vauthors=Rañoa R, Zarracina J}}</ref> including transmission by unvaccinated visitors to Disneyland in California, during the [[Disneyland measles outbreak]].<ref name="Alazraki11" /><ref>{{cite news |date=January 19, 2015 |title=Measles outbreak worsens in US after unvaccinated woman visits Disneyland |url=https://www.theguardian.com/us-news/2015/jan/14/measles-outbreak-spreads-unvaccinated-woman-disneyland |access-date=June 1, 2015 |website=The Guardian |vauthors=Glenza J}}</ref> 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 the patients (165 out of 288, or 57%) during that time were confirmed to be unvaccinated by choice; 30 (10%) were confirmed to have been vaccinated.<ref name="cdc2014a">{{cite journal |vauthors=Gastañaduy PA, Redd SB, Fiebelkorn AP, Rota JS, Rota PA, Bellini WJ, Seward JF, Wallace GS |date=June 2014 |title=Measles - United States, January 1-May 23, 2014 |url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6322a4.htm?s_cid=mm6322a4_w |journal=MMWR. Morbidity and Mortality Weekly Report |volume=63 |issue=22 |pages=496–499 |pmc=5779360 |pmid=24898167}}</ref> The final count of measles in 2014 was 668 cases in 27 states.<ref name="CDCdata">{{cite web |last=CDC |date=June 30, 2015 |title=Measles Cases and Outbreaks |url=https://www.cdc.gov/measles/cases-outbreaks.html |access-date=July 2, 2015}}</ref>

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.<ref name="CDCdata" /> On July 2, 2015, the first confirmed death from measles in twelve years was recorded. An [[immunocompromised]] woman in Washington State was infected and later died of [[pneumonia]] due to measles.<ref>{{cite web |date=July 2, 2015 |title=Measles led to death of Clallam Co. woman; first in US in a dozen years |url=http://www.doh.wa.gov/Newsroom/2015NewsReleases/15119WAMeaslesRelatedDeath |url-status=dead |archive-url=https://web.archive.org/web/20190507002748/https://www.doh.wa.gov/Newsroom/2015NewsReleases/15119WAMeaslesRelatedDeath |archive-date=May 7, 2019 |access-date=July 2, 2015 |work=Press Release |publisher=Washington Department of Health}}</ref>

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, Arizona|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.<ref>{{cite news |date=July 8, 2016 |title=Arizona measles outbreak: immigration workers blamed for refusing vaccines |url=https://www.theguardian.com/us-news/2016/jul/08/arizona-measles-outbreak-immigration-detention-workers |access-date=10 March 2019 |work=[[The Guardian]] |vauthors=Henley J}}</ref>

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.<ref>{{cite web |title=Measles – Minnesota Dept. of Health |url=http://www.health.state.mn.us/divs/idepc/diseases/measles/ |url-status=dead |archive-url=https://web.archive.org/web/20170610014848/http://www.health.state.mn.us/divs/idepc/diseases/measles/ |archive-date=June 10, 2017 |access-date=July 20, 2017 |website=Health.state.mn.us}}</ref><ref>{{cite news |date=June 1, 2017 |title=Measles outbreak in Minnesota surpasses last year's total for the entire country |url=https://www.washingtonpost.com/national/health-science/imams-in-us-take-on-the-anti-vaccine-movement-during-ramadan/2017/05/26/8660edc6-41ad-11e7-8c25-44d09ff5a4a8_story.html |newspaper=The Washington Post |vauthors=Sun LH}}</ref><ref>{{cite web |date=8 May 2017 |title=Anti-vaccine groups blamed in Minnesota measles outbreak |url=http://www.cnn.com/2017/05/08/health/measles-minnesota-somali-anti-vaccine-bn/index.html |access-date=26 May 2017 |website=CNN |vauthors=Howard J}}</ref><ref>{{cite news |date=10 May 2017 |title=Minnesota measles outbreak follows anti-vaccination campaign |url=https://www.newscientist.com/article/mg23431253-200-minnesota-measles-outbreak-follows-antivaccination-campaign/ |access-date=26 May 2017 |work=[[New Scientist]] |language=en-US |publication-date=13 May 2017 |issue=3125}}</ref><ref name="Zdechlik_2017">{{cite news |date=3 May 2017 |title=Unfounded Autism Fears Are Fueling Minnesota's Measles Outbreak |url=https://www.npr.org/sections/health-shots/2017/05/03/526723028/autism-fears-fueling-minnesotas-measles-outbreak |access-date=26 May 2017 |work=NPR.org |language=en |vauthors=Zdechlik M}}</ref> 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,<ref>{{cite news |title=Anti-vaccine groups blamed in Minnesota measles outbreak |url=https://edition.cnn.com/2017/05/08/health/measles-minnesota-somali-anti-vaccine-bn/index.html |access-date=2018-11-13 |work=CNN |vauthors=Howard J}}</ref><ref>{{cite news |date=3 May 2017 |title=Understanding The History Behind Communities' Vaccine Fears |url=https://www.npr.org/sections/health-shots/2017/05/03/526595475/understanding-the-history-behind-communities-vaccine-fears |access-date=February 15, 2019 |newspaper=NPR |vauthors=Sohn E}}</ref><ref>{{cite journal |vauthors=Dyer O |date=May 2017 |title=Measles outbreak in Somali American community follows anti-vaccine talks |journal=BMJ |volume=357 |pages=j2378 |doi=10.1136/bmj.j2378 |pmid=28512183 |s2cid=27124692}}</ref><ref>{{cite news |date=May 5, 2017 |title=Anti-vaccine activists spark a state's worst measles outbreak in decades |url=https://www.washingtonpost.com/national/health-science/anti-vaccine-activists-spark-a-states-worst-measles-outbreak-in-decades/2017/05/04/a1fac952-2f39-11e7-9dec-764dc781686f_story.html |access-date=February 17, 2019 |newspaper=[[The Washington Post]] |vauthors=Sun LH}}</ref> despite the fact that multiple studies have shown no connection between the [[MMR vaccine]] and [[autism]].<ref name="Gerber" />

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.<ref>{{cite news |date=2019-01-17 |title=New York Confronts Its Worst Measles Outbreak in Decades |url=https://www.nytimes.com/2019/01/17/nyregion/measles-outbreak-jews-nyc.html |access-date=2019-01-19 |work=The New York Times |language=en-US |issn=0362-4331 |vauthors=Otterman S}}</ref><ref>{{cite web |date=January 8, 2019 |title=NY tackles 'largest measles outbreak' in state's recent history |url=https://www.cnn.com/2019/01/08/health/measles-outbreak-ny-bn/index.html |access-date=2019-01-19 |website=CNN |vauthors=Howard J}}</ref>

In January 2019, Washington state reported [[2019 Pacific Northwest measles outbreak|an outbreak of at least 73 confirmed cases of measles]], most within [[Clark County, Washington|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.<ref>{{cite web |date=January 28, 2019 |title=Amid measles outbreak, legislation proposed to ban vaccine exemptions |url=https://www.seattletimes.com/seattle-news/amid-measles-outbreak-legislation-proposed-to-ban-vaccine-exemptions/ |access-date=January 28, 2019 |website=The Seattle Times |vauthors=Goldstein-Street J}}</ref><ref>{{cite web |date=February 4, 2019 |title=Washington state is averaging more than one measles case per day in 2019 |url=https://www.nbcnews.com/storyline/measles-outbreak/measles-outbreak-southwestern-washington-rises-50-cases-n966751 |website=NBC News |vauthors=Charles S}}</ref><ref>{{cite web |title=Amid Measles Outbreak, Anti-Vaxx Parents Have Put Others' Babies At Risk |url=https://www.msn.com/en-ph/lifestyle/family/amid-measles-outbreak-anti-vaxx-parents-have-put-others-e2-80-99-babies-at-risk/ar-BBTbIBq |website=MSN}}</ref><ref>{{cite web |date=January 27, 2019 |title=Washington declared a public health emergency over measles. Thank vaccine-refusing parents. |url=https://www.vox.com/2019/1/27/18199514/measles-outbreak-2018-clark-county-washington |website=Vox |vauthors=Belluz J}}</ref><ref>{{cite web |date=January 28, 2019 |title="Dangerous" anti-vaxx warning issued by Washington officials as cases in measles outbreak continue to rise |url=https://www.newsweek.com/dangerous-anti-vaxx-warning-issued-washington-officials-cases-measles-1306997 |website=Newsweek}}</ref><ref>{{cite web |date=January 23, 2019 |title=Public health emergency declared over measles in anti-vax hotspot near Portland, Oregon |url=https://www.cbsnews.com/news/measles-outbreak-public-health-emergency-declared-in-anti-vax-hotspot-near-portland-oregon-clark-county-washington/ |access-date=February 5, 2019 |website=Cbsnews.com}}</ref>

==== Wales, measles (2013–) ====
{{See also|2013 Swansea measles epidemic}}

In 2013, an outbreak of measles occurred in the Welsh city of Swansea. One death was reported.<ref name="over">{{cite news |date=July 3, 2013 |title=Swansea measles epidemic officially over |url=https://www.bbc.com/news/uk-wales-23168519 |access-date=October 8, 2014 |work=BBC News |quote=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 [[Lancet MMR autism fraud|later discredited]], with health officials insisting the vaccine was completely safe.}}</ref> 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.<ref>{{cite news |date=July 10, 2013 |title=Swansea measles epidemic: Worries over MMR uptake after outbreak |url=https://www.bbc.com/news/uk-wales-politics-23244628 |access-date=October 8, 2014 |work=BBC News}}</ref> 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.<ref name="over" /> June 5, 2017, saw a new measles outbreak in Wales, at Lliswerry High School in the town of [[Newport (Wales)|Newport]].<ref>{{cite news |date=22 June 2017 |title=600 children get MMR jab after measles outbreak in Newport |url=https://www.bbc.co.uk/news/uk-wales-south-east-wales-40366937 |work=BBC News |publisher=BBC}}</ref>

==== United States, tetanus ====
Most cases of pediatric [[tetanus]] in the U.S. occur in unvaccinated children.<ref>{{cite journal |vauthors=Fair E, Murphy TV, Golaz A, Wharton M |date=January 2002 |title=Philosophic objection to vaccination as a risk for tetanus among children younger than 15 years |journal=Pediatrics |volume=109 |issue=1 |pages=E2 |doi=10.1542/peds.109.1.e2 |pmid=11773570 |doi-access=}}</ref> 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, for $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.<ref>{{cite news |date=8 March 2019 |title=An unvaccinated child contracted tetanus. It took two months and more than $800K to save him. |url=https://www.washingtonpost.com/health/2019/03/08/an-unvaccinated-child-contracted-tetanus-it-took-two-months-more-than-k-save-him/ |access-date=10 March 2019 |newspaper=[[Washington Post]] |vauthors=Wang A}}</ref>

==== Romania, measles (2016–present) ====
[[File:Ovidiu Covaciu ESC2017.webm|thumb|Ovidiu Covaciu on how the Romanian antivaccine movement threatens Europe (2017)]]

As of September 2017, a measles epidemic was ongoing across Europe, especially Eastern Europe. In Romania, there were about 9300 cases, and 34 people (all unvaccinated) had died.<ref name="Covaciu">{{cite web |date=5 November 2017 |title=How the Romanian anti-vaccine movement threatens Europe |url=https://www.youtube.com/watch?v=wFpAiHCQ85g |archive-url=https://ghostarchive.org/varchive/youtube/20211030/wFpAiHCQ85g |archive-date=2021-10-30 |access-date=6 November 2017 |website=European Skeptics Congress |publisher=European Council of Skeptical Organisations |vauthors=Covaciu O}}{{cbignore}}</ref> 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.<ref name="Covaciu" /> 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.<ref>{{cite web |title=Centrul Național de Supraveghere şi Control al Bolilor Transmisibile – Informări săptămanale |url=http://www.cnscbt.ro/index.php/informari-saptamanale/rujeola-1/1143-situatia-rujeolei-in-romania-la-data-de-01-03-2019 |access-date=2019-03-07 |website=cnscbt.ro}}</ref>

==== Samoa, measles (2019) ====
{{main|2019 Samoa measles outbreak}}
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.<ref>{{cite web |title=Australia – Oceania :: Samoa – The World Factbook |url=https://www.cia.gov/the-world-factbook/countries/samoa/ |access-date=2019-12-06 |website=cia.gov – Central Intelligence Agency (July 2018 est.)}}</ref><ref name="DeathToll">{{cite web |date=2019-12-08 |title=Measles death toll rises to 68 in Samoa |url=https://www.rnz.co.nz/international/pacific-news/405090/measles-death-toll-rises-to-68-in-samoa |access-date=8 December 2019 |website=[[RNZ]] }}</ref><ref>{{cite web |title=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. |url=https://twitter.com/samoagovt/status/1202707973048418304}}</ref><ref>{{cite news |author=Pacific Beat |date=2019-11-26 |title=Samoa makes measles vaccinations compulsory after outbreak kills 32 |url=https://www.abc.net.au/news/2019-11-26/samoa-measles-emergency-claims-32-lives-as-death-toll-rises/11738138 |access-date=2019-11-26 |website=ABC News |language=en-AU}}</ref> 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.<ref>{{cite news |date=2019-11-17 |title=Samoa declares state of emergency over deadly measles outbreak |url=https://www.abc.net.au/news/2019-11-17/samoa-declares-state-of-emergency-over-measles-outbreak/11711576 |access-date=2019-11-26 |newspaper=ABC News |language=en}}</ref> [[UNICEF]] has sent 110,500 vaccines to Samoa. Tonga and Fiji have also declared states of emergency.<ref name="bbc">{{cite news |date=2019-11-23 |title=Samoa measles outbreak worsens |url=https://www.bbc.com/news/world-asia-50528834 |access-date=2019-11-26 |language=en-GB}}</ref>

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.<ref name="TheGuardian">{{cite news |date=2019-11-28 |title=Samoa measles outbreak: WHO blames anti-vaccine scare as death toll hits 39 |url=https://www.theguardian.com/world/2019/nov/28/samoa-measles-outbreak-who-blames-anti-vaccine-scare-death-toll |access-date=30 November 2019 |newspaper=The Guardian |agency=Agence France-Presse}}</ref> The reason for the two infants' deaths was incorrect preparation of the vaccine by two nurses who mixed vaccine powder with expired anesthetic.<ref name="nurse">{{cite news |author=Pacific Beat |date=2019-08-02 |title='Her body was turning black': Samoan nurses jailed for infant vaccination deaths |url=https://www.abc.net.au/news/2019-08-02/samoa-nurses-sentenced-manslaughter-infant-vaccination-deaths/11378494 |access-date=2019-11-29 |website=ABC News |language=en-AU}}</ref> As of November 30, more than 50,000 people were vaccinated by the government of Samoa.<ref name="nurse" />

===2019–2020 measles outbreaks===
{{main|2019–2020 measles outbreaks}}
{{Clear}}

== See also ==
{{Portal|History of science}}
*[[Chemophobia]]
*[[COVID-19 vaccine misinformation and hesitancy]]
*[[Measles resurgence in the United States]]
*[[Vaccine misinformation]]
*[[Therapeutic nihilism]]
*[[Vaccine shedding]]

== References ==
{{Reflist}}

== Further reading ==
{{refbegin|30em}}
* {{cite book | vauthors = Herlihy SM, Hagood EA, Offit PA |title=Your Baby's Best Shot: Why Vaccines Are Safe and Save Lives |publisher=Rowman & Littlefield Publishers |year=2012 |isbn=978-1442215788 |author-link2=E. Allison Hagood |author-link3=Paul A. Offit}}
* {{cite book | vauthors = Largent MA |title=Vaccine: The Debate in Modern America |publisher=Johns Hopkins University Press |year=2012 |isbn=978-1421406077}}
* {{cite book | vauthors = Myers MG, Pineda D |title=Do Vaccines Cause That?! A Guide for Evaluating Vaccine Safety Concerns |publisher=Immunizations for Public Health (i4ph) |year=2008 |isbn=978-0-9769027-1-3 |location=Galveston, TX}}
* {{cite book | vauthors = Offit PA |title=Autism's False Prophets: Bad Science, Risky Medicine, and the Search for a Cure |title-link=Autism's False Prophets: Bad Science, Risky Medicine, and the Search for a Cure |publisher=Columbia University Press |year=2008 |isbn=978-0-231-14636-4 |author-link=Paul Offit}}
* {{cite book | vauthors = Offit PA |title=Deadly Choices: How the Anti-Vaccine Movement Threatens Us All |publisher=Basic Books |year=2012 |isbn=978-0465029624 |author-link=Paul Offit}}
* {{cite book | veditors = Buckley GJ | author1 = ((National Academies of Sciences, Engineering, and Medicine)) | author2 = Health and Medicine Division | author3 = Board on Global Health | author4 = Forum on Microbial Threats | title = Vaccine Access and Hesitancy: Part One of a Workshop Series: Proceedings of a Workshop—in Brief | location = Washington (DC) | publisher = National Academies Press (US) | date = 13 August 2020 | doi = 10.17226/25895 | pmid = 32816420 | isbn = 978-0-309-68160-5 | url = https://www.ncbi.nlm.nih.gov/books/NBK561117/ }} 
* {{cite journal | vauthors = Bedford H, Elliman D | title = Concerns about immunisation | journal = BMJ | volume = 320 | issue = 7229 | pages = 240–243 | date = January 2000 | pmid = 10642238 | pmc = 1117437 | doi = 10.1136/bmj.320.7229.240 }}
* {{cite journal | vauthors = Davies P, Chapman S, Leask J | title = Antivaccination activists on the world wide web | journal = Archives of Disease in Childhood | volume = 87 | issue = 1 | pages = 22–25 | date = July 2002 | pmid = 12089115 | pmc = 1751143 | doi = 10.1136/adc.87.1.22 }}
* {{cite journal | vauthors = Hanratty B, Holt T, Duffell E, Patterson W, Ramsay M, White JM, Jin L, Litton P | title = UK measles outbreak in non-immune anthroposophic communities: the implications for the elimination of measles from Europe | journal = Epidemiology and Infection | volume = 125 | issue = 2 | pages = 377–383 | date = October 2000 | pmid = 11117961 | pmc = 2869610 | doi = 10.1017/S0950268899004525 }}
* {{cite journal | vauthors = Miller CL | title = Deaths from measles in England and Wales, 1970-83 | journal = British Medical Journal | volume = 290 | issue = 6466 | pages = 443–444 | date = February 1985 | pmid = 3918622 | pmc = 1417782 | doi = 10.1136/bmj.290.6466.443 }}
* {{cite journal |vauthors=Naono A |year=2006 |title=Vaccination Propaganda: The Politics of Communicating Colonial Medicine in Nineteenth-Century Burma |url=https://archive.org/download/VaccinationPropagandaThePoliticsOfCommunicatingColonialMedicineIn/4.1naono.pdf |journal=SOAS Bulletin of Burma Research |volume=4 |issue=1 |pages=30–44 }}
* {{cite journal | vauthors = Orenstein WA, Hinman AR | title = The immunization system in the United States - the role of school immunization laws | journal = Vaccine | volume = 17 | issue = Suppl 3 | pages = S19–S24 | date = October 1999 | pmid = 10559531 | doi = 10.1016/S0264-410X(99)00290-X }}
* {{cite journal | vauthors = Richardson PD, Mohammed SF, Mason RG, Steiner M, Kane R | title = Dynamics of platelet interaction with surfaces in steady flow conditions | journal = Transactions - American Society for Artificial Internal Organs | volume = 25 | issue = 7473 | pages = 147–151 | year = 2004 | pmid = 524574 | pmc = 524574 | doi = 10.1136/bmj.329.7473.1049 }}
* {{cite journal | vauthors = Spier RE | title = Ethical aspects of vaccines and vaccination | journal = Vaccine | volume = 16 | issue = 19 | pages = 1788–1794 | date = November 1998 | pmid = 9795382 | pmc = 7173252 | doi = 10.1016/S0264-410X(98)00169-8 }}
* {{cite journal | vauthors = Vermeersch E | title = Individual rights versus societal duties | journal = Vaccine | volume = 17 | issue = Suppl 3 | pages = S14–S17 | date = October 1999 | pmid = 10627239 | doi = 10.1016/s0264-410x(99)00289-3 }}
* {{cite journal | vauthors = Wolfe RM, Sharp LK, Lipsky MS | title = Content and design attributes of antivaccination web sites | journal = JAMA | volume = 287 | issue = 24 | pages = 3245–3248 | date = June 2002 | pmid = 12076221 | doi = 10.1001/jama.287.24.3245 | doi-access =  }}
* {{cite web | vauthors = Friedlander E | year = 2007 | title = The anti-immunization activists: a pattern of deception | url = http://www.pathguy.com/antiimmu.htm | access-date = 2007-11-13 | work = The Pathology Guy | archive-date = March 19, 2018 | archive-url = https://web.archive.org/web/20180319101705/http://www.pathguy.com/antiimmu.htm | url-status = dead }}
* {{cite web |vauthors=Mooney C |date=October 2, 2013 |title=If You Distrust Vaccines, You're More Likely to Think NASA Faked the Moon Landings |url=https://www.motherjones.com/environment/2013/10/vaccine-denial-conspiracy-theories-gmos-climate |magazine=Mother Jones |access-date=2016-02-02 |quote=Psychologist [[Stephan Lewandowsky]], who studies conspiracy theories and how they motivate the denial of science. }}
* {{cite web |title=Six common misconceptions about immunization |url=https://www.who.int/immunization_safety/aefi/immunization_misconceptions/en/ |archive-url=https://web.archive.org/web/20031226120650/http://www.who.int/immunization_safety/aefi/immunization_misconceptions/en/ |url-status=dead |archive-date=December 26, 2003 |date=February 16, 2006 |publisher=World Health Organization |access-date=2006-11-02 }}
{{refend}}

== External links ==
{{wikiquote}}
*{{cite web |url=https://www.who.int/immunization/en/ |title=Immunizations, vaccines and biologicals |publisher=World Health Organization}}
*{{cite web |url=https://www.cdc.gov/vaccines/ |title=Vaccines & immunizations |date=2018-09-04 |publisher=Centers for Disease Control and Prevention}}
*{{cite serial |series=Frontline |title=The Vaccine War |url=https://www.pbs.org/wgbh/frontline/documentary/vaccines/? |network=PBS |date=April 27, 2010}}
* {{cite web |author1=Institute of Global Health Innovation |title=Global attitudes towards a COVID-19 vaccine |url=https://www.imperial.ac.uk/media/imperial-college/institute-of-global-health-innovation/GlobalVaccineInsights_ICL-YouGov-Covid-19-Behaviour-Tracker_20210520_v2.pdf |website=Imperial College London |publisher=Covid Data Hub |date=May 2021}}
* {{cite web |title=Vaccine Education Center |url=https://www.chop.edu/centers-programs/vaccine-education-center |website=Children's Hospital of Philadelphia |date=November 19, 2014 }}

{{Conspiracy theories}}
{{Vaccines}}
{{Authority control}}

{{DEFAULTSORT:Vaccine hesitancy}}
[[Category:Vaccine hesitancy| ]]
[[Category:Autism pseudoscience]]
[[Category:Articles containing video clips]]
[[Category:Health-related conspiracy theories]]