Issues in Interdisciplinarity 2020-21/Evidence in the fight against anti-vaccine movements

Introduction Despite the common impression that anti-vaccination movements emerged through the Internet, they arose as soon as vaccination started being popularised. The vaccine against smallpox in the 1800s faced immediate hostility, seen as ‘unchristian’ and a violation of people’s personal liberty.Durbach, N. They might as well brand us: Working class resistance to compulsory vaccination in Victorian England. The Society for the Social History of Medicine. 2000;13:45-62.Wolfe, R.M., Sharpe, L.K. Anti-vaccinationists past and present. BMJ. 2002. 2002;325:430-432. Available online at <https://doi.org/10.1136/bmj.325.7361.430> Although the ways of expressing and spreading this opposition have evolved, the motives behind it today are still the same, opposing public health and medicine to civil liberty and choice. Biology Biological evidence promotes vaccination: the larger the vaccinated population, the better. Yellow Fever Yellow Fever is a disease prevalent in Africa that can be fatal, involving kidney deterioration and jaundice.Tomori O. Yellow Fever: The Recurring Plague. Critical Reviews in Clinical Laboratory Sciences [Internet]. 2004 Jan [cited 2020 Dec 2];41(4):391–427. Available from: https://pubmed.ncbi.nlm.nih.gov/15487593/ It does not have any specific treatment and is responsible for 30,000 deaths every year, with a Case Fatality Rate of 50% or higher in severe cases. Being spread by mosquitoes, it cannot be eradicated, hence the importance of vaccination to reduce the number of its victims. Research has shown that the 17D (YF-17D) vaccine is efficient after 10 days in 95% of the patients, lasting for up to 30-35 years.Muyanja E, Ssemaganda A, Ngauv P, Cubas R, Perrin H, Srinivasan D, et al. Immune activation alters cellular and humoral responses to yellow fever 17D vaccine. Journal of Clinical Investigation [Internet]. 2014 Jun 9 [cited 2020 Dec 2];124(7):3147–58. Available from: https://www.jci.org/articles/view/75429 Although the WHO recommends a single vaccination, study has shown that its efficiency is limited (with only 50.4% of Malian children still seropositive after 3-5 years), suggesting a second administration is required to reach an 80% immunity of the population, preventing yellow fever outbreaks.Domingo C, Fraissinet J, Ansah P, Kelly C, Bhat N, Sow S, et al. Long-term immunity against yellow fever in children vaccinated during infancy: a longitudinal cohort study [Internet]. The Lancet. Infectious diseases. 2019 [cited 2020 Dec 2]. Available from: https://pubmed.ncbi.nlm.nih.gov/31543249/ Some evidence in the biological domain however shows harmful effects of the vaccine. Several pathologies have been linked to this vaccination, such as transverse myelitis Bartol KD, Aguirre JL, Labruzzo SV, Henriet RP. Transverse myelitis associated with yellow fever vaccination. Proceedings (Baylor University Medical Center) [Internet]. 2019 Apr 1 [cited 2020 Dec 2];32(2):283. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6541067/, encephalitis McMahon A, Eidex R, Marfin A, Russell M, Sejvar J, Markoff L, et al. Neurologic disease associated with 17D-204 yellow fever vaccination: a report of 15 cases [Internet]. Vaccine. 2007 [cited 2020 Dec 2]. Available from: https://pubmed.ncbi.nlm.nih.gov/17240001/, and peripheral facial paralysis Martins Rde M, Pavão A, de Oliveira P, dos Santos P, Carvalho S, Mohrdieck R, et al. Adverse events following yellow fever immunization: Report and analysis of 67 neurological cases in Brazil [Internet]. Vaccine. 2014 [cited 2020 Dec 2]. Available from: https://pubmed.ncbi.nlm.nih.gov/24837504/.. Nevertheless, the vaccine remains the most efficient way to prevent yellow fever and its adverse effects are very low, going from 0.4 to 0.8 cases per 100 000 vaccines. Vaccine efficacy Vaccine efficacy is calculated according to the difference between vaccinated and unvaccinated people who catch a disease.Zimmer C. 2 Companies Say Their Vaccines Are 95% Effective. What Does That Mean? The New York Times [Internet]. 2020 Nov 20 [cited 2020 Nov 21]; Available from: https://www.nytimes.com/2020/11/20/health/covid-vaccine-95-effective.html According to the Centres for Disease Control and PreventionCenters for Disease Control and Prevention. [Internet]. 2019 [cited 2020 Dec 2]. Available from: https://www.cdc.gov/vaccines/vpd/vaccines-diseases.html, IPV is 90% effective against polio for two doses (99-100% for three doses), making the US polio-free since 1979, the vaccine against chickenpox is 90% effective (two doses), and MMR vaccine is about 93% effective for one dose (97% for two doses) at preventing measles, leading to a 99% reduction of cases in the US. Biological quantitative evidence therefore largely promotes (compulsory) vaccination, as the vaccines administered often have very high efficacy rates and help stop the spread of (or even eradicate) diseases. The few biological evidence used by the anti-vaccine movements often aims to show the causality between certain vaccines and diseases or infant deaths. However this evidence is often flawed Osawa M, Nagao R, Kakimoto Y, Kakiuchi Y, Satoh F. Sudden Infant Death After Vaccination: Survey of Forensic Autopsy Files. The American Journal of Forensic Medicine and Pathology [Internet]. 2019 Sep 1 [cited 2020 Dec 3];40(3):232–237. Available from: https://journals.lww.com/amjforensicmedicine/FullText/2019/09000/Sudden_Infant_Death_After_Vaccination__Survey_of.5.aspx or irrelevant statistically, compared to the number of lives saved by vaccination – preventing 2 to 3 million deaths every year Immunization coverage [Internet]. Who.int. World Health Organization: WHO; 2018 [cited 2020 Dec 3]. Available from: https://www.who.int/en/news-room/fact-sheets/detail/immunization-coverage- raising nevertheless ethical questions about the 'collateral damage' of vaccination. Ethics Ethics focus mainly on qualitative evidence concerning people's freedom and safety, presenting arguments that tend to support optional vaccination.Ethical Issues and Vaccines | History of Vaccines. Available from : https://www.historyofvaccines.org/content/articles/ethical-issues-and-vaccines Philosophy Philosophy in Ethics prompts reflection on what can and cannot be done, representing anti-vaccination movements' main focus. Their concerns oppose utilitarianism 4. Duignan B, West HR. Utilitarianism | philosophy. In: Encyclopædia Britannica [Internet]. 2017. Available from: https://www.britannica.com/topic/utilitarianism-philosophyand consequentialismThe Editors of Encyclopedia Britannica. Consequentialism | ethics. In: Encyclopædia Britannica [Internet]. 2009. Available from: https://www.britannica.com/topic/consequentialism, highlighting the risks of vaccination for individuals rather than the overall population's safety.Isaacs D, Kilham H, Leask J, Tobin B. Ethical issues in immunisation.[Internet] Vaccine. [cited 11 December 2020] 2009;27(5):615-618. Available from: https://www.sciencedirect.com/science/article/pii/S0264410X08015077. The example of Andrew Wakefield and the Lancet MMR autism fraud illustrates this. His study in the ’90s falsely stated that autism was a side effect of the MMR vaccine,Hussain A, Ali S, Ahmed M, Hussain S. The Anti-vaccination Movement: A Regression in Modern Medicine. Cureus. 2018 Jul 3;10(7). Available from : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6122668/ resulting in an epidemic of rubella in the USA, showing the dangers of anti-vaccination movements, harming the population's health.Reef SE, Frey TK, Theall K, Abernathy E, Burnett CL, Icenogle J, et al. The Changing Epidemiology of Rubella in the 1990s. JAMA. 2002 Jan 23;287(4):464. ‌Giubilini A. The ethics of vaccination. Cham, Switzerland: Palgrave Macmillan; 2019. Furthermore, anti-vaccine activists question the government’s right to force an individual's vaccination to attain herd immunity, despite refusalO’Doherty K, Smith C, McMurtry C. Hésitation face à la vaccination : considérations éthiques vues de multiples perspectives. La santé publique à une ère marquée par le doute : origines religieuses et culturelles de l’hésitation des Canadiens face à la vaccination.[Internet] 2019;:51-72. Available from: https://savoirs.usherbrooke.ca/handle/11143/16025, leading to cases like Henning Jacobson's trial in the 20th century.Mariner WK, Annas GJ, Glantz LH. Jacobson v Massachusetts: it’s not your great-great-grandfather’s public health law. Am J Public Health. 2005;95:581- 90.El-Amin AN, Parra MT, Kim-Farley R, Fielding JE. Ethical issues concerning vaccination requirements.[Internet] Public Health Reviews. [cited 11 December 2020] 2012;34: epub ahead of print. Available from : https://publichealthreviews.biomedcentral.com/track/pdf/10.1007/BF03391666.pdf Anti-vaxxers perceive vaccination as an invasion of autonomy and freedom, especially of children's rights, asking when a parent’s objection can be overcome.Salmon DA, Omer SB. Individual freedoms versus collective responsibility: immunization decision-making in the face of occasionally competing values. Emerging Themes in Epidemiology. 2006 Sep 27;3(1). Available from : https://pubmed.ncbi.nlm.nih.gov/17005041/ Religion Religion is another central matter in Ethics, the freedom of belief being a fundamental right. Vaccines were long seen as evil, being considered « unnatural ».Sauvayre R, Ethique de la croyance, confiance et valeur epistémique, Le cas de la controverse scientifique entourant le vaccin contre la rougeole [Internet]. Revue française d’éthique appliquée,n°8, pages 47 à 61, Cairn. 2019. [cited 13 december 2020]. Available from https://www.cairn.info/revue-francaise-d-ethique-appliquee-2019-2-page-47.htm Christianism for instance rejects vaccines containing embryonic origins derived from aborted foetuses, considered morally incompatible. Islam on the other hand, is opposed to certain vaccines that contain traces of pork gelatine, not being halal. Those reasons are hard to overcome in movements to fight anti-vaccination as they are more than evidence but beliefs.Pelčić G, Karačić S, Mikirtichan GL, Kubar OI, Leavitt FJ, Cheng-tek Tai M, et al. Religious exception for vaccination or religious excuses for avoiding vaccination. Croatian Medical Journal [Internet]. 2016 Oct;57(5):516–21. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5141457/ Internet and Social Media Finally, Ethics are involved in the role of the Internet and social media,Chiou L, Tucker CE. Fake News and Advertising on Social Media: A Study of the Anti-Vaccination Movement. SSRN Electronic Journal. 2018; ‌ which represents an increasing threat for vaccination.Mavragani A, Ochoa G. The Internet and the Anti-Vaccine Movement: Tracking the 2017 EU Measles Outbreak. Big Data and Cognitive Computing. 2018 Jan 16;2(1):2. Available from :https://www.mdpi.com/2504-2289/2/1/2#cite ‌ 43% of websites on Google associated to the key words « vaccination » or « immunisation » are led by anti-vaccination movementsHussain A, Ali S, Ahmed M, Hussain S. The Anti-vaccination Movement: A Regression in Modern Medicine. Cureus. 2018 Jul 3;10(7). Available from : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6122668/Tafuri S, Gallone MS, Cappelli MG, Martinelli D, Prato R, Germinario C. Addressing the anti-vaccination movement and the role of HCWs. Vaccine [Internet]. 2014 Aug;32(38):4860–5. Available from: https://www.sciencedirect.com/science/article/pii/S0264410X13015053 supported by accounts like « Beware the Needle » on Youtube or Instagram, spreading fake news that feed conspiracy theories. These websites represent dangerous content within anyone's reach, discrediting vaccination and governments' intentions, failing their ethical responsibility to inform, in addition to endangering the population.Johnson NF, Velásquez N, Restrepo NJ, Leahy R, Gabriel N, El Oud S, et al. The online competition between pro- and anti-vaccination views. Nature [Internet]. 2020 May 13 [cited 2020 May 13];582:1–4. Available from: https://www.nature.com/articles/s41586-020-2281-1 ‌ Public Health Public health as a discipline is the science of promoting the population’s health as a whole.Detels R, Beaglehole R, Lansang M, Gulliford M. The development of the discipline of public health [Internet]. Oxford Medicine Online. 2011 [cited 9 December 2020]. 5th edition, DOI 10.1093/med/9780199218707.001.0001. Available from: https://oxfordmedicine.com/view/10.1093/med/9780199218707.001.0001/med-9780199218707-section-01 It plays a crucial role in solving tensions in the evidence proposed in various disciplines, but also within them. Overall, public health professionals try to fight the anti-vaccine movement. Compulsory vaccines Governments can enforce mandatory vaccines to avoid the resurgence of a disease by promoting herd immunity, based on evidence relying on principles commonly used in Public Health. The “harm principle”, developed by John Stuart Mill, declares that unvaccinated people could be a danger to society as spreaders of the disease. Additionally, the “precautionary principle” states that preventive measures must be taken when a country is threatened by a virus.Nelson El Amin A, Parra M T, R. Kim-Farley, Fielding J.E. Ethical Issues Concerning Vaccination Requirements? Public Health Reviews, Vol 34, No 1. [date unknown]. These principles apply utilitarianism, prioritising the well-being of the majority rather than the individual's.Azhar Hussain, Syed Ali, Madiha Ahmed, Sheharyar Hussain. The anti-vaccination Movement: A regression in Modern Medicine [Internet]. Cureus. 2018. 10(7): e2919 [cited 9 december 2020]. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6122668/ Hence, evidence in biostatistics, showing that punctual negative effects are negligible in front of the overall success of vaccines,Department of Health, Government of Western Australia, Comparison of the effects of diseases and the side effects of vaccines [Internet]. Australian Immunisation handbook. 2013. 9th edition. [cited 14 december 2020]. Available from https://ww2.health.wa.gov.au/Articles/A_E/Comparisons-of-the-effects-of-diseases-and-the-side-effects-of-vaccines/ mirrors public health’s goal of assuring the population’s safety (sometimes at the expense of the individual's). However, vaccine exemptions for medical, religious, and philosophical reasons exist, based on the right of the individual's choiceErin Walkinshaw. Mandatory vaccinations: The International Landscape [Internet]. CMAJ Medical Knowledge that matters. 2011. 183(16): e1167–e1168 [cited 9 december 2020]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3216445/, although their validity varies widely. In the United States, 43 states allow religious exemptions, while only 15 allow philosophic exemptions.Malone K. M. and Hinman A. R. Chapter 13 – Vaccination Mandates: The Public Health Imperative and Individual Rights. [Internet]. [publisher unknown]. [date unknown]. [cited 9 december 2020]. Available from https://www.cdc.gov/vaccines/imz-managers/guides-pubs/downloads/vacc_mandates_chptr13.pdf Overall, public health does not consider much personal choice – which is one of the arguments used by anti-vaccination movements –, and some countries like the US seek to consider ethics more by imposing less compulsory vaccines. Education In the fight against anti-vaxxers, education plays a crucial role. Today 70% of parents go to the internet to educate themselves on vaccinationKata A. Anti-vaccine activists, Web 2.0, and the postmodern paradigm – An overview of tactics and tropes used online by the anti-vaccination movement [Internet]. Science Direct. 2012. [cited 9 december 2020]. Available from https://www-sciencedirect-com.libproxy.ucl.ac.uk/science/article/pii/S0264410X11019086, but the overwhelming amount of misinformation leads to a confused population, often deprived of valid evidence. To educate families, trained healthcare providers Tafuri S, Gallone M.S, Cappelli M.G, Martinelli D, Prato R, Germinario C. Addressing the anti-vaccination movement and the role of HCWs [Internet]. Science Direct. 2014. 20, 25, 2778-3789 [cited 9 december 2020]. Available from https://www.sciencedirect.com/science/article/pii/S0264410X13015053# remind the dangers of certain diseases and explain herd immunity as well as the process of vaccines' commercialisation.Arede M, Bravo-Araya M, Bouchard E, Singh Gill G, Plajer V, Shehraj A, and Shuaib A. Y. Combating Vaccine Hesitancy: Teaching the Next Generation to Navigate Through the Post Truth Era. [Internet]. Frontiers in Public Health. 2019. 6: 381 [cited 9 december 2020]. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6339919/Nelson El Amin A, Parra M. T, Kim-Farley R, Fielding J. E, MD, MPH. Ethical Issues Concerning Vaccination Requirements? Public Health Reviews, Vol 34, No 1. [date unknown]. [cited 9 December 2020]Online education campaigns have also proved to be efficient, with 66% of parents and 88% of pregnant women raising awareness and checking up on their children’s vaccination after having seen such campaigns in Australia.Gardiner D, Ffrench S and Franks A. Childhood Immunisation education campaign evaluation. [Internet]. Department of Health. 2017. ID: HEALTH/17-18/03437 [cited 9 december 2020]. Available from https://www.health.gov.au/sites/default/files/childhood-immunisation-education-campaign-phase-one-evaluation.pdf These strategies reduce interdisciplinary conflicts, simply by educating people instead of depriving them from their free will. Conclusion Altogether, the fight against the anti-vaccination movement is far from finished, due to contradictory evidence between disciplines. Today, as the Covid-19 vaccines are facing “vaccine hesitancy” and misinformation,Lazarus J. V., Ratzan S. C., Palyew A., Gostin L. O., Larson H. J., Rabin K., Kimball S, El-Mohandes A, A global survey of potential acceptance of a Covid-19 vaccine. [Internet]. Nature Medicine. 2020. [cited 14 december 2020]. Available from https://www.nature.com/articles/s41591-020-1124-9Megget K, Even Covid-19 can’t kill the anti-vaccination movement [Internet]. The BMJ. 2020. 369:m2184 [cited 14 december 2020]. Available from https://www.bmj.com/content/369/bmj.m2184it is necessary for Public Health to gain the trust of the population in order to reach enough vaccination coverage. References