Confronting the evolution and expansion of anti-vaccine activism in the USA in the COVID-19 era

Abstract

Over the past two decades, anti-vaccine activism in the USA has evolved from a fringe subculture into an increasingly well organised, networked movement with important repercussions for public health. The COVID-19 pandemic has exacerbated this evolution and magnified the reach of vaccine misinformation. Anti-vaccine activists, who for many years spoke primarily to niche communities hesitant about childhood vaccinations, have used traditional and social media to amplify vaccine-related mistruths about COVID-19 vaccines while also targeting historically marginalised racial and ethnic communities. These efforts contributed to COVID-19 vaccine hesitancy and expanded the movement, with early indications suggesting that this hesitancy could now also be increasing hesitancy that existed pre-pandemic towards other vaccines. It is important to understand the implications of this recent evolution of anti-vaccine activism on vaccination uptake and the promotion of sound public health strategies. In this Viewpoint, we summarise the latest developments in US-based anti-vaccine activism and propose strategies for confronting them. In the years preceding the COVID-19 pandemic, anti-vaccine activism became more visible in the USA. Three patterns are noteworthy, and are outlined below. Before the pandemic, anti-vaccine activism increasingly aligned with conservative political identity. Two developments were crucial to this conservative shift. One was California's 2015 legislative effort to eliminate personal-belief exemptions for school vaccinations (bill SB-277), during which anti-vaccine activists mobilised to broaden their following beyond its traditional natural-living, left-leaning base through deliberate activation of, and outreach to, potential Tea Party and libertarian allies.1DiResta R Lotan G Anti-vaxxers are using Twitter to manipulate a vaccine bill. Wired, June 8, 2015https://www.wired.com/2015/06/antivaxxers-influencing-legislation/Date accessed: August 15, 2022Google Scholar, 2Haltinner K Sarathchandra D Tea Party health narratives and belief polarization: the journey to killing grandma.AIMS Public Health. 2017; 4: 557-578Crossref PubMed Google Scholar The other was the formation of influential political action committees (eg, Texans for Vaccine Choice) that lobbied state legislatures and promoted conservative political candidates with anti-vaccine positions.3Kupferschmidt K Why Texas is becoming a major antivaccine battlefield.Science. Dec 1, 2016; https://www.science.org/content/article/why-texas-becoming-major-antivaccine-battlefieldDate accessed: August 26, 2022Google Scholar, 4Hotez PJ Texas and its measles epidemics.PLoS Med. 2016; 13e1002153Crossref PubMed Scopus (42) Google Scholar, 5Lakshmanan R Sabo MA Lessons from the front line: advocating for vaccine policies at the Texas Capitol during turbulent times.J Appl Res Child. 2019; 2019: 10Google Scholar For anti-vaccine activists, this mutualism enabled access to money, political influence, and broader audiences. For the libertarian right, it provided a cohort of politically active Americans whose support could be directed towards other causes.6Haelle T This is the moment the anti-vaccine movement has been waiting for. New York Times, Aug 31, 2021https://www.nytimes.com/2021/08/31/opinion/anti-vaccine-movement.htmlDate accessed: August 15, 2022Google Scholar, 7Frankel S How some parents changed their politics in the pandemic. New York Times, Aug 3, 2022https://www.nytimes.com/2022/08/01/technology/anti-vax-parents-political-party.htmlDate accessed: August 15, 2022Google Scholar Concurrently, anti-vaccine activists' pre-pandemic messaging increasingly shifted from expressions of concern about health impacts and safety (eg, claims that vaccines cause autism) to a philosophical focus on liberty evidenced in arguments about health and medical freedom and parental rights.5Lakshmanan R Sabo MA Lessons from the front line: advocating for vaccine policies at the Texas Capitol during turbulent times.J Appl Res Child. 2019; 2019: 10Google Scholar, 8Hotez PJ America's deadly flirtation with antiscience and the medical freedom movement.J Clin Invest. 2021; 131e149072Crossref PubMed Scopus (11) Google Scholar, 9Matthews KRW Tan MT Medical freedom, privacy, and fear of discrimination: the 2017 Texas Legislative Session anti-vaccine arguments. Rice University's Baker Institute for Public Policy, Houston, TX2018Google Scholar This shift served to place the growing movement in terms more likely to draw the interests of conservatives and libertarians, for whom scientific consensus around the safety, efficacy, and benefit of vaccination was less salient than concerns about liberty and perceptions of unwelcome government interference. In activism, network building is key for recruiting and retaining participants and achieving strategic goals. Pre-pandemic, anti-vaccine activists adeptly leveraged social media to shape opinion, gain allies, and influence policy. After California passed SB-277 in 2015, a collection of loosely federated health-freedom organisations with names such as Freedom Keepers emerged in other states, establishing active social media accounts.10The Virality ProjectMemes, magnets and microchips: narrative dynamics around COVID-19 vaccines.Stanford Digital Repository. 2022; 1: 0·1Google Scholar These social media accounts shared common naming conventions and visual branding elements, maintained messaging discipline, and cross-promoted each other's local activism efforts—showing that the anti-vaccine movement was already nationally networked before the COVID-19 pandemic.6Haelle T This is the moment the anti-vaccine movement has been waiting for. New York Times, Aug 31, 2021https://www.nytimes.com/2021/08/31/opinion/anti-vaccine-movement.htmlDate accessed: August 15, 2022Google Scholar, 11Mays M Anti-vaccine protesters are likening themselves to civil rights activists. Politico, Sept 18, 2019https://www.politico.com/story/2019/09/18/california-anti-vaccine-civil-rights-1500976Date accessed: August 15, 2022Google Scholar Reflecting broader, growing trends in anti-intellectual or anti-science populist discourse (especially in right-wing media outlets), clinicians and other health professionals who were publicly involved in pro-vaccine policy or commentary in advance of the pandemic were subject to harassment, physical threats, and violence by anti-vaccine activists. Media coverage documented numerous harassment campaigns, including those targeting vaccine scientist Peter Hotez, one of the members of this Viewpoint,12Hotez P Communicating science and protecting scientists in a time of political instability.Trends Mol Med. 2022; 28: 173-175Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar California State Senator and paediatrician Richard Pan for coauthoring California's 2020 law SB-276 that tightened standards for medical exemptions from vaccines,11Mays M Anti-vaccine protesters are likening themselves to civil rights activists. Politico, Sept 18, 2019https://www.politico.com/story/2019/09/18/california-anti-vaccine-civil-rights-1500976Date accessed: August 15, 2022Google Scholar and paediatrician Nicole Brown for her popular, vaccine-promoting TikTok content.13Simpson L Pediatrician gets death threats after posting a pro-vaccination video on TikTok reassuring young people that they don't cause autism. Daily Mail, Jan 19, 2020https://www.dailymail.co.uk/news/article-7905327/Pediatrician-gets-DEATH-THREATS-posting-video-TikTok-saying-vaccines-dont-cause-autism.htmlDate accessed: August 15, 2022Google Scholar Although anti-vaccine activism was already increasing in the USA and internationally, the 2020 emergence of COVID-19 served as an accelerant, helping turn a niche movement into a more powerful force. Whereas earlier anti-vaccine activism focused primarily on parents and school immunisation requirements, the universal nature of the COVID-19 pandemic provided anti-vaccine activists with concerned audiences that were far larger and broader. As the pandemic unfolded, anti-vaccine activists capitalised on discontent over pandemic measures such as physical distancing, school closures, and vaccine and mask mandates, joining right-wing groups, some elected officials, and some Christian nationalist pastors in opposing public health interventions via appeals to health liberty, and downplaying the severity of COVID-19.14Bergengruen V How the antivax movement is taking over the right. Time, Jan 26, 2022https://time.com/6141699/anti-vaccine-mandate-movement-rally/Date accessed: August 15, 2022Google Scholar, 15McWhinney J How a San Diego church became a nexus of anti-vaccine, anti-COVID lockdown and right-wing political organizing. Politico, May 16, 2022https://voiceofsandiego.org/2022/05/16/how-a-san-diego-church-became-a-nexus-of-anti-vaccine-anti-covid-lockdown-and-right-wing-political-organizing/Date accessed: August 25, 2022Google Scholar The start of COVID-19 vaccine trials provided opportunities for anti-vaccine activists to discredit the vaccine development and evaluation process.16Hotez P Batista C Ergonul O et al.Correcting COVID-19 vaccine misinformation: Lancet Commission on COVID-19 vaccines and therapeutics task force members.EClinicalMedicine. 2021; 33100780Summary Full Text Full Text PDF PubMed Scopus (36) Google Scholar Anti-vaccine advocacy groups worked to call the trials into question and spread doubt among Americans who either lacked familiarity with the process, or lacked trust in the health-care system. As the national roll-out of vaccinations began, they highlighted stories of purported side-effects (and conspiracy theories) and worked to undermine public confidence in vaccine safety and efficacy among a broader public audience who were searching for information about whether to vaccinate.17Nazar S Pieters T Plandemic revisited: a product of planned disinformation amplifying the COVID-19 “infodemic”.Front Public Health. 2021; 9649930Crossref PubMed Scopus (19) Google Scholar, 18Choi J Lieff SA Meltzer GY et al.Anti-vaccine attitudes among adults in the US during the COVID-19 pandemic after vaccine rollout.Vaccines. 2022; 10: 933Crossref Scopus (2) Google Scholar Notably, the activists treated the identification of adverse effects (such as myocarditis) by scientific authorities as more evidence of conspiracy rather than a demonstration of how vaccine safety systems operate. They shaped their messaging to resonate with particular audiences,19Frenkel S Black and Hispanic communities grapple with vaccine misinformation. New York Times, March 10, 2021https://www.nytimes.com/2021/03/10/technology/vaccine-misinformation.htmlDate accessed: December 11, 2022Google Scholar including supporters of former US President Donald Trump, for whom anti-vaccine rhetoric resonated,20Porter T How a New York billionaire-funded anti-vax group is contributing to the vaccine hesitancy that's crippling the US recovery. Business Insider, Aug 24, 2021https://www.businessinsider.com/ican-billionaire-funded-antivax-group-trump-fans-ties-2021-8Date accessed: December 11, 2022Google Scholar and historically marginalised racial and ethnic groups they had targeted pre-pandemic. Examples include promoting messaging that tied COVID-19 vaccines to past medical abuses such as the Tuskegee syphilis study when targeting Black communities,21Stone W An anti-vaccine film targeted to Black Americans spreads false information. Kaiser Health News, June 9, 2021https://khn.org/news/article/an-anti-vaccine-film-targeted-to-black-americans-spreads-false-information/Date accessed: December 11, 2022Google Scholar or intensifying existing mistrust in health-care and government institutions for Latino people,22Longoria J Acosta D Shaydanay U Smith R A limiting lens: how vaccine misinformation has influenced Hispanic conversations online. First Draft, Dec 8, 2022https://firstdraftnews.org/wp-content/uploads/2021/12/COVID-19_VACCINE_MISINFORMATION_HISPANIC_COMMUNITIES.pdfDate accessed: December 11, 2022Google Scholar and fuelling concerns of fertility-related COVID-19 vaccine side-effects that resonate with women.23Fossett K The myth about women and the COVID-19 vaccine that won't die. Politico, March 26, 2021https://www.politico.com/newsletters/women-rule/2021/03/26/the-myth-about-women-and-the-covid-19-vaccine-that-wont-die-492263Date accessed: December 11, 2022Google Scholar Starting in 2021, anti-vaccine activists have challenged COVID-19 vaccine policies in court.24Stanley-Becker I Resistance to vaccine mandates is building. A powerful network is helping. Washington Post, May 26, 2021https://www.washingtonpost.com/health/2021/05/26/vaccine-mandate-litigation-siri-glimstad-ican/Date accessed: December 12, 2022Google Scholar, 25Egelko B Ninth Circuit upholds firing of UC Irvine medical ethics director who refused COVID-19 vaccine. San Francisco Chronicle, Nov 23, 2022https://www.sfchronicle.com/politics/article/Ninth-Circuit-upholds-firing-of-UC-Irvine-medical-17607616.phpDate accessed: December 12, 2022Google Scholar Much of the anti-vaccine information on social media moved through networks of so-called influencers.26Center for Countering Digital HateThe disinformation dozen.https://counterhate.com/research/the-disinformation-dozen/Date: March 24, 2021Date accessed: February 23, 2023Google Scholar Some were long-time anti-vaccine activists and others had established their audiences in wellness, politics, parenting, or other spheres. Many of these influencers are ideologically motivated, but some, including several prominent anti-vaccine influencers, profit from their audiences by selling anti-vaccine books and products (eg, alternative treatments), and monetising websites with advertising revenue or affiliate links to anti-vaccine groups.26Center for Countering Digital HateThe disinformation dozen.https://counterhate.com/research/the-disinformation-dozen/Date: March 24, 2021Date accessed: February 23, 2023Google Scholar In at least one case, influencers selling anti-vaccine products founded a medical freedom-focused super political action committee.27Smith MR Reiss J Inside one network cashing in on vaccine disinformation. Associated Press, May 13, 2021https://apnews.com/article/anti-vaccine-bollinger-coronavirus-disinformation-a7b8e1f33990670563b4c469b462c9bfDate accessed: December 12, 2022Google Scholar On social media, sensationalism, outrage, and controversy are often effective tools for generating audience attention and growing, engaging, or monetising a following. The rancorous, partisan tone of much of the conversation surrounding public health response to the pandemic led to new actors—including partisan pundits, politicians, wellness influencers, sport figures, celebrities, and even clinicians, scientists, and academics—taking visible roles in arguing the health-freedom perspective, while often spreading false and misleading claims about COVID-19 vaccine efficacy or safety. In this way, the pandemic has served to greatly increase the number of voices with larger audiences shaping the public conversation about vaccines. The growing group of influencers use simple and disciplined messaging to question vaccines. This directness presents challenges to government authorities that have often issued variable, difficult-to-interpret guidance on COVID-19 vaccinations.10The Virality ProjectMemes, magnets and microchips: narrative dynamics around COVID-19 vaccines.Stanford Digital Repository. 2022; 1: 0·1Google Scholar Although intensive media attention over COVID-19 immunisation and mitigation campaigns has decreased, influencers and audiences who found COVID-19 misinformation compelling have not dispersed. Rather, building on their successes, anti-vaccine activists have attacked vaccination efforts at the state and local levels with new vigour, and new allies. At the state level, anti-COVID-19 vaccine mandate efforts have expanded to undermine existing vaccination requirements for schools and the health-care workforce. For example, with anti-vaccine activist encouragement, Texas lawmakers introduced legislation to remove routine vaccination school requirements during the 2021 legislative session,28Hall B Bill SB 1669. Texas Legislature Online.https://capitol.texas.gov/BillLookup/history.aspx?LegSess=87R&Bill=SB1669Date: Nov 3, 2021Date accessed: February 20, 2023Google Scholar and the 2022 Texas Republican Party platform now includes natural and unalienable rights not to be vaccinated.292022 Platform Committee MembersPlatform and resolutions as amended and adopted by the 2022 State Convention of the Republican Party of Texas. Republican Party of Texas, TexasJuly 6, 2022https://texasgop.org/2022platform/Date accessed: August 26, 2022Google Scholar During the start of the 2022 state legislative sessions, states such as Kansas30Fairchild B Burris J Garber R et al.Prohibiting the secretary of health and environment from requiring COVID-19 vaccination for children attending school. HB 2498. Kansas State Legislature.http://kslegislature.org/li/b2021_22/measures/hb2498/Date: Jan 20, 2022Date accessed: February 20, 2023Google Scholar and Oklahoma31Standridge R Roberts S Bill SB 1171. Oklahoma State Legislature.http://www.oklegislature.gov/BillInfo.aspx?Bill=sb1171&Session=2200Date: Feb 7, 2022Date accessed: February 20, 2023Google Scholar introduced legislation to prohibit COVID-19 vaccine school-entry requirements. Although none of this legislation has passed, many of these bills will probably be reintroduced in future sessions. Anti-vaccine activism has also increased at the local level, emphasising the importance of having a presence and building on momentum to influence vaccination policies via activism directed towards school boards, unions, and county governments.32Zuckerman J Meet the anti-vax doctor who just won a local school board race. Ohio Capital Journal.https://ohiocapitaljournal.com/2022/01/14/meet-the-anti-vax-doctor-who-just-won-a-local-school-board-race/Date: Jan 14, 2022Date accessed: August , 2022Google Scholar, 33Kukura J Anti-vaxxers bring chaos to Healdsburg, rallying around unvaccinated city council member. SFist.https://sfist.com/2021/12/07/anti-vaxxers-bring-chaos-to-healdsburg-rallying-around-unvaccinated-city-council-member/Date: Dec 7, 2021Date accessed: July 29, 2022Google Scholar Immediate action is needed to counter these dynamics and respond to this movement. Fundamentally, the public health, scientific, and policy communities must recognise that anti-vaccine campaigns are networked. Within the USA, anti-vaccine messaging and political activism is franchised with health-freedom communities established in each state to rapidly activate for legislative or protest purposes.10The Virality ProjectMemes, magnets and microchips: narrative dynamics around COVID-19 vaccines.Stanford Digital Repository. 2022; 1: 0·1Google Scholar Despite being distinct entities, these groups or individuals amplify each other's social media content and calls-to-action, sharing unified messaging and their views that vaccine mandates violate liberty, nationally. In contrast, public health networks and communications can be minimally coordinated because they remain largely siloed by their state and institution. Even public health professionals active in communicating on social media individually are often doing so in an ad hoc, grassroots manner, with public officials often having limited ability to speak out (eg, due to institutional restrictions).34Foxhall K The growing culture of censorship by PIO. Columbia Journalism Review, Aug 3, 2022https://www.cjr.org/criticism/public-information-officer-access-federal-agencies.phpDate accessed: August 13, 2022Google Scholar National vaccine groups promote much-needed pro-vaccine messages but are often underfunded and overwhelmed by further-reaching anti-vaccine activists. Relevant community influencers or individuals with large social media followings are rarely incorporated into pro-public-health communication efforts. Although physicians are key messengers of vaccination promotion, some (notably in academic or government-appointed positions) have engaged in media efforts to create public distrust in COVID-19 vaccines.10The Virality ProjectMemes, magnets and microchips: narrative dynamics around COVID-19 vaccines.Stanford Digital Repository. 2022; 1: 0·1Google Scholar, 35Soule D Florida Surgeon General Ladapo appears on anti-vaccine podcast, promotes medical falsehoods. Tallahassee Democrat, Nov 4, 2022https://www.tallahassee.com/story/news/politics/2022/11/04/florida-surgeon-general-joseph-ladapo-podcast-vaccine-falsehoods/8259063001/Date accessed: December 12, 2022Google Scholar To address this expanded threat to US public health and security, we recommend three measures consistent with a so-called whole of society approach,36Ortenzi F Marten R Valentine NB Kwamie A Rasanathan K Whole of government and whole of society approaches: call for further research to improve population health and health equity.BMJ Glob Health. 2022; 7e009972Crossref PubMed Scopus (3) Google Scholar in which public health agencies collaborate with diverse (eg, academic, civic, and private sector) stakeholders. First, we suggest the development of networked communities capable of reaching the public at the right time, at the right place, and with the right messenger about vaccine-related information—especially to pre-empt and pre-bunk37Garcia L Shane T A guide to prebunking: a promising way to inoculate against misinformation. First Draft, June 29, 2021https://firstdraftnews.org/articles/a-guide-to-prebunking-a-promising-way-to-inoculate-against-misinformation/Date accessed: December 12, 2022Google Scholar well funded and amplified messages disseminated by the anti-vaccine movement. This action entails a shift in approach for the US public health communication model, from the use of one credible messenger (that is vulnerable to discrediting attacks), to a broad, diverse, and coordinated network of expert messengers and influencers. These stakeholders—including leaders of local, historically marginalised, or faith communities38Moore D Mansfield LN Onsomu EO Caviness-Ashe N The role of Black pastors in disseminating COVID-19 vaccination information to Black communities in South Carolina.Int J Environ Res Public Health. 2022; 198926Crossref Scopus (0) Google Scholar, 39Martinez-Bianchi V Maradiaga Panayotti GM Corsino L et al.Health and wellness for our Latina community: the work of the Latinx Advocacy Team & Interdisciplinary Network for COVID-19 (LATIN-19).N C Med J. 2021; 82: 278-281PubMed Google Scholar—can simultaneously share similar messages of factual information to their specific audiences.40Watts C How do we amplify truth in the face of overwhelming lies? Part 2: overcoming vaccine hesitancy in the U.S. & the 2021 challenge to save American democracy. Selected Wisdom. Substack, San Francisco, CAMay 30, 2021https://clintwatts.substack.com/p/how-do-we-amplify-truth-in-the-faceDate accessed: August 15, 2022Google Scholar Such an aggregated, coordinated approach makes it difficult for anti-vaccine activist efforts to undermine public trust in messages and lone experts. Second, we suggest input is solicited from outside the usual public health agencies. Countering the array of expanded efforts by anti-vaccine activists and groups or individuals who influence or monetise disinformation efforts necessitates a wide breadth of expertise. Thus, interdisciplinary and intersectoral collaborations (eg, the Virality Project10The Virality ProjectMemes, magnets and microchips: narrative dynamics around COVID-19 vaccines.Stanford Digital Repository. 2022; 1: 0·1Google Scholar) are essential for developing effective responses.41Sharfstein JM Callaghan T Carpiano RM et al.Uncoupling vaccination from politics: a call to action.Lancet. 2021; 398: 1211-1212Summary Full Text Full Text PDF PubMed Scopus (27) Google Scholar Third, we suggest these networked and coordinated communities are leveraged to counter relevant trends in anti-vaccine efforts. This action will include separating narratives about liberty from anti-vaccine attitudes and mitigating anti-vaccine activist harassment of public health communicators. Separating these narratives requires diverse, trusted voices to stress the value of collective action to secure public health gain and economic security, while being mindful of public concerns for personal liberties that vary in form and intensity across social groups and locations. Activating networks to publicly aid individuals facing harassment will provide victims with valuable credibility and support from professionals and the general population (eg, the Shots Heard Round the World initiative42Wolynn T Hermann C Shots heard round the world: better communication holds the key to increasing vaccine acceptance.Nat Immunol. 2021; 22: 1068-1070Crossref PubMed Scopus (1) Google Scholar). Building networked, coordinated initiatives will be challenging, but the stakes are too high to ignore. Without concerted efforts to counter the anti-vaccine movement, the USA faces an ever-growing burden of morbidity and mortality from an increasingly undervaccinated, vaccine-hesitant society. Contributors RMC led the conceptualisation and writing of the first draft of the Viewpoint with TC and RD as collaborators and input from a writing group comprised of NTB, CC, APG, PJH, SBO, RL, and WEP. All authors provided critical intellectual content for revising the draft manuscript. All authors had full access to the information described in the manuscript. The Lancet Commission on Vaccine Refusal, Acceptance, and Demand in the USA is cohosted by the Yale Institute for Global Health and the Baylor College of Medicine. All authors are Commissioners. PJH is a developer of a COVID-19 vaccine construct, which was licensed by Baylor College of Medicine to Biological E, a commercial vaccine manufacturer for scale-up, production, testing, and licensure. NTB reports personal fees from WHO, Centers for Disease Control and Prevention, Sanofi, and Merck outside of the submitted work. RMC reports receiving research grant funding from Novo Nordisk Foundation (Denmark), outside of the submitted work. RL reports grants from Pfizer, GlaxoSmithKline, Sanofi Pasteur, and Merck, and personal fees from BIO, outside of the submitted work. YAM is a member of a Data Safety Monitoring Board for Pfizer and is a site Principal Investigator for a Pfizer vaccine trial, outside the submitted work. MMM reports personal fees from law firms representing retail pharmacies, generic drug companies, and a health insurer that have sued branded drug companies for marketing and antitrust law violations, outside of the submitted work, and serves as an adviser to Verily Life Sciences on a mobile app designed to facilitate safe return to work and school during COVID-19. DJO reports grants from the US National Institutes of Health, outside the submitted work. DAS reports personal fees from Pfizer, Janssen, and Moderna, is on advisory boards and receives compensation from these companies for time attending meetings, and reports grants from Merck, outside of the submitted work. All other authors declare no competing interests.