Antivaxxers have long opposed vaccine mandates of any kind, but in particularly they’ve always despised school vaccine mandates. During the pandemic, this opposition predictably resulted in spillover to opposition to vaccine mandates for health care workers or by any private company, whether mandated by government or decided upon by a private entity. What a lot of people who only started paying attention to the antivaccine movement since it became impossible to ignore during the pandemic often appear unaware of is that this opposition to vaccine mandates is nothing new. Indeed, it’s been a feature of the antivaccine movement since long before I ever started paying attention. The endgame of the antivaccine movement has always been the elimination of all vaccine mandates, including school vaccine mandates Indeed, going back to before the pandemic, I’ve warned for a long time that the endgame of the antivaccine movement is the elimination of all vaccine mandates of any kind, be the mandate for school or daycare, healthcare workers, or workers of any kind. They want all such mandates gone, so that their “freedom” is not impacted, and they don’t even have to go to the minor difficulty (in most states) of obtaining a personal belief exemption.

I was reminded of this history over the weekend, when, while doing what I’ve done for nearly two decades and perusing the dark underbelly of antivaccine social media in order to keep an eye on what the opposition is doing, I naturally perused Robert F. Kennedy Jr.’s Children’s Health Defense website. Given RFK Jr.’s prominence in the antivaccine movement since 2005, CHD is, of course, a mandatory stop on any tour of antivax websites. On Friday, CHD published an article under the byline of The Defender Staff (the news part of CHD is referred to as The Defender) titled “A COVID Silver Lining? More Parents Than Ever Questioning ‘Routine’ Childhood Vaccines“, with a blurb that read:

Children and teen vaccination rates began plummeting with the onset of the pandemic, and as concerns surfaced around the safety of COVID-19 vaccines, some parents also began questioning the need for the long list of other vaccines recommended by public health officials.

As you might imagine, RFK Jr. and his band of antivaxxers think it’s a good thing that the suspicion of COVID-19 vaccines is metastasizing to long-used childhood vaccines, such as MMR, the polio vaccine, and all the other vaccines on the childhood vaccination schedule recommended by the CDC. I’ll discuss this more in a moment, but first, let’s look at the facts.

Declining childhood vaccination rates endanger children

Declining childhood vaccination rates since the pandemic first hit are indeed a problem. Early on, this decline was due to closure of pediatrics and family practice clinics for routine medical care other than emergencies. As noted in Science last month:

In what UNICEF Executive Director Catherine Russell called a “red alert,” childhood vaccination rates in many countries worldwide have dropped to the lowest level since 2008, in part because of the COVID-19 pandemic. UNICEF and the World Health Organization together track inoculations against diphtheria, pertussis, and tetanus—which are administered as one vaccine—as a marker for vaccination coverage overall. In 2021, only 81% of children worldwide received the recommended three doses of the combined vaccine, down from 86% in 2019. As a result, some 25 million children remain insufficiently protected against the three dangerous diseases.

The majority of children who missed vaccines were in underdeveloped countries, but the US was not immune, its childhood vaccination rate having fallen as well, as the Association of American Medical Colleges (AAMC) warned earlier this month in an article titled “How distrust of childhood vaccines could lead to more breakouts of preventable diseases“:

The latest data from the Centers for Disease Control and Prevention (CDC) show that most of those children have since gotten their shots. However, the national childhood vaccination rate among kindergarteners declined by 1%, from 95% in 2019 to 94% in 2021.

“One percent may sound like nothing, but it’s not nothing … when you put it in terms of number of doses or kids,” says Kelly Whitener, JD, an associate professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.

According to CDC data, approximately 211,000 kindergarteners did not have all required vaccines in 2021, compared with about 201,000 in 2019, even with 2021 enrollment down by 10%.

Before the pandemic, antivaxxers loved to point to numbers like a 94% childhood vaccination rate overall and ask why doctors were so concerned over a “minor” decline. I’d point out that community/herd immunity requires a high vaccination rate for very transmissible diseases (e.g., measles). More importantly, averaging out the vaccination rate for large areas (such as the whole country or individual states) can mask much larger declines clustered in communities where parents with a high degree of vaccine hesitancy tend to cluster. Those communities with much lower vaccination rates than the surrounding area can then serve as foci of outbreaks of vaccine-preventable diseases.

We saw this very dynamic at play the year before the pandemic, when measles outbreaks were reported in a number of places in the US. The most famous of these outbreaks, however, occurred in the Orthodox Jewish communities in New York, specifically in Brooklyn and Rockland County. The Brooklyn Orthodox Jewish community, it turns out, has been a hotbed of vaccine hesitancy for a long time, having suffered a rather large outbreak in 2013, when an unvaccinated adolescent returned from London and brought measles with them. In 2019, the Orthodox communities in Rockland County and Brooklyn suffered more outbreaks of measles as a result of low vaccine uptake promoted by antivaccine misinformation targeted at them from outsiders like Del Bigtree and an antivaccine rabbi named Hillel Handler. In 2019, much of the misinformation was being spread in a very “old school” manner, in the form of a 40-page handbook called “The Vaccine Safety Handbook” published by a group called Parents Educating and Advocating for Children’s Health, or PEACH. These days, the misinformation is spreading on Telegram and in WhatsApp groups.

Here’s a blast from that past, just to give you an idea:

As I wrote last November, the very same communities were being targeted with misinformation about COVID-19 and COVID-19 vaccines. I also hasten to add that the antivaccine activism in these particular Orthodox communities is not typical; in my state, for instance, Orthodox religious authorities have a history of working with public health officials to encourage vaccination in their communities.

My point is not so much to focus on this particular group—I could easily focus on a number of other communities targeted by antivaccine misinformation)—other than as a convenient example to illustrate that history matters, and when childhood vaccination rates fall slightly in the US overall there is a risk that they’ll fall a lot in areas like Rockland County and Brooklyn. For example, remember that case of polio in the US that made the news last month? Guess where it occurred? You guessed it: Rockland County, where an unvaccinated 20-year-old man was hospitalized in June for paralytic polio.

The story is complicated by the finding that the man had developed polio from the vaccine-derived strain used in the oral polio vaccine (OPV), which has not been used in the US in over 20 years because in rare cases the attenuated (weakened) polio virus used for the vaccine can recombine to become a disease-causing form. However, the risk is low (As Scott Gavura noted recently, in 10 years during which 10 billion doses of OPV were administered, fewer than 800 cases of vaccine-derived paralytic polio were reported, and the injected version of the polio vaccine protects against vaccine-derived polio.) and in impoverished areas the OPV has many advantages, including being much cheaper and easier to administer. Again, without getting lost in the weeds, the point is that if vaccine uptake declines as a result of increased distrust of childhood vaccines due to fear of COVID-19 vaccines, we’re likely to see the first outbreaks in communities that have historically had a low degree of confidence in childhood vaccines and health authorities.

That is, of course, a feature, not a bug, of antivaccine messaging; indeed, as I pointed out a couple of months ago, “new school” anti-COVID-19 vaccine antivaxxers are sounding more and more like “old school” antivaxxers when it comes to childhood vaccines, and that is not a good thing.

Spillover of vaccine distrust: “A silver lining”?

Unsurprisingly, where you and I (and anyone who supports science-based medicine) see an alarming trend, RFK Jr. and his antivax minions see a “silver lining”. In the article, The Defender Staff starts out by recounting how childhood vaccine uptake fell dramatically in 2020 all over the world and how, contrary to what was expected, it has not yet rebounded to prepandemic levels. Naturally, since I’m a native Michigander and have lived in Michigan since 2008 after having returned to my home state after a 20-year sojourn away for residency, PhD studies, fellowship, and my first academic job, this passage caught my attention more than any other in RFK Jr.’s recounting of “spillover” vaccine hesitancy from COVID-19 vaccines and is also part of the reason why, when I saw this article, I immediately decided that this would be my topic for this week’s SBM post:

When Michigan compared its 2020 vaccination data against the 2016-2019 period, it found vaccination coverage had declined in “all milestone age cohorts, except for birth-dose hepatitis B coverage.”

At this juncture, state officials are openly speculating that COVID-19 shots — thus far rejected by the parents of 97% of under-5-year-olds — are the reason parents are increasingly ambivalent about childhood vaccination more generally.

Referring to this “spillover doubt,” a Michigander public health spokesperson said parents who once accepted childhood vaccination without question are now saying, “Wait a minute. Do I really need these vaccines?” and asking, “How are these vaccines made?”

According to another Michigan official, “vaccination” — the “V-word” — has become a “trigger word” for irate parents who believe government not only overstepped its authority during COVID-19 but is fraudulently pushing unsafe vaccines on their little ones.

To expand on the issue of antivaccine misinformation celebrated by RFK Jr in Michigan, let’s look at one of its citations, a Bridge Michigan article from four weeks ago:

At the LMAS health department in the Upper Peninsula, a social media post about an “immunization” clinic prompted one resident to accuse the health department of sneaking COVID vaccines in among other routine childhood shots, said Kerry Ott, department spokesperson.

Vaccination opponents have “gained new members because of COVID,” she said.

Ott said “vaccination” is now considered a “trigger word” among those who feel the government overstepped its authority during COVID or who have doubts about vaccines developed to combat the virus.

“I wasn’t expecting to be accused of trying to vaccinate people with the COVID vaccine and telling them that it’s polio,” Ott said. “There is a solid wall of people that are not going to budge from believing these conspiracy theories, and I have not found a way to even open a conversation with folks on that side (and) behind that line.”

Again, antivaccine misinformation is always rooted in conspiracy theories, just like all science denial.

It’s not just Michigan, either. In April, POLITICO published a story describing how COVID-19 vaccine distrust is spilling over to childhood vaccines, with public health officials in ten states reporting that they are concerned about an increasing number of families. Also, consistent with what I’ve been writing here and elsewhere, the manner in which antivaxxers over the last decade have increasingly made their messages to the general public (as opposed to their social media messaging to hardcore antivaxxers) about “freedom” and “parental rights” more than specific claims of vaccine harms has paid off spectacularly since COVID-19 hit:

Parents who were hesitant to vaccinate their children before the pandemic have now been joined by people who think the government mishandled the crisis, see Covid-19 vaccine mandates as federal overreach, or are exposed to misinformation about childhood vaccinations, said Rupali Limaye, professor of International Health at the Johns Hopkins Bloomberg School of Public Health.

“You get a decline in trust towards your government, and people looking for other sources to inform their decision-making process,” she said. “So they go to social media, [where] misinformation is outpacing evidence-based information.”

Immunization advocates say it was easier to bat down spurious claims that drove pre-pandemic hesitancy, such as that vaccines cause autism. But it’s harder to push back against an argument about personal freedom from government mandates.

“I would have told you in April 2020 that that was going to actually be our moment to turn the anti-vaccine tide,” said Melissa Wervey Arnold, CEO of the Ohio Chapter of the American Academy of Pediatrics. “Unfortunately, instead, the freedom movement took over.”

I noted early in the pandemic how rapidly antivaxxers so quickly joined the more general reaction against public health interventions designed to slow the spread of COVID-19 and right wing conspiracy theorists (including QAnon). I even predicted that this confluence would spread to distrust of all childhood vaccines, having noted that a decade ago antivax ideology was shifting to become more and more tightly associated with far right wing politics, even as popular culture still mistakenly viewed antivax beliefs as more associated with the hippy-dippy crunchy left and the “progressive” RFK Jr. was openly cavorting with far right wing movements and outright fascist groups were more and more aligning themselves with antivaxxers. Basically, what was once an ideology that spanned right and left (and tended to be more associated with the left) long ago started becoming much more associated with right-wing antigovernment, anti-regulation ideologies. Obviously, I consider this a very dangerous development, while antivaxxers like RFK Jr. are rejoicing.

RFK Jr. and minions recount a number of antivax conspiracy theories as factual and, instead of being misinformation, as very much justifiable reasons for parents to be suspicious of vaccines. I won’t cite them all, other than to point out that they include the misuse of the Vaccine Adverse Events Reporting System (VAERS), a frequent topic on this blog recently and dating to back before the pandemic; the false claim that vaccines cause sudden infant death syndrome (SIDS), which they don’t; a related claim that there was a large drop in SIDS early in the pandemic because infants were missing routine vaccines (also not true); false claims that unvaccinated children are much healthier than vaccinated children (also definitely not true); and more.

Again, the point is not so much to refute each bit of misinformation being firehosed in this article, most of which has been discussed at one time or another on this very blog, but rather to point out that, as predicted, the antivaccine misinformation, disinformation, and conspiracy theories about COVID-19 vaccines are inevitably spilling over to all vaccines. Naturally, RFK Jr. is ecstatic, quoting an antivaccine doctor whose attention whoring apparently worked to get the attention of CHD’s staff:

Which is where the “silver lining” comes in, in which RFK Jr.’s crew pivots to “natural health”:

Sadly, whatever temporary or longer-lasting silver lining may have emerged from the COVID-19-induced lull in childhood vaccination, children and their parents still face many challenges.

According to a Centers for Disease Control and Prevention study, the weight status of children and adolescents who were already overweight or obese worsened significantly during 2020, and children’s food insecurity is rising both domestically and internationally.

In addition, the massive social and behavioral changes commanded through government restrictions have prompted dire headlines about young people’s mental health — although experts caution these could counterproductively lead to overdiagnosis and overmedication with black-box-warning drugs known to cause violence and suicide.

Rather than more vaccines or drugs that have never delivered on their hype or promises, what children and youth need to thrive are the slower-but-surer public health fundamentals — such as solid nutrition, safe housing and economic security — and the loving attention of their parents.

Does anyone want to guess what that last part about “health fundamentals” is about before clicking on the link? (No cheating if you’ve already clicked on the link!) The link goes to an article on CHD citing a low quality ecological analysis in India that concludes that sanitation and nutrition do more to prevent vaccine-preventable diseases than vaccines do. (Remember what I’ve written about how easily the ecological fallacy can mislead in epidemiology going back something like 14 years?) The study claims to find that a “one percentage point increase in households with toilets corresponds with 0.33 fewer measle cases per 1000” for children under five. Given that measles is a highly transmissible respiratory disease, it doesn’t even make sense that more toilets and better sanitation would have much of an effect on measles transmission, certainly not more than the MMR vaccine. Going along with that is something not mentioned by CHD, namely that no such association was observed for diphtheria, pertussis, or tetanus, given that diphtheria and pertussis are, like measles, both also diseases transmitted through respiration.

COVID-19 distrust metastasizes

Unfortunately, CHD is not incorrect about one thing, namely that distrust of COVID-19 vaccines is indeed spilling over to infect public attitudes about routine childhood vaccination. The AAMC notes, as I did above, that the first effects will likely be seen in areas with traditionally low uptake of vaccines, but, thanks to the fusion of right-wing messaging equating vaccine mandates with assaults on “freedom”, I fear that it likely won’t just be there for long.

According to AAMC:

In addition to pockets of vaccine hesitancy among likeminded communities, the U.S. has also seen an uptick in vaccine distrust in certain regions of the country. In Texas, for example, conscientious exemptions have increased from 0.45% of K-12 students in the 2010-2011 school year to 2.7% in the 2021-2022 school year, according to data from the Texas Department of State Health Services. For private schools, the vaccine exemption rate for the last school year was 4.23%, but some schools report even higher rates. One private school in Travis County, Texas, had 43% of its student population exempt from at least one vaccine, while nearly 50 schools recorded more than 10% of their student populations with exemptions.

Of course, Texas has a long history of resistance to vaccine mandates due to vaccine resistance being conflated with “freedom”. Indeed, in 2016 I observed that when the next big outbreaks of vaccine-preventable diseases happen, they’ll probably happen in Texas, a point I reiterated in 2019. (Also remember that a decade ago the Texas Republican Party included planks in its party platform opposing vaccine mandates and supporting the teaching of creationism in schools; again, the affinity between the far right and antivaccine beliefs is, contrary to what so many of the intelligentsia seem to think, not new.) If anything, events have made me think that I was correct, although I would also add Florida, Idaho, and a number of other states with high levels of COVID-19 conspiracism in the public discourse to that list.

I also fear that these predictions by Drs. Paul Offit and Rupali Lamaye are correct:

In many ways, he worries that there is little that scientists can do to reverse the trend of vaccine distrust.

“Academic institutions can answer scientific questions … [but] the majority aren’t [refusing vaccines] because there’s a specific scientific concern,” Offit says. “The data are there; the issue is this cultural issue” of distrusting the government and federal mandates.

Rupali Lamaye, PhD, MPH, deputy director of the International Vaccine Access Center at Johns Hopkins Bloomberg School of Public Health, also believes that there will be repercussions down the road to continued resistance to vaccines.

“I think this is going to be our future for a bit. We’re going to continue to see outbreaks,” she says. “We’ve lost too much trust over the pandemic.”

There was a time years ago when I naïvely believed that a major outbreak of a vaccine-preventable disease would bring the vaccine-hesitant and antivaxxers back to seeing the value of vaccination and the misinformation that claimed that they caused so much harm and didn’t work. I had learned long before the pandemic how naïve I had been, as I witnessed outbreak after outbreak leading antivaxxers to double down. Then came COVID-19, killing over a million people in the US alone and likely tens of millions worldwide, which not only didn’t dampen antivaccine misinformation but rather turbocharged it beyond anything I had ever seen before in my nearly quarter of a century paying attention to the antivaccine movement.

If there’s one thing that the pandemic has shown about antivaccine beliefs and science denial, it’s that the information deficit model of distrust of science, which posits that science denial can be reversed by providing accurate information (i.e., that good information is enough to chase away bad information) is very much lacking. When a belief becomes embedded in an ideology that is core to a person’s self-identity, as distrust of vaccines has for so many, it is incredibly difficult to combat. Indeed, I’ve likened it to changing a person’s politics or religion, because, when you come right down to it, it’s a lot like that. That’s not to say that debunking can’t work. It can and does. It’s just that providing “good information” to counter “bad information” is in most cases not enough. Think of it this way: Does just providing accurate information about evolution affect the beliefs of creationists, whose beliefs are nearly always based on their religious beliefs? Usually not. Promoting good science is important, but it is not enough.

Unfortunately, there is a reason why antivaxxers are rejoicing.

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Posted by David Gorski

Dr. Gorski's full information can be found here, along with information for patients. David H. Gorski, MD, PhD, FACS is a surgical oncologist at the Barbara Ann Karmanos Cancer Institute specializing in breast cancer surgery, where he also serves as the American College of Surgeons Committee on Cancer Liaison Physician as well as an Associate Professor of Surgery and member of the faculty of the Graduate Program in Cancer Biology at Wayne State University. If you are a potential patient and found this page through a Google search, please check out Dr. Gorski's biographical information, disclaimers regarding his writings, and notice to patients here.