Saying the Lancet Fee on Vaccine Refusal, Acceptance, and Demand within the USA

Vaccines are one of the most effective tools for the prevention of infectious diseases.1

  • Fine PEM
  • Mulholland K
  • Scott JA
  • Edmunds WJ

However, the success of immunisation programmes depends on widespread acceptance and high coverage of vaccination.2

  • Hardt K
  • Bonanni P
  • King S
  • et al.

Vaccine strategies: optimising outcomes. Over the past decade, vaccine refusal has accelerated in the USA, with increased non-medical exemptions to school immunisation requirements that have been linked to outbreaks of vaccine-preventable diseases.3

  • Phadke VK
  • Bednarczyk RA
  • Salmon DA
  • Omer SB

Association between vaccine refusal and vaccine-preventable diseases in the United States: a review of measles and pertussis. Although vaccine refusal is not uniformly spread across the USA and national childhood vaccination rates remain high, vaccination has declined in many communities and school districts that are consequently at increased risk of outbreaks of vaccine-preventable diseases.4

  • Olive JK
  • Hotez PJ
  • Damania A
  • Nolan MS

The state of the antivaccine movement in the United States: a focused examination of nonmedical exemptions in states and counties.Achieving optimal and uniform vaccine acceptance is a complex challenge, especially because early evidence suggests that key factors affecting vaccine acceptance may have shifted over the past few years. Anti-vaccine activities are prominent,5America and Europe’s new normal: the return of vaccine-preventable diseases. but are only a part of why vaccine refusal has increased. Other factors include ongoing distrust of the medical community, particularly among socially vulnerable communities, and poor or inconsistent public communications on the safety of vaccines to prevent emerging pandemic threats.Organised anti-vaccine activities are a concern. In the past, the US anti-vaccine movement generally operated at the fringes of society, but it has now expanded its reach through increased political activities and amplification on the internet, social media, and e-commerce platforms.5America and Europe’s new normal: the return of vaccine-preventable diseases. Homegrown anti-vaccine organisations at the state and national levels, combined with weaponised health attacks from some foreign nations, now dominate the internet through coordinated disinformation.5America and Europe’s new normal: the return of vaccine-preventable diseases.,  6

  • Doustmohammadi S
  • Cherry JD

The sociology of the antivaccine movement.,  7Anti-science extremism in America: escalating and globalizing.,  8

  • Broniatowski DA
  • Jamison AM
  • Qi S
  • et al.

Weaponized health communication: Twitter bots and Russian trolls amplify the vaccine debate. One recent study found that just two homegrown anti-vaccine organisations were responsible for more than half of all anti-vaccine advertisements on Facebook.9

  • Jamison AM
  • Broniatowski DA
  • Dredze M
  • Wood-Doughty Z
  • Khan D
  • Quinn SC

Vaccine-related advertising in the Facebook Ad Archive. National and international organisations now host regular anti-vaccine conferences and stage rallies.7Anti-science extremism in America: escalating and globalizing. Additionally, in many states, such as California, Oklahoma, and Texas, political action committees influence or lobby state legislatures, often through libertarian or far-right legislators touting so-called health freedom.7Anti-science extremism in America: escalating and globalizing. This movement has built on a growing interest in non-pharmaceutical interventions and alternative medicine, and heightened scepticism of the drug industry.10

  • Frass M
  • Strassl RP
  • Friehs H
  • Müllner M
  • Kundi M
  • Kaye AD

Use and acceptance of complementary and alternative medicine among the general population and medical personnel: a systematic review.The repercussions of these efforts cost lives. The number of measles cases in the USA increased in the past few years;11

  • Paules CI
  • Marston HD
  • Fauci AS

Measles in 2019—going backward. in 2019, there were more than 1200 cases of measles and multiple hospitalisations and intensive care unit admissions.12

  • Patel M
  • Lee AD
  • Clemmons NS
  • et al.

National update on measles cases and outbreaks—United States, January 1–October 1, 2019. Adolescents are also unnecessarily placed at risk for human papillomavirus cancers as are adults,13

  • Senkomago V
  • Henley SJ
  • Thomas CC
  • Mix JM
  • Markowitz LE
  • Saraiya M

Human papillomavirus-attributable cancers—United States, 2012–2016. and many Americans die every year from influenza.14

  • Shang M
  • Blanton L
  • Brammer L
  • Olsen SJ
  • Fry AM

Influenza-associated pediatric deaths in the United States, 2010–2016. The USA is potentially facing frequent and costly public health crises due to outbreaks of infectious diseases arising from low vaccine acceptance.Racial, ethnic, and economic disparities are issues that need to be addressed in efforts to build vaccine acceptance. COVID-19 transmission, morbidity, and mortality have disproportionately affected essential workers, Americans living in low-income neighbourhoods, and communities of colour, which reflects the effects of systemic racism.15The Lancet
The plight of essential workers during the COVID-19 pandemic. Similar disparate health outcomes have occurred in other pandemics, such as the H1N1 influenza pandemic in 2009, and they are likely to arise in future disease outbreaks.16

  • Quinn SC
  • Jamison AM
  • An J
  • Hancock GR
  • Freimuth VS

Measuring vaccine hesitancy, confidence, trust and flu vaccine uptake: results of a national survey of White and African American adults. Vaccine refusal is partly linked to distrust resulting from historical exploitation17

  • Scharff DP
  • Mathews KJ
  • Jackson P
  • Hoffsuemmer J
  • Martin E
  • Edwards D

More than Tuskegee: understanding mistrust about research participation. and current mistreatment of socially vulnerable communities.18

  • Vedam S
  • Stoll K
  • Taiwo TK
  • et al.

The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States.,  19

  • Warren RC
  • Forrow L
  • Hodge Sr, DA
  • Truog RD

Trustworthiness before trust—Covid-19 vaccine trials and the Black community. In some cases, anti-vaccine groups specifically target vulnerable populations. Effective outreach and engagement are needed to encourage acceptance of vaccines and support communities that are most vulnerable to outbreaks.Despite the high number of COVID-19 cases, hospitalisations, and deaths in the USA,20Johns Hopkins University
Coronavirus Resource Center: COVID-19 Dashboard by the Center for Systems Science and Engineering at Johns Hopkins University. many Americans report that they will not take a COVID-19 vaccine.21

  • Hamel L
  • Kirzinger A
  • Lopes L
  • Kearney A
  • Sparks G
  • Brodie M

KFF COVID-19 vaccine monitor: January 2021. Potential reasons for refusal include concern over the speed of COVID-19 vaccine development, politicised comments by national leaders, organised efforts by anti-vaccine groups, and hesitancy while COVID-19 vaccine clinical trial data are not yet readily available. Reluctance to vaccinate with safe and effective COVID-19 vaccines will impede achievement of the high vaccination coverage needed to prevent COVID-19 mortality and SARS-CoV-2 spread.

The Lancet has established the Commission for Vaccine Refusal, Acceptance, and Demand in the USA to design a multisectoral plan for public policy to support high acceptance of safe and effective vaccines in the USA. Our goal is to understand and report on the state of vaccine acceptance and its potential link to vaccine hesitancy. Additionally, we will work to identify and predict future trends in vaccine acceptance and impacts on the public health community. We will also identify and assess demand-side vaccine uptake interventions and solutions to counter anti-vaccine information.

Our Commissioners, comprising a group that is diverse across discipline, gender, and career stage, include leaders in vaccinology, public health, social and behavioural science, law, and public policy. Together, these Commissioners will collaborate on six areas. First, we will examine trends in vaccine hesitancy, refusal, and acceptance at the state, county, and school district levels, and their effects on public health. Second, we will model the public health implications of what will happen in the future if present trends in vaccine hesitancy, refusal, and acceptance continue. Third, Commissioners will determine the role of anti-vaccine organisations (and in some cases foreign governments) in suppressing vaccine acceptance through media or political activities. Fourth, we will evaluate vaccine refusal among low-income populations and communities of colour. Fifth, Commissioners will assess approaches to detect and mitigate the impact of anti-vaccine activities on social media, such as the spread of misinformation and politicisation of vaccines. Finally, we will make recommendations to shape a new public policy for ensuring high vaccine acceptance in the USA. We intend our recommendations to be relevant for the US Congress, US federal agencies, state legislatures, and academic and non-governmental societies and organisations, and to encompass interagency responses for addressing vaccine refusal.

The Commission had its first meeting in 2020, and we aim for a first interim report on COVID-19 vaccines in the coming months. We expect to present a comprehensive report on broader vaccine acceptance and hesitancy in the USA by 2022. We will post updates about the Commission’s ongoing work on the Commission website. We are hopeful that confidence in and acceptance of vaccines in the USA can be improved through a cooperative strategy.

The Lancet Commission on Vaccine Refusal, Acceptance, and Demand in the USA is co-hosted by the Yale Institute for Global Health and the Baylor College of Medicine. PJH is a developer of a COVID-19 vaccine construct, which was licensed by Baylor College of Medicine to Biological E Ltd, a commercial vaccine manufacturer for scale-up, production, testing and licensure. RMB reports personal fees from Ascension Health Alliance, Kaiser Hospital and Health Plan, CPSI, Convatec Plc, Oak Street Health, and PDI, Inc, outside the submitted work. NTB reports grants and personal fees from Merck, outside the submitted work. RMC reports grants from Novo Nordisk Foundation (Denmark), outside the submitted work. RL reports grants from Pfizer, GlaxoSmithKline, Sanofi Pasteur, and Merck and personal fees from BIO, outside the submitted work. YAM is a member of a Data Safety Monitoring Board for Pfizer, outside the submitted work. MMM reports personal fees from law firms representing retail pharmacies and generic drug companies that have sued other drug companies for antitrust law violations, outside the submitted work. DJO reports grants from the US National Institutes of Health and Agency of Healthcare Research and Quality, outside the submitted work. DRR reports her family own stocks in GlaxoSmithKline, a vaccine manufacturer, and she served in an unpaid, volunteer capacity on Moderna’s ethics allocation committee. DAS reports grants and personal fees from Merck, grants from Walgreens, and personal fees from Janssen, outside the submitted work. The other authors declare no competing interests.

The Commissioners of the Lancet Commission on Vaccine Refusal, Acceptance, and Demand in the USA are Peter J Hotez, Rebecca E Cooney, Regina M Benjamin, Noel T Brewer, Alison M Buttenheim, Timothy Callaghan, Arthur Caplan, Richard M Carpiano, Chelsea Clinton, Renee DiResta, Jad A Elharake, Lisa C Flowers, Alison P Galvani, Rekha Lakshmanan, Yvonne A Maldonado, SarahAnn M McFadden, Michelle M Mello, Douglas J Opel, Dorit R Reiss, Daniel A Salmon, Jason L Schwartz, Joshua M Sharfstein, and *Saad B Omer.

Texas Children’s Center for Vaccine Development, Departments of Pediatrics and Molecular Virology and Microbiology, National School of Tropical Medicine, Baylor College of Medicine, Houston, TX, USA (PJH); Department of Biology, Baylor University, Waco, TX, USA (PJH); Hagler Institute for Advanced Study at Texas A&M University, College Station, TX, USA (PJH); James A Baker III Institute for Public Policy, Rice University, Houston, TX, USA (PJH); Scowcroft Institute of International Affairs, Bush School of Government and Public Service, Texas A&M University, College Station, TX, USA (PJH); The Lancet, New York, NY, USA (REC); Gulf States Health Policy Center, Bayou La Batre, AL, USA (RMB); Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA (NTB); Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA (NTB); Department of Family and Community Health, University of Pennsylvania School of Nursing, and Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA (AMB); Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, USA (TC); New York University Langone School of Medicine, New York University, New York, NY, USA (AC); School of Public Policy, University of California, Riverside, CA, USA (RMC); Department of Sociology, University of California, Riverside, CA, USA (RMC); Clinton Foundation, New York, NY, USA (CC); Mailman School of Public Health, Columbia University, New York, NY, USA (CC); Stanford Internet Observatory, Stanford University, Stanford, CA, USA (RD); Yale Institute for Global Health, New Haven, CT, USA (JAE, SMM, SBO); Yale School of Public Health, New Haven, CT, USA (JAE); Department of Obstetrics & Gynecology, Emory University, Atlanta, Georgia, USA (LCF); Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, USA (APG); The Immunization Partnership, Houston, TX, USA (RL); Stanford University School of Medicine, Stanford, CA, USA (YAM); Department of Internal Medicine (Infectious Diseases), Yale School of Medicine, New Haven, CT, USA (SMM, SBO); Stanford Law School, Stanford, CA, USA (MMM); Center for Health Policy/Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA (MMM); Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA, USA (MMM); Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA (DJO); Seattle Children’s Research Institute, Seattle, WA, USA (DJO); UC Hastings College of Law, San Francisco, CA, USA (DRR); Institute for Vaccine Safety, Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA (DAS); Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA (JLS); Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA (JMS); Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT 06510, USA (SBO)

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Article Info

Publication History

Published: February 24, 2021

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DOI: https://doi.org/10.1016/S0140-6736(21)00372-X

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© 2021 Elsevier Ltd. All rights reserved.

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