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Essays on Vaccination

Vaccines essay topics and outline examples, essay title 1: "the vital role of vaccines in public health: debunking myths and upholding science".

Thesis Statement: Vaccines are a cornerstone of public health, and it is crucial to dispel misinformation and emphasize the overwhelming scientific evidence supporting their safety and efficacy.

Essay Outline:

• Introduction
• The History and Impact of Vaccines
• Common Vaccine Myths and Misconceptions
• Scientific Evidence Supporting Vaccines
• Vaccine Safety and Adverse Effects
• The Importance of Herd Immunity
• Addressing Vaccine Hesitancy

Essay Title 2: "Vaccination Mandates: Balancing Individual Rights with Public Health"

Thesis Statement: While respecting individual rights is essential, vaccination mandates are a legitimate measure to safeguard public health and prevent outbreaks of vaccine-preventable diseases.

• The Concept of Vaccination Mandates
• Individual Rights and Autonomy
• Public Health Concerns and Disease Prevention
• Legal and Ethical Considerations
• Case Studies of Vaccine Mandates
• Opposition and Challenges to Mandates

Essay Title 3: "The Impact of Vaccine Disinformation on Public Health: A Global Challenge"

Thesis Statement: The proliferation of vaccine disinformation poses a significant threat to public health, and addressing this challenge is vital to ensure widespread vaccine acceptance and disease control.

• The Spread and Impact of Vaccine Disinformation
• Factors Contributing to Vaccine Hesitancy
• The Role of Social Media and Online Platforms
• Countering Vaccine Disinformation Efforts
• Global Initiatives and Collaborations
• Case Studies on Successful Interventions

The Issues Surrounding Vaccination and Its Importance

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Vaccination – The Greatest Invention of All Times

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The Ethical Theories and Issues Surrounding Vaccination in America

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Chickenpox: History, Symptoms and Treatment

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Vaccination, also known as immunization, is a medical procedure that involves the administration of a vaccine to stimulate the immune system and provide protection against specific infectious diseases. It is a preventive measure designed to enhance the body's natural defenses by introducing harmless fragments of the disease-causing agent or weakened or inactivated forms of the pathogen.

The mechanism of vaccination involves introducing a weakened or inactivated form of a disease-causing agent, such as a virus or bacterium, into the body. This prompts the immune system to recognize and respond to the pathogen. When a vaccine is administered, it stimulates the immune system to produce an immune response, similar to what would happen during a natural infection. The immune system recognizes the foreign antigens present in the vaccine and mounts a defense by producing antibodies and activating immune cells. These immune responses help the body develop immunity against the specific pathogen. Vaccination can also involve the use of genetically engineered proteins or pieces of the pathogen to stimulate an immune response. These components are known as antigens and can be derived from the outer coats of viruses or the cell walls of bacteria. By introducing these harmless components of the pathogen into the body, vaccines help the immune system recognize and remember the specific pathogen. This way, if the individual is later exposed to the actual disease-causing agent, their immune system can mount a rapid and effective response to neutralize or eliminate the pathogen, preventing the development of the disease or reducing its severity.

1. Inactivated Vaccines 2. Live Attenuated Vaccines 3. Subunit, Recombinant, and Conjugate Vaccines 4. mRNA Vaccines 5. Viral Vector Vaccines

The origin of vaccination can be traced back to ancient times, although the concept was not fully understood at the time. The practice of vaccination, as we know it today, began with the discovery of immunization against smallpox by Edward Jenner in the late 18th century. Jenner, an English physician, observed that milkmaids who had contracted cowpox, a much milder disease, seemed to be protected against smallpox. In 1796, he conducted an experiment where he took material from a cowpox sore and inoculated it into an eight-year-old boy named James Phipps. Afterward, Jenner exposed the boy to smallpox, but he did not develop the disease. This groundbreaking experiment led to the development of the smallpox vaccine. The term "vaccination" itself comes from the Latin word "vacca," meaning cow, as the original smallpox vaccine was derived from cowpox. Jenner's work paved the way for the development of vaccines against other infectious diseases, and vaccination quickly became a widely accepted method for preventing and controlling the spread of deadly diseases.

Public opinion on vaccination varies across different societies and individuals. Overall, vaccination has been widely accepted and supported by the majority of the population, recognizing its significant role in preventing and controlling infectious diseases. Vaccines have been instrumental in eradicating or significantly reducing the impact of diseases such as smallpox, polio, measles, and more. However, there are also pockets of skepticism and opposition towards vaccination, driven by various factors such as misinformation, fear, religious beliefs, or concerns about vaccine safety. This has led to the emergence of anti-vaccine movements and vaccine hesitancy in some communities. Public opinion on vaccination is influenced by various factors, including access to accurate information, trust in healthcare professionals and scientific research, cultural and religious beliefs, personal experiences, and the influence of social media and other communication channels. Efforts to promote vaccination and address vaccine hesitancy involve public health campaigns, education, and communication strategies to provide accurate information about vaccines, address concerns, and emphasize the importance of vaccination in protecting individual and public health.

1. Disease prevention 2. Herd immunity 3. Public health impact 4. Safety and effectiveness 5. Global impact

1. Vaccine safety concerns 2. Personal freedom and choice 3. Misinformation and skepticism 4. Religious or philosophical objections 5. Perception of low disease risk

1. According to the World Health Organization (WHO), vaccines prevent between 2-3 million deaths worldwide every year. 2. Smallpox is the only disease that has been totally eradicated through vaccination. 3. Vaccines have significantly reduced the global burden of infectious diseases. For instance, measles deaths decreased by 73% worldwide between 2000 and 2018. 4. The influenza vaccine helps reduce the risk of severe illness and hospitalization. In the United States, annual flu vaccination prevented an estimated 7.5 million flu illnesses during the 2019-2020 season. 5. The average vaccine takes around 10-15 years of research and development before it is widely available.

The topic of vaccination is of paramount importance when considering the impact it has had on public health. Writing an essay about vaccination provides an opportunity to explore the profound significance of this medical intervention. Vaccination has played a pivotal role in preventing and controlling infectious diseases, saving countless lives worldwide. By delving into the subject, one can highlight the historical development of vaccines, their mechanisms of action, and the scientific evidence supporting their effectiveness. Furthermore, examining the topic of vaccination allows for an exploration of the public health implications, including the concept of herd immunity and the role of vaccination in disease eradication efforts. It also provides a platform to address the various arguments surrounding vaccine hesitancy and vaccine refusal, shedding light on the importance of accurate information, education, and communication. Moreover, the essay can delve into the ethical considerations surrounding vaccination policies, such as balancing individual autonomy with the collective responsibility for public health. By exploring these aspects, one can foster a deeper understanding of the challenges, controversies, and potential solutions in promoting vaccination uptake.

1. American Academy of Pediatrics. (2018). Immunization information for parents. https://www.healthychildren.org/English/safety-prevention/immunizations/Pages/default.aspx 2. Centers for Disease Control and Prevention. (2021). Vaccines & immunizations. https://www.cdc.gov/vaccines/index.html 3. Gust, D. A., Darling, N., Kennedy, A., & Schwartz, B. (2008). Parents with doubts about vaccines: Which vaccines and reasons why. Pediatrics, 122(4), 718-725. https://doi.org/10.1542/peds.2007-0538 4. Larson, H. J., de Figueiredo, A., Xiahong, Z., Schulz, W. S., Verger, P., Johnston, I. G., Cook, A. R., Jones, N. S., & the SAGE Working Group on Vaccine Hesitancy. (2016). The state of vaccine confidence 2016: Global insights through a 67-country survey. EBioMedicine, 12, 295-301. https://doi.org/10.1016/j.ebiom.2016.08.042 5. MacDonald, N. E., Hesitancy SAGE Working Group. (2015). Vaccine hesitancy: Definition, scope and determinants. Vaccine, 33(34), 4161-4164. https://doi.org/10.1016/j.vaccine.2015.04.036 6. Offit, P. A., Quarles, J., Gerber, M. A., Hackett, C. J., & Marcuse, E. K. (2002). Addressing parents' concerns: Do vaccines cause allergic or autoimmune diseases? Pediatrics, 110(6), 1113-1116. https://doi.org/10.1542/peds.110.6.1113 7. Omer, S. B., Salmon, D. A., Orenstein, W. A., deHart, M. P., & Halsey, N. (2009). Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases. New England Journal of Medicine, 360(19), 1981-1988. https://doi.org/10.1056/NEJMsa0806477 8. Smith, P. J., Humiston, S. G., Parnell, T., Vannice, K. S., & Salmon, D. A. (2011). The association between intentional delay of vaccine administration and timely childhood vaccination coverage. Public Health Reports, 126(Suppl 2), 135-146. https://doi.org/10.1177/00333549111260S219 9. World Health Organization. (2019). Ten threats to global health in 2019. https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019 10. World Health Organization. (2021). Immunization coverage. https://www.who.int/news-room/fact-sheets/detail/immunization-coverage

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• Americans’ Largely Positive Views of Childhood Vaccines Hold Steady

2. What Americans think about COVID-19 vaccines

Table of contents.

• Americans’ positive evaluations of MMR vaccines remain largely steady in wake of debate over coronavirus vaccines
• Partisan differences widen over requiring MMR vaccines in K-12 schools
• Parents of children under 18 see slightly higher risks from MMR vaccines than other adults
• Majorities of Americans see positive societal impact from childhood vaccines, though about four-in-ten wonder if they are all necessary
• Most parents report that their children have received an MMR vaccine
• Doctors are trusted at least some as sources of information about the health effects of MMR vaccines
• Interviews with those concerned about MMR vaccines reveal desires to rely on multiple sources of information, ones with trustworthy motives
• 62% of Americans say positives of COVID-19 vaccines outweigh negatives, though sizable shares see modest health benefits and meaningful risks
• 34% of U.S. adults say they have had a recent booster shot; about as many say they are fully vaccinated but have had no recent booster
• Americans’ appreciation, ambivalence both evident in the sentiments they use to describe COVID-19 vaccines 
• Fewer than a third of Americans now express concern about getting a serious case of COVID-19
• In-depth interviews reveal ongoing concerns about safety of COVID-19 vaccines and frustrations over requirements to get them
• Older Americans more likely to say they have had a flu shot this season
• Americans are divided over the value of medical treatments today
• Acknowledgments
• Methodology
• Appendix A: Detailed charts on views of childhood vaccines
• Appendix B: Detailed charts on views of COVID-19

More than two years after the COVID-19 vaccines were widely available for adults in the United States, Americans provide mixed assessments of the value and potential risks of these vaccines.

Overall, a majority of Americans believe the benefits of the coronavirus vaccines outweigh the risks and tend to align with the idea that COVID-19 vaccines have saved millions of lives. At the same time, fewer than half consider the preventative health benefits of the vaccines to be high and more describe the risk of side effects as medium or high than view them as low.

How people evaluate the benefits and risks from these vaccines is strongly tied with the choices they have made about getting vaccinated. And for parents, their attitudes and actions also line up closely with the choices they have made for their minor children.

In a sign of limited public enthusiasm for COVID-19 vaccines, only about a third of U.S. adults have the highest level of available protection against the coronavirus, saying they have been fully vaccinated and have received a booster shot within the last six months. (Booster shots designed for newer variants of the coronavirus have been available since September 2022, about six months before the survey was conducted.) A similar share say they were fully vaccinated but have not received a booster shot in the past six months and about a fifth of U.S. adults say they have not been vaccinated against COVID-19.

The unprecedented speed of development for the coronavirus vaccines was widely hailed as an achievement for science. But the public’s comfort with the long-term impacts of these vaccines still has much room to grow. A majority of Americans continue to say the statement “we don’t really know yet if there are serious health risks from COVID-19 vaccines” describes their views very or somewhat well. This view is about as widely held today as it was in August 2021, less than a year after vaccines became widely available.

In-depth qualitative interviews with people who express some concerns around these vaccines highlight the salience of questions about their long-term safety. For other interviewees, concern about risk of side effects is coupled with a view that there is little to gain from getting a COVID-19 vaccine either because they see themselves at low risk of serious harm from the 62% of Americans say positives of COVID-19 vaccines outweigh negatives, though sizable shares see modest health benefits and meaningful risks or because the vaccine does not prevent infection from the disease.

People’s practices related to getting a flu vaccine each year tend to align with their choices around getting the coronavirus vaccine. And, as with the coronavirus vaccine, older adults are more likely to say they get a flu shot regularly.

More broadly, Americans are evenly divided over medical treatments today, with about half saying that treatments today are worth the costs because they allow people to live longer, better lives while the other half says that medical treatments these days often create as many problems as they solve. Most Americans agree, however, that the cost of quality medical treatments today is a big problem.

Overall, 62% of U.S. adults say that the benefits of COVID-19 vaccines outweigh the risks, while a much smaller share think the risks outweigh the benefits (36%).

Even so, when asked to rate the preventative health benefits of COVID-19 vaccines from very high to very low, fewer than half of Americans (45%) rate the benefits as high. More say their benefits are either medium (25%) or low (29%).

When it comes to evaluating the risk of side effects, 58% of Americans rate the risk as high (33%) or medium (25%), while a smaller share (41%) see the risk as low.

People’s ratings of the benefits and risks of coronavirus vaccines are strongly aligned with their own choices related to getting the vaccines. For instance, 64% of those who see the preventative health benefits as very high are fully vaccinated and recently boosted within the past six months, compared with much smaller shares of those who rate the health benefits as medium or low.

Partisan divisions have been prominent in views of the country’s handling of the coronavirus outbreak, as well as in assessments of COVID-19 vaccines themselves. Democrats are about twice as likely as Republicans to say the benefits of coronavirus vaccines outweigh the risks (84% vs. 40%). Similarly, Democrats are much more likely than Republicans to rate the preventative health benefits of COVID-19 vaccines as high (67% to 23%). And 74% of Republicans rate the risk of side effects as at least medium compared with a smaller share of Democrats (42%).

Upper-income adults and those with a four-year college degree also tend to be more positive in their assessments of COVID-19 vaccines than other adults. For example, 71% of upper-income Americans say the benefits of COVID-19 vaccines outweigh the risks, compared with 61% of lower-income Americans. For more, refer to Appendix B .

The rise of the omicron variant of COVID-19 spurred the development of bivalent booster shots designed to offer better protection from this strain of the coronavirus. These updated boosters were widely available to U.S. adults in September 2022, about six months before the Center survey was conducted. Uptake of these new boosters was reportedly slow last fall when they first became available.

About one-third of U.S. adults (34%) say they are fully vaccinated and have received a booster shot in the last six months. A similar share (33%) say they are fully vaccinated for COVID-19 but have not received a recent booster shot. About one-in-five U.S. adults (21%) say they have not received a COVID-19 vaccine. (Another 7% report having received one shot but would need one more to be fully vaccinated.)

The oldest Americans are more likely to report having received a recent booster and are much less likely to be unvaccinated than younger adults. Among adults ages 65 and older, 53% say they have received a recent booster. Another 25% of this group say they were fully vaccinated but have not received a recent booster. Just 13% say they have not gotten a COVID-19 vaccine.

For comparison, 23% of adults ages 18 to 29 say they have received a recent booster, while 40% say they are fully vaccinated but have not gotten a recent booster shot and another 24% say they have not been vaccinated.

There are wide differences between political parties when it comes to COVID-19 vaccination status, as well as differences within each party group by age, consistent with past Center findings.

Overall, 49% of Democrats say they have had a recent booster shot. Another 32% say they are fully vaccinated but have not had a recent booster and just 9% of Democrats say they were not vaccinated. By contrast, just 20% of Republicans say they have received a recent booster shot; 34% say they are fully vaccinated but have not received a booster and 33% say they did not get a COVID-19 vaccine.

Within each party, adults ages 50 and older are more likely than their younger counterparts to say they are fully vaccinated and have received a recent booster shot. Age differences are particularly wide among Democrats. Three-quarters of Democrats ages 65 and older say they are fully vaccinated and have had a recent booster shot. Among Democrats ages 18 to 29, 30% say they have done this.

While Republicans overall are much less likely than Democrats to say they have received a recent booster shot, age differences also exist within the GOP. For instance, Republicans ages 65 and older are more likely to say they are recently boosted (36%) than those ages 18 to 29 (10%). 

Children’s coronavirus vaccination status is closely tied to their parent’s status

The Center survey asked parents of minors about their child’s COVID-19 vaccination status. In all, 36% of these parents report that their child or youngest child has received a coronavirus vaccine.

Parents of older children are more likely than those with young children to report that their child is vaccinated. A 62% majority of parents of teens (ages 13 to 17) say their child is vaccinated. In contrast, just 17% of parents of children ages 0 to 4 say this.

Vaccines have been available for older children longer than for younger children. Older teens – those ages 16 and 17 – became eligible for one of the coronavirus vaccines at the same time as adults in December 2020. Children and teens ages 12 to 15 became eligible in May 2021. Later that fall, in November 2021, children ages 5 to 11 could receive a coronavirus vaccine. A coronavirus vaccine for younger children – those ages 6 months to 5 years – was not available until June 2022.

Access to COVID-19 vaccines for young children is more limited than for older children, as many pharmacies have minimum age requirements for vaccine eligibility and only some pediatricians administer COVID-19 vaccines to young children. By comparison, pharmacies have been one of the main distribution points for vaccines given to older children as well as adults.

There’s a strong connection between a parent’s own COVID-19 vaccination status and the decision they have made for their child. Most parents who are fully vaccinated and have recently gotten a booster (71%) say their child has received a coronavirus vaccine. In contrast, just 6% of parents who are not vaccinated say their child has received a coronavirus vaccine.

Public views about COVID-19 vaccines remain complex, as evidenced by the mix of sentiments Americans apply to them. About two-thirds (66%) say that the statement “COVID-19 vaccines have saved millions of lives” describes their views very or somewhat well. A majority (57%) also say “staying up-to-date with vaccines for COVID-19 is part of being a good community member” describes how they feel at least somewhat well.

At the same time, many Americans worry that information about COVID-19 vaccines has been held back. A 56% majority say “public health officials are not telling us everything they know about COVID-19 vaccines” describes their views very or somewhat well.

Americans also express concerns about serious risks coming to light in the future. A majority (57%) say the statement “we don’t really know yet if there are serious health risks from COVID-19 vaccines” describes how they feel at least somewhat well.

Underscoring challenges interpreting guidance about vaccines, 55% say the statement “it’s hard to make sense of all the information about COVID-19 vaccines” describes their views very or somewhat well.

Compared with other sentiments included in the survey, a somewhat smaller share of Americans (44%) say the statement “it makes me angry when vaccination for COVID-19 is required” describes their own views very or somewhat well.

There’s been little change since August 2021 regarding public concerns over information about COVID-19 vaccines and concerns about future health impacts. The shares expressing a sense that public health officials are withholding information, uncertainty over potential serious risks from the vaccines, and difficulties making sense of information about vaccines are all roughly the same as those captured in a 2021 Center survey .

The sentiments Americans use to describe COVID-19 vaccines are strongly connected with their own choices about getting the shots.

Fully vaccinated and boosted Americans tend to hold positive views of the vaccines’ value and are much less likely to express concerns about them than other adults. Among this group, 68% say the statement “COVID-19 vaccines have saved millions of lives” describes their views very well and 61% say the same about staying up-to-date with COVID-19 vaccines as part of being a good community member.

Those who have not been vaccinated for COVID-19 are much less inclined to see the vaccines as having saved millions of lives (just 3% say this describes their views very well). A majority of those who have not been vaccinated say it makes them angry when COVID-19 vaccines are required (67% say this describes their views very well) and nearly as many (60%) say the idea that public health officials are not telling us everything they know about the vaccines describes their views very well.

In addition, 46% of those who have not gotten a COVID-19 vaccine say the statement “we don’t really know yet if there are serious health risks from COVID-19 vaccines” describes their views very well; roughly two-thirds (66%) say this describes their views very or somewhat well.

People who have been fully vaccinated but have not received a recent booster in the past six months fall somewhere in the middle, with a mix of positive and negative views about the coronavirus vaccines. For example, a majority of this group (72%) sees the statement that “COVID-19 vaccines have saved millions of lives” as being at least somewhat in line with their views. At the same time, a majority of this group (63%) also says the statement “we don’t really know if there are serious health risks from these vaccines” describes their views at least somewhat well.

Personal concern about getting a serious case of COVID-19 has gradually declined since November 2020. In the new survey, 29% of Americans are very or somewhat concerned that they will get COVID-19 and require hospitalization. This share is down 24 percentage points from November 2020.

Concern about unknowingly spreading COVID-19 has also declined since the first year of the coronavirus outbreak, though it remains somewhat higher than personal concern about getting a serious case. About four-in-ten U.S. adults (41%) say they are at least somewhat concerned they might unknowingly spread COVID-19 to others. This is a decrease of 23 points from November 2020 and 8 points from September 2022, the last time the Center asked this question.

As Center surveys found earlier in the coronavirus outbreak , people who have not been vaccinated express less concern about getting a serious case of the disease (or unknowingly spreading it) than those who have received a vaccine.

Those who are recently boosted and fully vaccinated against COVID-19 are the most likely to be concerned about getting a serious case of the disease.

Among this group, 38% say they are very or somewhat concerned they will get COVID-19 and require hospitalization and 54% say they are at least somewhat concerned about unknowingly spreading the disease to others.

Beyond vaccination status, lower family incomes and the lack of health insurance are associated with higher levels of concern about getting a serious case of COVID-19. And Black, Hispanic and English-speaking Asian adults all express higher levels of concern than White adults. For more, refer to Appendix B .

To better understand concerns about COVID-19 vaccines, the Center conducted in-person, qualitative interviews across four U.S. cities with 22 adults who hold some level of vaccine hesitancy.

Many of the interview participants raised concerns about the rapid development of COVID-19 vaccines, the potential for long-term side effects, and the limited period of time for which these vaccines have been tested for potentially adverse effects. Asked about the safety of the COVID-19 vaccines, some participants described their views in the following ways:

“And it hasn’t been around long, and I just feel like a test dummy for it, along with everybody else that got it.” – Woman, age 35-44, Jacksonville, Florida

“I think it’s not that well-tested. So with the kids, we usually get the vaccines. They’ve been out there for a long time and they still have some type of side effects. … So I don’t see how something developed in six months could be totally safe.” – Man, age 50-54, Cincinnati, Ohio

Another who said that he had few concerns about the safety of the coronavirus vaccines for himself questioned how the new vaccines could be safe for those with underlying health conditions:

“I mean, you can’t do a long-term test in a year, right, as quickly as they got them out. For people like that, I was more concerned than myself, who have some sort of underlying health issue that they just can’t run a long-term effect on how this vaccine is going to affect a person with that health.” – Man, age 25-34, Jacksonville, Florida

Interviewees were asked to share any particular concerns they had about the safety of coronavirus vaccines. Some referenced information they had heard from family and friends about a range of side effects from being sick for a few days to more serious side effects like developing Bell’s palsy or having “mini strokes.” And several interviewees mentioned concerns about myocarditis or pointed to the NFL player who collapsed on the field during a game as a possible side effect from the COVID-19 vaccines. (NFL player Damar Hamlin has confirmed the cause of his collapse was commotio cordis , a rare cause of cardiac arrest that can occur following a blow to the chest.)

Concerns about serious side effects from the COVID-19 vaccines loomed large in participants’ thinking about whether or not their child should be vaccinated.

“So I feel like there’s more concern for side effects in her because she’s still growing. And if something truly did go wrong then I would rather have those issues upon me than on her. So let’s do the sample test on me first before giving it to her.” – Man, age 35-44, Seattle, Washington

“It’s too quick. You got young kids, they have their whole life. If they found out at 18 that they had myocarditis problems or something like that, you would feel awful as a parent if you gave your child that shot.” – Man, age 35-44, Cincinnati, Ohio

For some interviewees, concerns about the potential long-term side effects from the COVID-19 vaccines were also rooted in a sense that the vaccines have done little to limit the spread of the coronavirus or have limited personal value for their own health. Some in this group saw their health history as putting them at low risk for getting a serious case of the disease or felt they have natural immunity from having had COVID-19 in the past.

Participants expressed a range of views about how much they value information from doctors and other health care providers about COVID-19 vaccines

Interview participants who spoke positively of information from doctors or other health care providers about the COVID-19 vaccines tended to have a specific, personal relationship in mind. And some found mixed advice from those sources:

“Who do I trust personally? My uncle who’s a doctor, and every step of the way I’ve asked him questions because he’s not on either side of the fence. He’s very just factual, fact based.” – Man, age 50-64, Jacksonville, Florida

“I have friends who are physicians who are completely against it. I have friends who are physicians who are completely fine with it. And then I’ve talked to nurses and other people who are literally on the front lines in hospitals and have been and they’re saying, ‘Well, we don’t trust it yet.’” – Man, age 25-34, Phoenix, Arizona

But some interviewees with concerns about the COVID-19 vaccines gave no special credibility to information from doctors or other medical professionals. As one woman put it:

“[Doctors are] not very credible because, again, that’s the personal opinion of the doctor. So if this doctor believes in it and this doctor doesn’t, and you go see this doctor and I go see this one, then we’ve got two different information. Everybody has, like I said, their formed opinions.” – Woman, age 25-34, Phoenix, Arizona

Another woman raised questions about the motives of many doctors, saying:

“I think a lot of doctors [support the vaccine] because they get people visiting from pharmaceutical companies that are trying to push things, sell their pharmaceuticals.” – Woman, age 50-54, Phoenix, Arizona

On a broader question about who participants turned to for reliable information about the COVID-19 vaccines, several interviewees talked about relying on family, friends and other sources they see as having trustworthy motives.

“It just doesn’t feel like you can ever trust what information you’re getting, because you can look at one source and they’ll tell you one thing, and then you look at another source that seems to be just as credible as the first source and they’ll tell you the exact opposite thing. So yeah, it’s really hard to make decisions based on that, and that’s why I try to make my decisions based on just my circle of people that I know, as much as I can trust that and as educated as we might be on making those decisions. It’s hard to trust reliability from outside sources, because it feels like we get contradictory information all the time.” – Man, age 35-44, Phoenix, Arizona

“I would say medical studies where people are just really trying to understand it and they’re not coming at it with an agenda. So I would believe that.” – Woman, age 50-54, Phoenix, Arizona

“I think generally the CDC is a good source of information. But again, I think we’re just kind of in an age where there’s too much information out there, information and misinformation. It all depends on whose spin you see on it. That makes it kind of tough for them, I’m sure.” – Man, age 50-64, Jacksonville, Florida

Interviewees expressed frustration over polarized conversations about COVID-19 vaccines, and for some, lasting resentment over feeling forced to get vaccinated

One of the overarching themes that emerged from these conversations was frustration about the polarized environment in the U.S. around vaccines. Several of the interviewees mentioned these divides over the vaccines and the difficulty of having an open conversation about their concerns and decisions.

“You just feel separate from others, just because you chose not to get the shot.” – Woman, age 35-44, Cincinnati, Ohio

“People aren’t open-minded to the people that don’t believe in it. … Some people are just so close-minded, that they think that because the people on TV are telling you to get it, that you’re supposed to get it. I think that’s what bothered me the most. It was like, I have an opinion, I do my own research, I talk to my doctor, and just because they tell you to get it doesn’t mean you just run right out and get it.” – Woman, age 50-54, Cincinnati, Ohio

Several interviewees also pointed to feeling pressured to get vaccinated, whether explicitly or implicitly, as well as their frustration that government spokespeople and others have not fully owned up to changing information about the health risks and benefits of the COVID-19 vaccines.

“And it’s like, ‘No, and it should be my choice.’ You know, my body, my choice, kind of a thing.” – Woman, age 25-34, Phoenix, Arizona

“It just the fact that it was being pushed on everybody, push, push, push. In my mind it was all crap because A, I’d already had the virus or I’d already … Yeah, I’d already had the virus, so I already had natural immunity. There was no way that I needed it, even if I came down …” – Man, age 50-64, Jacksonville, Florida

“I think they should be honest with who actually needs it.” – Man, age 35-44, Cincinnati, Ohio

“Well, there’s probably a lot that bothers me, but I think the thing that bothers me the most is how if we can’t as a society admit that we were wrong about something, or that the data changed and maybe some of our decisions should change, and so one side of the aisle or the other side had decided on something, they weren’t going to let up.” – Man, age 35-44, Cincinnati, Ohio

About half of Americans (49%) report they have gotten a flu shot since August. A similar share (48%) say they typically get a flu shot every year while 13% say they do so every few years and 38% of Americans say they rarely or never get a flu shot.

Older Americans are particularly likely to say they got a flu shot this year. Seven-in-ten adults ages 65 and older say they have gotten a flu shot this season, compared with 38% of those ages 18 to 29. These age patterns are consistent with those seen in past Center surveys.

Health insurance status is also related. Those with health insurance coverage are more likely than those without it to get a flu shot (51% vs. 21%).

These patterns are generally consistent with other studies looking at the factors related to getting a flu vaccine .

There is a strong relationship between Americans’ practices around getting an annual flu shot and their COVID-19 vaccination status , with those fully vaccinated and recently boosted for COVID-19 the most likely to say they regularly get a flu shot.

The Center survey also included questions measuring the public’s broad views about medical treatments and their sense of possible problems in health and medical care today.

Overall, Americans are evenly divided over the value of current medical treatments: 49% say medical treatments are worth the costs because they allow people to live longer and better-quality lives, while the same share says these treatments often create as many problems as they solve. Views on this issue are about the same as a 2018 Center survey .

Views about the overall value of medical treatments these days are closely tied to family income levels and health insurance status.

Two-thirds of upper-income Americans say medical treatments these days are worth the costs because they allow people to live longer, better-quality lives. Only 34% of upper-income Americans say medical treatments often cause as many problems as they solve. In contrast, 58% of lower-income Americans say medical treatments often cause as many problems as they solve.

Those with no health insurance – a group that’s more likely than others to have lower family incomes — are also more inclined to see medical treatments as creating as many problems as they solve; about two-thirds (65%) take this position while a third say that medical treatments are worth the costs because they allow people to live longer, better-quality lives.

Men are modestly more likely than women to say medical treatments are worth the costs because they allow people to live longer and better-quality lives (54% vs. 45%).

Adults ages 65 and older are more likely than younger adults to emphasize the benefits of medical treatments these days, although these differences are relatively modest. In all, 56% of those ages 65 and older say that medical treatments are worth the costs compared with 46% of those under 30.

Costs continue to rank at the top of Americans’ list when it comes to problems with medical treatments today.

Asked to rate a series of possible problems in getting medical treatments, 84% of U.S. adults say it is a big problem that the cost of treatments makes quality medical care unaffordable. Just 14% say this is a small problem and 2% say this is not a problem.

A similar share (83%) said costs were a big problem in a 2018 Center survey.

A majority of Americans (57%) also say people relying too much on prescription medications that may not be necessary is a big problem these days. The share who consider this a big problem is down 11 percentage points from 2018, however.

Other concerns are less widely shared: 47% of U.S. adults say it is a big problem that side effects from medical treatments create as many problems as they solve and 43% call it a big problem that new treatments are made available before we understand their effects.

Problems that rank lower for the public include the idea that evaluating the safety and effectiveness of new treatments is too slow (39% say this is a big problem), that new treatments are so complex patients cannot make informed decisions (37% say this is a big problem) and that health care providers are too quick to order tests and procedures that may not be necessary (35% say this is a big problem).

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The importance of vaccinations.

Last Updated August 2023 | This article was created by familydoctor.org editorial staff and reviewed by Deepak S. Patel, MD, FAAFP, FACSM

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Childhood vaccines: what they are and why your child needs them, immunization schedules, preventive services for healthy living.

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There has been confusion and misunderstandings about vaccines. But vaccinations are an important part of family and public health. Vaccines prevent the spread of contagious, dangerous, and deadly diseases. These include measles, polio, mumps, chicken pox, whooping cough, diphtheria, HPV, and COVID-19.

The first vaccine discovered was the smallpox vaccine. Smallpox was a deadly illness. It killed 300 million to 500 million people around the world in the last century. After the vaccine was given to people, the disease was eventually erased. It’s the only disease to be completely destroyed. There are now others close to that point, including polio.

When vaccination rates decline, cases of preventable diseases go up. This has been happening in recent years with measles. As of July 7, 2023, the Centers for Disease Control has been notified of 18 confirmed cases in 12 U.S. jurisdictions. That may not seem like a lot but compare it with just 3 cases during the same time in 2022. By the end of 2022, there were 121 cases. Almost all those cases could have been prevented with vaccines.

What are vaccines?

A vaccine (or immunization) is a way to build your body’s natural immunity to a disease before you get sick. This keeps you from getting and spreading the disease.

For some vaccines, a weakened form of the disease germ is injected into your body. This is usually done with a shot in the leg or arm. Your body detects the invading germs (antigens) and produces antibodies to fight them. Those antibodies then stay in your body for a long time. In many cases, they stay for the rest of your life. If you’re ever exposed to the disease again, your body will fight it off without you ever getting the disease.

Some illnesses, like strains of cold viruses, are fairly mild. But some, like COVID-19, smallpox or polio, can cause life-altering changes. They can even result in death. That’s why preventing your body from contracting these illnesses is very important.

How does immunity work?

Your body builds a defense system to fight foreign germs that could make you sick or hurt you. It’s called your immune system. To build up your immune system, your body must be exposed to different germs. When your body is exposed to a germ for the first time, it produces antibodies to fight it. But that takes time, and you usually get sick before the antibodies have built up. But once you have antibodies, they stay in your body. So, the next time you’re exposed to that germ, the antibodies will attack it, and you won’t get sick.

Path to improved health

Everyone needs vaccines. They are recommended for infants, children, teenagers, and adults. There are widely accepted immunization schedules available. They list what vaccines are needed, and at what age they should be given. Most vaccines are given to children. It’s recommended they receive 12 different vaccines by their 6th birthday. Some of these come in a series of shots. Some vaccines are combined so they can be given together with fewer shots.

The American Academy of Family Physicians (AAFP) believes that immunization is essential to preventing the spread of contagious diseases. Vaccines are especially important for at-risk populations such as young children and older adults. The AAFP offers vaccination recommendations,  immunization schedules , and information on disease-specific vaccines.

Being up to date on vaccines is especially important as children head back to school. During the 2021 school year, state-required vaccines among kindergarteners dropped from 95% to 94%. In the 2021-2022 year it fell again to 93%. Part of this was due to disruptions from the COVID-19 pandemic.

Is there anyone who can’t get vaccines?

Some people with certain immune system diseases should not receive some types of vaccines and should speak with their health care providers first.  There is also a small number of people who don’t respond to a particular vaccine. Because these people can’t be vaccinated, it’s very important everyone else gets vaccinated. This helps preserve the “herd immunity” for the vast majority of people. This means that if most people are immune to a disease because of vaccinations, it will stop spreading.

Are there side effects to vaccines?

There can be side effects after you or your child get a vaccine. They are usually mild. They include redness or swelling at the injection site. Sometimes children develop a low-grade fever. These symptoms usually go away in a day or two. More serious side effects have been reported but are rare.

Typically, it takes years of development and testing before a vaccine is approved as safe and effective. However, in cases affecting a global, public health crisis or pandemic, it is possible to advance research, development, and production of a vaccine for emergency needs. Scientists and doctors at the U.S. Food and Drug Administration (FDA) study the research before approving a vaccine. They also inspect places where the vaccines are produced to make sure all rules are being followed. After the vaccine is released to the public, the FDA continues to monitor its use. It makes sure there are no safety issues.

The benefits of their use far outweigh any risks of side effects.

What would happen if we stopped vaccinating children and adults?

If we stopped vaccinating, the diseases would start coming back. Aside from smallpox, all other diseases are still active in some part of the world. If we don’t stay vaccinated, the diseases will come back. There would be epidemics, just like there used to be.

This happened in Japan in the 1970s. They had a good vaccination program for pertussis (whooping cough). Around 80% of Japanese children received a vaccination. In 1974, there were 393 cases of whooping cough and no deaths. Then rumors began that the vaccine was unsafe and wasn’t needed. By 1976, the vaccination rate was 10%. In 1979, there was a pertussis epidemic, with more than 13,000 cases and 41 deaths. Soon after, vaccination rates improved, and the number of cases went back down.

Things to consider

There have been many misunderstandings about vaccines. There are myths and misleading statements that spread on the internet and social media about vaccines. Here are answers to 5 of the most common questions/misconceptions about vaccines.

Vaccines do NOT cause autism.

Though multiple studies have been conducted, none have shown a link between autism and vaccines.  The initial paper that started the rumor has since been discredited.

Vaccines are NOT too much for an infant’s immune system to handle.

Infants’ immune systems can handle much more than what vaccines give them. They are exposed to hundreds of bacteria and viruses every day. Adding a few more with a vaccine doesn’t add to what their immune systems are capable of handling.

Vaccines do NOT contain toxins that will harm you.

Some vaccines contain trace amounts of substances that could be harmful in a large dose. These include formaldehyde, aluminum, and mercury. But the amount used in the vaccines is so small that the vaccines are completely safe. For example, over the course of all vaccinations by the age of 2, a child will take in 4mg of aluminum. A breast-fed baby will take in 10mg in 6 months. Soy-based formula delivers 120mg in 6 months. In addition, infants have 10 times as much formaldehyde naturally occurring in their bodies than what is contained in a vaccine. And the toxic form of mercury has never been used in vaccines.

Vaccines do NOT cause the diseases they are meant to prevent.

This is a common misconception, especially about the flu vaccine. Many people think they get sick after getting a flu shot. But flu shots contain dead viruses—it’s impossible to get sick from the shot but mild symptoms can occur because the vaccine may trigger an immune response, which is normal. Even with vaccines that use weakened live viruses, you could experience mild symptoms similar to the illness. But you don’t actually have the disease.

We DO still need vaccines in the U.S., even though infection rates are low.

Many diseases are uncommon in the U.S. because of our high vaccination rate. But they haven’t been eliminated from other areas of the world. If a traveler from another country brings a disease to the U.S., anyone who isn’t vaccinated is at risk of getting that disease. The only way to keep infection rates low is to keep vaccinating.

Questions to ask your doctor

• Why does my child need to be vaccinated?
• What are the possible side effects of the vaccination?
• What do I do if my child experiences a side effect from the vaccine?
• What happens if my child doesn’t get all doses of the recommended vaccines? Will he or she be able to go to daycare or school?
• We missed a vaccination. Can my child still get it late?
• Are there new vaccines that aren’t on the immunization schedules for kids?
• What should I do if I don’t have health insurance, or my insurance doesn’t cover vaccinations?
• What vaccinations do I need as an adult?
• Why do some people insist they became sick after getting the flu vaccine?

Centers for Disease Control and Prevention: Vaccines & Immunizations

Last Updated: August 10, 2023

This article was contributed by familydoctor.org editorial staff.

Copyright © American Academy of Family Physicians

This information provides a general overview and may not apply to everyone. Talk to your family doctor to find out if this information applies to you and to get more information on this subject.

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The first vaccines

Vaccine effectiveness, vaccine types, table of vaccine-preventable diseases.

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What is a vaccine?

A vaccine is a suspension of weakened, killed, or fragmented microorganisms or toxins or other biological preparation, such as those consisting of  antibodies ,  lymphocytes , or mRNA , that is administered primarily to prevent disease.

A vaccine is made by first generating the antigen that will induce a desired immune response. The antigen can take various forms, such as an inactivated virus or bacterium, an isolated subunit of the infectious agent, or a recombinant protein made from the agent. The antigen is then isolated and purified, and substances are added to it to enhance activity and ensure stable shelf life. The final vaccine is manufactured in large quantities and packaged for widespread distribution. Learn more about mRNA vaccine creation.

What is a vaccine delivery system?

A vaccine delivery system is the means by which the immune-stimulating agent constituting the vaccine is packaged and administered into the human body to ensure that the vaccine reaches the desired tissue. Examples of vaccine delivery systems include liposomes , emulsions , and microparticles.

How do vaccines work?

A vaccine imitates infection so as to encourage the body to produce antibodies against infectious agents. When a vaccinated person later encounters the same infectious agent, their immune system recognizes it and can fight it off. Learn more.

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vaccine , suspension of weakened, killed, or fragmented microorganisms or toxins or other biological preparation, such as those consisting of antibodies , lymphocytes , or messenger RNA (mRNA), that is administered primarily to prevent disease .

A vaccine can confer active immunity against a specific harmful agent by stimulating the immune system to attack the agent. Once stimulated by a vaccine, the antibody-producing cells, called B cells (or B lymphocytes ), remain sensitized and ready to respond to the agent should it ever gain entry to the body. A vaccine may also confer passive immunity by providing antibodies or lymphocytes already made by an animal or human donor. Vaccines are usually administered by injection (parenteral administration), but some are given orally or even nasally (in the case of flu vaccine). Vaccines applied to mucosal surfaces, such as those lining the gut or nasal passages, seem to stimulate a greater antibody response and may be the most effective route of administration. (For further information, see immunization .)

The first vaccine was introduced by British physician Edward Jenner , who in 1796 used the cowpox virus (vaccinia) to confer protection against smallpox , a related virus, in humans. Prior to that use, however, the principle of vaccination was applied by Asian physicians who gave children dried crusts from the lesions of people suffering from smallpox to protect against the disease. While some developed immunity, others developed the disease. Jenner’s contribution was to use a substance similar to, but safer than, smallpox to confer immunity. He thus exploited the relatively rare situation in which immunity to one virus confers protection against another viral disease . In 1881 French microbiologist Louis Pasteur demonstrated immunization against anthrax by injecting sheep with a preparation containing attenuated forms of the bacillus that causes the disease. Four years later he developed a protective suspension against rabies .

After Pasteur’s time, a widespread and intensive search for new vaccines was conducted, and vaccines against both bacteria and viruses were produced, as well as vaccines against venoms and other toxins. Through vaccination, smallpox was eradicated worldwide by 1980, and polio cases declined by 99 percent. Other examples of diseases for which vaccines have been developed include mumps , measles , typhoid fever , cholera , plague , tuberculosis , tularemia , pneumococcal infection, tetanus , influenza , yellow fever , hepatitis A, hepatitis B , some types of encephalitis , and typhus —although some of those vaccines are less than 100 percent effective or are used only in populations at high risk. Vaccines against viruses provide especially important immune protection, since, unlike bacterial infections, viral infections do not respond to antibiotics .

The challenge in vaccine development consists in devising a vaccine strong enough to ward off infection without making the individual seriously ill. To that end, researchers have devised different types of vaccines. Weakened, or attenuated , vaccines consist of microorganisms that have lost the ability to cause serious illness but retain the ability to stimulate immunity. They may produce a mild or subclinical form of the disease. Attenuated vaccines include those for measles, mumps, polio (the Sabin vaccine ), rubella , and tuberculosis. Inactivated vaccines are those that contain organisms that have been killed or inactivated with heat or chemicals. Inactivated vaccines elicit an immune response, but the response often is less complete than with attenuated vaccines. Because inactivated vaccines are not as effective at fighting infection as those made from attenuated microorganisms, greater quantities of inactivated vaccines are administered. Vaccines against rabies , polio (the Salk vaccine ), some forms of influenza , and cholera are made from inactivated microorganisms. Another type of vaccine is a subunit vaccine, which is made from proteins found on the surface of infectious agents. Vaccines for influenza and hepatitis B are of that type. When toxins, the metabolic by-products of infectious organisms, are inactivated to form toxoids , they can be used to stimulate immunity against tetanus , diphtheria , and whooping cough (pertussis).

In the late 20th century, advances in laboratory techniques allowed approaches to vaccine development to be refined. Medical researchers could identify the genes of a pathogen (disease-causing microorganism) that encode the protein or proteins that stimulate the immune response to that organism. That allowed the immunity-stimulating proteins (called antigens ) to be mass-produced and used in vaccines. It also made it possible to alter pathogens genetically and produce weakened strains of viruses . In that way, harmful proteins from pathogens can be deleted or modified, thus providing a safer and more-effective method by which to manufacture attenuated vaccines.

Recombinant DNA technology has also proven useful in developing vaccines to viruses that cannot be grown successfully or that are inherently dangerous. Genetic material that codes for a desired antigen is inserted into the attenuated form of a large virus, such as the vaccinia virus, which carries the foreign genes “piggyback.” The altered virus is injected into an individual to stimulate antibody production to the foreign proteins and thus confer immunity. The approach potentially enables the vaccinia virus to function as a live vaccine against several diseases, once it has received genes derived from the relevant disease-causing microorganisms. A similar procedure can be followed using a modified bacterium, such as Salmonella typhimurium , as the carrier of a foreign gene.

Vaccines against human papillomavirus (HPV) are made from viruslike particles (VLPs), which are prepared via recombinant technology . The vaccines do not contain live HPV biological or genetic material and therefore are incapable of causing infection. Two types of HPV vaccines have been developed, including a bivalent HPV vaccine, made using VLPs of HPV types 16 and 18, and a tetravalent vaccine, made with VLPs of HPV types 6, 11, 16, and 18.

Another approach, called naked DNA therapy, involves injecting DNA that encodes a foreign protein into muscle cells. The cells produce the foreign antigen, which stimulates an immune response.

Vaccines based on RNA have been of particular interest as a means of preventing diseases such as influenza , cytomegalovirus infection, and rabies . Messenger RNA (mRNA) vaccines are advantageous because the way in which they are made allows them to be developed more quickly than vaccines made via other methods. In addition, their production can be standardized, enabling rapid scale-up for the manufacture of large quantities of vaccine. Novel mRNA vaccines are safe and effective; they do not contain live virus, nor does the RNA interact with human DNA.

Vaccine-preventable diseases in the United States , presented by year of vaccine development or licensure.

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Getting the COVID-19 Vaccine

This article is part of a series of explainers on vaccine development and distribution. Learn more about vaccines – from how they work and how they’re made to ensuring safety and equitable access – in WHO’s Vaccines Explained series.

Vaccines are a critical tool in the battle against COVID-19, and getting vaccinated is one of the best ways to protect yourself and others from COVID-19.

Getting vaccinated is safer than getting infected 

Vaccines train our immune system to recognize the targeted virus and create antibodies to fight off the disease without getting the disease itself. After vaccination, the body is ready to fight the virus if it is later exposed to it, thereby preventing illness.

Most people who are infected with SARS-CoV-2, the virus that causes COVID-19, develop an immune response within the first few weeks, but we are still learning how strong and lasting that immune response is, and how it varies between different people.

People who have already been infected with SARS-CoV-2 should still get vaccinated unless told otherwise by their health care provider. Even if you’ve had a previous infection, the vaccine acts as a booster that strengthens the immune response. There have also been some instances of people infected with SARS-CoV-2 a second time, which makes getting vaccinated even more important.

What to expect during vaccination

Medical professionals can best advise individuals on whether or not, and when, they should receive a vaccine. A health worker will administer the vaccine, and the person receiving it will be asked to wait for 15–30 minutes before leaving the vaccination site. This is so that health workers can observe individuals for any unexpected reactions following vaccination.

Like any vaccine, COVID-19 vaccines can cause mild-to-moderate side effects, such as a low-grade fever or pain or redness at the injection site. These should go away on their own within a few days. See WHO’s Safety of COVID-19 Vaccines explainer and Vaccines Safety Q&A to learn more about common side effects and find out who should consult with a doctor before vaccination.

Vaccine doses

For some COVID-19 vaccines, two doses are required . It’s important to get the second dose if the vaccine requires two doses.

For vaccines that require two doses, the first dose presents antigens – proteins that stimulate the production of antibodies – to the immune system for the first time. Scientists call this priming the immune response. The second dose acts as a booster, ensuring the immune system develops a memory response to fight off the virus if it encounters it again.

Because of the urgent need for a COVID-19 vaccine, initial clinical trials of vaccine candidates were performed with the shortest possible duration between doses. Therefore an interval of 21–28 days (3–4 weeks) between doses is recommended by WHO. Depending on the vaccine, the interval may be extended for up to 42 days – or even up to 12 weeks for some vaccines – on the basis of current evidence.

There are many COVID-19 vaccines being developed and produced by different manufacturers around the world. WHO recommends that a vaccine from the same manufacturer be used for both doses if you require two doses. This recommendation may be updated as further information becomes available.

Safety against infection and transmission after vaccination

Available clinical trials have shown COVID-19 vaccines to be safe and highly effective at preventing severe disease. Given how new COVID-19 is, researchers are still looking into how long a vaccinated person is likely to be protected from infection, and whether vaccinated people can still transmit the virus to others. As the vaccine rollout expands, WHO will continue to monitor the data alongside regulatory authorities.

Safe and effective vaccines are making a significant contribution to preventing severe disease and death from COVID-19. As vaccines are rolling out and immunity is building, it is important to continue to follow all of the recommended measures that reduce the spread of SARS-CoV-2. This includes physically distancing yourself from others; wearing a mask, especially in crowded and poorly ventilated settings; cleaning your hands frequently; covering any cough or sneeze in your bent elbow; and opening windows when indoors.

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Importance of Vaccines: Resources & Information

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• Published: 09 November 2023

To vaccinate or not to vaccinate? The interplay between pro- and against- vaccination reasons

• Marta Caserotti 1 ,
• Paolo Girardi 2 ,
• Roberta Sellaro 1 ,
• Enrico Rubaltelli 1 ,
• Alessandra Tasso 3 ,
• Lorella Lotto 1 &
• Teresa Gavaruzzi 4  

BMC Public Health volume  23 , Article number:  2207 ( 2023 ) Cite this article

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By mid 2023, European countries reached 75% of vaccine coverage for COVID-19 and although vaccination rates are quite high, many people are still hesitant. A plethora of studies have investigated factors associated with COVID-19 vaccine hesitancy, however, insufficient attention has been paid to the reasons why people get vaccinated against COVID-19. Our work aims to investigate the role of reasons in the decision to get vaccinated against COVID-19 in a representative sample of 1,689 adult Italians (March–April 2021) balanced in terms of age, gender, educational level and area of residence.

Through an online questionnaire, we asked participants to freely report up to three reasons for and against COVID-19 vaccination, and the weight each had in the decision to get vaccinated. We first investigated the role of emotional competence and COVID-19 risk perception in the generation of both reasons using regression models. Next, we studied the role that the different reasons had in the vaccination decision, considering both the intention to vaccinate (using a beta regression model) and the decision made by the participants who already had the opportunity to get vaccinated (using a logistic regression model). Finally, two different classification tree analyses were carried out to characterize profiles with a low or high willingness to get vaccinated or with a low or high probability to accept/book the vaccine.

High emotional competence positively influences the generation of both reasons (ORs > 1.5), whereas high risk perception increases the generation of positive reasons (ORs > 1.4) while decreasing reasons against vaccination (OR = 0.64). As pro-reasons increase, vaccination acceptance increases, while the opposite happens as against-reasons increase (all p  < 0.001). One strong reason in favor of vaccines is enough to unbalance the decision toward acceptance of vaccination, even when reasons against it are also present ( p  < 0.001). Protection and absence of distrust are the reasons that mostly drive willingness to be vaccinated and acceptance of an offered vaccine.

Conclusions

Knowing the reasons that drive people’s decision about such an important choice can suggest new communication insights to reduce possible negative reactions toward vaccination and people's hesitancy. Results are discussed considering results of other national and international studies.

Peer Review reports

Introduction

By mid 2023 the European Union reached nearly 75% vaccine coverage for the primary vaccine cycle against COVID-19, with countries such as Croatia, Slovakia, and Poland falling short of 60% and others such as France, Portugal, and Italy close to 90% [ 1 ]. Although vaccination rates are, on average, quite high, many people are still hesitant. Vaccine hesitancy indicates the delay or refusal of a vaccine despite availability in vaccine services [ 2 , 3 ] and is a multidimensional construct, resulting from the interaction between individual, social, and community aspects [ 4 ]. In the last two years, a plethora of studies have investigated factors associated with COVID-19 vaccine hesitancy showing, for example, that vaccine hesitancy is higher in women [ 5 , 6 ], in young people [ 5 , 7 , 8 ], in people with low education [ 8 , 9 ], low trust in authorities [ 10 , 11 ], and strong conspiracy beliefs [ 5 , 12 , 13 ]. However, to the best of our knowledge no one has investigated the interplay that pro- and against- vaccination reasons may play in the choice to get vaccinated, namely what happens when a person has both pro- and against-vaccine considerations. Trying to fill this gap in the literature, our work aims to investigate how different reasons and the importance people place on them are likely to influence the decision to get vaccinated against COVID-19.

In line with the vaccine hesitancy continuum defined by SAGE [ 2 ], while extremely pro-vax people are likely to express only reasons pro-vaccination and extremely no-vax people are likely to express only reasons against vaccination, individuals who fall between the two extreme end-points are likely to feel some doubts. This large number of people offer us the unique opportunity to assess which category of reasons (pro- vs. against- vaccination) is more impactful in driving people's vaccination decisions. As it is reasonable to imagine, among the reasons for choosing to get (or not) vaccinated some reasons are more rational, while others are more related to affect. For example, there are people who rationally recognize the importance of vaccines but at the same time are frightened by the side effects. Thus, the decision to get (or not) vaccinated is the result of a complex process, in which costs and benefits are weighed more or less rationally. Indeed, while several studies have pointed out that the decision to vaccinate is due to cognitive rather than emotional processes [ 14 , 15 , 16 , 17 ], others have highlighted the role of affect and risk perception in the vaccination decision [ 18 , 19 , 20 ]. Thus, the intention to accept the vaccine is driven by emotional and affective feelings as much as by cognitive and rational judgments. Particular attention to what people feel and think about vaccine-preventable diseases and vaccination in general is paid in the model developed by the “Measuring Behavioral and Social Drivers of Vaccination” (BeSD), a global group of experts established by the World Health Organization [ 21 ]. This model encompasses two groups of proximal antecedents of vaccination, namely, what people think and feel (e.g., perceived risk, worry, confidence, trust and safety concerns) and social processes (e.g., provider recommendation, social norms and rumors). Antecedents affect vaccination motivation (i.e., vaccination readiness, willingness, intention, hesitancy), which can then be strengthened or weakened by practical issues (such as vaccine availability, convenience and cost but also requirements and incentives), resulting in acceptance, delay or refusal of vaccination (vaccination behavior).

Although some studies have considered whether the cognitive or affective component has greater weight in determining the intention to vaccinate, no one, to the best of our knowledge, has studied the interplay between pro- and against- vaccination reasons, nor the weight these have in the choice to vaccinate. In addition to the drivers already studied in the literature [ 5 , 6 , 7 , 8 , 11 , 12 ], we believe that the focus on this interaction may be relevant to better understand the complex phenomena related to vaccine hesitancy. Few recent studies have attempted to investigate the complexity of vaccination choice by studying the reasons why people choose to get (or not) vaccinated against COVID-19. Fieselmann and colleagues [ 22 ] highlighted that among the reasons that reduce adherence to vaccination are a low perception of its benefits, a low perception of the risk of contracting COVID-19, health concerns, lack of information, distrust of the system, and spiritual or religious reasons. Another study, instead, shed light on the reasons that encourage hesitant people to consider vaccination, such as protecting themselves, their family, friends and community from COVID-19, and being able to return to normal life [ 23 ].

In the present study we asked the participants to spontaneously come up with their own reasons to get (or not) vaccinated, without limiting or influencing them with a set of predefined options to choose from, thus aiming to obtain more genuine answers that may better capture the intuitive aspect of people’s opinions (for a similar reasoning see [ 24 ]). The procedure we used has been implemented by Moore et al. [ 23 ], the only study, as far as we know, that asked for reasons with an open-ended question. Critically, in their study, participants were asked to report only reasons in favor of vaccination (e.g., "What are your reasons for getting the COVID-19 vaccine?"), excluding reasons against. By contrast, we asked participants to freely report up to three reasons in favor and up to three reasons against COVID-19 vaccination and to rate on a 5-point Likert scale their weight in the decision about getting (or not) vaccinated.

From a theoretical point of view, the reasons pro- and against vaccination may be seen within the framework of prospect theory [ 25 , 26 ] which suggests that people evaluate the outcome of a choice based on a reference point, against which losses and gains are determined: the former below this point, the latter above this point. Importantly, especially in this specific context, losses and negative consequences are weighted more than gains and benefits, making us hypothesize that if a person has one reason for and one reason against the vaccine, which are of equal importance, they will more likely lean toward choosing not to vaccinate. Consistently, it is known that negative experiences have a greater impact than neutral or positive ones (i.e., the negativity bias [ 27 ]).

Besides delving into the reasons that may influence the choice to get (or not) vaccinated, it would be interesting to also look at the individual differences that may determine the reporting of pro- and against- vaccination reasons and their valence. In this regard, the literature suggests that risk perception and emotion regulation can both have a great impact in the decision to get vaccinated. For instance, studies conducted during H1N1 influenza have shown that perception of disease-related risk is one of the strongest predictors of vaccine adherence [ 28 , 29 ]. Additional insights have been provided by more recent studies investigating the role of COVID-19 risk perception in the decision to get vaccinated against COVID-19. Viswanath and colleagues [ 30 ] showed that people are more willing to vaccinate themselves and those under their care to the extent to which they feel more vulnerable to COVID-19 and rate the consequences of a possible infection as severe. Such a relationship between COVID-19 risk perception and intention to vaccinate was confirmed by another study using a cross-sectional design, which focused on the early months of the pandemic [ 31 ]. This study also examined how risk perception changed during the pandemic phases and showed that during the lockdown, compared to the pre-lockdown phase, also those who reported some hesitancy were more likely to get vaccinated when they perceived a strong COVID-19 risk.

With regard to emotion regulation, the literature suggests that people react differently to affective stimuli [ 32 ] and that their decisions are influenced by their abilities to regulate emotions [ 33 , 34 ]. Recent works investigating the relationship between hesitancy in pediatric vaccinations and the emotional load associated with vaccinations, have shown that a negative affective reaction is one of the factors leading to lower vaccine uptake [ 35 , 36 ]. Specifically, Gavaruzzi and colleagues [ 36 ] showed that concerns about vaccine safety and extreme views against vaccines are associated with vaccine refusal. Interestingly, they also showed that parents' intrapersonal emotional competences, i.e., their ability to manage, identify, and recognize their own emotions, is critical to vaccine acceptance for their children. Therefore, in our study we measured people's risk perception and emotional competencies to assess their possible role in the production of reasons in favor and against vaccination.

As described in Fig.  1 , the relationship between different domains of interest can be hierarchically structured, using a directed acyclic graph, starting from the risk perception and emotion regulation, to the generation of pro- and against- vaccination reasons and their valence, and finally to the vaccination willingness/adherence. With respect to the mentioned structure, we are interested to investigate the following research hypotheses:

The number and weight associated with reasons pro- and against-vaccination should be influenced by individual differences in the ability to regulate emotions;

The number and weight associated with pro-vaccination reasons should be influenced by individual differences in COVID-19 risk perception;

A higher number of strong (i.e., with high weight) reasons pro- (vs. against-) vaccination should correspond to a more (vs. less) likelihood to accept the vaccination.

Generating an equal number of reasons in favor and against vaccination should lead to a weaker likelihood to accept the vaccination.

Directed Acyclic Graph (DAG) between variables considered in the study (PEC: Short Profile of Emotional Competence scale)

As we conducted the study between March and April 2021, a time when vaccinations were being progressively rolled out, we decided to consider the role of personal reasons on both the intention to get vaccinated (for those who had not yet had the opportunity to get vaccinated) and the choice already made (e.g., vaccine received or booked vs. refused).

Finally, through a non-parametric classification analysis, we will explore how specific pro- and against-vaccination reasons impact the decision to get (or not) vaccinated. Specifically, we will investigate the role that different categories of reasons play in the choice to vaccinate.

Participants

Data collection was commissioned to a survey and market research agency (Demetra Opinions.net), with the aim of securing a representative sample of the adult (+ 18) Italian population, estimated at 49.8 million [ 37 ]. The sample was balanced in terms of age, gender, educational level (middle school or lower, high school, degree or higher), and area of residence (North, Center, South, and Islands). The agency distributed via email the survey link to its panelists, who freely decided whether to participate in the study in exchange for financial compensation. Out of 1,833 participants who started the questionnaire, 77 (4%) were excluded because they did not complete the survey and 16 (0.9%) were excluded since they reported offensive content in open-ended questions. Finally, 124 (6.8%) participants were excluded because of missing information. Thus, the final sample consisted of 1,689 participants. The project was approved by the ethical committee for Psychology Research of the University of Padova (Italy), with protocol number 3911/2020 and informed consent was obtained for all participants.

We developed an ad-hoc questionnaire including a series of open-ended and closed questions (see Additional file 1 : Appendix 2 for the full material). We first investigated the vaccination status of the participants, asking whether they already had received at least the first dose, whether they had booked it or were still ineligible, and finally whether they had refused the vaccination. Those not yet eligible were asked to rate how likely they would be to get vaccinated at the time they responded (0 =  Not at all likely , 100 =  Extremely likely ). Then, we asked participants to report a maximum of three reasons both in favor of the COVID-19 vaccine and against it (in counterbalanced order) and to rate how much each of the reported reasons weighed in their choice to vaccinate or not, on a 5-point likert scale (1 =  Not at all , 5 =  Extremely ). Due to the sparsity on the rate and the number of provided reasons we re-coded the provided information into two semi-quantitative variables, one for pro- and one for against- vaccination reasons, as following: missing/invalid reasons, low average rating (answers 1–3 on the Likert scale) and 1–3 reasons, high rating (answers 4–5 points on the Likert scale) and 1 reason, and high average rating (answer 4–5 points on the Likert scale) and 2–3 reasons.

The questionnaire also included the 20-item Short Profile of Emotional Competence scale (S-PEC; [ 38 ]) to measure intra- and inter-personal emotional competences separately. The intra-personal scale (10 items) refers to emotional competences related to oneself and it includes items such as "In my life I never make decisions based on my emotions'' or "I don't always understand why I react in a certain way". The inter-personal scale (10 items) refers to emotional competences related to other people and it includes items such as “If I wanted, I could easily make someone feel uneasy” or “Most of the time, I understand why the people feel the way they do”. All items are answered on a 7-point likert scale (1 =  Not at all agree , 7 =  Completely agree ). The internal consistency of the S-PEC scale, measured by means of Cronbach’s α, was adequate (α = 0.81). Further, we measured participants' risk perception of COVID-19 by asking them to indicate how scared they felt of the virus, how serious they think the disease is, how likely they think they are to get sick, and how worried they feel about the various mutations [ 10 , 31 ]. We then asked participants to report their age, gender, educational level, their occupation (health workers, white-collar workers, entrepreneurs, other non-health-related contract forms, and the unemployed), whether they already had COVID-19 (No or don't know, Yes asymptomatic, Yes with few symptoms, and Yes with severe symptoms). The questionnaire was pilot tested by 30 participants who filled the questionnaire first then were asked to discuss and comment on the comprehension of the wording of questions and answer options. Two questions were slightly reworded to improve clarity.

Scoring of reasons

In the first instance, a bottom-up process from reasons to categories was followed by reading a sample of both types of reasons, with the aim of constructing initial categorizing patterns. Examples of pro-vaccination reasons include protection of personal and public health, return to normality, and civic duty; while reasons against vaccination include fears for one's health, sociopolitical perplexity, and distrust of science and institutions (see Additional file 1 : Appendix 1). At this stage, response information was added to the categorizations indicating whether the responses were valid or missing/invalid. Specifically, valid responses had both a reason and the respective weight; missing/invalid responses were those where reason, weight or both were missing or with utterly unrelated concepts or meaningless strings or letters. Finally, by applying a top-down process, we constructed macro categories by merging specific conceptually assimilated categories, so as to avoid the dispersion of data into too many ramifications (see Table S 5 ).

Statistical analysis

Descriptive analysis.

All the analyses were performed only on respondents with no missing observations on the variables of interest (1,681, 92%) excluding also a limited number of those with a non-valid set of pro- or against-vaccination reasons (Table S 1 ; 0.9%). The study variables were summarized in frequency tables and figures (frequency for categorical variables, median and Interquartile Range (IQR) for continuous variables). Kruskal–Wallis tests were computed to compare the distribution of continuous variables across the categories of vaccine status. Categorical variables were compared using chi-squared or Fisher's exact test where expected frequencies in any combination were less than 10. Statistical significance was assumed at the 5% level.

COVID-19 Perceived risk—exploratory factor analysis

An Exploratory Factorial Analysis (EFA) was performed on groups of variables related to COVID-19 perceived risk: scare, severity, contagiousness, and the likelihood of mutation. Since the presence of limited support (0–100 scale) and non-normal marginal distribution, the EFA was performed using a weighted least square mean and variance adjusted (WLSMV) estimator. We extracted from the EFA only the first factor, which explained the highest percentage of variance (Table S 2 ; 61%). The estimated loadings were then used to calculate the regression factor scores. The number and the name of items included, their internal consistency (Cronbach’s α), the estimated loadings, and the proportion of deviance explained are reported in Table S 2 .

Propensity score weighting

At the time of data collection (March–April 2021), the vaccine offer was not opened to the entire population. To adjust the estimates of the following regression models for the propensity to receive the vaccine, we estimated a logistic regression model in which the dependent variable was the response to the question about a previous vaccination offer (Yes/No), while all the factors that can influence the vaccine proposal served as independent variables: age-class (young ≤ 25, young adult 26–45, adult 46–65, elderly 66–84), gender (male, female), occupational status (health worker, not at work, not health worker-employer, not health worker-entrepreneur, not health worker-other), educational level (low = middle school or lower, medium = high school, high = degree or higher), key worker status (yes, no, I don’t know), past COVID-19 contagion (no, yes asymptomatic, yes low symptoms, yes severe symptoms), and familiar status (single/in a relation, married/cohabitant, divorced/separated/other). The predicted probability was used to estimate the weights for the following regression models using a framework based on an inverse probability of treatment weighting (IPTW; for further details, see [ 39 ]).

Regression models

Our research questions can be summarized by trying to describe the relationship exploited by the directed acyclic graph in Fig.  1 . The first step regression model aims to assess how S-PEC scores (inter- and intra-personal) and COVID-19 risk perception influenced the reasons pro- and against-vaccination produced by participants while considering the presence of a set of confounders (age-class, gender, occupational status, educational level, key worker status, and familial status).

Since both the pro- and against-vaccination reasons are formed by a categorical variable with 4 levels (missing/invalid, low 1/2/3 reasons, high 1 reason, high 2/3 reasons), we evaluated whether S-PEC and COVID-19 risk perception scores influenced the distribution of pro- and against-vaccination reasons employing two different multinomial regression models including all the previously mentioned variables (S-PEC, COVID-19 risk perception, and confounders). The overall significance of a variable in the model was tested using an analysis of the variance (ANOVA).

The second step in the analyses was taken to investigate whether the generation of pro- and/or against-vaccination reasons affected the willingness to be vaccinated or the vaccine acceptance. Each participant reported their willingness to get vaccinated on a 0–100 scale or, in case a COVID-19 vaccine had been already offered, their vaccination status (done, booked, or refused). For respondents who had not yet been contacted for booking/getting the vaccination, we evaluated whether pro- and/or against vaccination reasons influenced the willingness to be vaccinated by employing a beta regression model in which the respondent variable scale (0–100) was rescaled to be a relative frequency [ 40 ]. The full models included the semi-quantitative pro- and against-vaccination reasons variables and, even if non-statistically significant, all the confounders in order to adjust for age class, gender, educational level, occupational status, familial status, and key worker status. Beta regression coefficients were estimated using a maximum likelihood estimator (MLE). Results were presented in terms of Odds Ratios (ORs) by exponentiating the estimated coefficients and producing a relative 95% Confidence Interval (95% CI).

A further regression analysis was conducted through a logistic regression model to explain which factors influenced vaccine acceptance (done/booked vs. refused) among those who already received the vaccine offers. The full model included the same variables considered in the previous beta regression model, after recoding the variables related to pro- and against-vaccination reasons into a binary form (missing/invalid vs. presence of at least one valid reason) due to low sample size and the sparsity of the response variable. As a consequence, we tested a simplified version of Hypothesis 3, considering the presence (vs. missing/invalid) of pro- or against-vaccination reasons in order to test their influence on the probability of having accepted/booked the vaccination.

Results were reported employing ORs and relative 95% Confidence Interval (95% CI).

Both the beta regression and logistic regression were weighed using an IPTW scheme to take into account the presence of a different probability of a vaccine offer among respondents.

The presence of an interaction between pro- and against-vaccination reasons was tested by means of a likelihood ratio test. The regression models were estimated through the R 4.0 program (R Core Team, 2021), and for the beta regression we employed the betareg package [ 41 ].

Classification tree analysis

Two different classification tree analyses were carried out to characterize profiles with a low or high willingness to get vaccinated (respondents who had not yet been offered a vaccine) or with a low or high probability to accept/book the vaccine (respondents who had already received a vaccine offer).

Although the dependent variables were non-normally distributed (scale 0–100 or binary 0/1), we considered them continuously distributed adopting a splitting criterion based on the analysis of the variance (ANOVA). We tested the inclusion in the model considering the type of pro- or against-vaccination reasons. A tree pruning strategy was adopted to reduce classification tree overfitting considering the overall determination coefficient (R 2 ) as an indicator and fixing that at each classification step in the tree if the R 2 did not increase by 0.5% the tree should be stopped. Classification tree analysis was performed using the rpart package [ 42 ] on R environment [ 43 ].

The main characteristics of the respondents by vaccination status (received, booked, not yet, and refused) were reported in Table 1 . Among respondents, 23.3% were offered the vaccination and, among them, 13.8% refused it (Fig. S 1 ). Among those not yet eligible, willingness to be vaccinated showed a median value of 80 points (average: 68.7). The distribution of gender was almost equal (51% females, 49% male), and the median age was 47 years old (IQR: 34–57 years). Educational level was low in 41% of the sample, while the most represented employment status was not at work (39%) followed by employed (37%), and entrepreneur (9.8%). A quarter (26%) of respondents classified themselves as key workers during the COVID-19 pandemic. The predominance of respondents (63%) were married or living with a partner, while only 9% had had a COVID-19 infection.

COVID-19 risk perception and the S-PEC score (intra- and inter-personal) were categorized into three categories according to empirical tertiles (low:1 st tertile, medium: 2 nd tertile, high: 3 rd tertile). The level of COVID-19 risk perception differed across vaccination status ( p  < 0.001). The reasons pro- and against-vaccination have a different distribution according to COVID-19 vaccination status (Table 2 ). The highest frequency of pro-vaccination reasons was reported by those who received the COVID-19 vaccination; conversely the lowest frequency of pro-vaccination reasons was generated by those who refused the vaccine, whereas, intermediate frequencies were shown by people who were not yet offered the vaccination and those who had booked the vaccine, who reported a comparable distribution of the number of pro-vaccination reasons. A reverse pattern was exhibited for against-vaccination reasons, which were generated with the highest percentage by respondents who refused the vaccine (in particular high and multiple reasons). Conversely those who have booked/done the COVID-19 vaccine showed the lowest frequency of reasons against vaccination, while respondents without a vaccine offer reported an intermediate frequency of reasons against vaccination.

The estimated results of the propensity score model for the vaccine offer are shown in Table S 3 . Respondents older than 65 years exhibited a nearly four-fold increase in the probability to be contacted for the vaccination with respect to the reference age-class (≤ 25 years). All non-health employees showed a high drop in the probability of having received the vaccination offer, while the probability increased as the educational level increased. Being a key worker during pandemic resulted in an increased probability of having received the vaccination proposal while no statistical significant influence was observed for the past COVID-19 contagion or for familial status. The distribution of the propensity score by vaccine status obtained by the model is reported in Fig. S 1 , in which it is shown that the distribution is different by vaccine offer, but the two density functions partially overlap. The discriminant power of the propensity score estimated was only discrete (ROC analysis, AUC: 71.8%).

The results of the multinomial regression models which investigated the effect of emotional competences and risk perception on the generation and the predictors of pro- and against-vaccination reasons with respect to missing/invalid level and the reference categories are presented in Table 3 (see also Fig.  1 ). Compared to the reference category (missing/invalid), high values of S-PEC-self were associated with a higher probability to report pro- and against-vaccination reasons (all ORs > 1.5), while high values of S-PEC-others were associated with a mild probability to report multiple pro-vaccination reasons (all ORs > 1.42). A high (vs. low) COVID-19 risk perception increased the frequency of one strong pro-vaccination reason while it had a null or low decremental effect on the frequency of against weak vaccination reasons. Further, medium (vs. low) COVID-19 risk perception only increased the strong pro-vaccination. Compared to the reference age-class (young), adults and elderly showed a higher probability to generate a strong unique pro-vaccination reason (adults vs. young OR: 1.72, 95%CI: 1.07–2.77); elderly vs. young OR: 2.24, 95%CI: 1.26–4.00), while lower probability to generate against vaccination reasons was observed for elderly compared to young respondents (OR: 0.48, 95%CI: 0.26–0.90). Female participants generated fewer strong pro-vaccination reasons (ORs < 0.73), and also fewer multiple weak against-vaccination reasons (OR: 0.68, 95%CI: 0.51–0.91) compared to male participants. Overall, the occupational status did not affect the generation of pro- and against-vaccination reasons (ANOVA test p  > 0.05); however an increased frequency of low 1/2/3 against-vaccination reasons emerged among the category “Other—not health workers” compared to the reference group represented by health workers (OR: 2.52, 95%CI:1.09–5.86). Pro-vaccination reasons are more frequent as the educational level becomes higher, while the relation of the educational level with against- vaccination reasons appears weaker and significantly increased only for the presence of multiple weak reasons against vaccination (High vs. Low educational level, OR: 2.10, 95%CI: 1.45–3.03). Not being a key worker is related to a higher frequency of multiple strong both pro- and against vaccination reasons. The familiar status did not seem to be related to the frequency or the strength of the reasons, except for the status of divorced/separate/other that, with respect to the reference category single/in a relation, showed a twofold increase in the frequency of a strong unique against vaccination reason.

Through a beta regression model we investigated the predictors of willingness to be vaccinated for the participants who had not yet received the vaccination offer. As shown in Table 4 , the generation of pro- and against-vaccination reasons strongly influences the willingness to be vaccinated. The predicted probability from the combination of pro- and against-vaccination reasons is shown in Fig.  2 (and Table S 4 ): respondents who did not report any reasons had an average predicted probability above 60%, while the presence of at least one reason against vaccination decreased the willingness to be vaccinated, in particular in the case of strong multiple against vaccination reasons. On the other hand, the presence of at least one pro-vaccination reason strongly increased the probability. In the end, the presence of both strong multiple pro and against vaccination reasons resulted in a high probability of getting the vaccine. Regression models adjusted by propensity score weighting allowed us to comment the influence of potential confounders: males reported an increased willingness to be vaccinated (vs. females; OR: 1.26, 95%CI: 1.11–1.42), and so did those with a high educational level (vs. low; OR: 1.22, 95%CI: 1.04–1.44) while the opposite was true among no key workers (vs. key workers; OR: 0.85, 95%CI: 0.72–0.99).

Predicted willingness to get vaccinated by interaction between pro- and against-vaccination reasons

Finally, with a logistic model we investigated the predictors of vaccine acceptance\booking. As shown in Table 5 , people who accepted or booked the COVID-19 vaccine were more likely to show pro-vaccination reasons and less likely to show against-vaccination reasons. Interestingly, when both kinds of reasons were provided, the probability of getting/booking the vaccine remained nevertheless very high (Fig.  3 ). Compared to the age class [46-65], younger age classes reported a strong reduction in the probability to have accepted/booked the vaccine. Male participants (OR: 1.53, 95%CI: 1.10–2.12) and those with a high educational level (OR: 2.65, 95%CI: 1.60–4.54) showed an increased probability of vaccine acceptance/booking when compared to females and participants with medium educational level, respectively. Being a health worker had a strong and positive influence on the probability of getting/booking the vaccine with respect to those employed as no health workers (OR: 6.61, 95%CI: 2.10–30.9).

Predicted COVID-19 vaccine acceptance/booking probability by interaction between pro- and against-vaccination reasons

Two regression tree models were estimated separately on the willingness to be vaccinated for those who had not yet received the vaccine offer and on the booking/acceptance of the vaccination in case of vaccine offer. Results are shown in Fig.  4 . Considering the willingness to be vaccinated, the presence of distrust in the vaccination was the most discriminant variable; this latter in conjunction with reasons related to protection, herd immunity, and the absence of no clinical trials guided the willingness to be vaccinated. In particular, the combination of the absence of reasons related to distrust and the presence of protection reasons showed the highest values on the intention to get vaccinated (average value = 83 points, 22% of the sample). On the other side, the presence of at least one reason related to distrust without any positive reasons concerning protection, herd immunity, and trust predicted the lowest willingness to be vaccinated (average value = 29 points, 6% of the sample).

Regression tree for the willingness to be vaccinated (left) and for COVID-19 vaccine acceptance/booking (right) by selected type of pro- and against-vaccination reasons

The sense of protection given by the vaccine or the trust in the vaccination was the main reason for vaccination acceptance/booking (average probability = 0.96 and 1.00, 33% and 5% of the sample, respectively). The combination of the absence of protective reasons and the presence of doubts about the lack of clinical studies results in the lowest likelihood of accepting/booking the vaccination (average probability = 0.40, 3% of the sample). The presence of distrust and the belief in herd immunity were the other discriminant reasons with intermediate results in terms of the probability to accept/book the vaccination.

The frequency of each category of pro- and against-vaccination reasons by COVID-19 vaccine status is shown in Table S 5 .

In the present study we aimed to investigate the reasons behind the decision to get (or not) vaccinated against COVID-19 by asking participants to report up to three reasons in favor and three reasons against the COVID-19 vaccination and to indicate the weight these reasons had in their decision. Although some researchers discourage categorization, the sparsity of the responses related to the number of reasons and their weight implies a semi-quantitative solution since a simple variable multiplication between rating and frequency (recoding to zero in case of zero reasons) is not feasible. In this case, this approach was not satisfactory as such coding would not allow differences underlying identical scores to emerge. For example, only 1 strong motivation (rating 5) would be coded in the same way as three motivations with weights 1, 2, and 2. Instead, we decided to categorize the combination of frequency-weight reasons as categorical variables (missing/invalid, low 1/2/3 reasons, high 1 reason, high 2/3 reasons) in which rating and number of reasons are combined into a single variable. This categorization allows us not only to study the weight that different categories have on the decision to get vaccinated but also to overcome the risk of imputing a specific value for missing responses.

As shown in Fig.  1 , analyses were run in two steps. The first step aimed to assess how emotional competences and risk perception impacted the generation of reasons pro- and against-vaccination (Hypotheses 1A and 1B), whereas the second step investigated how different reasons affected the intention to get vaccinated (Hypotheses 2 and 3). The results support the hypotheses that emotional competences and risk perception play a significant role. Regarding emotional competence as measured by the S-PEC, the results show that high intra-personal emotional competence positively influences the production of stronger and more numerous pro-vaccination and against-vaccination reasons (confirming Hypothesis 1A). This result suggests that greater awareness of one's emotions and of what one is feeling promotes higher fluency in the production of reasons about the vaccination. Research has shown that people can be ambivalent about vaccines and hold both positive and negative reasons [ 2 , 44 ]. It is reasonable to assume that, compared to people with low intra-personal emotional competences, those with high intra-personal emotional competences are more likely to have higher awareness of these contrasting attitudes and to embrace them without suppressing one of the two stances. Furthermore, the results showed that only high inter-personal emotional competences influence the generation of multiple strong reasons in favor of vaccination, and this appears to be related to the perception of vaccines as a public good and a tool to protect others. As for risk perception, a moderate to high perception of risk associated with COVID-19 influences the generation of strong pro-vaccination reasons (confirming Hypothesis 1B). These results are in line with the literature showing that a high perception of risk associated with COVID-19 positively influences the decision to get vaccinated [ 30 , 31 , 45 , 46 , 47 ]. In particular, perceiving a medium/high risk leads to generating a high number of reasons strongly in favor of vaccination, while reducing the number and weight of the reasons against the vaccine. The main premise of the psychological literature examining the relationship between risk perception and affect is that one’s behaviors are affected by rapid and intuitive evaluations, either positive or negative, people make while assessing things happening around them [ 48 , 49 ]. Thus, an event is evaluated not only on the basis of objective information, but also on the basis of the experienced feelings. Emotional competence, which is clearly related to affect, also modulates how we perceive and process the emotional component underlying our judgments [ 36 ].

The results also show that, compared with younger people, those over 45 more frequently produce reasons in favor of vaccines while those over 65 produce fewer reasons against vaccination. These results are in line with the fact that younger people are at lower risk of severe consequences than older people [ 50 ], but can also be explained by considering that age was particularly salient during the period of the data collection, as the vaccination campaign was phased out by age groups, starting from the elderly. As for gender, women produced less strong pro-vaccine and weak-against vaccine reasons than men. These results are congruent with the general findings in the literature on vaccine hesitancy showing that females are more hesitant than males [ 5 , 51 , 52 ]. Furthermore, medium and high educational levels favored the production of both pro- and against-vaccination reasons, whereas not being in a relationship or being divorced/separated increased the generation of a strong reason against vaccination. Consistent with previous work [ 53 ], we confirmed that non-health professionals participants or non-key workers categories showed a lower intention to get vaccinated and a higher likelihood of having refused the vaccine compared to health care and key workers.

Once the role of demographics aspects and individual differences on the generation of reasons pro and/or against vaccination had been established, we ran two additional models to assess the role that those reasons have on the decision to accept the vaccination (see Fig.  1 ). More specifically, we tested the hypothesis that a higher number of pro- (vs. against-) vaccination reasons, connoted by a higher weight, corresponded to a stronger (vs. weaker) acceptance of vaccination (Hypothesis 2). Since data collection took place between March and April 2021, when the vaccination campaign had already started in Italy, we developed two different regression models, with the first investigating the willingness to be vaccinated in participants who were not yet offered the vaccine and the second investigating the likelihood of accepting/booking or refusing the vaccine in those who already received the offer. In particular, thanks to the propensity score weighting technique, we managed to reduce the estimates bias, especially for those factors (age, occupational status, and educational level) that influenced the vaccine offer the most [ 54 ]. The results of the two models are very similar, as the intention to get vaccinated and the likelihood of having accepted/booked the vaccine are predicted by the same factors. Specifically, the production of strong positive reasons increases either the intention to get vaccinated or having accepted/booked the vaccination. In contrast, generating strong negative reasons reduces vaccination intention and predicts the refusal of the vaccination. Hypothesis 2 is thus confirmed.

Results on the interactions between reasons, pro- and against-vaccination, and vaccination intention or vaccination choice are particularly worthy of attention. The third hypothesis was derived from the literature on prospect theory [ 25 , 26 ], suggesting that at equal intensity subjective losses are more important in determining a decision than subjective gains. We therefore expected that negative reasons would count more than positive reasons in deciding whether to get vaccinated or to accept the vaccine. However, in contrast to our hypothesis, the results showed that just the generation of a single positive reason with a strong weight was enough to shift behavior and attitude in favor of the vaccination, regardless of the number and weight of negative reasons. In other words, vaccine refusal is predicted by the absence of any positive strong reasons, while when people generate both positive and negative reasons, the positive ones seem to yield a particularly important role when having a strong weight. According to prospect theory, people evaluate their goals depending on the reference point they focus on. During the pandemic, the vaccination offered an opportunity to be safer, reduced the risk of infection, and more generally appeared as the best way to re-open and get back to life as it was before COVID-19. After a year of pandemic characterized by periods of lockdown and some re-opening attempts, people were likely feeling in a state of loss (e.g., the lost freedom to go out and meet with friends and family, the lost freedom of traveling) and were looking forward to whatever chance available to recover and return to their previous lifestyle and habits. Just as those who gamble are willing to do anything to make up for a loss, so probably those who were not entirely certain about the vaccine were more willing to take risks to recover the loss in quality of life. It follows that the pandemic emergency made people forgo some of their doubts about the vaccine when, at the same time, they had reasons to get their shot. In addition, several studies [ 19 , 55 , 56 ] have highlighted the relationship between anticipated regret and vaccination, showing that anticipated regret is associated with an increased likelihood of adhering, or having one's children adhere, to vaccine offerings. Trusting that the vaccine would work, focusing less on its potential side effects, made sense for people who were looking forward to recovering what was perceived (and was indeed) a loss of quality of life and freedom, because they desired to be back doing the things had ever enjoyed doing (e.g., going to restaurants, movies, etc.). This finding is also interesting from a communicative perspective: providing positive reasons that resonate well with people and have therefore a strong weight for them could offset their doubts, yielding to a greater acceptance of COVID-19 vaccination.

Therefore, it is crucial to consider what kind of reasons drive the decision toward or against vaccination. Allowing participants to openly report their reasons pro- or against- vaccination can facilitate a freer exploration of the concerns and reservations of the most hesitant individuals [ 24 ], thus providing valuable insights for shaping future vaccine-related communications. In fact, thanks to the regression tree on vaccination intention, it emerges that positive attitudes toward vaccines are strongly determined by "Protection" and "Community Protection" reasons. The fact that the sense of individual and collective protection is among the principal determinants of the decision with respect to COVID-19 vaccines suggests that in general vaccination is seen as a means of avoiding nefarious clinical consequences. The effect of the sense of communal protection as the reason favoring vaccination and of other-oriented S-PEC in determining the generation of multiple pro-vaccine motivations confirms previous results suggesting that people often are more willing to get vaccinated primarily to protect their loved ones [ 57 , 58 , 59 ], especially when they have a good understanding of how community immunity works [ 60 , 61 ]. However, it is worth mentioning that, at the time the study was conducted (March–April 2021), there was still uncertainty about whether COVID-19 vaccines could provide sterilizing immunity (i.e., could prevent the transmission of the infection) in addition to protecting the individual. To foster people's willingness to get vaccinated, it is crucial from a public health perspective that people understand that even when vaccines do not yield sterilizing immunity, vaccination can still increase protection of others by reducing the circulation of the virus.

The reasons that influenced the willingness to be vaccinated or the vaccination acceptance/booking were generally in line with the existing literature, although they differed depending on whether respondents had already been offered a vaccine or not: among those who did not received a vaccination offer, the main reasons promoting vaccination acceptance were protection against COVID-19 for oneself, one's family, friends, and community [ 23 ], while among the main reasons that reduced vaccination adherence for those who got the vaccine offer we found the lack of clinical trials [ 62 , 63 ], as well as the distrust of institutions and science [ 22 ]. This latter emerged as the most reported negative reason by those who have refused the vaccine and those who have not yet received the vaccine offer. Thus, effective communication aimed at defusing the perception of risk regarding vaccines themselves should focus on enhancing trust in the scientific process and experimental rigor. Indeed, these reasons were deemed as very important not only by those who refused the vaccination, but also by those who had not yet been offered the vaccine, and even by those who held mixed feelings but eventually chose to get vaccinated. While it is unlikely that individuals firmly against vaccination will be persuaded by simple interventions [ 64 ], we should keep in mind that vaccine hesitancy is a dynamic process. As such, reducing hesitancy or enhancing ambivalence, for example through motivational interviewing (e.g., [ 65 , 66 ]), could potentially lead to small shifts towards greater vaccine acceptance.

Our findings are also in line with the results of other international studies that have used a qualitative approach to examine reasons for and against vaccinations. For example, Hamilton and colleagues [ 67 ] employed a qualitative content analysis to extract the main motivations for and concerns about COVID-19 vaccination from medical records obtained by 102 consults in Australia. The study was conducted in June 2021, and revealed that most consults were driven by doubts about the vaccine available and recommended at that time (i.e., ChAdOx1-S, also known as Vaxzevria), followed by need for further information regarding vaccines and vaccination, also considering specific comorbidities. Notwithstanding the peculiarity of the Australian context in which a very low number of COVID-19 infections was observed, the analysis performed by Hamilton et al. [ 67 ] revealed a set of themes that largely overlaps with the reasons identified in our study. Indeed, among the reason to get vaccinated, 5 themes emerged: a) Protection, b) Occupational or facility responsibility or requirement, c) Trust in primary healthcare physician, d) Autonomy, and e) Civic duty, likewise, concerns about vaccination were mainly in terms of: a) Perceived vaccine risks, b) Perceived vaccine performance, c) Uncertainty, d) Autonomy, and e) Fairness in access. An aspect worth noting is that after the consultation, 81% of participants received the vaccination, 19% did not. Consistent results were observed in another study by Purvis and colleagues [ 68 ] conducted in the USA, which focused specifically on “hesitant adopters”, i.e. those who accepted vaccination but showed some level of hesitancy. To note that in this study the focus was on factors influencing the decision to get the COVID-19 vaccine, not on reasons against it. The authors interviewed 49 participants as a follow up of a larger study ( N  = 2022) conducted from mid-September 2021 through mid-October 2021, to explore factors that influenced their decision-making process about COVID-19 vaccination [ 68 ]. Two main themes emerged, each with four subthemes: 1) sociocultural context (political, cultural, health professionals, employment, and media environment) and 2) individual and group influences (attitudes and beliefs related to vaccines, family and social networks, free to return to normal, and COVID-19 outcomes).

As for the Italian context, to the best of our knowledge, only one study (i.e., [ 69 ]) attempted to provide a qualitative examination of the concept associated with vaccination in general, through open-ended and closed questions. Notably, this study was conducted a year later than our own study (April–May 2022) and was administered to a non-representative sample of Italians. The authors used a combination of closed and open-ended questions to assess concepts associated with vaccination in general. Consistent with our findings, Boragno et al. reported that participants who had been vaccinated against COVID-19 (92% of the sample) frequently mentioned concepts related to protection and salvation, whereas those who were not vaccinated frequently mentioned mistrust and ambivalence as concepts associated with vaccination [ 69 ].

This study has some limitations. First, COVID-19 perceived risk score was obtained only with respect to the disease and a similar score should be of interest for the COVID-19 vaccine. Second, data were collected during a vaccine offer limited to a well-defined slice of the population and the investigation on the vaccine acceptance/booking has, as a consequence, a limited sample size. Finally, the lack of a longitudinal perspective does not allow us to evaluate how strong the association is between the willingness to get vaccinated, vaccine acceptance and potential changes in risk perception. Thus, we cannot generalize our results beyond the period of data collection and to other countries or health systems. Since the dynamics have now changed, results may not apply to the decision to get a booster shot or not or an annual shot, however it might be interesting to study what motivations are most relevant now. Likewise, it remains to be established whether our results are generalisable to other populations.

Future studies could consider how the interaction between perceived risk associated with the disease and perceived risk associated with the vaccine influences the choice to get the shot. Furthermore, it would be important to explore how we can harness the reasons that most hold back vaccination in a specific communication strategy for the most hesitant people. Moreover, at the time of data collection, the vaccination campaign was still at an early stage, and only a small portion of the population had already received their shot. Therefore, we believe that it might be of particular interest to know more in detail, with a larger sample, what are the reasons that to date, almost 2 years after the release of the vaccine, still make some people reject the vaccine. Only by knowing these reasons will it be possible to develop appropriate vaccination campaigns.

In conclusion, our work examined pro- and against-vaccination reasons and how these, and their interaction, influence the decision to get vaccinated or not. Specifically, high emotional competence and risk perception influence the generation of pro- and against-vaccination reasons and that the presence of a strong pro-vaccination reason shifts intention toward vaccination. We also highlighted the category of reasons that influence intention to vaccinate. That said, given that the discussion about the next doses is still open and that in any case the next pandemic is a matter of when and not if [ 70 ], it is of paramount importance to know the best way to counteract vaccine hesitancy, fostering more effective communication strategies.

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Marta Caserotti, Roberta Sellaro, Enrico Rubaltelli & Lorella Lotto

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Additional file 1: appendix 1..

Scoring for pro- and against-vaccination reasons.  Appendix 2. Structure of the questionnaire. Table S1. Selection criteria. Table S2. Number of items, internal consistency (Cronbach’s α), name of the items and their estimated loadings, total deviance explained by the loadings and proportion of variance explained by EFA for COVID-19 perceived risk. Table S3. Odds ratios (ORs) estimated by the logistic model for the propensity score weighting for the COVID-19 vaccine offer. Table S4 . Predicted willingness to get vaccinated by combination of pro- and against-vaccination reasons by category of reference.  Table S5. Frequency of reported categories of pro- and against-vaccination reasons overall, and by COVID-19 vaccine status. Figure S1. Distribution of the propensity scores by vaccine offer.

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Caserotti, M., Girardi, P., Sellaro, R. et al. To vaccinate or not to vaccinate? The interplay between pro- and against- vaccination reasons. BMC Public Health 23 , 2207 (2023). https://doi.org/10.1186/s12889-023-17112-6

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Long-term risk of autoimmune diseases after mRNA-based SARS-CoV2 vaccination in a Korean, nationwide, population-based cohort study

• Seung-Won Jung   ORCID: orcid.org/0000-0003-4874-1513 1   na1 ,
• Jae Joon Jeon   ORCID: orcid.org/0000-0002-5805-826X 1   na1 ,
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The long-term association between mRNA-based coronavirus disease 2019 (COVID-19) vaccination and the development of autoimmune connective tissue diseases (AI-CTDs) remains unclear. In this nationwide, population-based cohort study involving 9,258,803 individuals, we aim to determine whether the incidence of AI-CTDs is associated with mRNA vaccination. The study spans over 1 year of observation and further analyses the risk of AI-CTDs by stratifying demographics and vaccination profiles and treating booster vaccination as time-varying covariate. We report that the risk of developing most AI-CTDs did not increase following mRNA vaccination, except for systemic lupus erythematosus with a 1.16-fold risk in vaccinated individuals relative to controls. Comparable results were reported in the stratified analyses for age, sex, mRNA vaccine type, and prior history of non-mRNA vaccination. However, a booster vaccination was associated with an increased risk of some AI-CTDs including alopecia areata, psoriasis, and rheumatoid arthritis. Overall, we conclude that mRNA-based vaccinations are not associated with an increased risk of most AI-CTDs, although further research is needed regarding its potential association with certain conditions.

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Introduction.

Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) results in the development of coronavirus disease 2019 (COVID-19), and it has spread globally since 2020. COVID-19 has emerged as a notable pandemic, causing a substantial burden on public health, as > 50% of the world’s population has been infected with it, according to a 2022 global seroprevalence survey 1 , 2 .

Shortly after the COVID-19 outbreak, vaccines emerged as a crucial intervention to address the pandemic. These vaccines were developed primarily by two main technological platforms replicating incompetent adenoviral vectors and mRNA 3 . In particular, though the effectiveness of vaccine wanes over time and as virus variants such as Omicron, mRNA-based COVID-19 vaccines show generally significant efficacy, preventing 46–92% of SARS-CoV-2 infections, 74–87% of hospitalisations, and 62–92% of severe illnesses, as defined by the National Institutes of Health criteria 4 . Moreover, recent clinical research or systematic reviews concerning mRNA COVID-19 vaccines have confirmed their generally favourable safety profiles 5 , 6 , 7 .

Although the COVID-19 vaccine has played a crucial role in combatting the pandemic, the mRNA COVID-19 vaccine is reportedly also associated with adverse events, notably cardiac complications such as myo- and pericarditis 8 , 9 , 10 . In particular, the potential association between the mRNA COVID-19 vaccine and autoimmune connective tissue diseases (AI-CTDs) has been actively studied. A few systemic autoimmune diseases, such as autoimmune hepatitis and nephropathies, have been identified as being potentially associated with mRNA vaccines 11 , 12 . While previous studies have suggested an association between mRNA vaccines and several systemic autoimmune diseases, there are limited studies demonstrating the development of AI-CTDs following mRNA vaccination in large populations over a period of > 1 year, despite the low incidence and slow development of AI-CTDs. These uncertainties and adverse effects of mRNA vaccines have heightened public scepticism regarding vaccination and necessitated a risk-benefit analysis of vaccination.

In this study, we aim to determine whether the incidence of AI-CTDs is associated with mRNA vaccination against SARS-CoV2.

Study population

The primary cohort was established by combining the National Health Insurance Service (NHIS) and Korea Disease Control and Prevention Agency (KDCA) databases, which comprised the healthcare data of > 99% of the entire Korean population and their COVID-19 diagnosis and vaccination profiles. In total, 9,258,803 individuals who had received at least one dose of the mRNA-based COVID-19 vaccine were included (Fig.  1 ). As COVID-19 vaccines have been administered nationwide in South Korea, the proportion of unvaccinated individuals was minimal 13 . Therefore, the use of unvaccinated individuals as comparators could have resulted in improper cohort selection and potential selection bias. We consequently established a historical control cohort within mRNA-vaccinated individuals, but the observational period was shifted back 2 years from the date of the first dose of mRNA vaccination of the historical control cohort. In total, 4,445,333 and 4,444,932 patients were included in the vaccination and historical control cohorts, respectively, and all were observed for ≥ 1 year. The baseline demographic and general health characteristics of each cohort are summarised in Table  1 . The covariates were well-balanced after the inverse probability of treatment weighting (IPTW). The COVID-19 vaccination profiles, such as the type of mRNA vaccine or history of non-mRNA vaccination, are summarised in Supplementary Table  1 . The mean follow-up times for the vaccination and historical control cohorts were 471.24 ± 66.16 days and 471.28 ± 66.15 days, respectively.

This nationwide population-based cohort study combined data from the Korea Disease Control and Prevention Agency (KDCA) and the COVID-19 National Health Insurance Service (NHIS) cohort (K-COV-N cohort). The study included approximately 20% of the total South Korean population. This primary cohort comprised all individuals vaccinated with at least one dose of the mRNA-based COVID-19 vaccine (BNT162b2, Pfizer-BioNTech; mRNA-1273, Moderna) until 31 December 2022. Subsequently, half of the primary cohort was extracted to establish the vaccination cohort, and the study index was defined as the date of the first dose of the mRNA-based COVID-19 vaccine. A historical control cohort was established by extracting the other half of the primary cohort as the control, and its study index was assigned as the date of the first dose of the mRNA-based COVID-19 vaccine minus 2 years. A total of 4,445,333 vaccination and 4,444,932 control cohorts were selected and observed until 31 December 2022 and 31 December 2020, respectively. Abbreviations: COVID-19, Coronavirus 2019 disease.

Autoimmune connective tissue diseases following mRNA vaccination

Cumulative incidence plots for the AI-CTDs are shown in Fig.  2 , with Supplementary Fig.  1 providing additional details, including cumulative incidence for positive and negative control outcomes, as well as the cumulative number of events for each time point. The risks of developing incident AI-CTDs in the vaccination and historical control cohorts are shown in Fig.  3 . To mitigate the risk of type I error induced by multiple comparisons, we employed a Bonferroni correction for 27 predefined outcomes and used an adjusted 99.81% confidence interval (99% CI) to determine statistical significance. Individuals who had the mRNA COVID-19 vaccine did not incur higher risks of developing most AI-CTDs such as alopecia areata (adjusted hazard ratio [aHR], 1.00; 99% CI, 0.96–1.04), alopecia totalis (aHR, 0.79; 99% CI, 0.68–0.93), psoriasis (aHR, 0.80; 99% CI, 0.77–0.84), vitiligo (aHR, 0.95; 99% CI, 0.88–1.02), anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (aHR, 1.09; 99% CI, 0.72–1.66), sarcoidosis (aHR, 1.06; 99% CI, 0.78–1.44), Behcet disease (aHR, 0.69; 99% CI, 0.58–0.82), Crohn’s disease (aHR, 0.92; 99% CI, 0.77–1.09), ulcerative colitis (aHR, 0.97; 99% CI, 0.87–1.08), rheumatoid arthritis (aHR, 0.86; 99% CI, 0.84–0.89), systemic sclerosis (aHR, 1.01; 99% CI, 0.73–1.38), Sjogren’s syndrome (aHR, 1.07; 99% CI, 0.96–1.18), ankylosing spondylitis (aHR, 0.95; 99% CI, 0.87–1.04), dermato/polymyositis (aHR, 1.02; 99% CI, 0.77–1.35), and bullous pemphigoid (BP) (aHR, 1.53; 99% CI, 0.90–2.60). However, individuals in the mRNA vaccination cohort were at considerably higher risk of developing systemic lupus erythematosus (SLE) (aHR, 1.16; 99% CI, 1.02–1.32) than those in the historical control cohort.

The cumulative incidence plot shows the cumulative incidences of autoimmune connective tissue diseases in mRNA-based COVID-19 vaccination cohort and historical control cohort. The shaded area shows a 95% confidence interval for the cumulative incidences. Additional information, including cumulative incidence for positive and negative control outcomes, as well as the cumulative number of events for each time point, was presented in Supplementary Fig.  1 . Abbreviation: ANCA, anti-neutrophil cytoplasmic antibody; COVID-19, coronavirus disease 2019.

To minimise the differences in baseline characteristics between the vaccination and historical control cohorts, predefined covariates, including demographics, socioeconomic status, and comorbidities, were balanced using inverse probability of treatment weighting. Subsequently, the incidence in the vaccination cohort compared to that in the historical control cohort was estimated using multivariable Cox proportional hazards analysis after adjusting for all predefined covariates. The forest plot depicts adjusted hazard ratios (aHRs) in individuals with mRNA-based COVID-19 vaccination compared with historical controls, with the confidence interval (CI) adjusted to 99.81% for Bonferroni correction but presented as 99% CI for simplicity. The point estimate (centre) represents the aHR, and the horizontal line (error bar) shows the range of the 99% CI. The incidence rate was calculated as the number of events divided by 10,000 person-years, with the population at risk also presented. Abbreviations: aHR, adjusted hazard ratio; ANCA, antineutrophil cytoplasmic antibody; CI, confidence interval; COVID-19, coronavirus disease 2019; HR, hazard ratio.

Validation of the results using positive and negative control outcomes

To validate these findings, we evaluated the risks of positive and negative control outcomes associated with mRNA vaccination. For the positive control outcomes, the risk of myocarditis (aHR, 7.20; 99% CI, 4.37–11.86), pericarditis (aHR, 2.75; 99% CI, 1.95–3.88), and Guillain–Barre syndrome (aHR, 1.62; 99% CI, 1.16–2.25) were considerably higher in the vaccination cohort than in the historical control cohort (Fig.  3 ). Conversely, the risk of having negative control outcomes was not considerably higher in the vaccination cohort than in the historical control cohort (benign skin tumour (aHR, 1.02; 99% CI, 1.00–1.05), melanoma in situ (aHR, 1.21; 99% CI, 0.64–2.29), and tympanic membrane perforation (aHR, 0.84; 99% CI, 0.77–0.91)).

Stratified analysis by sex, age, and vaccination profile

In subgroup analyses, we compared the vaccination and historical control cohorts stratified by sex, age (< 40 vs. ≥ 40), type of mRNA-based COVID-19 vaccine (BNT162b2, Pfizer–BioNTech vs. mRNA-1273, Moderna), cross-vaccination status with any history of non-mRNA COVID vaccination (ChAdOx1 nCoV-19 [AZD1222], Oxford–AstraZeneca or Ad26.COV2.S, Janssen–Johnson & Johnson, or others) prior to mRNA vaccination, and any history of COVID-19 diagnosis. In general, there were no significant differences between the two cohorts in the subgroup analyses for most outcomes (Figs.  4 – 5 ), with Supplementary Figs.  2 – 11 providing additional details for each stratified analysis. However, women who had received the mRNA vaccine had a significantly higher risk of developing BP (aHR, 2.67; 99% CI, 1.11–6.42) (Fig.  4 a, b ). In addition, aged ≥ 40 years who had undergone mRNA vaccination tended to have a higher risk of developing BP (aHR, 1.53; 99% CI, 0.90–2.61) (Fig.  4 c, d ). In the stratified analysis based on the type of mRNA vaccine received, individuals who received the BNT162b2 vaccine had a significantly higher risk of developing SLE (aHR, 1.18; 99% CI, 1.02–1.36) (Fig.  5 a, b ). In addition, cross-vaccination with non-mRNA vaccines did not independently affect the incident risk of any AI-CTDs (Fig.  5 c, d ). In analyses according to the status of COVID-19 diagnosis, the incidence was not higher for almost all AI-CTDs, except SLE in individuals with COVID-19 diagnosis (aHR, 1.23; 99% CI, 1.05–1.44) (Supplementary Figs.  6 and 7 ).

The forest plot depicts adjusted hazard ratios (aHRs) and 99% confidence intervals (CIs) in individuals with mRNA-based COVID-19 vaccination compared with historical controls. The point estimate (centre) represents the aHR, and the horizontal line (error bar) shows the range of the 99% CI. The incident risks of autoimmune disorder outcomes were stratified by sex (( a ) Male or ( b ) Female) and age (( c ) < 40 years or ( d ) ≥ 40 years). Additional details, including unadjusted HRs and population at risk, were provided in Supplementary Figures.; Male subgroup (Supplementary Fig.  2 ), female subgroup (Supplementary Fig.  3 ), subgroup aged < 40 years (Supplementary Fig.  4 ), and subgroup aged ≥ 40 years (Supplementary Fig.  5 ). Abbreviations: aHR, adjusted hazard ratio; ANCA, antineutrophil cytoplasmic antibody; CI, confidence interval; COVID-19, coronavirus disease 2019.

The forest plot depicts adjusted hazard ratios (aHRs) and 99% confidence intervals (CIs) in individuals with mRNA-based COVID-19 vaccination compared with historical controls. The point estimate (centre) represents the aHR, and the horizontal line (error bar) shows the range of the 99% CI. The incident risks of autoimmune disorder outcomes were stratified by the type of mRNA vaccine (( a ) BNT162b2 or ( b ) mRNA-1273) and the history of cross-vaccination (( c ) Only mRNA vaccination or ( d ) Cross-vaccination with non-mRNA vaccination (AZD12222 or Ad26.COV2.S)). Additional details, including unadjusted HRs and population at risk, were provided in Supplementary Figures.; Subgroup who received the BNT162b2 vaccine (Supplementary Fig.  8 ), subgroup who received the mRNA-1273 vaccine (Supplementary Fig.  9 ), subgroup who received only mRNA-based vaccines (Supplementary Fig.  10 ), and subgroup who had a history of cross-vaccination with any non-mRNA vaccines (Supplementary Fig.  11 ). Abbreviations: aHR, adjusted hazard ratio; ANCA, antineutrophil cytoplasmic antibody; CI, confidence interval; COVID-19, coronavirus disease 2019.

Booster vaccination

In total, 2,284,342 individuals had the booster mRNA vaccination (3rd dose of mRNA vaccination) among the vaccination cohort. In extended Cox proportional hazard analyses treating booster vaccination as time-varying covariate, the risk of alopecia areata (aHR, 1.12; 99% CI, 1.05–1.19), psoriasis (aHR, 1.16; 99% CI, 1.06–1.27), and rheumatoid arthritis (aHR, 1.14; 99% CI, 1.08–1.21) were greater in individuals who had booster vaccination compared to those who had not (Fig.  6 ).

The forest plot depicts adjusted hazard ratios (aHRs) with 99% confidence intervals (CIs) in individuals within the vaccination cohort according to prior history of booster vaccination, defined by the administration of 3rd additional dose of the mRNA-based COVID-19 vaccine following the completion of the two-dose primary series of the same mRNA-based COVID-19 vaccine. The point estimate (centre) represents the aHR, and the horizontal line (error bar) shows the range of the 99% CI. Among the vaccination cohort, 2,284,342 individuals were vaccinated with a booster dose and the extended Cox proportional hazard analyses treating booster vaccination as a time-varying covariate were conducted for the variability of vaccination status during the observation period. The numbers of events of autoimmune disorder outcomes and population at risk were presented for each group divided based on booster vaccination status, with the number of events specifically shown before and after the booster vaccination in the individuals with booster vaccination group. Abbreviations: aHR, adjusted hazard ratio; ANCA, antineutrophil cytoplasmic antibody; CI, confidence interval; COVID-19, coronavirus disease 2019; HR, hazard ratio.

BNT162b2 and mRNA-1273 were the first mRNA vaccines approved by the US Food and Drug Administration (FDA) for combatting COVID-19 14 . While prior studies have suggested that non-mRNA vaccinations or COVID-19 infections increase the risk of patients developing autoimmune diseases, data on the long-term effects of mRNA vaccine administration on AI-CTDs are scarce 15 , 16 , 17 . Our study investigated the effect of mRNA vaccination on the occurrence of AI-CTDs by observing at least 1-year period in a nationwide population-based setting comprising more than 8 million individuals. In this analysis, the incidence of most AI-CTDs was not associated with mRNA vaccination. However, we observed an increased risk of developing some AI-CTDs after booster vaccination.

We previously reported no significant difference in the risk of developing AI-CTDs between the mRNA vaccination group and the historical control group at a mean follow-up of 100 days 18 . Our results were generally aligned with the previous study, but we found some gaps in an increased risk of some AI-CTDs, including SLE. This may be attributed to differences in the demographic characteristics of the study population and observational periods across the studies. Given the indolent course of AI-CTDs, these results suggest that long-term surveillance for the development of AI-CTDs after mRNA vaccination may be warranted.

Although the association between mRNA vaccination and SLE remains unclear, there have been cases in which SLE has developed following mRNA vaccination 19 . mRNA vaccination reportedly leads to elevated plasma anti-dsDNA antibody levels, and the extracellular self-DNA influences the pathogenesis of AI-CTDs, including SLE 20 , 21 . Another study found that booster vaccinations increase circulating cell-free DNA in B cells, T cells, and monocytes 22 . In addition, the observed risk of SLE varied according to the type of mRNA vaccine and the history of non-mRNA vaccination. Further studies are needed to elucidate whether factors such as mRNA dose may contribute to these differences 23 , 24 .

The association between BP and mRNA vaccination remains to be elucidated, however, the vaccinated female population shows a 2.67-fold higher risk of BP development than the non-vaccinated female population in the subgroup analysis stratified by sex. The US case series of subepidermal blistering eruptions (including BP) following mRNA vaccination reported it to be more common in women and after the age of 40 25 . Similarly, our study tended to a higher risk of BP in women and in patients over 40 years of age following mRNA vaccination than in historical controls. This result may suggest the need to monitor BP development in females who have received mRNA-based vaccines.

Furthermore, our study found that booster vaccination was associated with an increased risk of developing certain AI-CTDs, such as alopecia areata, psoriasis, and rheumatoid arthritis, albeit the effect size was small. This finding could be associated with autoimmune flare-ups following repeated mRNA vaccination, which can cause subclinical diseases to become active and diagnosed 26 , 27 , 28 . The result of our study may indicate the necessity for additional monitoring when administering booster vaccinations. However, it should be interpreted cautiously due to the potential healthy vaccine effect. In addition, booster vaccinations have shown substantial safety and potential benefits of improving humoral immune response preventing COVID-19 diagnosis or reducing disease severity 29 . Moreover, an additional dose of the vaccine could serve as a strategy to address the limitation of its waning efficacy over time 30 . Therefore, our results are not sufficient to discourage booster vaccination and suggest that regular and long-term monitoring may be necessary to ensure the early detection and management of any emerging risks associated with repeated vaccinations.

This study has several strengths. First, we used the national medical data of ~ 10 million people and national information on COVID-19 infection and vaccination profiles. Second, the risk of incident AI-CTDs was measured with a large sample size and longer observation period, more than the mean follow-up period of 471 days, than that used in previous studies 18 . Third, we designed a historical control cohort to minimise selection bias and examined the reliability of the analysis by evaluating positive and negative outcome controls. Fourth, we considered several confounding factors such as sex, age, type of mRNA vaccine, cross-vaccination, and COVID-19 diagnosis status to consider their potential impacts and designed an analysis treating booster vaccination as a time-varying covariate to account for its variability during the observation.

However, this study has some limitations. First, the analysis was conducted on individuals belonging to a single ethnic group. Since autoimmune disease-associated single nucleotide polymorphisms vary by ethnicity, our results may not be generalisable to other populations 31 . Second, although our study has one of the longest follow-up periods among mRNA vaccine studies reported to date, this duration may still be considered too short, given that the development of AI-CTDs can take years to decades after trigger exposure 32 . Moreover, the observation period of 2 years before the index date may not have been long enough to identify pre-existing AI-CTDs due to their indolent onset. Therefore, some incident cases in this study could have had their onset prior to the observation. Third, considering the global decline in the use of healthcare services during the COVID-19 pandemic, some outcomes of interest may have been underdiagnosed during this period 33 , 34 . Nevertheless, we investigated negative control outcomes to address these concerns. Fourth, potential misclassified cases related to using ICD-10 code claim data could be existed in our study. To mitigate this risk, we considered patients with three or more visits under the same ICD-10 code as having AI-CTDs.

In conclusion, our study results suggest that mRNA vaccination is generally not associated with a higher risk of most AI-CTDs. However, given that the risk of SLE and BP was increased in certain demographic conditions such as age and sex, long-term monitoring is necessary after mRNA vaccination for the development of AI-CTDs. Our results can provide clinical insights into mRNA therapeutics, and further research is needed regarding the association between mRNA-based vaccines and AI-CTDs 35 .

Data source

This nationwide population-based cohort study was conducted using data from the KDCA COVID-19 NHIS (K-COV-N) cohort. The NHIS database provided comprehensive data consisting of demographics, insurance eligibility data (insurance type and area of residence), socioeconomic status (income level), inpatient and outpatient healthcare records (disease diagnoses and procedures), prescriptions, and national health examination results (alcohol use and smoking) of > 99% of the total population of South Korea 36 . The underlying disease of a population was confirmed when that disease was identified at ≥ 3 inpatient or outpatient visits using the corresponding International Classification of Diseases, Tenth Revision (ICD-10) diagnostic codes. The corresponding ICD-10 codes for the underlying diseases are summarised in Supplementary Table  2 . Medical records that can identify past medical history before the index date and incident events during the observation period have been available since January 1, 2016. The South Korean government manages the NHIS COVID-19 registry, and the KDCA provides data regarding the COVID-19 vaccine, such as the type, dose, and vaccination date. This study was approved by the Korean National Institute for Bioethics Policy, and the research number for this study was KDCA-NHIS-2023-1-500.

In the NHIS database, 15,076,899 individuals, approximately 30% of the total South Korean population, underwent a general health examination in 2018. According to the data provider’s regulations, we were required to limit our study population to 10 million due to privacy and data capacity constraints. Consequently, we randomly selected 9,945,450 participants, approximately 20% of the total population of South Korea. After excluding individuals with incomplete general health examination reports, 9,258,803 individuals vaccinated with at least one dose of the mRNA-based COVID-19 vaccine (BNT162b2 or mRNA-1273) until 31 December 2022 were selected. We subsequently extracted half of the primary cohort to establish the vaccination cohort, whose index was the date of administration of the first dose of the mRNA-based COVID-19 vaccine. As COVID-19 vaccination was conducted nationwide in South Korea, as of October 2022, the overall vaccination coverage rate among adults meeting the requirements for the primary series of each COVID-19 vaccine introduced in South Korea was 96.6% 13 . Therefore, using unvaccinated individuals as controls for comparison could have led to inappropriate cohort selection and potential selection bias. Instead, our study uses historical controls as comparators. The other half of the primary cohort was used to form historical control cohorts, while the observational period of the control group was shifted back by 2 years from the date of the first dose of mRNA vaccination of individuals. The two cohort groups were followed up from the respective study index date to disease diagnosis, emigration, death, or the end of the study period. The vaccination group was observed until 31 December 2022, and the historical cohort group until 31 December 2020.

We assessed the incidence and risk of developing AI-CTDs associated with the mRNA-based COVID-19 vaccine during the follow-up period by restricting the study population to patients without a history of the respective outcomes before the study index date. The occurrence of each outcome disease was defined when that disease was identified at ≥ 3 in- or outpatient visits using the corresponding ICD-10 diagnostic codes. We established and evaluated three positive control outcomes (myocarditis, pericarditis, and Guillain–Barre syndrome), which are reportedly significantly associated with the COVID-19 vaccine, as well as negative control outcomes (benign skin tumour, melanoma in situ, and tympanic membrane perforation), which are less likely to be associated with the COVID-19 vaccine, to ensure the validity of our study 37 . The corresponding ICD-10 codes of autoimmune connective tissue diseases and predefined positive and negative control outcomes are summarised in Supplementary Table  2 .

Although both the vaccination and historical control cohorts were derived from the same primary cohort, there could be residual differences in baseline characteristics that were potentially linked to the occurrence of disease outcomes. Therefore, we considered predefined covariates, including demographics and socioeconomic status, such as age, sex, insurance type (standard vs Medicaid), income level (divided into quartiles based on health insurance premiums), area of residence (urban vs rural area), and general health examination data mentioned earlier. In the general health examination data, we established the current smoking status and defined drinking as routine alcohol consumption, regardless of the amount or frequency. In addition, we set several chronic diseases as predefined covariates and listed their corresponding ICD-10 codes in Supplementary Table  2 . The covariates were balanced between the two cohorts using IPTW.

Statistical analysis

The baseline demographic characteristics are presented as means with standard deviations and frequencies with percentages, depending on the variable types. Propensity scores for individuals were estimated based on predefined covariates representing the possibility of belonging to the vaccination cohort. These scores were used to calculate the inverse probability of treatment weights, obtained by dividing the probability of belonging to the vaccination cohort by 1 minus the probability of being in the vaccination cohort: the probability of belonging to the vaccination cohort / (1–the probability of being in the vaccination cohort). The covariate balance was assessed using standardised mean differences before and after the application of the IPTWs. Subsequently, the risk of predefined outcomes in the vaccination cohort was estimated and compared with that in the historical control cohort. Statistical analysis involved multivariable Cox proportional hazards analysis after adjusting for all predefined covariates used to calculate the IPTWs. Each analysis for outcomes included only the population at risk by excluding those who had already been diagnosed with the target outcome at the index date or before. Stratified subgroup analyses were conducted according to the sex, age (< 40 vs ≥ 40), type of mRNA-based COVID-19 vaccine (BNT162b2 vs mRNA-1273), history of having a non-mRNA COVID vaccine such as the viral vector vaccine (ChAdOx1 nCoV-19 (AZD1222) or Ad26.COV2.S) prior to mRNA vaccination, and whether COVID-19 was diagnosed or not. We also aimed to further ascertain the impact of booster vaccination, defined by the administration of 3rd additional dose of the mRNA-based vaccine following the completion of the two-dose primary series of the same mRNA-based vaccine, on the incidence of AI-CTDs. As an individual’s vaccination status may change during the observation, we conducted extended Cox proportional hazard analyses with booster vaccination as a time-varying covariate. To minimise the risk of false findings, such as type I errors due to multiple comparisons, we applied the Bonferroni correction for 27 predefined outcomes. Consequently, statistical significance was determined based on the adjusted confidence interval for 27 comparisons. All statistical analyses were conducted using SAS statistical software (version 9.4; SAS Institute, Cary, NC, USA) and R statistical software (version 3.4.1; R Foundation for Statistical Computing, Vienna, Austria).

Reporting summary

Further information on research design is available in the  Nature Portfolio Reporting Summary linked to this article.

Data availability

The datasets analysed during the current study are available in the National Health Insurance Service in South Korea. This protects the confidentiality of the data and ensures that Information Governance is robust. Applications to access health data in South Korea should be submitted to the National Health Insurance Service in South Korea. Information can be found at https://nhiss.nhis.or.kr/bd/ab/bdaba000eng.do .

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Acknowledgements

This study used the KDCA and NHIS databases for policy and academic research. The research number for this study was KDCA-NHIS-2023-1-500. The KDCA is the Korea Disease Control and Prevention Agency, Republic of Korea. The NHIS is part of the National Health Insurance Service of the Republic of Korea. Funding: This research was supported by funding from the Research Programme of the Korea Medical Institute. This research was also supported by a grant from the Korea Health Technology Research and Development Project through the Korea Health Industry Development Institute (KHIDI), the Ministry of Health & Welfare, Republic of Korea (grant number: HI23C1506; S.L.), and by a grant from the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT; no. RS-2023-00249120; S.L.).

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Department of Dermatology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea

Seung-Won Jung, Jae Joon Jeon, You Hyun Kim, Sung Jay Choe & Solam Lee

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S.J.C. and S.L. have full access to all data in the study and take responsibility for the integrity and accuracy of the data analysis. S.W.J. and S.L. were involved in the conceptualisation and design of the study. S.W.J., J.J.J., Y.H.K., S.J.C. and S.L. contributed to the study methodology and data curation. S.W.J. and J.J.J. were involved in the analysis, data interpretation, and draughting of the manuscript. S.J.C. and S.L. contributed to the data validation, visualisation, and critical revision of the manuscript. S.W.J., J.J.J., Y.H.K., S.J.C. and S.L. administered the project.

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Jung, SW., Jeon, J.J., Kim, Y.H. et al. Long-term risk of autoimmune diseases after mRNA-based SARS-CoV2 vaccination in a Korean, nationwide, population-based cohort study. Nat Commun 15 , 6181 (2024). https://doi.org/10.1038/s41467-024-50656-8

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The Resurgence of Measles: Is Adolescent Vaccination the Key??

5 Pages Posted: 23 Jul 2024

vernika tyagi

Maulana Azad Medical College

Kshitij Saurabh

Post Graduate Institute of Child Health

Bhanu Kiran Bhakhri

Introduction: Measles is a highly infectious disease with an effective vaccine despite, that the goal of measles elimination has been unachievable so far. India has the highest number of measles cases in the world as per the World Health Organization in 2023, thus putting the goal of eliminating measles in jeopardy for the nation. This study aimed to describe the clinical-epidemiological characteristics of children diagnosed with measles at a tertiary hospital in North India. Methods: The study was a retrospective, observational study conducted over six months and included all children diagnosed with measles and classified as per WHO criteria. The clinical history, immunization details, laboratory parameters, and outcome were recorded and analyzed. Results: Eighty-one children were classified as measles as per the WHO criteria. Among them, 70 (86.4%) were laboratory-confirmed,4 (4.93%) were epidemiologically linked, and 7 (8.64%) were clinically compatible measles cases, respectively. The median age of children was 12 months (IQR-3.25) and twenty-seven (33.3%) were less than nine months of age. Thirty-nine children (48.1%) did not receive even a single dose of vaccine. There was a significant difference between immunized and non-immunized cases in terms of respiratory distress (p=0.041) and oxygen requirement (p=0.044). Conclusion: There is a significant gap in the utilization of immunization services. We need to strengthen the current immunization practices to achieve our goal of measles elimination. The large number of young infants and older children affected emphasizes the need for adolescent and adult immunization. Funding: None to declare. Declaration of Interest: None to declare. Ethical Approval: The ethical approval was obtained from the ethics committee of the institute

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One of my earliest childhood memories was watching my father, a doctor, make house calls to his patients around Nashville. Witnessing his healing, empathy, and dedication to the science of medicine first inspired me to follow in his footsteps — not just as a physician, but in his passion to make the world a healthier, better place for all. It inevitably guided me to the halls of the U.S. Capitol as a senator representing my home state of Tennessee.

In those halls, I saw the greatness of this country at its best moments — times of bipartisanship, when the health, happiness, well-being, and freedom of the American people were prioritized above all else.

That was 17 years ago. Since then, we have watched that bipartisanship crumble and those good moments become fewer and farther between, reaching a precipice during the COVID-19 pandemic –– a precipice we are dangerously close to careening over.

The pandemic not only led to a devastating loss of life, but it also gave rise to a scourge of misinformation causing a level of distrust in medicine and science unseen in modern times. Never in my lifetime has the word ‘vaccine’ been so controversial. As a physician, and as a representative of the American people, it’s disappointing, but it is by no means insurmountable.

Recent data on vaccine hesitancy must be our wake-up call –– our rallying cry –– to right the ship, most importantly for our young people. The CDC has reported that immunization rates for critical vaccines like MMR, DTaP, and polio continue to fall, dropping below levels from the 2011-2012 school year, amounting to nearly 250,000 children who may not be protected against measles and other infectious diseases. We are already witnessing the effects.

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With the emergence of a measles vaccine in the early 1960s, we saw a 99% reduction in measles cases in the U.S., achieving the elimination goal in 2000. However, due to vaccine hesitancy since then, we have witnessed an alarming rise in outbreaks across the country. Between November 2022 and February 2023, a measles outbreak affected several schools and daycares in central Ohio, infecting 85 children — 80 of whom were unvaccinated. Already this year, there have been 11 outbreaks in the U.S., with cases spanning 22 states. Of this year’s cases, 65% of the children under age 5 were hospitalized.

Globally, outbreaks of other vaccine-preventable diseases like polio and cholera are also on the rise, and will almost certainly make their way to the U.S. These diseases know no borders, and if vaccination rates continue to decline here, the relatively small number of cases we have now could very quickly become tens or hundreds of thousands of infected people.

Vaccines have, and continue to be, our greatest defense in preventing infectious diseases and safeguarding public health. Historical data underscores their success. The introduction of the polio vaccine in 1955 drastically reduced the number of polio cases, contributing to the Americas being declared polio-free in 1994​​. Recent studies have also shown the high efficacy of COVID-19 vaccines, with mRNA vaccines like those from Moderna and Pfizer demonstrating effectiveness rates of over 90% in preventing severe illness and hospitalization​. Furthermore, the new RSV immunization, nirsevimab, has shown 90% effectiveness in preventing RSV-related hospitalizations in infants​.

Children and parents line up outside the Children's Hospital to receive polio vaccines, Cincinnati, ... [+] Ohio, April 24, 1960. The day marked to first day that the vaccine was made available to US children and was popularly referred to as 'Sabin Sunday,' after Dr. Albert Sabin whose research at the hospital lead to the vaccine. (Photo by Cincinnati Museum Center/Getty Images)

In addition to their effectiveness, vaccines have a robust safety profile with minimal risk of side effects, having been subject to rigorous studies and double-blind tests. Contrary to what rampant misinformation would have you believe, the vast majority of vaccine side effects are mild and temporary, such as a low-grade fever. These successes and safety assurances highlight the critical role of vaccines in combating both long-standing and emerging infectious diseases, underscoring the importance of continued vaccination efforts.

Vaccines are critical for more than individual health, they also ensure the safety of those around us. A virus’s effects are exponential: One unvaccinated individual can cause severe illness among entire communities and lead to preventable loss of life, especially among the most vulnerable — including children, grandparents, front-line workers, and the immune-compromised like transplant recipients, whose lives hang in the balance.

It falls to all of us to correct the course, combat misinformation, get vaccinated, and urge our loved ones to do the same. And to our lawmakers –– the men and women fortunate enough to hold offices that are a public trust –– it is past time to live up to the roles bestowed by the American people. It is the responsibility of our leaders to take the sometimes uncomfortable, even unpopular, position when the health and safety of our people are at stake. Trust the science, trust the medicine, work together, and boldly combat the rising vaccine hesitancy and skepticism that needlessly put our nation at risk.

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The unintended consequences of COVID-19 vaccine policy: why mandates, passports and restrictions may cause more harm than good

Kevin bardosh.

1 School of Public Health, University of Washington, Seattle, Washington, USA

2 Division of Infection Medicine, University of Edinburgh, Edinburgh, UK

Alex de Figueiredo

3 Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK

Rachel Gur-Arie

4 Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland, USA

5 Oxford-Johns Hopkins Global Infectious Disease Collaborative (GLIDE), University of Oxford, Oxford, UK

Euzebiusz Jamrozik

6 Ethox and the Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, UK

James Doidge

7 Intensive Care National Audit and Research Centre (ICNARC), London, UK

8 Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK

Trudo Lemmens

9 Faculty of Law and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada

Salmaan Keshavjee

10 Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA

Janice E Graham

11 Department of Pediatrics (Infectious Diseases), Dalhousie University, Halifax, Nova Scotia, Canada

Stefan Baral

12 Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA

Associated Data

There are no data in this work.

Vaccination policies have shifted dramatically during COVID-19 with the rapid emergence of population-wide vaccine mandates, domestic vaccine passports and differential restrictions based on vaccination status. While these policies have prompted ethical, scientific, practical, legal and political debate, there has been limited evaluation of their potential unintended consequences. Here, we outline a comprehensive set of hypotheses for why these policies may ultimately be counterproductive and harmful. Our framework considers four domains: (1) behavioural psychology, (2) politics and law, (3) socioeconomics, and (4) the integrity of science and public health. While current vaccines appear to have had a significant impact on decreasing COVID-19-related morbidity and mortality burdens, we argue that current mandatory vaccine policies are scientifically questionable and are likely to cause more societal harm than good. Restricting people’s access to work, education, public transport and social life based on COVID-19 vaccination status impinges on human rights, promotes stigma and social polarisation, and adversely affects health and well-being. Current policies may lead to a widening of health and economic inequalities, detrimental long-term impacts on trust in government and scientific institutions, and reduce the uptake of future public health measures, including COVID-19 vaccines as well as routine immunisations. Mandating vaccination is one of the most powerful interventions in public health and should be used sparingly and carefully to uphold ethical norms and trust in institutions. We argue that current COVID-19 vaccine policies should be re-evaluated in light of the negative consequences that we outline. Leveraging empowering strategies based on trust and public consultation, and improving healthcare services and infrastructure, represent a more sustainable approach to optimising COVID-19 vaccination programmes and, more broadly, the health and well-being of the public.

Summary box

• Mandatory COVID-19 vaccine policies have been used around the world during the COVID-19 pandemic to increase vaccination rates. But these policies have provoked considerable social and political resistance, suggesting that they have unintended harmful consequences and may not be ethical, scientifically justified, and effective.
• We outline a comprehensive set of hypotheses for why current COVID-19 vaccine policies may prove to be both counterproductive and damaging to public health. Our framework synthesizes insights from behavioural psychology (reactance, cognitive dissonance, stigma, and distrust), politics and law (effects on civil liberties, polarization, and global governance), socio-economics (effects on inequality, health system capacity and social wellbeing) and the integrity of science and public health (the erosion of public health ethics and regulatory oversight).
• Our analysis strongly suggests that mandatory COVID-19 vaccine policies have had damaging effects on public trust, vaccine confidence, political polarization, human rights, inequities and social wellbeing. We question the effectiveness and consequences of coercive vaccination policy in pandemic response and urge the public health community and policymakers to return to non-discriminatory, trust-based public health approaches.

Introduction

Since 2021, mandatory proof-of-vaccination policies have been implemented and justified by governments and the scientific community to control COVID-19. These policies, initiated across the political spectrum, including in most liberal democracies, have spread globally and have involved: workplace mandates (eg, a ‘no jab, no job’ US federal mandate); green passes/vaccine passports that limit access to social activities and travel (eg, Israel, Australia, Canada, New Zealand and most European countries); school-based mandates (eg, most North American universities); differential lockdowns for the unvaccinated (eg, Austria and Australia); the use of vaccine metrics in lifting lockdowns and other restrictions (eg, Australia, Canada and New Zealand); differential access to medical insurance and healthcare (eg, Singapore); and mandatory population-wide vaccination with taxes, fines, and imprisonment for the unvaccinated (eg, the Philippines, Austria, Greece) (see table 1 ).

The global turn towards mandatory COVID-19 proof-of-vaccination policies*

*This is not a comprehensive list of policies, which are rapidly changing in early 2022. This list excludes the use of segregated lockdowns of the unvaccinated (eg, Austria, Germany, Australia), entry requirements for international travel, fines and penalties (including restricted access to social services and medical care, business capacity restrictions and threats of imprisonment) and the use of vaccine metrics to inform other restrictions. There is a significant variation in how countries recognise infection-derived immunity, allow religious, philosophical and/or medical exemptions and incorporate testing as an alternative to vaccination. In addition, some countries have implemented a combination of policies and interventions, so each is not mutually exclusive. As of March 2022, some countries also shifted course and decided to not implement these policies due to changing epidemiological circumstances and sociopolitical resistance. Adapted from Reuters. 136

The publicly communicated rationale for implementing such policies has shifted over time. Early messaging around COVID-19 vaccination as a public health response measure focused on protecting the most vulnerable. This quickly shifted to vaccination thresholds to reach herd immunity and ‘end the pandemic’ and ‘get back to normal’ once sufficient vaccine supply was available. 1 2 In late summer of 2021, this pivoted again to a universal vaccination recommendation to reduce hospital/intensive care unit (ICU) burden in Europe and North America, to address the ‘pandemic of the unvaccinated’.

COVID-19 vaccines have represented a critical intervention during the pandemic given consistent data of vaccine effectiveness averting COVID-19-related morbidity and mortality. 3–6 However, the scientific rationale for blanket mandatory vaccine policies has been increasingly challenged due to waning sterilising immunity and emerging variants of concern. 7 A growing body of evidence shows significant waning effectiveness against infection (and transmission) at 12–16 weeks, with both Delta and Omicron variants, 8–13 including with third-dose shots. 14 15 Since early reports of post-vaccination transmission in mid-2021, it has become clear that vaccinated and unvaccinated individuals, once infected, transmit to others at similar rates. 16 Vaccine effectiveness may also be lower in younger age groups. 17 While higher rates of hospitalisation and COVID-19-associated morbidity and mortality can indeed be observed among the unvaccinated across all age groups, 3–6 broad-stroke passport and mandate policies do not seem to recognise the extreme risk differential across populations (benefits are greatest in older adults), are often justified on the basis of reducing transmission and, in many countries, ignore the protective role of prior infection. 18 19

Mandate and passport policies have provoked community and political resistance including energetic mass street protests. 20 21 Much of the media and civil debates in liberal democracies have framed this as a consequence of ‘anti-science’ and ‘right-wing’ forces, repeating simplistic narratives about complex public perceptions and responses. While vaccine mandates for other diseases exist in some settings (eg, schools, travel (eg, yellow fever) and, in some instances, for healthcare workers (HCWs)), 22 population-wide adult mandates, passports, and segregated restrictions are unprecedented and have never before been implemented on this scale. These vaccine policies have largely been framed as offering ‘benefits’ (freedoms) for those with a full COVID-19 vaccination series, 23 24 but a sizeable proportion of people view conditioning access to health, work, travel and social activities on COVID-19 vaccination status as inherently punitive, discriminatory and coercive. 20 21 25–28 There are also worrying signs that current vaccine policies, rather than being science-based, are being driven by sociopolitical attitudes that reinforce segregation, stigmatisation and polarisation, further eroding the social contract in many countries. Evaluating the potential societal harms of COVID-19 pandemic restrictions is essential to ensuring that public health and pandemic policy is effective, proportionate, equitable and legally justified. 29 30 The complexity of public responses to these new vaccine policies, implemented within the unique sociopolitical context of the pandemic, demands assessment.

In this paper, we reflect on current COVID-19 vaccine policies and outline a comprehensive set of hypotheses for why they may have far-reaching unintended consequences that prove to be both counterproductive and damaging to public health, especially within some sociodemographic groups. Our framework considers four domains: (1) behavioural psychology, (2) politics and law, (3) socioeconomics, and (4) the integrity of science and public health (see figure 1 ). Our aim is not to provide a comprehensive overview or to fully recapitulate the broad ethical and legal arguments against (or for) COVID-19 vaccine mandates and passports. These have been comprehensively discussed by others. 31–33 A full review of the contribution of mandates and passports to COVID-19 morbidity and mortality reductions is not yet possible, although some existing studies on vaccine uptake are cited below. Rather, our aim is to add to these existing arguments by outlining an interdisciplinary social science framework for how researchers, policymakers, civil society groups and public health authorities can approach the issue of unintended social harm from these policies, including on public trust, vaccine confidence, political polarisation, human rights, inequities and social well-being. We believe this perspective is urgently needed to inform current and future pandemic policies. Mandatory population-wide vaccine policies have become a normative part of pandemic governance and biosecurity response in many countries. We question whether this has come at the expense of local community and risk group adaptations based on deliberative democratic engagement and non-discriminatory, trust-based public health approaches.

Conceptual framework. We consider a broad conceptual framework spanning core aspects of behavioral psychology, politics and the law, the socio-demographic drivers of health inequality and the integrity of science and public health.

What can we learn from the behavioural sciences?

Reactance, entrenchment and vaccine uptake.

Apart from mandatory vaccination of the elderly (planned in Czech Republic, Greece, Malaysia and Russia), most policies do not specify individuals at higher risk of severe COVID-19 outcomes–among whom COVID-19 vaccine uptake rates, and vaccine confidence, are very high. 34 35

Although studies suggest that current policies are likely to increase population-level vaccination rates to some degree, 36–39 gains were largest in those under 30 years old (a very low-risk group) and in countries with below average uptake. 36 Moreover, insights from behavioural psychology suggest that these policies are likely to entrench distrust and provoke reactance —a motivation to counter an unreasonable threat to one’s freedom. Literature reviewed by Drury et al , 40 including a survey by Porat et al 41 in the UK and Israel, found that compulsory COVID-19 vaccination would likely increase levels of anger, especially in those who are already mistrustful of authorities, and do little to persuade the already reluctant. Two experiments in Germany and the USA found that a new COVID-19 vaccine mandate would likely energise anti-vaccination activism, reduce compliance with other public health measures, and decrease acceptance to future voluntary influenza or varicella (chickenpox) vaccines. 42 43 A third experiment found that selective mandates increased reactance when herd immunity targets were not clearly explained 44 —which most governments failed to communicate adequately and convincingly as they shifted their rationale from herd immunity to hospital/ICU admission metrics. De Figueiredo et al 45 found that vaccine passports in the UK would induce a net decrease in inclination to get vaccinated among those who had not received a full vaccination dose, while Bell et al 46 found that UK HCWs who felt pressured to get vaccinated were more likely to have declined the COVID-19 vaccine. Jørgensen et al 47 found that the reintroduction of vaccine passports in late 2021 in Denmark increased distrust among the unvaccinated. Finally, recent evidence from France suggests that the passe sanitaire was associated with increased vaccination but that it did so to a lower extent among the most vulnerable, may have contributed to increased nocebo effects and did not reduce vaccine hesitancy itself; the authors concluded: “Mandatory vaccination for COVID-19 runs the risk of politicising vaccination further and reinforcing distrust of vaccines.” 48

Cognitive dissonance

The public interpretation of these policies has occurred within the context of the rapidly changing pandemic. Oftentimes, public announcements and media coverage have oversimplified, struggled to communicate potential adverse events (including a potentially higher risk in the convalescent) 49 and overstated vaccine efficacy on transmission. Significant public concerns about safety signals and pharmacovigilance have been furthered by the lack of full transparency in COVID-19 clinical trial data 50 51 as well as shifting data on adverse effects, such as blood-clotting events, 52 myocarditis 53 and altered menstrual periods. 54 These changes have been associated with changes to vaccination guidelines in terms of eligibility for different vaccines in some countries. Mandates, passports and segregated restrictions create an environment where reactance effects are enhanced because people with low vaccine confidence see contradictory information as validating their suspicions and concerns. The pressure to vaccinate and the consequences of refusal heighten people’s scrutiny of information and demand for clarity and transparency. Current policies have likely facilitated various layers of cognitive dissonance —a psychological stress precipitated by the perception of contradictory information.

Citing the potential for backlash and resistance, in December 2020, the director of the WHO’s immunisation department stated: “I don’t think we envision any countries creating a mandate for [COVID-19] vaccination.” 55 Many governments originally followed with similar public statements, only to shift positions, often suddenly, in mid or late 2021 during the Delta or Omicron surge, including in Austria (the first country to announce a full population-wide mandate). 56 57 Cognitive dissonance may have been compounded by the changing rationale provided for vaccine mandate policies, which originally focused on achieving herd immunity to stop viral transmission and included public messaging that vaccinated people could not get or spread COVID-19. Policies often lacked clear communication, justification and transparency, contributing to persistent ambiguities and public concerns about their rationale and proportionality. 58 In late 2021, however, the re-introduction of onerous non-pharmaceutical interventions in countries with mandates and passports perpetuated cognitive dissonance, since governments had made promises that vaccination would ensure a ‘return to normal’ and many people (especially younger people) had vaccinated based on these announcements. 36 48

When mandate rules are perceived to lack a strong scientific basis, the likelihood for public scrutiny and long-term damage to trust in scientific institutions and regulatory bodies is much higher. A good example is the lack of recognition of infection-derived immunity in employer-based vaccine mandates and passports in North America, including most universities and colleges. 59 Despite clear evidence that infection-derived immunity provides significant protection from severe disease on par with vaccination, 18 31 prior infection status has consistently been underplayed. Many individuals with post-infection immunity have been suspended or fired from their jobs (or pushed to leave) or been unable to travel or participate in society 31 56–59 while transmission continued among vaccinated individuals in the workplace. This inconsistency was widely covered in American conservative and libertarian-leaning media in ways that reinforced distrust not only about the scientific basis of vaccine policies but also the entire public health establishment, including the US Centers for Disease Control and Prevention (CDC).

Stigma as a public health strategy

Since 2021, public and political discourse has normalised stigma against people who remain unvaccinated, often woven into the tone and framing of media articles. 60 Political leaders singled out the unvaccinated, blaming them for: the continuation of the pandemic; stress on hospital capacity; the emergence of new variants; driving transmission to vaccinated individuals; and the necessity of ongoing lockdowns, masks, school closures and other restrictive measures (see table 2 ). Political rhetoric descended into moralising, scapegoating, and blaming using pejorative terms and actively promoting stigma and discrimination as tools to increase vaccination. This became socially acceptable among pro-vaccine groups, the media and the public at large, who viewed full vaccination as a moral obligation and part of the social contract. 61 The effect, however, has been to further polarise society—physically and psychologically—with limited discussion of specific strategies to increase uptake especially in communities where there would be disproportionately larger individual and societal benefits. There is rarely a discussion of who and why people remain unvaccinated. Vaccine policy appears to have driven social attitudes towards an us/them dynamic rather than adaptive strategies for different communities and risk groups.

Political rhetoric regarding the unvaccinated

PM, Prime Minister.

Leveraging stigma as a public health strategy, regardless of whether or not individuals are opposed to vaccines, is likely to be ineffective at promoting vaccine uptake. 62 Unvaccinated or partially vaccinated individuals often have concerns that are based in some form of evidence (eg, prior COVID-19 infection, data on age-based risk, historical/current trust issues with public health and governments, including structural racism), personal experiences (eg, direct or indirect experience of adverse drug reactions or iatrogenic injuries, unrelated trauma, issues with access to care to address adverse events, etc) and concerns about the democratic process (eg, belief that governments have abused their power by invoking a constant state of emergency, eschewing public consultation and over-relying on pharmaceutical company-produced data) that may prevent or delay vaccination. 45 46 63–66 Inflammatory rhetoric runs against the pre-pandemic societal consensus that health behaviours (including those linked to known risk factors for severe COVID-19, for example, smoking and obesity) do not impact the way medical, cultural or legal institutions treat individuals seeking care. Some governments discussed or imposed medical insurance fines or premiums on the unvaccinated, while hospital administrators considered using vaccination status as a triage protocol criterion. The American Medical Association released a statement decrying the refusal to treat unvaccinated patients 67 but this has not prevented the ongoing narrative of shaming and scapegoating people choosing not to get vaccinated.

Trust, power and conspiracy theories

Trust is one of the most important predictors of vaccine acceptance globally 68 69 including confidence in COVID-19 vaccines. 63 70 71 Data show that being transparent about negative vaccine information increases trust and Petersen et al 72 found that when health authorities are not transparent, it can increase receptivity to alternate explanations.

COVID-19 vaccine policies have the potential to erode vaccine confidence, trust and the social contract in the particular context of the pandemic, which has exacerbated social anxieties, frustrations, anger and uncertainty. By the time COVID-19 vaccine mandates were introduced, many communities had struggled under lockdowns and other severe public health restrictions, undergone a succession of pandemic waves with changing rules that stretched public confidence in government, had their economic security and livelihoods negatively impacted and been exposed to a media-induced culture of fear perpetuated by an abundance of conflicting and confusing information. All of this occurred within the broader global trend of increasing inequities between North and South, rich and poor, as well as the erosion of trust in institutions and experts.

It is likely that many of the alternative explanations of the pandemic, often called conspiracy theories, were further entrenched when vaccine policies were forcefully implemented in 2021, creating a strong confirmation bias that governments and corporate powers were acting in an authoritarian manner. Those who resist vaccine mandates and passports are more likely to have low trust in government and scientific institutions, 25–28 63 64 and these beliefs and distrust have likely grown due to the propensity of policies to justify social segregation, creating new forms of activism. Furthermore, multiple social perceptions and logics about science, technology and corporate and government power have been grafted onto the public discussion about COVID-19 vaccines, specifically related to authoritarian biosurveillance capabilities. 73 These include concerns about the adoption of implantable tracking devices (including microchips), digital IDs, the rise of social credit systems and the censorship of online information by technology companies and state security agencies. The COVID-19 pandemic happens to coincide with far-reaching technological advances that do provide the capability for new forms of mass state surveillance. 74 75 For example, emerging biocompatible intradermal devices can be used to hold vaccine records, 76 while multifunction implantable microchips (that can regulate building access and financial payments, much like cellphones) are now available on the market. 77 Aspects of vaccine passport policies (dependent on QR codes) combined with these innovations—as well as censorship by social media companies of vaccine clinical trial and safety issues from reputable sources like the BMJ 78 —have likely reinforced and exacerbated suspicion and distrust about the impartiality of public health guidance and vaccines. 79 It is highly likely that reactance effects generated by current vaccine policies have increased the view that public health is influenced by powerful sociopolitical forces acting in the private interest, which may damage future social trust in pandemic response.

The political and legal effects of vaccine mandates, passports and restrictions

The erosion of civil liberties.

The COVID-19 vaccine policies that we have outlined represent a broad interference with the rights of unvaccinated people. While some governments introduced mandates and passports through the democratic process (eg, Switzerland, Austria, France), many policies were imposed as regulations , decrees, orders or directions under states of emergency and implemented in ways that allowed ad hoc juridical decisions and irregular and overpermissive private sector rules, with limited accountability or legal recourse to address rights violations. 58

Vaccine passports risk enshrining discrimination based on perceived health status into law, undermining many rights of healthy individuals: indeed, unvaccinated but previously infected people may generally be at less risk of infection (and severe outcomes) than doubly vaccinated but infection-naïve individuals. 80 A weekly negative SARS-CoV-2 test is often seen as a compromise in lieu of full vaccination status, but this places additional burdens (including financial) on the unvaccinated while also risking reputational damage. Employer-imposed mandates that do not provide reasonable accommodation (eg, testing, relocation or reassignment of duties) or that require people to be vaccinated following prior infection even where employees can work remotely, arguably constitute a disproportionate imposition of a health intervention without workplace-related justification. 81 Many countries have also tightened the ability to seek religious, medical or philosophical exemptions, open to unclear decision-making and political interference. 82 Perhaps the most high-profile case to date involves the deportation of the top-ranked men’s tennis player, Novak Djokovic, at the Australian Open 2022, despite having been granted a medical exemption on the basis of documented prior infection. 83 While media outlets were quick at hinting about problems in his official submission, the Minister of Immigration accepted that he had a valid test result and that he posed only a ‘very low’ risk to the health of Australians. 84 Yet, the court ruled that it was reasonable for the Minister to conclude that Mr Djokovic’s presence could ‘foster anti-vaccination sentiment’ and thus have a negative impact on vaccination and boosters. 84 It endorsed Mr Djokovic characterisation as a threat to Australian ‘civil order and public health’. 83 84 The case underlines concerns of vaccine mandates and passports as a tool for disproportionate policy that circumvents normative civil liberties and process.

There are also significant privacy issues with passports, which involve sharing medical information with strangers. Having set these population-wide passport precedents, it is conceivable that they could be expanded in the near future to include other personal health data including genetic tests and mental health records, which would create additional rights violations and discrimination based on biological status for employers, law enforcement, insurance companies, governments and tech companies. COVID-19 vaccine passports have normalised the use of QR codes as a regulated entry requirement into social life; in France and Israel, double-vaccinated citizens lost their ‘status’ when passports required a booster dose in 2021/2022. 85 86 Technology companies interested in biosurveillance using artificial intelligence and facial recognition technology have obtained large contracts to implement vaccine passports and now have a financial interest in maintaining and expanding them. 87

Political polarisation

COVID-19 vaccine policies have generated intense political debate, mass street protests and energised new populist movements with varied political views. 20 21 25–28 56 Studies show that while many support these policies, others view them as inherently coercive, discriminatory, disproportionate and counter to liberal values of bodily autonomy, freedom of choice and informed consent. 25–28 It is clear that current policies are divisive and unpopular with many, even vaccinated people, and that they have become a source for collective rage and anger, notably for those who have been fired from their jobs or isolated and barred from social life.

COVID-19 vaccine policies may influence upcoming elections. For instance, right-wing and populist parties in Germany (the Alternative for Germany), Canada (People’s Party) and Austria (Freedom Party) have come out strongly against medical segregation. After implementing the world’s first population-wide mandatory vaccine policy in February 2022, Austria suspended it 6 days before police would impose fines (max €3600), partially due to legal concerns, mass street protests and the fact that the rate of vaccination had not significantly improved (20% of adults remain unvaccinated). 56 88 In 2022, the US Supreme Court struck down the Biden administration’s federal vaccine mandate as unconstitutional, 89 just as it came into effect for 80 million workers (although upholding the mandate for HCWs); republicans had long criticised the mandates. 90 91 In Martinique and Guadalupe, vaccine passports have led to months of political unrest and violent protests that threaten the stability of the French government. 48 Pottinger 92 argued that mandates and passports could trigger insurrection and civil war in South Africa.

Just as the smallpox vaccination mandates in 1850s Britain created the first ‘anti-vax’ movement, 93 the backlash against COVID-19 policies is energising a global network connected by modern communication technology against these measures. These backlashes may contribute to increased distrust of other vaccines and foster new forms of radicalisation and protest. While mainstream news outlets have voiced concern about the rising ‘anti-vaccination fervour’ among the far-right, and potential for violence, 94 centre and left politicians have also used this rhetoric for their own agenda. In Canada, Prime Minister Trudeau used majority support for mandatory vaccination and passports to divide the conservative opposition in the 2021 federal election. The end to exemptions for unvaccinated truckers crossing the US–Canadian border precipitated the trucker ‘freedom convoy’ protests in early 2022 in Canada, which led to weeks of protesters occupying streets outside parliament. The protest ended with the unprecedented invoking of the Emergencies Act, equivalent to martial law, which was heavily criticised by civil liberty organisations and included the freezing of protester bank accounts. 95 96 In the USA, California and New York (Democrat-controlled states) have implemented COVID-19 vaccine passports for children while Florida, Georgia and Texas (Republican-controlled) are introducing legislation to remove childhood school vaccine mandates in general. Some medical freedom and anti-vaccination groups have made increasingly false and inflammatory claims, and business owners and employees requiring QR codes for entry have been targeted for abuse, in some cases. In turn, pro-vaccine advocates have equated anti-mandate social groups as ‘anti-vaxxers’ and even domestic terrorists, calling for government agencies and social media companies to strengthen censorship laws. Echo chambers have skewed the reasonableness of risk assessment of some pro-mandate individuals, who now fear that unvaccinated people are ‘unsafe’—physically but also culturally—despite the scientific evidence. Political polarisation and radicalisation—both anti-mandate and pro-mandate—will increase if punitive vaccine policies continue.

Disunity in global health governance

Current vaccine policies risk furthering disunity in global health governance. Despite the WHO stating in early 2022 that boosters would prolong the pandemic by contributing to vaccine hoarding and low supply, 97 universities (including some global health departments) in wealthy countries have mandated boosters for low-risk healthy students and faculty, 59 when vaccination rates remained low in many low/middle-income countries (LMICs). 98 Efforts to pressure pharmaceutical companies (who developed vaccines with the support of publicly funded research money) to remove patent protections have proven unsuccessful. 99 100 Pharmaceutical companies have ensured that the costs of adverse effects are borne by governments 101 ; in turn, the world’s tens of millions of migrants and asylum-seekers may be denied COVID-19 vaccines because of legal liability issues. 102 Simultaneously, some scientists are calling the unvaccinated (as a homogeneous group) the source of future variants (‘variant factories’) fuelling inflammatory rhetoric 103 that may have contributed to the heavily criticised reaction to close international borders to southern Africa during the spread of Omicron in late 2021. International travellers, especially from the global south, have been barred from travelling to high-income countries based on the type of received vaccine.

The rollout of vaccine passports and mandates is financially costly and diverts resources and focus away from other interventions. In Canada, $1 billion was pledged by the Trudeau government for vaccine passports 104 and in New York State, the Excelsior Pass App-system developed by IBM will cost more than $27 million. 87 Importantly, focus on ‘the unvaccinated’ as the cause of health system collapse diverts public attention away from global equity failures and deep structural challenges facing public health capacity in many countries. It absolves governments of attending to other strategies for opening schools and keeping public spaces safe, including improved ventilation and paid sick leave. The indiscriminate global adoption of current COVID-19 vaccine policies may also compromise national sovereignty by skewing health priorities in LMICs, taking budgets away from other important health priorities and disregarding public opinion—a new form of vaccine colonialism. Perhaps more significantly, it is possible that vaccination metrics become tied to international financial agreements and development loans and that pharmaceutical and technology companies influence the global adoption of passport systems and mandate policies for the current but also future pandemics.

Socioeconomic impacts

Increasing disparity and inequality.

Historically, marginalised groups—those facing economic challenges and racial and minority groups—tend to have less confidence in vaccination programmes and are more likely to be distrustful. 63–66 68–71 This raises the possibility that current vaccine policies may fuel existing inequity. 105 A rapid policy briefing by the Nuffield Council on Bioethics 106 emphasised that immunity passports could ‘create coercive and stigmatising work environments’ and are ‘more likely to compound than redress…structural disadvantages and…social stigmatisation’. 106 It is highly likely that mandates and passports have been implemented in ways that discriminate against disadvantaged groups including immigrants, the homeless, isolated elderly people, those with mental illness, specific cultural and religious groups, those in precarious living circumstances, and people with certain political views and values. Moreover, communities who have historically been subject to state surveillance, segregation, structural racism, trauma or violence may be more likely to resist medical mandates. In Israel, reports suggest that Bedouin and Palestinian communities in the Occupied Palestinian Territory have faced major barriers to vaccine access, with more distrust of vaccination and bureaucratic barriers to accessing and using green passes even when vaccinated. 58 Similar challenges have been raised among Europe’s Roma and in black communities in the UK and USA. 45 66 107 Altogether, rather than enhancing human agency and strengthening communities and social cohesion, many current vaccine policies—including monthly fines for non-compliance (eg, Greece and Austria)—may work to disempower individuals and contribute to long-term psychosocial stress and disharmony.

Reduced health system capacity

The pandemic has created immense strain on health systems, contributing to disruptions in global immunisation programmes 108 and burnout in healthcare and social care workers that risk worsening clinical outcomes for all patients. These trends may be exaggerated by the current policy push towards mandatory COVID-19 vaccination of healthcare/social care workers and firing of unvaccinated staff. The ethical arguments against these policies have been outlined by others. 31 33 109

Despite these considerations, many countries may lose frontline staff due to mandates. By December 2021, despite the forthcoming imposition of a (later rescinded) vaccine mandate for patient-facing National Health Service (NHS) workers, 8% of medical practitioners in the UK (73 000 people) remained unvaccinated. 110 In late 2021, Quebec (Canada) dropped its proposed mandate for HCWs, citing the devastating labour shortage it would cause in hospital systems (3% of staff, or 14 000, were unvaccinated). 111 Both cases created immense stress on already overburdened health staff and administrators, and were decried for their lack of clarity and clumpy policy process. 112

Exclusion from work and social life

COVID-19 vaccination policies that disproportionately restrict people’s access to work, education, public transport and social life can be considered a violation of constitutional and human rights. 113 The economic effects of restricting access to work may also have indirect implications for dependents of the unvaccinated. A survey in October 2021 in the USA found that 37% of unvaccinated participants (5% of participants overall) would leave their job if their employer required them to get a vaccine or get tested weekly; this rose to 70% of unvaccinated participants (9% of all participants) if weekly testing was not an option. 114 Economic deprivation and parental stress resulting from restricted access to work and exclusion from social life may have long-term psychological and livelihood consequences on individuals, families and especially children. 30 Commentators have also highlighted the potential impact of mandates in creating supply chain bottlenecks in certain commodities and with cross-border trade and argued that changing vaccine rules and regulations threaten to negatively impact overall economic recovery in some sectors of the economy including tourism. 115

The integrity of science and public health

Erosion of key principles of public health ethics and law.

Current vaccine policies may erode core principles of public health ethics. As some of those supporting mandates recognise, 113 116 and contrary to the media portrayal that ‘the unvaccinated are entirely free to decline’, many COVID-19 vaccine policies clearly limit choice and the normal operation of informed consent. This has placed medical professionals in an awkward position, blurring the lines between voluntary and involuntary vaccination. It is clear that many who are vaccinated did so because of the serious consequences of refusal, such as loss of employment and livelihood or access to social events and travel. We should pause to consider the extent to which current policies, and how they are implemented in clinical settings, sets a precedent for the erosion of informed consent into the future and impact the attitude of the medical profession to those who are reticent to undergo a specific medical procedure.

According to public health ethics, the principle of proportionality requires that the benefits of a public health intervention must be expected to outweigh the liberty restrictions and associated burdens. 32 It would violate the proportionality principle to impose significant liberty restrictions (and/or harms) in exchange for trivial public health benefits, particularly when other options are available. Evidence shows that the efficacy of current COVID-19 vaccines on reducing transmission is limited and temporary, 7–16 likely lower in younger age groups targeted for vaccine mandates and passports 36 and that prior infection provides, roughly speaking, comparable benefit. 18 31 80 The effectiveness of vaccine mandates in reducing transmission is likely to be smaller than many might have expected or have hoped for, and decrease over time. These issues have been widely discussed in the public arena, raising the idea that many current vaccine policies are no longer being guided by the best science but are rather being used to punish individuals who remain unvaccinated and to shape public opinion and compliance. Some governments have publicly admitted this much; in the words of French President Emmanuel Macron, the aim is to ‘piss off [the unvaccinated] …to the end. This is the strategy.’ 117 Mandating a third dose for young boys to attend college or university in America has been widely discussed in the US media despite the lack of evidence for substantial clinical benefit, 59 118 and with evidence of small but still significant risk of myocarditis that compounds with each dose. 119–121 Scandinavian countries have taken a precautionary and voluntary approach in their recommendations to the vaccination of children, with Swedish authorities stating that ‘[because of] a low risk for serious disease for kids, we don’t see any clear benefit with vaccinating them’. 122 This furthers the perception that current COVID-19 school vaccine mandates (eg, in California) are disproportionate, especially as safety studies in young children remain relatively sparse. 123

Proportionality is also a key condition from a constitutional and human rights perspective. 113 124 125 The formal requirements of legal proportionality tests, which differ slightly depending on jurisdiction and context, generally reflect a balancing similar to the one in public health ethics. In part because of legally required restraint when it comes to assessing the reasonableness of complex policy interventions, several courts, human rights tribunals and committees, and labour arbitrators have upheld mandates as proportionate or made statements as to their legitimacy. 113 This appears to have led to a broad presumption that mandates are legally unproblematic. But a common requirement of legal proportionality is that no other, less rights-restricting measures are available that can reasonably achieve the key public health goal. Accommodation of the workplace, or alternatives to vaccination such as testing, should be and have often been identified by courts, tribunals and arbitrators, as being a core element of the legality of mandates. 81 113 124 126 Mandates imposing unconditional vaccination, those ignoring the role of prior infection, and those ignoring a shifting risk/benefit balance depending on specific populations, should be considered suspect from a legal proportionality perspective.

When members of the public perceive mandates to be ethically and legally problematic and in violation of established norms of informed consent and proportionality, this will erode trust in public health and scientific institutions and even courts that endorsed or actively promoted such policies. This presents a challenging paradox for experts and authorities: will pro-mandate scientists and organisations come to acknowledge that mandates and passports were disproportionate policy responses? One key aspect of building trust in science and public health involves the open acknowledgement of when experts are wrong and when policies were misguided; however, it appears that many officials have doubled down in their narratives. This may undermine key ethical and legal criteria for policy and have damaging effects on the integrity of public health itself.

Erosion of trust in regulatory oversight

COVID-19 vaccines were developed in record time to meet an urgent public health need and have been accepted by billions of people, preventing deaths, severe hospitalisation and long-term sequelae from SARS-CoV-2. 3–6 COVID-19 vaccines have also generated at least $100 billion profit for pharmaceutical companies, especially Pfizer. 127 Has the acceptance of mandates and passports—and the rhetoric around ‘anti-vaxxers’—contributed to a cultural shift in norms of scientific and corporate transparency and accountability?

Governments have refused to disclose the details of contracts with manufacturers, including for additional doses or ‘next-generation’ vaccines. 99 Vaccines are typically not approved until 2 years of follow-up data are gathered, 2 but given the urgency of the COVID-19 pandemic and international harmonisation of new agile regulations, the novel mRNA COVID-19 vaccines were placed into emergency use in Europe and North America in late 2020. 128 There is concern that, in the fog of crisis, vaccine policy is being driven by vaccine manufacturers rather than independent scientific and regulatory review. For example, in April 2021, Moderna informed their investors that they were expecting a robust ‘variant booster market’ as a source of profits. Similarly, Pfizer CEO Albert Bourla suggested that a fourth dose of vaccine would be necessary, without any clinical trial data or independent evaluation that the benefits of subsequent doses outweigh any risks, nor consideration of the changing clinical dynamics with the Omicron variant. 118 This only adds to distrust over decision-making around vaccine use and ensuing mandates. The public is aware of the history of corporate pharmaceutical malfeasance and criminal and civil settlements in the billions of dollars, including with Pfizer, in part resulting from marketing practices and misrepresentation of safety and efficacy of medicines. 50 51 129

The nature of mandates, passports and restrictions has increased public demands for scientific accountability and transparency—shown to be fundamental to building long-term confidence in vaccination. 130 This has increased the need to diligently track all safety signals for adverse effects in specific demographics 131 and explore trends in overall population mortality and potential non-specific effects. 132 However, the original clinical trial data remain unavailable for independent scientific scrutiny 50 51 ; a whistleblower raised important concerns about data integrity and regulatory oversight practices at a contract company helping with Pfizer’s clinical trials in the USA. 133 After a Freedom of Information Act (FOIA) request by a civil society group (see: https://phmpt.org ), the US Food and Drug Administration (FDA) requested (ultimately denied by a federal judge) 75 years to fully release internal documents and communications related to the regulatory process between FDA and Pfizer. In September 2021, an FDA advisory committee voted 16–2 against boosting healthy young adults in the USA but was over-ridden by the White House and CDC, leading to the resignation of two top FDA vaccine experts. 118 Such efforts have only increased the perception that regulatory agencies are ‘captured’ by industry and would conveniently ignore a higher than usual adverse effect ratio to control the pandemic. Concerns have been raised about the lack of due process in vaccine injury compensation claims for the COVID-19 vaccines, 100 which are to be borne by governments and not pharmaceutical companies. A video of a US congressional roundtable on COVID-19 vaccine adverse events with medically confirmed vaccine-injured individuals from the original clinical trials, a US military clinician and Peter Doshi (senior editor of the BMJ) was permanently removed by YouTube. 134 These practices do not reinforce confidence that authorities are being transparent or applying optimal standards for regulatory safety, efficacy and quality for these novel vaccines—standards which should arguably be more stringent given the legal precedent for mandates and passports.

The adoption of new vaccination policies has provoked backlash, resistance and polarisation. It is important to emphasise that these policies are not viewed as ‘incentives’ or ‘nudges’ by substantial proportions of populations 25–28 41 45 especially in marginalised, underserved or low COVID-19-risk groups. Denying individuals education, livelihoods, medical care or social life unless they get vaccinated—especially in light of the limitations with the current vaccines—is arguably in tension with constitutional and bioethical principles, especially in liberal democracies. 30–33 While public support consolidated behind these policies in many countries, we should acknowledge that ethical frameworks were designed to ensure that rights and liberties are respected even during public health emergencies.

Vaccination policies can be an important tool in the promotion of the right to health, but they need to be proportionate and designed to achieve a clearly defined goal. Some of those supporting current restrictions based on vaccination status 116 seem to accept too easily that these measures are indeed proportionate; that they are not more restrictive than necessary; that they are effective in preventing transmission and protecting the healthcare system from collapse; and that there are no options available other than punitive mandates, passports and segregated restrictions. As illustrated above, we believe that current vaccine policies have failed on these fronts and are no longer fit for purpose.

We encourage social and behavioural scientists, bioethicists, epidemiologists, legal scholars, and others to assess the benefits and harms of COVID-19 vaccination policies, along with wider open multidisciplinary discussion and debate. Empirical assessments may or may not validate the concerns presented in this paper—but their generation is critical in engagement with politicians, scientists, and organisations to reconsider current policies affecting those who remain unvaccinated as well as those who vaccinated due to threats and pressure. COVID-19 will not be the last public health emergency and it remains critical that we understand the reasons these approaches were adopted and provide robust evidence to improve future policymaking in times of health emergencies. 135 If not, the proclivity for mandates, passports, restrictions, fines and punishments is likely to become an accepted policy response for the next pandemic irrespective of whether such policies are truly effective, ethical and socially harmful.

If current policies are to continue, public health-associated bureaucracies and society will have to increase coercion to address current and future resistance and, in the process, come to leverage strategies more consistent with policing than public health. We may also see political forces double down and use people who have chosen not to get vaccinated as a collective, psychological and political tool to scapegoat and reinforce a false notion of safety among vaccinated people as they yearn to resume social and economic life. Policymakers should reflect on the necessity of enforcing what is essentially a new two-tier, segregated social system and how this will affect different social groups now and into the future—behaviourally, politically and socioeconomically—as well as the impact of such policies on the integrity of science and public health itself.

There are other options to address the pandemic and it is not too late to return to non-coercive public health measures, including pro-social language and community leadership for vaccination, especially to protect high-risk groups. 7 Future investments in public health capacity, especially health providers who build relationships of trust working in communities, will be essential to engage in positive reforms. Improving data transparency, media independence and broad public debate and scrutiny about COVID-19 vaccine policies will also be essential to maintain population trust, help people better understand the risks and benefits of the continued use of current vaccines, and to inform research on improvements and future policies.

Acknowledgments

We would like to thank an anonymous reviewer for their critical feedback on an early draft.

Handling editor: Seye Abimbola

Twitter: @KevinBardosh, @ID_ethics

Contributors: KLB wrote the original draft. All authors contributed substantially to the development, revision and finalisation of the manuscript.

Funding: Funding was provided to KLB through a Wellcome Trust Society and Ethics Fellowship (10892/B/15/ZE). EJ and RG-A also received funding from the Wellcome Trust UK (grant numbers 221719 (RG-A and EJ) and 216355 (EJ)). TL received funding from two University of Toronto Connaught grants: Advancing Anti-Corruption, Transparency and Accountability Mechanisms to Tackle Corruption in the Pharmaceutical System, and Advancing Rights-based Access to COVID-19 Vaccines as part of Universal Health Coverage.

Competing interests: Within the past 2 years, AdF was involved in Vaccine Confidence Project collaborative grants with Janssen Pharmaceutica outside of the submitted work and holds a Merck grant to investigate COVID-19 vaccine attitudes.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement

Ethics statements, patient consent for publication.

Not required.

Ethics approval

Not applicable.

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New Delhi, Jul 25 (PTI) Mankind Pharma on Thursday said it will fully acquire Bharat Serums and Vaccines from Advent International for around Rs 13,630 crore.

The company has entered into a definitive agreement to acquire a 100 per cent stake in the Bharat Serums and Vaccines (BSV) for an enterprise value of around Rs 13,630 crore, Mankind Pharma said in a statement.

This strategic move marks a significant leap for the drug maker, positioning it as a leader in the Indian women’s health and fertility drug market, alongside access to other high entry barrier products in critical care with established complex R&D tech platforms, it added. PTI MSS BAL BAL

This report is auto-generated from PTI news service. ThePrint holds no responsibility for its content.

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Who is JD Vance? What to know about Donald Trump's VP pick

Former President Donald Trump  tapped JD Vance  to be his running mate at the Republican National Convention , catapulting the Ohio GOP senator even more into the national spotlight.

Here’s what you need to know about Vance.

More: Trump made MAGA happen. JD Vance represents those who will inherit it

Where is JD Vance from?

Vance grew up in Middletown, Ohio. He described a childhood consumed by poverty and abuse in his best-selling 2016 memoir , "Hillbilly Elegy." Vance's mother struggled with drug addiction, so he spent many of his formative years with his grandmother – known to him as Mamaw.

How old is JD Vance?

Vance is 39. If elected, he would be the youngest vice president since Richard Nixon. His birthday is Aug. 2, 1984.

Did JD Vance serve in the military?

Vance joined the Marines Corps after high school and served as a public affairs marine in Iraq.

Is JD Vance married?

Vance is married to Usha Chilukuri Vance. She had been working as a litigator at Munger, Tolles & Olson, but a spokesperson said she chose to leave the firm in the wake of her husband’s vice presidential nomination.

The couple has three young children: Ewan, Vivek and Mirabel.

Where does JD Vance live?

Vance and his family live in the East Walnut Hills neighborhood of Cincinnati. The senator also bought a $1.5 million home in Alexandria, Virginia, last year, Politico reported .

How long has JD Vance been in politics?

Vance was first elected to the U.S. Senate in 2022 after defeating former Democratic Rep. Tim Ryan for an open seat in Ohio.

What’s the history between Vance and Trump?

Vance openly criticized Trump in 2016 as pundits used his memoir to explain the former president's popularity with white, rural voters. He previously suggested Trump could be "America’s Hitler," called him noxious and compared him to an opioid.

But Vance changed his tune as he geared up for his 2022 Senate run, deleting controversial tweets and crediting Trump for the work he did in office. He secured Trump's endorsement in a chaotic Republican Senate primary and is now one of the former president's most loyal allies.

JD Vance didn't vote for Donald Trump in 2016

In one NPR interview , he joked that he would rather write his dog on the ballot than vote for Trump or Hillary Clinton.

"I think that I'm going to vote third party because I can't stomach Trump," the "Hillbilly Elegy" author said at the time. "I think that he's noxious and is leading the white working class to a very dark place."

What are Vance's policy positions?

Vance personifies what's known as the New Right , a populist conservatism that rejects many traditional Republican views. He supports tariffs on trade and opposes U.S. intervention in foreign conflicts, particularly the war between Russia and Ukraine. He's also spoken out against potential cuts to Social Security.

Some of Vance's work in the Senate has been bipartisan. He introduced a rail safety bill with Sen. Sherrod Brown after the train derailment in East Palestine, Ohio. He also worked with Massachusetts Sen. Elizabeth Warren on legislation to hold executives accountable for failed banks.

At the same time, many of his other bills reflect conservative views. For example, Vance introduced legislation to ban gender-affirming care for minors and a bill to eliminate diversity programs in the federal government.

Where does JD Vance stand on abortion?

Vance opposes abortion and often says the government should find ways to encourage people to have children.

Like other Republicans, however, Vance changed how he discusses the issue after Ohio and other states voted in favor of abortion access last year. In a December CNN interview , he said Republicans must "accept that people do not want blanket abortion bans."

More recently, he told Meet the Press that he supports access to the abortion drug mifepristone.

Haley BeMiller is a reporter for the USA TODAY Network Ohio Bureau, which serves the Columbus Dispatch, Cincinnati Enquirer, Akron Beacon Journal and 18 other affiliated news organizations across Ohio.