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Special Feature

Countering Vaccine Misinformation

Danielson, Lindsey MS, FNP-C; Marcus, Blima DNP, RN, ANP-BC; Boyle, Lori MSN, RN, AGPCNP-BC

AJN The American Journal of Nursing: October 2019 - Volume 119 - Issue 10 - p 50–55
doi: 10.1097/01.NAJ.0000586176.77841.86
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ABSTRACT: Evidence consistently shows that vaccines are safe, effective, and cost-efficient. Yet preventable outbreaks of infectious diseases are occurring in the United States, leading to a strong public response and intense scrutiny of the antivaccine movement and its persistent spread of misinformation. Social media has been a major platform for such misinformation, and recent examinations have found that nurses are not exempt from engaging in antivaccine discourse.

By practicing evidence-based care, addressing health literacy, and becoming involved in public health policy, nurses can be excellent advocates for immunization and may help prevent additional outbreaks of preventable diseases.

In light of recent outbreaks of infectious diseases in the United States, the authors explore the evidence behind vaccine safety and efficacy and discuss nurses' role in correcting misinformation and advocating for immunization.

Lindsey Danielson is a recent graduate of the Georgetown University School of Nursing and Health Studies and resides in Houston, TX; Blima Marcus is an adjunct professor at the Hunter-Bellevue School of Nursing in New York City; and Lori Boyle is an NP at Associates in Vascular Care in Middletown, NJ. Contact author: Lindsey Danielson, lhd32@georgetown.edu. The authors have disclosed no potential conflicts of interest, financial or otherwise.

While ample evidence reveals that vaccines—among the greatest achievements in science and public health—are safe, cost-effective, and successful in reducing or eliminating disease, widespread vaccine hesitancy is currently threatening to reverse the progress that public implementation of immunization has made in the past few decades.1 In the United States, recent disease outbreaks are prompting intense scrutiny of the dissemination of vaccine misinformation, particularly on social media. This article will explore the evidence behind the safety and effectiveness of vaccines, and discuss the role of nurses in countering misinformation.

The terms vaccine hesitant or vaccine denier—used throughout the article—are based on definitions provided by the World Health Organization (WHO). Vaccine hesitant describes a person who is hesitant about vaccines but still receptive to scientific evidence, while vaccine denier refers to a person who is against vaccination, denies scientific evidence, and uses rhetorical arguments to give the false appearance of legitimate debate.2

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CURRENT U.S. OUTBREAKS AND THE PUBLIC RESPONSE

According to the Centers for Disease Control and Prevention (CDC), between January 1 and August 29, there were 1,234 cases of measles across 31 states in the United States, with the largest outbreaks occurring in New York and Washington.3 (For the latest numbers, visit: www.cdc.gov/measles/cases-outbreaks.html.) In addition, between January 1 and July 19, 45 states and the District of Columbia reported a total of 1,799 cases of mumps.4 (For the latest numbers, visit: www.cdc.gov/mumps/outbreaks.html.)

Such outbreaks underscore the importance of maintaining herd immunity—also known as community immunity—which allows for indirect protection from preventable diseases for those who either cannot be vaccinated or are immunocompromised. By requiring the majority of the population to be vaccinated, community immunity decreases the odds of disease transmission to vulnerable individuals. For example, for herd immunity to be achieved for measles, approximately 93% to 95% of the population must be vaccinated.5

As of 2018, the median vaccination coverage for two doses of measles–mumps–rubella (MMR) vaccine in kindergarten students throughout the United States was 94.3%.6 Yet despite this high rate, outbreaks have been occurring in clusters of underimmunized individuals.7, 8 For example, in Washington—one of the two states with the largest measles outbreaks—the Department of Health reported that in 2017 only about seven in 10 toddlers received all their recommended vaccines.9 Likewise in New York, schools have been struggling with widely varying vaccination rates. In Rockland County, schools reported immunization rates ranging from 19% to 100%, with an average of 91% for the 2016-2017 and 2017-2018 school years; alarmingly, one school reported that none of its students had been vaccinated.10

Figure

Figure

The measles outbreak in Washington prompted the state's governor, Jay Inslee, to issue a local public health emergency.11 The New York City Department of Health and Mental Hygiene also issued an emergency declaration requiring all individuals living within the affected zip codes to receive the MMR vaccine or face a fine of $1,000.12 This declaration followed multiple attempts to educate the public on the importance of vaccinations and to restrict unvaccinated children from attending school.13

Public reaction to outbreaks has been strong. News outlets such as the Washington Post and the New York Times have been shedding light on the increasing use of nonmedical vaccine exemptions, prompting calls for tighter legislation.14 In addition, the Food and Drug Administration recently threatened to enact federal vaccine policies if outbreaks continue to occur.15 And as of this writing, Facebook, Amazon, Pinterest, and YouTube have taken steps to limit the ubiquity of antivaccine advertisements and misinformation on social media.16-19

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VACCINES: EXAMINING THE EVIDENCE

Public immunization has been shown to reduce the cases of such vaccine-preventable diseases as diphtheria, measles, paralytic poliomyelitis, rubella, congenital rubella syndrome, and smallpox by over 92%, and the mortality rate from these diseases by 99%.20 The CDC estimates that between 1994 and 2014, vaccinations prevented more than 21 million hospitalizations and 732,000 deaths among children born in the United States.21 And according to Margaret Chan, director-general of the WHO, “Vaccines prevented at least 10 million deaths between 2010 and 2015 worldwide.”22

Consider, for example, the effectiveness of the MMR vaccine: According to a large Cochrane study involving approximately 14,700,000 children, one dose is at least 95% effective in preventing measles and 92% effective in preventing secondary measles cases among household contacts.23 Two doses, according to the CDC, are about 97% effective.24

Studies also consistently reveal that vaccines have an overall high safety profile. A systematic review of 67 studies showed that severe adverse events associated with vaccines are extremely rare,25 but may include anaphylaxis, immune thrombocytopenia purpura, and intussusception. Anaphylaxis can present with all vaccines and has been shown to occur at a rate of 1.31 per 1 million vaccine doses.26 Immune thrombocytopenia purpura may result from the MMR vaccine at approximately one case per 40,000.27 Lastly, intussusception may occur with the rotavirus vaccine at a rate of approximately one to two cases per 100,000.28

Two studies by the Institute of Medicine (now known as the National Academy of Medicine), commissioned by the U.S. Department of Health and Human Services, also conclude that few health problems are caused by vaccines, and that there is no evidence of major safety concerns with the childhood immunization schedule.29, 30

In addition to their efficacy and safety, vaccines present a financial benefit: in one study, the net return on immunizations amounted to 44 times their cost, thanks to the value of people living longer and healthier lives.31 And in a systematic review of 78 studies, the majority of studies revealed favorable cost-effectiveness profiles for adult vaccinations.32 This is likely the reason why insurance companies, including Medicare and Medicaid, implement such incentives as the Merit-Based Incentive Payment System (MIPS) for providers who meet immunization benchmarks. According to the Centers for Medicare and Medicaid Services (CMS) website, “MIPS was designed to tie payments to quality and cost efficient care, drive improvement in care processes and health outcomes, increase the use of healthcare information, and reduce the cost of care.”33

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HEALTH LITERACY AND THE ROLE OF SOCIAL MEDIA

Health literacy is imperative to the accurate assessment of the credibility and quality of information on vaccines, and the ability to analyze the relative risks and benefits of immunization. But alarmingly, only 12% of adults in the United States have proficient health literacy, and 14% have below basic health literacy.34

Inadequate health literacy becomes even more concerning when one considers that of the estimated 95% of North Americans who use the Internet, 79% use Facebook—a platform that previously allowed antivaccine information to be easily found through its search algorithms.35, 36 Furthermore, about 75% to 80% of Internet users search for health information online, and 70% of those users say the information they encounter influences their treatment decisions. Most alarmingly, about 52% of users believe that almost all or most health information found online is credible.37

Antivaccine misinformation commonly gains exposure online without being filtered or reviewed. Indeed, parents who exempt children from vaccination are more likely to have rated information from an antivaccine website such as the National Vaccine Information Center (previously known as Dissatisfied Parents Together) higher than information received from health care professionals, the CDC, the National Academy of Medicine, and local or state health departments.38 A recent example is the case of a young Ohio teen named Ethan Lindenberger who testified at a 2019 Senate hearing that he had been vaccinated against his mother's wishes. His mother, he said, became an antivaccine advocate after reading misinformation online, mainly from sources like Facebook.39

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NURSES' ROLE IN ADVOCATING FOR IMMUNIZATION

A positive and trusting relationship between nurses and their patients has been shown to enhance patients' health and increase their capacity for health maintenance.40 Nurses should honor this relationship by providing factual, evidence-based information on the benefits of vaccines,41 and by recognizing patients' positions on immunizations, building trust, and adapting educational materials in a way that effectively addresses safety concerns.42

Specifically, nurses can advocate for vaccines by:

Practicing evidence-based care. Quality improvement measures—available from such organizations as the CMS and the Agency for Healthcare Research and Quality (AHRQ)43—are typically developed from research findings, clinical practice, and clinical guidelines, and may facilitate better outcomes, foster respect among professional colleagues as well as between clinicians and patients, and enhance the quality of the health care system.44

Addressing health literacy. Although the relationship between health literacy and vaccine acceptance remains unclear, education is essential to helping patients evaluate the relative risks and benefits of immunization, discern between credible and noncredible sources, and make well-informed choices.45, 46 In addition, taking health literacy universal precautions by assuming that all patients may have difficulty comprehending health-related information ensures that evidence regarding vaccines is effectively delivered. Resources such as the AHRQ Health Literacy Universal Precautions Toolkit can be helpful in that regard.47 (To access the toolkit, visit www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html.)

Becoming involved in public health initiatives. Antivaccine groups, increasingly organized and effective in engaging policymakers, often aim to change laws that limit unvaccinated individuals from attending public institutions such as schools. These groups also recruit members who can help campaign for their preferred political candidates, donate to their cause, and travel to state capitals to testify on behalf of antivaccine legislation.48 Nurses can counter these groups by advocating for vaccine-promoting policies, working with their local immunization coalitions, engaging legislators, and participating in National Immunization Awareness Month (NIAM), an event that takes place annually in August.49 (To support vaccine advocacy during NIAM, the National Public Health Information Coalition's website provides toolkits, logos, banners, and immunization resources, along with prewritten articles that can be freely published and disseminated via newsletters, websites, and local news outlets.49)

Local immunization coalitions—important promoters of public health—offer nurses an opportunity to network with other vaccine advocates to ensure that children are vaccinated before attending school, educate the community on the value of vaccines, and become involved in state legislation efforts.50 In addition, organizations such as Voices for Vaccines and Nurses Who Vaccinate can help inform nurses of current events, offer advice on effective communication techniques, and provide evidence-based information regarding vaccines.51, 52

Engaging legislators is a valuable, yet underused, way for nurses to advocate for policy change. Legislators can be contacted via e-mail, phone, in-person meetings, and public events. As they tend to be busy and involved with many issues, a one-minute prepared speech or a brief and carefully written letter can increase the chances of engaging them effectively.53 To find local representatives, visit websites such as Common Cause (www.commoncause.org), which features a search engine titled “Find Your Representatives,” or Congress.gov, which, in addition to listing the names of representatives, provides the status of active state and federal legislation.54, 55

It's important to note that nurses, too, have engaged in sharing misinformation regarding the safety or efficacy of vaccines, a few going so far as to host blogs, social media groups, or websites that deliberately promote an antivaccine stance.56 In 2018 a nurse in Texas was terminated from her job after posting information about a patient with measles on Facebook. While her termination was ultimately caused by her violation of privacy laws, she was also found to be sharing misinformation about vaccines online.57, 58

Studies regarding the effect of vaccine-denying nurses on public health are still lacking, but nurses' contribution to misinformation is concerning, as it can lead to poor patient outcomes. Nurses' own failure to be immunized can also greatly hinder public health, because unvaccinated clinicians may transmit health care–associated infections such as measles to their patients. Recently, a health care worker employed on a pediatric unit in England who had never been vaccinated with the MMR vaccine traveled to France, where a measles outbreak was ongoing. Subsequently, this nurse—for whom 110 contacts were identified—infected three pediatric patients with measles.59

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COUNTERING VACCINE MISINFORMATION

While the WHO lists vaccine hesitancy as a top-10 global threat,1 data have shown that providing scientific evidence to counter antivaccination attitudes isn't always effective and can even backfire.60 Studies suggest that complex cognitive mechanisms cause antivaccine misinformation to become rooted in memory, making correction difficult.61

The most effective approach to addressing vaccine hesitancy has been shown to be dialogue based.62 However, as vaccine hesitancy is complicated, a multifaceted approach is needed. The American Academy of Pediatrics recommends listening to vaccine-hesitant parents and promoting partnerships with them, engaging in conversation in a nonconfrontational manner, being open about what is and isn't known about vaccines, and discussing state laws affecting vaccinations.63

Many resources are available to help nurses answer difficult vaccine-related questions.25, 41 One such resource that we recommend is the article “Promoting Childhood Immunizations” by Victoria Lynn Anderson.64

Unfortunately, messages tailored to refute vaccine misperceptions and increase immunization rates are unlikely to change the stance of vaccine deniers. In fact, these messages may actually reduce the intention to vaccinate and even increase parents' fears of serious adverse events.65 But there are effective ways to address this pushback: According to the WHO, the general public—not the vaccine denier—should be the target audience of vaccine information. When engaging with a vocal vaccine denier in public, nurses should aim to reveal to the public the techniques the vaccine denier is using and correct the misinformation. The goal is to facilitate the public's resilience against misinformation and to support vaccine-hesitant people in accepting immunizations.2 See Table 1 for a summary of recommendations for countering vaccine misinformation.

Table 1

Table 1

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REFERENCES

1. World Health Organization. Ten threats to global health in 2019. 2019. https://www.who.int/emergencies/ten-threats-to-global-health-in-2019.
2. Schmid P, MacDonald N. How to respond to vaccine deniers in public. Copenhagen, Denmark: World Health Organization, Regional Office for Europe; 2017. Best practice guidance; http://www.euro.who.int/__data/assets/pdf_file/0005/315761/Best-practice-guidance-respond-vocal-vaccine-deniers-public.pdf.
3. Centers for Disease Control and Prevention. Measles cases and outbreaks. 2019. https://www.cdc.gov/measles/cases-outbreaks.html.
4. Centers for Disease Control and Prevention. Mumps cases and outbreaks. Atlanta; 2019. https://www.cdc.gov/mumps/outbreaks.html.
5. Funk S. Critical immunity thresholds for measles elimination [powerpoint]. London: Centre for the Mathematical Modelling of Infectious Diseases; London School of Hygiene and Tropical Medicine; 2017 Oct 189. https://www.who.int/immunization/sage/meetings/2017/october/2._target_immunity_levels_FUNK.pdf.
6. Mellerson JL, et al Vaccination coverage for selected vaccines and exemption rates among children in kindergarten—United States, 2017-18 school year. MMWR Morb Mortal Wkly Rep 2018;67(40):1115–22.
7. Lieu TA, et al Geographic clusters in underimmunization and vaccine refusal. Pediatrics 2015;135(2):280–9.
8. Phadke VK, et al Association between vaccine refusal and vaccine-preventable diseases in the United States: a review of measles and pertussis. JAMA 2016;315(11):1149–58.
9. Washington State Department of Health. Washington immunization scorecard 2017. Olympia, WA; 2019 Feb. DOH 348-709. https://www.doh.wa.gov/Portals/1/Documents/Pubs/348-709-WashingtonImmunizationScorecard.pdf.
10. Esposito F. What is the measles vaccination rate at my school? Check here. Rockland/Westchester Journal-News Apr 1, 2019. https://www.lohud.com/story/news/2019/04/01/what-measles-outbreak-vaccination-rate-my-school/3332715002.
11. Inslee J. Proclamation by the Governor: public health emergency. Jan 25, 2019. https://www.governor.wa.gov/sites/default/files/proclamations/19-01%20State%20of%20Emergency.pdf.
12. NYC Health [City of New York]. Health topics: measles. 2019. https://www1.nyc.gov/site/doh/health/health-topics/measles.page.
13. Barbot O. Order of the Commissioner: All persons who reside, work or attend school in the neighborhood of Williamsburg, Brooklyn, New York and to the parents and/or guardians of any child who resides, works or attends school in the neighborhood of Williamsburg, Brooklyn, New York. New York City Department of Health and Mental Hygiene; Apr 9, 2019. https://www1.nyc.gov/assets/doh/downloads/pdf/press/2019/emergency-orders-measles.pdf.
14. Bailey SP. Some anti-vaccination parents cite religious exemptions. Measles outbreaks could change that. Washington Post 2019 Feb 21. https://www.washingtonpost.com/religion/2019/02/21/some-anti-vaccination-parents-cite-religious-exemptions-measles-outbreaks-could-change-that.
15. Ducharme J. FDA head says the federal government may have to set vaccine policies if state laws continue to allow outbreaks. Time 2019 Feb 21. https://time.com/5534592/fda-commissioner-federal-government-vaccine-policies.
16. Cohen E, Bonifield J. Facebook to get tougher on anti-vaxers. CNN 2019 https://www.cnn.com/2019/02/25/health/facebook-anti-vaccine-content/index.html.
17. Sarlin J. Anti-vaccine movies disappear from Amazon after CNN Business report. CNN Business 2019 Mar 1. https://www.cnn.com/2019/03/01/tech/amazon-anti-vaccine-movies-schiff/index.html.
    18. Molina B. Pinterest is blocking all searches on vaccinations to stop spread of misinformation. USA Today Feb 21, 2019. https://www.usatoday.com/story/tech/news/2019/02/21/pinterest-blocks-vaccination-searches-halt-anti-vaxx-misinformation-spread/2938629002.
      19. Haller S. YouTube takes ad money away from anti-vax channels looking to profit, sway parents. USA Today 2019 Feb 25. https://www.usatoday.com/story/life/allthemoms/2019/02/25/youtube-takes-money-away-anti-vax-channels-trying-sway-parents/2982207002.
      20. Roush SW, et al Historical comparisons of morbidity and mortality for vaccine-preventable diseases in the United States. JAMA 2007;298(18):2155–63.
      21. Centers for Disease Control and Prevention. Report shows 20-year US immunization program spares millions of children from diseases [press release]. 2014 Apr 24. https://www.cdc.gov/media/releases/2014/p0424-immunization-program.html.
      22. Chan M. Ten years in public health 2007-2017. Geneva, Switzerland: World Health Organization; 2017 Apr 13. https://www.who.int/publications/10-year-review/dg-letter/en.
      23. Demicheli V, et al Vaccines for measles, mumps and rubella in children. Cochrane Database Syst Rev 2012(2):CD004407.
      24. Centers for Disease Control and Prevention. Vaccine for measles. 2019. https://www.cdc.gov/measles/vaccination.html.
      25. Maglione MA, et al Safety of vaccines used for routine immunization of U.S. children: a systematic review. Pediatrics 2014;134(2):325–37.
      26. McNeil MM, et al Risk of anaphylaxis after vaccination in children and adults. J Allergy Clin Immunol 2016;137(3):868–78.
      27. France EK, et al Risk of immune thrombocytopenic purpura after measles-mumps-rubella immunization in children. Pediatrics 2008;121(3):e687–92.
      28. World Health Organization. Global Advisory Committee on Vaccine Safety, 6-7 December 2017. Wkly Epidemiol Rec 2018;93(2):17–30.
      29. Institute of Medicine. The childhood immunization schedule and safety: stakeholder concerns, scientific evidence, and future studies. Washington, DC: National Academies Press; 2018. https://www.nap.edu/catalog/13563/the-childhood-immunization-schedule-and-safety-stakeholder-concerns-scientific-evidence.
      30. Stratton K, editors, et al. Adverse effects of vaccines: evidence and causality. Washington, DC: National Academies Press; 2011. Consensus study report; https://www.nap.edu/catalog/13164/adverse-effects-of-vaccines-evidence-and-causality.
      31. Ozawa S, et al. Return on investment from childhood immunization in low- and middle-income countries, 2011-20. Health Aff (Millwood) 2016;35(2):199–207.
      32. Leidner AJ, et al Cost-effectiveness of adult vaccinations: a systematic review. Vaccine 2019;37(2):226–34.
      33. Centers for Medicare and Medicare Services. Quality payment program: merit-based incentive payment system (MIPS). n.d. https://qpp.cms.gov/mips/overview.
      34. U.S. Department of Health and Human Services; Office of Disease Prevention and Health Promotion; HCA. America's health literacy: why we need accessible health information. Rockville, MD; 2008. Issue brief; https://health.gov/communication/literacy/issuebrief.
      35. Internet World Stats. Internet usage statistics for all the Americas: Miniwatts Marketing Group; 2018. Internet world stats: usage and population statistics; https://www.internetworldstats.com/stats2.htm.
      36. Telford T. Anti-vaxxers are spreading conspiracy theories on Facebook, and the company is struggling to stop them. Washington Post 2019 Feb 13. https://www.washingtonpost.com/business/2019/02/13/anti-vaxxers-are-spreading-conspiracy-theories-facebook-company-is-struggling-stop-them.
      37. Kata A. A postmodern Pandora's box: anti-vaccination misinformation on the Internet. Vaccine 2010;28(7):1709–16.
      38. Salmon DA, et al Factors associated with refusal of childhood vaccines among parents of school-aged children: a case-control study. Arch Pediatr Adolesc Med 2005;159(5):470–6.
      39. Ducharme J. ‘Propagating these lies is dangerous.’ Ohio teen vaccinated against his mother's wishes calls for end to misinformation. Time 2019 Mar 5. https://time.com/5544119/ethan-lindenberger-testimony.
      40. Strandås M, Bondas T. The nurse-patient relationship as a story of health enhancement in community care: a meta-ethnography. J Adv Nurs 2018;74(1):11–22.
      41. World Health Organization. Addressing vaccine hesitancy. Geneva; 2018 Sep 21. Immunization, vaccines and biologicals; https://www.who.int/immunization/programmes_systems/vaccine_hesitancy/en.
      42. Holland Wade G. Nurses as primary advocates for immunization adherence. MCN Am J Matern Child Nurs 2014;39(6):351–6.
      43. American Academy of Family Physicians. Quality measures. 2019. https://www.aafp.org/practice-management/improvement/measures.html.
      44. American Association of Nurse Practitioners. Practice management. Quality improvement. n.d. https://www.aanp.org/practice/practice-management/quality-improvement.
      45. Loan LA, et al Call for action: nurses must play a critical role to enhance health literacy. Nurs Outlook 2018;66(1):97–100.
      46. Lorini C, et al Health literacy and vaccination: a systematic review. Hum Vaccin Immunother 2018;14(2):478–88.
      47. Brega AG, et al. AHRQ health literacy universal precautions toolkit. Rockville, MD: Agency for Healthcare Research and Quality; 2018. https://www.ahrq.gov/sites/default/files/publications/files/healthlittoolkit2_4.pdf.
      48. Texans for Vaccine Choice. Landing page. n.d. https://www.texansforvaccinechoice.com.
      49. American Academy of Pediatrics. Immunizations: national immunization awareness month. 2018. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/immunizations/Pages/National-Immunization-Awareness-Month.aspx.
      50. National Network of Immunization Coalitions. Immunization Coalitions Network: welcome. 2019. https://www.immunizationcoalitions.org.
      51. Voices for Vaccines: Parents Speaking up for Immunization. About. 2015. https://www.voicesforvaccines.org/about.
      52. Nurses Who Vaccinate. Nurses who vaccinate are nurses who care. n.d. https://nurseswhovaccinate.org.
      54. Common Cause. Find your representatives. n.d. https://www.commoncause.org/find-your-representative.
      55. Congress.gov, Library of Congress. Current legislative activities: 116th Congress (2019-2020). 2019. https://www.congress.gov.
      56. Nurses for Vaccine Safety Alliance [Facebook page]. 2019. https://www.facebook.com/nfvsa/posts/775864702789619.
      57. Domonoske C. Texas nurse loses job after apparently posting about patient in anti-vaxxer group. NPR 2018 Aug 29. https://www.npr.org/2018/08/29/642937977/texas-nurse-loses-job-after-apparently-posting-about-patient-in-anti-vaxxer-group.
      58. Gorski D [“Orac”]. An antivaccine nurse (or physician) should not take care of children, period [blog post]. 2018.
      59. Baxi R, et al Outbreak report: nosocomial transmission of measles through an unvaccinated healthcare worker—implications for public health. J Public Health (Oxf) 2014;36(3):375–81.
      60. Horne Z, et al Countering antivaccination attitudes. Proc Natl Acad Sci U S A 2015;112(33):10321–4.
      61. Pluviano S, et al Misinformation lingers in memory: failure of three pro-vaccination strategies. PLoS One 2017;12(7):e0181640.
      62. Jarrett C, et al Strategies for addressing vaccine hesitancy—a systematic review. Vaccine 2015;33(34):4180–90.
      64. Anderson VL. Promoting childhood immunizations. J Nurse Pract 2015;11(1):1–10.
      65. Nyhan B, et al Effective messages in vaccine promotion: a randomized trial. Pediatrics 2014;133(4):e835–e842.
      Keywords:

      antivaccine; immunization; vaccine; vaccine denial; vaccine hesitancy

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