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Objectives. To understand how Twitter bots and trolls (“bots”) promote online health content. Methods. We compared bots’ to average users’ rates of vaccine-relevant messages, which we collected online from July 2014 through September 2017. We estimated the likelihood that users were bots, comparing proportions of polarized and antivaccine tweets across user types. We conducted a content analysis of a Twitter hashtag associated with Russian troll activity. Results. Compared with average users, Russian trolls (χ 2 (1) = 102.0; P < .001), sophisticated bots (χ 2 (1) = 28.6; P < .001), and “content polluters” (χ 2 (1) = 7.0; P < .001) tweeted about vaccination at higher rates. Whereas content polluters posted more antivaccine content (χ 2 (1) = 11.18; P < .001), Russian trolls amplified both sides. Unidentifiable accounts were more polarized (χ 2 (1) = 12.1; P < .001) and antivaccine (χ 2 (1) = 35.9; P < .001). Analysis of the Russian troll hashtag showed that its messages were more political and divisive. Conclusions. Whereas bots that spread malware and unsolicited content disseminated antivaccine messages, Russian trolls promoted discord. Accounts masquerading as legitimate users create false equivalency, eroding public consensus on vaccination. Public Health Implications. Directly confronting vaccine skeptics enables bots to legitimize the vaccine debate. More research is needed to determine how best to combat bot-driven content.

Objectives. To understand how Twitter accounts operated by the Russian Internet Research Agency (IRA) discussed vaccines to increase the credibility of their manufactured personas. Methods. We analyzed 2.82 million tweets published by 2689 IRA accounts between 2015 and 2017. Combining unsupervised machine learning and network analysis to identify “thematic personas” (i.e., accounts that consistently share the same topics), we analyzed the ways in which each discussed vaccines. Results. We found differences in volume and valence of vaccine-related tweets among 9 thematic personas. Pro-Trump personas were more likely to express antivaccine sentiment. Anti-Trump personas expressed support for vaccination. Others offered a balanced valence, talked about vaccines neutrally, or did not tweet about vaccines. Conclusions. IRA-operated accounts discussed vaccines in manners consistent with fabricated US identities. Public Health Implications. IRA accounts discussed vaccines online in ways that evoked political identities. This could exacerbate recently emerging partisan gaps relating to vaccine misinformation, as differently valenced messages were targeted at different segments of the US public. These sophisticated targeting efforts, if repeated and increased in reach, could reduce vaccination rates and magnify health disparities.

Objectives. To adapt and extend an existing typology of vaccine misinformation to classify the major topics of discussion across the total vaccine discourse on Twitter. Methods. Using 1.8 million vaccine-relevant tweets compiled from 2014 to 2017, we adapted an existing typology to Twitter data, first in a manual content analysis and then using latent Dirichlet allocation (LDA) topic modeling to extract 100 topics from the data set. Results. Manual annotation identified 22% of the data set as antivaccine, of which safety concerns and conspiracies were the most common themes. Seventeen percent of content was identified as provaccine, with roughly equal proportions of vaccine promotion, criticizing antivaccine beliefs, and vaccine safety and effectiveness. Of the 100 LDA topics, 48 contained provaccine sentiment and 28 contained antivaccine sentiment, with 9 containing both. Conclusions. Our updated typology successfully combines manual annotation with machine-learning methods to estimate the distribution of vaccine arguments, with greater detail on the most distinctive topics of discussion. With this information, communication efforts can be developed to better promote vaccines and avoid amplifying antivaccine rhetoric on Twitter.

Objectives. To analyze rural–urban differences in COVID-19 vaccination uptake, hesitancy, and trust in information sources in the United States. Methods. We used data from a large survey of Facebook users. We computed the vaccination, hesitancy, and decline rates and the trust proportions among individuals hesitant toward COVID-19 information sources for rural and urban regions in each state from May 2021 to April 2022. Results. In 48 states with adequate data, on average, two thirds of states showed statistically significant differences in monthly vaccination rates between rural and urban regions, with rural regions having a lower vaccination rate at all times. Far fewer states showed statistically significant differences when comparing monthly hesitancy and decline rates for urban versus rural regions. Doctors and health professionals received the highest level of trust. Friends and family were also among the most trusted sources in rural areas where the vaccination uptake was low. Conclusions. Rural–urban difference in hesitancy rates among those still unvaccinated was much smaller than the rural–urban difference in vaccination rates, suggesting that access to vaccines may be another contributor to the lower vaccination rates in rural areas. (Am J Public Health. 2023;113(6):680–688. https://doi.org/10.2105/AJPH.2023.307274 )

Objectives. To understand changes in how Facebook pages frame vaccine opposition. Methods. We categorized 204 Facebook pages expressing vaccine opposition, extracting public posts through November 20, 2019. We analyzed posts from October 2009 through October 2019 to examine if pages’ content was coalescing. Results. Activity in pages promoting vaccine choice as a civil liberty increased in January 2015, April 2016, and January 2019 (t[76] = 11.33 [P < .001]; t[46] = 7.88 [P < .001]; and t[41] = 17.27 [P < .001], respectively). The 2019 increase was strongest in pages mentioning US states (t[41] = 19.06; P < .001). Discussion about vaccine safety decreased (r s [119] = −0.61; P < .001) while discussion about civil liberties increased (r s [119] = 0.33; Py < .001]). Page categories increasingly resembled one another (civil liberties: r s [119] = −0.50 [P < .001]; alternative medicine: r s [84] = −0.77 [P < .001]; conspiracy theories: r s [119] = −0.46 [P < .001]; morality: r s [106] = −0.65 [P < .001]; safety and efficacy: r s [119] = −0.46 [P < .001]). Conclusions. The “Disneyland” measles outbreak drew vaccine opposition into the political mainstream, followed by promotional campaigns conducted in pages framing vaccine refusal as a civil right. Political mobilization in state-focused pages followed in 2019. Public Health Implications. Policymakers should expect increasing attempts to alter state legislation associated with vaccine exemptions, potentially accompanied by fiercer lobbying from specific celebrities.

A successful public health response to outbreaks such as COVID-19 depends on broad dissemination and widespread acceptance of accurate information.1 Yet, in recent weeks, inaccurate information and deceptive information have been plentiful. Even national leaders have offered misleading and sometimes false accounts of the risks facing the United States and the speed of vaccine development.2The barrage of false information has helped to erode trust in public health leaders and hinder efforts to contain the pandemic. Unless the public trusts that public health measures are grounded in the best available science, even if that science is incomplete and changing, individuals cannot be expected to follow public health recommendations, such as to shelter in place.Political leaders have not been alone in generating this climate of doubt. Many celebrities, pundits, and even some local health officials have downplayed the dangers for months. Rumors about the virus's origins, impending national lockdowns, and imminent cures have also circulated widely. This cacophony helps explain why spring breakers partied on Florida beaches while cities elsewhere shut down.

Objectives. We investigated how provider vaccine communication behaviors influence parental vaccination acceptance and visit experience. Methods. In a cross-sectional observational study, we videotaped provider–parent vaccine discussions (n = 111). We coded visits for the format providers used for initiating the vaccine discussion (participatory vs presumptive), parental verbal resistance to vaccines after provider initiation (yes vs no), and provider pursuit of recommendations in the face of parental resistance (pursuit vs mitigated or no pursuit). Main outcomes were parental verbal acceptance of recommended vaccines at visit’s end (all vs ≥ 1 refusal) and parental visit experience (highly vs lower rated). Results. In multivariable models, participatory (vs presumptive) initiation formats were associated with decreased odds of accepting all vaccines at visit’s end (adjusted odds ratio [AOR] = 0.04; 95% confidence interval [CI] = 0.01, 0.15) and increased odds of a highly rated visit experience (AOR = 17.3; 95% CI = 1.5, 200.3). Conclusions. In the context of 2 general communication formats used by providers to initiate vaccine discussions, there appears to be an inverse relationship between parental acceptance of vaccines and visit experience. Further exploration of this inverse relationship in longitudinal studies is needed.

COVID-19 vaccine development has advanced at lighting speed. Research that would normally require years has been completed in months. As a result of this unprecedented effort, two vaccine candidates, mRNA-1273 (Moderna, Cambridge, MA) and BNT162b2 (Pfizer, New York, NY), have been found to be safe and more than 90% effective in preventing symptomatic COVID-19 shortly after vaccination. These vaccines are extremely promising and will eventually be distributed widely. Unfortunately, as the science of vaccine development has swiftly progressed, the equally important science of community engagement, which should guide the establishment of mutually beneficial partnerships and promote eventual vaccine uptake, has lagged behind. Research methods focused on the development of effective public health interventions place communities- groups with shared culture, norms, beliefs, or language-at their core and emphasize the primacy of community ownership as essential for uptake and sustainability.1 Yet, communities of color (i.e., Black, Latinx, and Indigenous communities), who remain at highest risk for infection, have been peripheral, not central actors in the pursuit of COVID-19 vaccines. Instead, the tripartite relationship between industry, government, and academia has dominated the research enterprise related to COVID-19.The peripheral position of community has been evident since early in vaccine development. Notably, initial trial recruitment consisted of short-term community outreach, and more detailed plans for longer-term community engagement to support enrollment and eventual vaccine uptake commenced late in phase III trials. Such a critical oversight may be the Achilles' heel of this unprecedented effort. Deeply rooted mistrust bred by centuries of well-documented, abusive medical experimentation and ongoing structural racism impedes racially and ethnically diverse individuals' participation in clinical trials and threatens the uptake of future COVID-19 vaccines, particularly among Black individuals.