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Médecine et maladies infectieuses 46 (2016) 117–122

General review

The impact of the web and social networks on vaccination. New challenges
and opportunities offered to fight against vaccine hesitancy
Impact d’Internet et des réseaux sociaux sur la vaccination. Nouveaux défis et nouvelles
opportunités de lutte contre l’hésitation vaccinale
J.-P. Stahl a,∗ , R. Cohen b , F. Denis c , J. Gaudelus d,e , A. Martinot f , T. Lery g , H. Lepetit h
a Infectious Diseases Department, University of Grenoble, CHU de Grenoble, Grenoble, France
b CHU de Créteil, 40, avenue de Verdun, 94010 Créteil cedex, France
c CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France
d Hôpital Jean-Verdier, hôpitaux universitaires Paris-Deine-Saint-Denis, 93140 Bondy, France
e Université Paris-XIII, AP–HP, Paris, France
f University of Lille, CHU de Lille, EA 2694, 2, avenue Oscar-Lambret, 59037 Lille cedex, France
g GSK vaccines, 100, route de Versailles, 78163 Marly-le-Roi cedex, France
h Institut des Mamans, 2, rue Balny-d’Avricourt, 75017 Paris, France

Received 4 February 2016; accepted 11 February 2016

Available online 14 March 2016

Abstract
Objective. – Vaccine hesitancy is a growing and threatening trend, increasing the risk of disease outbreaks and potentially defeating health
authorities’ strategies. We aimed to describe the significant role of social networks and the Internet on vaccine hesitancy, and more generally on
vaccine attitudes and behaviors.
Methods. – Presentation and discussion of lessons learnt from: (i) the monitoring and analysis of web and social network contents on vaccination;
(ii) the tracking of Google search terms used by web users; (iii) the analysis of Google search suggestions related to vaccination; (iv) results from
the Vaccinoscopie© study, online annual surveys of representative samples of 6500 to 10,000 French mothers, monitoring vaccine behaviors and
attitude of French parents as well as vaccination coverage of their children, since 2008; and (v) various studies published in the scientific literature.
Results. – Social networks and the web play a major role in disseminating information about vaccination. They have modified the vaccination
decision-making process and, more generally, the doctor/patient relationship. The Internet may fuel controversial issues related to vaccination and
durably impact public opinion, but it may also provide new tools to fight against vaccine hesitancy.
Conclusion. – Vaccine hesitancy should be fought on the Internet battlefield, and for this purpose, communication strategies should take into
account new threats and opportunities offered by the web and social networks.
© 2016 Elsevier Masson SAS. All rights reserved.

Keywords: Vaccine hesitancy; Social network; Google; Internet; Web

Résumé
Objectif. – L’hésitation vaccinale constitue une menace grandissante, à même d’augmenter le risque d’épidémies et de faire échouer les stratégies
des autorités sanitaires. L’objectif de cette étude était de décrire le rôle conséquent des réseaux sociaux et d’Internet en matière d’hésitation vaccinale
et l’influence qu’ils exercent sur les attitudes et comportements relatifs à la vaccination.
Méthodes. – Présentation et description des leçons tirées : (i) d’une analyse du contenu publié sur Internet et sur les réseaux sociaux concernant la
vaccination ; (ii) d’une analyse des recherches effectuées par les internautes sur Google ; (iii) d’une analyse des suggestions proposées par Google
en matière de vaccination ; (iv) des résultats de l’étude Vaccinoscopie© menée chaque année, depuis 2008, auprès d’échantillons représentatifs

∗ Corresponding author.
E-mail address: JPStahl@chu-grenoble.fr (J.-P. Stahl).

http://dx.doi.org/10.1016/j.medmal.2016.02.002
0399-077X/© 2016 Elsevier Masson SAS. All rights reserved.
118 J.-P. Stahl et al. / Médecine et maladies infectieuses 46 (2016) 117–122

de mères françaises (de 6500 à 10 000) dont l’objectif est de suivre les attitudes et comportements des parents français en matière de vaccination
et d’évaluer les couvertures vaccinales des enfants ; et (v) de différentes études publiées sur le sujet. Résultats
Les réseaux sociaux et Internet jouent un rôle conséquent en matière de diffusion de l’information vaccinale et modifient le processus décisionnel
relatif à la vaccination et, de manière plus générale, la relation médecin/patient. Internet peut parfois alimenter certaines polémiques vaccinales,
influençant ainsi l’opinion publique. Cependant, Internet offre également de nouveaux outils de lutte contre l’hésitation vaccinale.
Conclusion. – La lutte contre l’hésitation vaccinale doit se jouer sur Internet. Les stratégies de communication en la matière doivent donc tenir
compte des nouvelles menaces et opportunités offertes par Internet et par les réseaux sociaux.
© 2016 Elsevier Masson SAS. Tous droits réservés.

Mots clés : Hésitation vaccinale ; Réseaux sociaux ; Google ; Internet ; Web

1. Introduction
Parents are increasingly skeptical about vaccine safety. Vac-
cine hesitancy has now become a threat to public health. First
of all, vaccine hesitancy leads to disease outbreaks, [1] such as
poliomyelitis [2], whooping cough [3], and measles as recently
observed in the United States [4] with the so-called “Disney-
land measles outbreak” or with the 2011 large-scale measles
epidemic (also affecting adults) in France [5]. Secondly, vac-
cine hesitancy is a major obstacle to vaccination policies. In
June 2013 for example, the Japanese Ministry of Health, Labor,
and Welfare suspended its recommendation for human papillo-
mavirus (HPV) vaccination after a series of highly publicized
alleged adverse events following immunization stoked public
doubt about the vaccine’s safety [6].
Vaccine hesitancy can be observed in many countries [7].
Data obtained by the media surveillance system shows that in
France the proportion of negative messages about vaccines is
particularly high: 154 times among 4900 negative messages
worldwide versus 45 times among 9157 neutral or positive
messages worldwide [7]. Consequently, France is particularly
affected with an insufficient vaccination coverage for meningo-
coccal and HPV infections. [8,9]
We will:
• describe and illustrate the impact of the Internet on vaccina-
tion information, decision process, attitude and behaviors;
• examine how the Internet may favor vaccine hesitancy but
also provide valuable resources to tackle vaccine skepticism.
2. Impact of the web and social networks on vaccination
2.1.1. The Internet plays a major role in producing and
disseminating information about vaccination
On average, the web and social networks (hereafter “the
Internet”) produce more than 48,000 contents related to vac-
cination every month (Fig. 1). However, this estimation based
on the monitoring of French main sources of digital contents is
below reality, as it does not take into account private contents or
discussions and searches related to specific vaccinations.
As a result, information related to vaccination has changed
in many respects:
• origin: with social networks, any web user may produce or
relay vaccine-related information to a large number of indi-
viduals;
• nature: as the issuance of information on vaccination is no
longer a matter of experts, and because parenting forums
and social networks offer premises for parents to gather and
discuss their parenting issues, the Internet produces more
subjective and emotional contents related to vaccination;
• speed: the Internet has accelerated the speed of information
and broken down barriers (Fig. 2). By providing tools, such

Fig. 1. Number of content related to vaccination from July 1st to December 31st, 2015 and share of media types.
Nombre de contenus publiés sur la vaccination du 1er juillet au 31 décembre 2015 et répartition en fonction des types de médias.
 J.-P. Stahl et al. / Médecine et maladies infectieuses 46 (2016) 117–122 119

700 500,000
450,000
600
400,000
500 350,000
Twitter
400 300,000
Facebook
250,000
300 Blogs
200,000
Forums
200 150,000
Youtube
100,000
100 News
50,000
0 0

Mar-…

May-…

Mar-…

May-…

Sept-…
Nov-…

Sept-…

Nov-…
Aug-…

Aug-…
Oct-2012

Jan-2013

Apr-2013

Jan-2014

Apr-2014
Dec-2012

Feb-2013

Jun-2013

Oct-2013
Jul-2013

Dec-2013

Jun-2014

Fig. 2. Impact of the complaint filed against the HPV vaccine on November 23rd ,
2013 on online messages. Number and origin of the online postings concerning
the HPV vaccination and the complaint filed against one of the HPV vaccines.
Impact du dépôt de la plainte visant la vaccination HPV le 23 novembre 2013 sur
le web. Nombre et origine des publications sur internet concernant la vaccination
HPV et le dépôt de plainte contre l’un des vaccins contre les HPV.
as “likes”, “shares”, and “tweets”, the Internet enables web
users to easily transmit real time information with respect to
an event, e.g., the filing of a suit.
Oct-2014
Jul-2014
Fig. 3. Monitoring of vaccine-related searches in France from October 2012 to
October 2014.
Suivi des recherches concernant la vaccination effectuées en France d’octobre
2012 à octobre 2014.
recommended HPV vaccination to a mother and her teenage
girl, the teenage girl was vaccinated in 48% of cases. In 2014,
the provider’s recommendation was followed in 30% of cases.
By contrast, Google’s influence may be substantial, and thus
for two reasons:

2.1.2. The web changes health behaviors and influencers

As the web provides for free, available at all time, anony-
mously accessible information, it empowers patients and incites
them to contribute to their health-related decisions [10,11].
Patients no longer want to be “patient” and this trend is expected
to grow as the generation born during the digital era, the so-called
“digital natives” become adults and parents.
This trend is supported by the analysis of 2117 vaccine-
related Google searches which shows that an average of 330,000
searches related to vaccination are conducted every month on
Google.fr (Fig. 3).
Although, as highlighted in a previous article [12], physi-
cians are still the primary source of information for mothers
who wonder whether or not to vaccinate their children (Fig. 4)
[13], increasingly, in case of controversy, physicians have dif-
ficulty to reassure and restore confidence. On the basis of
Vaccinoscopie© ’s data (Fig. 5), in 2010, when a physician
• Google suggests keywords to web users (Fig. 6); as a result,
Google may incite web users to research problematics that
they would otherwise not have been informed about;
• Google determines the content web users consult, as top
results displayed first by Google are more likely to be con-
sulted.
It is worth noting in this respect that the influence of Google
should increase as Google announced they are more than dou-
bling the size of their health condition database [14].
2.2. The Internet raises challenges to vaccination
2.2.1. The Internet may favor rumors
The information on the Internet is fast, uncontrolled, and
anonymous. Rumors may thus proliferate freely; in addition,
trolls may recklessly fuel information with the only objective

90% 90% 90% Physician (family physician or

84%
pediatrician)
Family and friends

Pharmacist
37%
33% 31% Internet
29%
16% 14%
12% 11% 14% 14% Other
11% 12% 10%
6% 6%
3% 3% 4% 4% 5%
I never have to / I've never had
0-2 years 6 years 11-15 14-15 to ask for advice on that maer
years years

Fig. 4. Source of information related to vaccination for mothers. Question asked: who do you consult to decide whether or not to vaccinate your children?
Suivi des recherches concernant la vaccination effectuées en France d’octobre 2012 à octobre 2014. Question posée : vers quelle(s) source(s) d’information vous
tournez-vous pour décider de faire (ou de ne pas faire) vacciner votre enfant ?
120 J.-P. Stahl et al. / Médecine et maladies infectieuses 46 (2016) 117–122
48%
41%
32%
32%
30%
2010 2011 2012 2013 2014
Fig. 5. Proportion of girls aged 14 to 15 years vaccinated on the physician’s
advice. Question asked: did your physician recommend cervical cancer vacci-
nation for your child? Vaccination status obtained from HPV vaccination dates
registered in health records.
Pourcentage de jeunes filles de 14–15 ans vaccinées lorsque le médecin a con-
seillé la vaccination. Question posée : votre médecin vous a-t-il conseillé de
faire vacciner votre enfant contre le cancer du col de l’utérus ? Statut vaccinal
issu du relevé des dates de vaccination HPV inscrite sur le carnet de santé.
of contemplating the confrontation of pro- and anti-vaccination
advocates.
Searches undertaken by web users and content consulted by
them are also dictated by Google algorithms. However, Google
algorithms are not governed by public health considerations.
Rather, as indicated by Google, “the search queries that you see
as part of Autocomplete reflect what other people are searching
Fig. 6. Search suggestions displayed by Google.fr and Google.co.uk.
Suggestions proposées par Google.fr et Google.co.uk.
for” [14]. Because web users may be tempted to click on worry-
ing suggestions, e.g., “vaccine causes autism” (Fig. 6), the extent
to which Google algorithms contribute to create hearsay and
maintain it alive or even magnify it may be questioned [15]. The
various libel lawsuits filed against Google in several countries by
individuals or entities for suggestions associated to their name
by Google tend to support this questioning. [16,17]. Finally,
another concern is that Google’s suggestions can be manipu-
lated by third parties [18], an action that could possibly tempt
unscrupulous anti-vaccine advocates.
2.2.2. Negative contents related to vaccination tend to
proliferate on the Internet
Internet users have few reasons to post positive messages
about vaccination. Why would a mother post about her child’s
vaccination if everything went well? By contrast, a mother would
be tempted to share her doubts or observations on forums and
social networks if she is hesitant to vaccinate her child or if her
child experienced adverse effects that she blames on the vaccine.
In this regard, parents whose children experience serious health
issues shortly after vaccination may confuse concurrency with
causality; they may be tempted to blame vaccination and start
advocating against vaccination.
Also, as described by various authors, anti-vaccine lobbyists
make an active use of the Internet to deliver and spread their
messages [19,20].
Finally, reporting the alleged risks of vaccination is easier and
less risky than promoting its benefits. Indeed, anyone can report
the alleged risks of vaccination; to do so, one just needs to be
aware of a particular case. By contrast, promoting the benefits
of vaccination or trying to counter its opponents’ arguments is
more complicated as:
• one needs access to information that is not readily available;
• one needs to understand this information;
• make it intelligible for everyone.
Individuals with access to such information are also not
always authorized to pass it on; they might require the approval
of the authority that they represent. In addition, legal actions are
now more frequently taken and promoting vaccination can be
hazardous. Vaccine advocates can therefore be dissuaded from
communicating about vaccination.
Therefore, action is urgently needed. Although Internet users
are largely in favor of vaccination, as parents have more rea-
sons to share concerns about vaccination than to make positive
statements about it, parents can wrongly deduce that most other
parents are reluctant to or against vaccination. This erroneous
perception is problematic as individuals are likely to act in the
general interest only if they think that everyone is taking the same
approach on a specific subject. Therefore, if parents believe that
other parents no longer vaccinate their children, they will be
tempted to do the same [21,22].
Finally, as recalled by Kahn et al., people give priority to and
remember information consistent with their own beliefs [23].
Therefore, doubt is quite difficult to alley once raised.
 J.-P. Stahl et al. / Médecine et maladies infectieuses 46 (2016) 117–122
2.2.3. The Internet provides valuable resources to fight
vaccine hesitancy
The monitoring of the Internet’s content may provide real
time, worldwide information as to any adverse event-related
to vaccination. It may also provide insights as to patients or
health professionals’ concerns about vaccination that need to be
addressed.
In case of crisis, the Internet offers tools to quickly provide
information to clinicians and parents. However, communica-
tion efforts should be made to formalize a resource that parents
and physicians could turn to; also search engine optimization
strategy must be adopted.
However, as discussed earlier, physicians remain the pri-
mary source of information for parents. Communication strategy
and efforts should therefore rely on them. The Internet could
provide valuable resources; in particular, tools could be pro-
vided to physicians to help them provide their patients with
personalized information, which have been shown as superior
to non-tailored information for improving compliance with rec-
ommended health behaviors [24,25]. Also, the Internet may
provide reminder system that can help improve observance of
vaccination schedules, as shown by a recently published study
[26,27].
Finally, as pointed out by Doctor Sue Swanson, Pediatrician,
author of the Seattle Mama Doc Blog for the Seattle Children
Hospital, [28] “we can start to take care of people outside of
the exam room. We can start to disseminate education asyn-
chronously” [29]. Given the success of her blog, followed by
thousands of parents, this type of communication means seems
to meet patients’ expectations.
3. Conclusion
The Internet may be viewed as a threat to vaccination. It can
however help restore trust in vaccination provided a large-scale
digital action plan is implemented; and in this respect, as Omer
et al. recommend it, we should “go big and go fast” [30]. Also,
the patient-provider relationship must evolve to tackle patients’
new expectations and needs; maybe patients should no longer
be called “patients” to help this evolution happen?
Contribution
HL performed the study and wrote the article.
JPS analyzed data and wrote the article.
Other authors analyzed data and reviewed the article.
Vaccinoscopie© is funded by GlaxoSmithKline Laboratories.
GSK did not have any role in the choice and analysis of data.
Disclosure of interest
All authors are members of the Vaccinoscopie© group.
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