Accepted Manuscript Review The Clinician's Guide to the Anti-Vaccinationists' Galaxy The Clinician's Guide to the Anti-Vaccinationists' Galaxy

Abstract In this paper we briefly review three common immunological misconceptions that feature prominently among anti-vaccinationists, and in turn, fuel patient and parental concerns, questions, and fears about vaccines. In particular, this Perspective covers a brief history of the anti-vaccine movement, and three common false immunological claims, namely, concerns over "antigenic overload", the induction of autoimmunity by vaccines, and the value of "natural immunity" versus vaccine-induced immunity. This is followed by a review of the harms that have been done by anti-vaccinationists, and a call to action. Regardless of the motivation behind such fears and anti-vaccine sentiment, common fears and concerns relevant to vaccines are evident and therefore are the subject of this Perspective. It is hoped that clinicians will find this information useful in answering concerns and misconceptions about vaccines, and in educating their patients. Preface Vaccines have been a modern miracle of science that have saved many millions of lives, eradicated one disease (smallpox), controlled many other infectious diseases, and improved our quality of life. Vaccine-preventable diseases now occur in the developed world at a fraction of the rate they occurred before the introduction of vaccines. Despite this, the routine use of vaccines is threatened by a spectrum of fears, mis-information, and anti-vaccinationist propaganda. In this article we discuss some of the most common misconceptions about vaccines and provide information that clinicians might find useful in countering anti-vaccine claims. Despite the fact that the routine use of vaccines over the last century has led to a marked decrease in the incidence of vaccine-preventable infectious diseases and epidemics, widespread suspicion, mistrust and anti-vaccine sentiment are at surprisingly high levels in the United States, Western Europe and even developing countries within Africa, India and others. Although vaccines have frequently provoked fears and anti-vaccine sentiment since their introduction (as discussed below), the resulting decrease in vaccine uptake might have more severe consequences today than at any other time in the past. The effects of vaccine refusal today are exacerbated by increased risks of exposure due to the extent of global travel unprecedented in the history of humankind, the lack of immune boosting from subclinical infection with wild viruses or bacteria that cause epidemic diseases (such as measles, mumps, rubella and pertussis) owing to the success of vaccination, and increases in the number of individuals with increased susceptibility to these diseases (such as the elderly and immunocompromised persons), and situations in which humans are crowded together (schools, training camps, sporting and musical events, airplanes, indoor shopping malls, etc.). Together, these factors result in increased risks for epidemics of vaccine-preventable infectious diseases, as shown by recent outbreaks of measles, pertussis, and varicella, among other vaccine-preventable diseases, in the United States, Europe, and elsewhere Why, despite decades of data demonstrating vaccine safety and efficacy, do antivaccinationists and vaccine fears exist? We acknowledge that a spectrum of anti-vaccine feelings exists from those fearful of real (but rare) or unsubstantiated vaccine side effects, to those with differing or conflicting values, those who are un-or mis-informed, those for whom innumeracy is an issue [10] (those who do not have an in-depth understanding of probability or statistics), denialists We believe that clinicians should be aware of these issues so that they might have an educational role in dealing with these concerns, fears, and misconceptions. While we hope this information benefits clinicians dealing with individuals from across the spectrum of concern, many of our comments are focused specifically on those at one end of the spectrum that we would label as "anti-vaccine." The title of this article emphasizes the communication divide that exists between scientists/clinicians and anti-vaccinationists. We have found (and we have heard the same from our colleagues) that discussions with anti-vaccinationists are otherworldly and alien as the anti-vaccinationists reject the scientific method and the peer-reviewed literature. Given that many of the claims of anti-vaccinationists appear to be immunological in content, it is fitting that clinicians have an understanding of the anti-vaccinationists&apos