Misinformation and Disinformation: An Increasingly Apparent Threat to Global Health Security

By Marc Trotochaud and Matthew Watson

In the broadest possible conception, communication is a system that allows humans to share information with one another. Words and images can shape how we perceive information, a factor that plays a large role in our decision-making processes. Messages can incite emotion, provoke dialogue, and, albeit rarely, shift one’s self-perception or understanding of their relationship with those around them. At our core, humans are social beings, and communication is the natural product of that reality.

In public health, researchers have spent decades studying the best way to use communication to prompt protective health behaviors. Vast numbers of academic studies continuously add to the pool of professional knowledge, and it is the prerogative of health communicators to efficiently relay new information to populations of interest. In health security, communication is a major factor in how we plan for and respond to threats that can impact large populations.

Over the past fifteen years, some aspects of the practice of communication have changed dramatically. The rapid accessibility of mobile devices and the rise of social media platforms (Facebook, Twitter, Instagram, SnapChat, and others) has created a very noisy information landscape, which presents new challenges for public health practitioners and health security professionals. 

Of these challenges, misinformation and disinformation propagation has commanded the public spotlight over the past few years and has significantly damaged the global informational landscape. This two-part post will detail the impact of health-related misinformation and disinformation, its effects on health security, and the potential for addressing this issue in the near future.  

How Did We Get to This Point? 

Misinformation and disinformation are not new, but it is clear that the changes in how people consume information has catalyzed their production. Traditionally, people received their information through interpersonal interactions or via a traditional media channels like TV, radio, or print. The conglomerates that produced news content had guidelines in place that let them play a gatekeeper role for public information. These guidelines were far from a perfect system, but there was a universal understanding of how this system worked, which established a familiarity with how information traveled.   

This understanding changed dramatically when social media platforms made their way into the informational landscape. These platforms were created to bring people closer together. They offered unmoderated content creation and the ability to easily access and share information. Regardless of the intricacies of each specific platform, they each shared a common goal of inducing interaction between users. In effect, they were building a network of individual two-way communication channels on a massively expanded scale. 

As the user bases for these sites grew, this two-way vision transformed into what’s come to be known as a “many-to-many” communication system. While many argue the technicalities of the title, there is agreement on this core principle: many individuals now have the ability to post information to many people, at any time and with limited regulation. Now multiple voices speak to a number of topics, and with a click of a button, any individual can share their personal thoughts with the world. This non-direct, two-way communication system has pivoted who shares and receives information, flipping the script on information seeking. With social media’s rapid introduction into the technological sphere and the fast adoption of a many-to-many system, the tradition gatekeepers of information quickly became outdated, and the lack of a coordinated effort to adjust opened a window for misinformation production.  

During this same time period, advances in mobile technology created the perfect mechanism for personalizing these new platforms, increasing the amount of time that users interacted with them. The opportunity to access social media at a moment’s notice has expedited its growth, and led to the hyper-connected society we live in today. 

Social media is not the sole cause of this ‘post truth era’, but its outsized role is undeniable. This new information landscape has changed the traditional model of information sharing with its full impacts still not completely known. 

Misinformation and Disinformation: The Bad and The Worse

To best understand the impact of misinformation and disinformation propagation, it is important to acknowledge the fundamental difference between the two: intent. Simply put, misinformation is wrong or misconstrued information. It can stem from any number of sources, and has been a common plight for centuries. It is not purposefully shared with the knowledge that it is incorrect, and generally, its drive is not malicious. Disinformation, on the other hand, is incorrect information shared for that very reason. This distinction in intent is often hard to ascertain in real time but is critical in how one approaches its correction. 

Modern disinformation campaigns are a particularly virulent strain of propaganda. When paired with powerful social media platforms, disinformation activities have the ability to spread quickly with increased reach. These activities have become the subject of recent controversy, and have spawned multiple federal investigations. The case that has elicited the greatest response was an alleged campaign fueled by Russian trolls during the 2016 presidential election. The court proceedings tied to this case brought about massive social media purges, and unearthed the presence of foreign companies running disinformation campaigns around the world. While these efforts are certainly a pressing political and national security issue, a recent analysis clearly demonstrated that there is a connection to health communication as well. 

This past August, the American Journal of Public Health published an article that outlined a disinformation campaign that used programmed “bots” and online trolls to purposefully muddy the waters and rile up controversy between those who advocate for routine vaccination and those who oppose it. The strategic aim of this particular disinformation campaign was to use public health as a wedge issue, and to fan the flames of societal discord. The perpetrators of what the authors deemed “weaponized health communication” carried out their mission internationally through multiple social media channels. While the investigators did not attribute the campaign to a person or state, a sizeable portion of these trolls and bots were Russian accounts. 

What this article demonstrates is concerning. Public health has been, and continues to be, a topic that foregoes political differences for the betterment of health and wellbeing. Targeting health issues with the intent to divide is contradictory of the uniting nature fundamental to the discipline. There is danger present when health topics are used to drive people apart, and now there is a clear example of that being the case. Identification of these disinformation campaigns is just the starting point for an uncertain future, and it’s clear that immediate action is needed to address this growing concern. The next step will be moving from retrospective identification to a more engaged, proactive messaging posture. 

The Impact on Health Security and Health Communication

Misinformation and disinformation have both direct and indirect effects on the field of health security. Of these, the impact of incorrect information in the decision-making process seems most apparent. In the event of a disaster or emergency, timely communication of accurate information can be a major component in saving lives. The misinformation atmosphere can complicate this directly by sharing information that isn’t true. The 2014 Ebola epidemic, for example, was the victim of viral rumors that impacted how people perceived their risk of disease. In future disasters, people seeking information will now have to engage more actively with a growing amount of available material, or accept the potential that the information is wrong. 

The growing amount of available material highlights one of the indirect impacts stemming from false information propagation: there is an ever-growing amount of false information online, and there’s evidence that says people may give more attention to it than the truth. Both true and false stories are vying for attention, and some are finding that it’s more difficult for their messages to stick out. The product of these developments is a massive amount of available information, all fighting to be seen. Target audiences now face an ‘information overload’, prompting them to take mental shortcuts in how they select information. How people take these shortcuts has been the subject of decades of psychosocial research, serving as the backbone for theories that try and determine their influence on individual decision making. Many speculate that this new information acquisition process has been the driving factor in producing pockets of individuals where incorrect ideas may widely be accepted as truth. Now, the challenge for health communication practitioners is not just sharing information, but rather, doing so while simultaneously persuading diverse audiences that science reflects the truth

In addition to these challenges, an underlying growth in public distrust is a disconcerting development for health communicators and health security professionals. In recent years, this phenomenon has become increasingly well documented and has frustrated professionals from a wide range of disciplines. Portions of the public will deny overwhelming empirical evidence, whether it’s aimed towards climate change or vaccine efficacy, in favor of information that supports their beliefs – so called ‘confirmation bias’. Studies have shown that this gap persists across various audiences, presenting a disconcerting outlook for communication and health security. There have always been people who express skepticism of the scientific method, but the widespread vocal nature of modern dissenters presents a particularly lively challenge that will be harder to address. 

It seems all but certain that misinformation and disinformation propagation will be a challenge for future health communication efforts. Health communication is and will continue to be a critical component to health security, adding increased pressure to finding a solution for this problem. There is no clear best path forward, and the next steps we take will determine the impact of messaging efforts in this permanently altered communication realm. 

We will explore the wide-range of potential options in the second half of this blog, Misinformation and Disinformation Propagation: What Now?

California: From Governator to Vaccinator

On June 30, California Governor Jerry Brown signed into law Senate Bill 277, removing personal belief and religious childhood vaccine exemptions across the state.[i]  With the new law, California becomes only the third state to limit vaccination exemptions to medical only—joining Mississippi and West Virginia.  This effort, on the heels of a measles outbreak at Disneyland that resulted in more than three hundred cases in seven states (as well as Mexico and Canada),[ii] is seen by many as a signature victory for public health (although not renowned vaccine expert, Jim Carrey). 

While there will undoubtedly be challenges in implementing the law statewide, the true test lies in quantifying its effect and determining the feasibility of similar measures nationwide.  Because California was known, historically, for its relatively lax childhood vaccination policies, the transition to the new, considerably stricter exemption policy provides a near-perfect test case for public health policy.  In order to effect positive change far beyond the state line, the California Department of Public Health (CDPH) needs to accurately measure the social and public health impact of SB 277 and share their experiences with other states seeking to update decades-old immunization policy.

At present, CDPH publishes yearly data, by school, for the number of children who are “up-to-date” on vaccinations, have a “permanent medical exemption” and have a “personal belief exemption”—broken down by those counseled by a healthcare practitioner and those who have not (“religious belief exemption”), after a law passed in 2013 requiring the counseling for non-religious personal belief exemptions.  These data are collected and reported for childcare facilities, at kindergarten enrollment and at seventh grade enrollment for all schools statewide.[iii]  The personal belief and religious exemptions will be phased out over the next several years as children progress to the next checkpoint (kindergarten or seventh grade), and the rates for vaccination and medical exemptions, in conjunction with incidence of vaccine-preventable diseases, will provide a baseline picture of the public health impact of SB 277.  CDPH does not currently collect data on the personal or family history conditions warranting medical exemptions.  In fact, there is currently no official form for documenting medical exemptions; a physician letter to the child’s school—maintained in the student’s file—is sufficient.[iv]  Additionally, CDPH does not publish data on exemptions broken down by individual physicians or providers.

While continuing to collect medical exemption rates and communicable disease incidence data is vital, these data alone may not provide a complete picture of the new law’s impact.  Incidence of vaccine-preventable diseases is expected to steadily decrease over the implementation period; however, it will not necessarily change dramatically.  Students are only assessed for vaccination status in preschool childcare, kindergarten and seventh grade, so it will take several years before all of the existing personal belief exemptions are fully phased out.  Additionally, in the absence of another significant event like the 2014-15 measles outbreak at Disney or the 2010 pertussis epidemic, the decrease in communicable disease cases in the coming year will be primarily driven by a return to baseline levels rather than an increase in vaccination.  The full impact of SB 277 may not be known for years to come, but there are vital data to be collected in the meantime.

Gauging the public reaction to the new law will require careful data collection and monitoring of trends beyond just exemption rates and disease incidence.  The number of medical exemptions alone (by school or provider) will not provide a complete vaccination picture for California.  For example, it is likely that a small but motivated percentage of parents who currently have personal belief exemptions for their children may seek to obtain unwarranted medical exemptions rather than have their children vaccinated.  Schools with recent outbreaks of pertussis or measles may have a high number of medical exemptions for these immunizations due to the number of children who recently had the disease.  Additionally, physicians or practices who specialize in treating immunocompromised children (e.g., HIV or pediatric cancer patients) would likely issue a disproportionate number of exemptions.  CDPH does not currently collect information on the medical conditions provided to justify medical exemptions, and these data, particularly their geographic distribution, may give state and local officials information vital to targeting public health interventions and maintaining herd immunity in schools and communities.  To fully understand changing trends in medical exemptions, California should consider implementing measures to identify the conditions associated with them.  Both of the other states that limit immunization exemptions to medical only have mechanisms in place to provide some measure of oversight for the exemption process.  West Virginia requires the approval of the State Immunization Officer in order to obtain a medical waiver,[v] and physicians in Mississippi must provide the medical condition for exemptions to their District Health Officer.[vi]  CDPH needs to consider ways to collect data on the conditions cited on medical exemptions, even if the state does not intend to manage the exemption process directly.  The California state Health and Safety Code grants local health departments complete access to health information relating to students’ immunization status,[vii] so this may be a mechanism through which to collect these data.  Regardless of how state and local public health officials monitor medical exemptions, data beyond the mere numbers need to be collected and analyzed to measure the full impact of the new policy.

In addition to data collection, CDPH public outreach programs to promote vaccination could strengthen the impact of SB 277.  The state of California should continue offering education for physicians emphasizing the importance of vaccination, providing communication strategies for use with reluctant parents and reinforcing the public health and legal implications of the new law for the practice of medicine.  Additionally, similar education efforts should be targeted at school officials and parents to increase awareness during the implementation of the new policy.  Continued public outreach initiatives are vital to ensuring the positive impact of SB 277.

The new vaccination policy was only recently signed into law, so CDPH is likely still in the early stages of planning with respect to establishing implementation and monitoring protocols.  California is poised to move forward as a leader in public health policy, and CDPH has a tremendous opportunity to accurately quantify the impact of the new policy on statewide public health.  Additionally, from a purely public health perspective, it has an obligation to share this information with other states considering similar measures.  In order to do so, CDPH officials must determine now, prior to the law taking effect in 2016, how best to collect and analyze data.  Some questions to ponder include:

  • How do they intend to identify or limit specific conditions related to medical exemptions? 
  • Will they consider monitoring exemption rates for individual physicians or practices? 
  • How much of these data will be provided to the public and in what form? 

Given the far-reaching implications of this new law on public health practice nationwide, California should be diligent and systematic as this law is implemented.  Active and directed collection of data now will provide a solid foundation for analysis, and a dedicated multi-year effort will ensure that social and public health trends are identified early to facilitate intervention as necessary.  California is in an ideal position to assess the impact of statewide vaccination policy, and it has an opportunity to make a lasting, positive impact on the health of the public across the state and far beyond its borders.


[i] California State Senate. Senate Bill 277. http://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201520160SB277. June 30, 2015. Accessed: July 17, 2015.

[ii] Chang, Alicia. Large Measles Outbreak Traced to Disneyland is Declared Over. The Big Story. Associated Press. http://bigstory.ap.org/article/f6c2abefb29d4c70ab89ffdb88672916/large-measles-outbreak-traced-disneyland-declared-over. Accessed: July 17, 2015.

[iii] California Department of Public Health. Immunization Levels in Child Care and Schools. July 9, 2015. https://www.cdph.ca.gov/programs/immunize/Pages/ImmunizationLevels.aspx. Accessed: July 17, 2015.

[iv] Shots for School. Immunizations > Exemptions. http://www.shotsforschool.org/laws/exemptions/. Accessed: July 17, 2015.

[v] West Virginia Department of Health and Human Resources. Medical Exemptions Information. http://www.dhhr.wv.gov/oeps/immunization/requirements/Pages/Medical-Exemption-Resource-Center.aspx. Accessed: July 17, 2015.

[vi] Mississippi State Department of Health. Medical Exemption Request. http://msdh.ms.gov/msdhsite/_static/resources/6296.pdf. Accessed: July 17, 2015.

[vii] State of California. Health and Safety Code, Section 120375. http://www.leginfo.ca.gov/cgi-bin/displaycode?section=edc&group=49001-50000&file=49073-49079.7. Accessed: July 17, 2015.

Honoring Vaccine Heroes

From: LEGO Ideas

From: LEGO Ideas

Over the next year, we have the opportunity to recognize some of the greatest public health achievements in history.  In 1796, Edward Jenner introduced to the world the smallpox vaccine (and the term “vaccination”), inoculating an eight-year-old boy with cowpox (vaccinia virus) and later showing the vaccination to be successful when the boy showed immunity to variola virus.  In addition to numerous other contributions to biology, Louis Pasteur administered an inactivated rabies virus to a boy bitten by a rabid dog in 1885 and demonstrated the efficacy of such a vaccine, pioneering the way for countless future immunization efforts.  In the face of a global polio pandemic, Jonas Salk followed in Pasteur’s footsteps and developed an inactivated polio vaccine, and efforts began almost immediately to quell the epidemic (and hopefully eradicate the disease).  In 1980, the WHO under the leadership of D.A. Henderson completed what Jenner began and declared smallpox eradicated, accomplishing what is arguably the single greatest feat in human history.

Little did these giants of public health, upon whose shoulders we stand today, know that they would one day be nominated for one of the highest honors to which man can be bestowed.  They have the opportunity to stand beside countless other legends in the echelon of recognition reserved for only the most influential of figures.  In the annals of history, the names Jenner, Pasteur, Salk and Henderson could be found right alongside the likes of Michelangelo; Cinderella; Admiral Ackbar; and Tank Top with Surfer Silhouette, Red Short Legs, Reddish Brown Ponytail and Swept Sideways Fringe Female Hair…immortalized as LEGO men.

Vaccine Heroes, a recent submission on the LEGO Ideas website, seeks to acknowledge the historical efforts of these public health pioneers in a series of LEGO vignettes.  Jenner is portrayed alongside a fair-skinned milkmaid; Pasteur is in his laboratory, ready to vaccinate rabies case Joseph Meister; and Salk stands at his transmission electron microscope, working diligently on his poliovirus vaccine.  The series culminates with a panorama of D.A. Henderson’s efforts leading the WHO Smallpox Eradication Program, complete with African scenery, animals and grateful natives.  Keep your fingers crossed that LEGO is willing to produce a historically accurate bifurcated needle to complete the set!

The submission needs 10,000 votes over the next year to be eligible for production.  You do have to create an account to vote, but just like a shot, the pain is minimal.

With the development of Ebola vaccines and the recent reemergence of vaccine-preventable diseases like pertussis and measles in the United States, now seems like an ideal time to promote the success of historical vaccination programs and pioneers.  If produced, this LEGO set will provide disease nerds and children of all ages with inspiration to investigate and celebrate these public health success stories!

D.A. and the WHO may have been counting down to zero, but we’re all counting up to 10,000!  Let’s get this project going viral!