Anti-Vaccine Movement and its Implications for Vaccination Coverage of the Brazilian Population: A Scoping Review

-Objective: Our intention was to analyze production on the anti-vaccine movement and its implications for vaccination of the Brazilian population in the indexed scientific literature. Methods: We used the systematic scoping review to search the following databases: PubMed, Scopus, Web of Science, Burry, Lilacs/BVS and Scielo.JBI and PRISMA-SCR international protocols were adopted for the search and screening of scope-related articles. The guiding question was built through the acronym PCC (population, concept and context). The information was extracted, categorized regarding the relationship with the theme of the anti -vaccine movement and the implications for vaccination coverage of the Brazilian and/or general population.


Introduction
he so-called "Anti-Vaccine Movement" gained strength from a fraudulent study published in The Lancet in 1998.In that article, physician Andrew Wakefield described that, after vaccination with the Triple Virus, an intestinal inflammatory condition would occur that would make the individual susceptible to mercurial toxins, which would lead to autism.The fraud was exposed sometime later by the General Medical Council, but the theory had already gained supporters worldwide. 1nti-vaccine movements are not recent and, as already mentioned, had their greatest demonstration over a century ago in Brazil, with similar episodes in different parts of the world such as England and the United States.Recently, worldwide cases of eradicated diseases have started to be reported.Like tetanus in children described in 2017 in Italy and the United States, generating in the latter an approximate cost of one million dollars spent on treatment, which could have been avoided with adequate vaccination, whose price revolves around thirty dollars. 2 Failure to vaccinate has disastrous consequences 1 and is directly related to the concepts of vaccine hesitancy, vaccine refusal and the antivaccination movement itself, 3 which has resulted in a reduction in vaccine coverage in Brazil.For example, from 2015 to 2020, there was a reduction of 41.72%, and in 2018, seven of the eight mandatory vaccines for children did not reach their coverage target, with the exception of BCG (Bacillus Calmette-Guérin). 1 According to Dubé et al (2014), 3 vaccine hesitancy consists of a heterogeneous group of individuals who demonstrate doubts about vaccination and therefore may delay, be reluctant, but still accept or refuse some or all vaccines.On the other hand, vaccine refusal, a term closely linked to the context, is related to the traditions, health and religion of a given population, and in low-and middle-income countries, it can be used to obtain other social services interventions that meet the needs of the community.The anti-vaccination movement, on the other hand, opposes any and all types of vaccination, including individuals who allocate part of their time and resources to express, mainly through digital media, their position with regard to vaccines since this movement also has the aim to attract new fans.Still according to the authors, the participants call themselves defenders of freedom of choice in relation to getting vaccinated and the transparency of public information with an anti-vaccination rhetoric, addressing controversial issues to legitimize their decisions.With the assumption that if the subject is in high proportion in the media, there is greater generation of fear in the population, resulting in the decline of immunizations.
In the present scoping review, based on the assumption presented, our intention was to analyze the production on the anti-vaccination movement and its implications for vaccination coverage of the Brazilian population in the indexed scientific literature.
As for the eligibility criteria, only scientific articles from primary studies were considered eligible to compose our sample.Searches were not carried out in gray literature sources -OpenGray, Catalog of annals of events -CIN/CNEN, theses and dissertations -BDTD and general sources such as Google Scholar, as well as possible non-indexed works.Studies in English, Spanish and Portuguese were accepted, and there was no time frame in the present study.

b) Data Extraction and Analysis
Using the eligibility criteria, titles, abstracts and full-text articles were screened by the following researchers: MDS; ADS; RFG; CTW.Training exercises were performed with the four evaluators for each screening level.Subsequently, they selected citations and full articles for inclusion, in pairs of independent work and blindly.Discrepancies between the four evaluators were resolved by consensus meeting and validation for the final insertions were performed by the fifth evaluator and SMD specialist.The Rayyan 6 software was also used as a tool, which consists of a web application developed by QCRI (Qatar Computing Research Institute), which was responsible for the process of screening articles and removing duplicates.
We entered all selected articles into a spreadsheet and extracted the following data: title of publication, name of authors, title of journal, country of journal, original language of publication, year of publication, relation of publication to the theme of the anti-vaccine movement and vaccination coverage and, finally, whether the publication mentioned implications of the anti-vaccination movement on vaccination coverage of the Brazilian population and/or the general population.At the same time, we also built an excel spreadsheet with the summaries and conclusions from the studies selected as sources of evidence.Next, for data analysis, we categorized the publications included in the study according to the relationship with the theme (1-the publication has no direct relationship with the theme; 2-the publication has a partial relationship with the theme; 3-the publication presents direct relationship with the theme).
We also categorized the implications mentioned by the publications (1-the publication mentions implications in the vaccination coverage of the Brazilian population; 2-the publication mentions implications in the vaccination coverage of the general population; 3the publication does not mention implications in the vaccination coverage of the Brazilian population and/or in general).
And finally, the file with the summaries and conclusions of the included studies were imported into the Iramuteq software, 7 through which the textual corpus analysis was carried out, specifically the similarity analysis, which is anchored in graph theory.Similarity analysis is defined mathematically as a probabilistic network represented by a graphic structure composed of relationships between words and their precepts.Each "node" in the graph represents a word, and the links between the nodes are the edges, which represent the probabilistic dependencies between the words (which, from a mathematical point of view are understood as variables). 8Thus, it is possible to demonstrate the relational structures in the form of acyclic and directed graphs (DAG's), as well as their probabilistic dependencies between the words in the nodes, 9 from the co-occurrence (frequency of occurrence and cooccurrence), between the words. 10The significance level was established at 5% in this analysis.

Results
Among the analyzed articles, 37 were included as sources of evidence (Figure 1).It was evident that the journals that published these articles have different scopes, such as vaccines, microbiology, medical sciences, social and behavioral sciences, law, health policies, environment and health, as well as health information and communication.Among the 37 publications, the journals come from the American, European and Asian continents, most of them located in the United States, Brazil and Canada.Additionally, the original language of the publications is mostly English (34 articles), with only 2 articles in Portuguese and 1 article in Spanish.
It is interesting to note that the publications ranged from 2001 to 2022, with only 2 articles in the period between 2000 and 2010, 21 articles in the period 2011 and 2020 and 14 articles in the period between 2021 and 2023.
As for the similarity analysis from the abstracts of the publications selected as sources of evidence (Figure 2), it was verified that there is a formation of a central nucleus that comprises the term "vaccine," and the division into four "branches of interest" that stand out in the graph which are identified with the terms: "vaccination," "public health", "information" and "antivaccination," the latter being divided into two branches with the terms "anti-vaccination movement" and "social."In the similarity analysis of the conclusions of these articles selected for the study (Figure 3), again the term "vaccine" appears as a central term and there are four branches of interest with strong connectors with the terms: "vaccination", "public health," "social" and "information." When we analyzed the relationship between the central theme of the 37 publications and the "Anti-Vaccine Movement" (Figure 4A), it was possible to observe that 28 (75.7%) had no direct relationship, 2 (5.4%) had a partial relationship with the theme and only 7 (18.9%)have a direct relationship.
And when we analyzed the mentions of the 37 publications regarding the implications of the "Antivaccine Movement" in the vaccination coverage of the Brazilian population and/or in general (Figure 4B), it was possible to observe that only 5 (  IV.

Discussion
The present scoping review sought to analyze the production on the anti-vaccination movement and its implications for vaccination coverage of the Brazilian population in the indexed scientific literature.
The 37 articles selected as sources of evidence made it possible to identify that, in the last two decades, there has been a significant increase in publications that address the theme of the "Anti-Vaccine Movement," going from 2 publications identified in the period from 2000 to 2010, increasing to 21 publications between 2011 and 2020 (ten times more), and between 2021 and 2023, already a number of 14 publications, which points to an increasing trend on the subject in the coming years.movement," despite the articles having become increasingly present and gaining greater attention, 31 is shown peripherally in our similarity graphs.This peripheral location of the "anti-vaccination movement" theme, as well as the absence of a direct relationship with the theme in most of the publications in our scoping review (28, 75.7%), indicates how this subject has been presented in the indexed scientific literature.
The publications selected as sources of evidence allowed us to perceive that there is a prevalence of use of the concepts of vaccine hesitation, vaccine refusal, with little mention of the term "Anti-Vaccine Movement" and the implications for vaccination coverage of the Brazilian population and/or in general.
From the similarity analysis carried out in the present study, it was possible to identify that the theme "vaccine" is a central theme in the publications, which is corroborated by the presence of the term in the center of the graphs of the abstracts and conclusions of the selected articles.The theme of the "anti-vaccination The term "anti-vaccination movement" seems to be gaining more visibility in scientific research with the advent of social networks and, mainly, "fake news," which since 2016 have contributed greatly to the reduction of vaccination coverage in the population.Fake news is considered false information disseminated irresponsibly and at high speed, mainly in digital media.For the elaboration of such news, there is a complete Such denial of science constitutes a major risk to Public Health, as demonstrated in the pandemic caused by Sars-CoV-2, in which empirical methods of prevention and treatment were passed on inconsequentially from individual to individual, evidencing the lack of respectand credibility to specialists and authorities in the area.Fake news circulates on the main social networks such as Facebook, Instagram, Twitter and Youtube, addressing a dangerous anti-vaccination discourse guided, by many, as the restriction of individual freedom being one of the consequences of vaccination. 48igital media, as well as mass media, are important tools for disseminating news and information.Shapers of beliefs and popular opinions, they should be used as means by health and government authorities, aiming at carrying out health education with awareness plans accessible to the population.It is necessary to note that in the midst of the "information society" there is so much disinformation shared and taken as truth. 49

Conclusion
The number of scientific publications on the anti-vaccination movement and its implications for vaccination coverage of the Brazilian population, from March 2001 to March 2022, is scarce and figures peripherally compared to the publications selected as sources of evidence in the present scoping review.
It is of great importance that new studies be carried out directly addressing this issue, clearly explaining the implications for the vaccination coverage of this population.absence of scientific information with respectable levels of evidence, being based on denialism that becomes more evident every moment. 47stematic scoping reviews have some limitations, such as the possibility of bias in the selection of studies, since not all studies can be included.In addition, the quality and availability of studies can affect the results.It is also important to consider that scoping reviews may not provide a complete summary of the results, since they do not carry out statistical analysis of the data.Additionally, a limitation of great relevance related to our work is the fact that for the study of this theme we are more in the field of ideas and associated with social networks.

Figure 2
Figure 2 13.5%) mentioned implications in the vaccination coverage of the Brazilian population, 6 (16.2%) mentioned implications in the vaccination coverage of the general population and 26 (70.3%) did not mention implications in the vaccination coverage of the Brazilian population and/or in general.Year 2023 Journ als I-A: The publication is not directly related to the theme.II-A: The publication is partially related to the theme.III-A: The publication is directly related to the theme.I-B: The publication mentions implications for vaccination coverage in the Brazilian population.II-B: The publication mentions implications for vaccination coverage in the general population.III-B: The publication does not mention implications for vaccination coverage in the Brazilian population and/or in general.

Figure 4 :
Figure 4: Graph with the number of publications and their relationship with the theme, in addition to mentions or not of implications for vaccination coverage in the Brazilian population and/or in general.
Journ alsAnti-Vaccine Movement and its Implications for Vaccination Coverage of the Brazilian Population: A Scoping Review

Table 1 :
). Synthesis of publications selected as sources of evidence in the PubMed, Scopus, Web of Science, Embase, Lilacs/BVS and SciELO electronic databases.Anti-Vaccine Movement and its Implications for Vaccination Coverage of the Brazilian Population: A Scoping Review