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cauz Feb. 2, 2019, 3:14 p.m.
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Weaponized Health Communication: Twitter Bots
and Russian Trolls Amplify the Vaccine Debate

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 asso-
ciated with Russian troll activity.
Results.
Compared with average users, Russian trolls (
c
2
(1)=102.0;
P
<
.001), so-
phisticated bots (
c
2
(1)=28.6;
P
<
.001), and

content polluters

(
c
2
(1)= 7.0;
P
<
.001)
tweeted about vaccination at higher rates. Whereas content polluters posted more
antivaccine content (
c
2
(1)= 11.18;
P
<
.001), Russian trolls ampli
fi
ed both sides. Un-
identi
fi
able accounts were more polarized (
c
2
(1)= 12.1;
P
<
.001) and antivaccine
(
c
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 le-
gitimate users create false equivalency, eroding public consensus on vaccination.
Public Health Implications.
Directly confronting vaccine skeptics enables bots to le-
gitimize the vaccine debate. More research is needed to determine how best to combat
bot-driven content. (
Am J Public Health.
Published online ahead of print August 23, 2018:
e1

e7. doi:10.2105/AJPH.2018.304567)
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