Pro- and anti-vaccination users use social media outlets, such as Twitter, to join conversations about vaccines, disseminate information or misinformation about immunization, and advocate in favour or against vaccinations. These users not only share textual content, but also images to emphasise their messages and influence their audiences. Though previous studies investigated the content of vaccine images, there is little research on how these visuals are distributed in digital environments. Therefore, this study explored how images related to vaccination are shared on Twitter to gain insight into the communities and networks formed around their dissemination. Moreover, this research also investigated who influences the distribution of vaccine images, and could be potential gatekeepers of vaccination information. We conducted a social network analysis on samples of tweets with images collected in June, September and October 2016. In each dataset, pro- and anti-vaccination users formed two polarised networks that hardly interacted with each other, and disseminated images among their members differently. The anti-vaccination users frequently retweeted each other, strengthening their relationships, making the information redundant within their community, and confirming their beliefs against immunisation. The pro-vaccine users, instead, formed a fragmented network, with loose but strategic connections that facilitated networking and the distribution of new vaccine information. Moreover, while the pro-vaccine gatekeepers were non-governmental organisations or health professionals, the anti-vaccine ones were activists and/or parents. Activists and parents could potentially be considered as alternative but trustworthy sources of information enabling them to disseminate misinformation about vaccinations.

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