Injection fears vs vaccine compliance
Baxter notes that injection fears have tripled over the last few decades, and suggests a correlation to the fact that the number of vaccines recommended by the Centers for Disease Control and Prevention (CDC) tripled in that same period. There are already strong recommendations across pediatric practice against alternate vaccine schedules, with the American Academy of Pediatrics (AAP) specifically warning against alternate schedules last summer.3 In that warning, AAP noted that 93% of pediatricians report being asked to deliver vaccines on an alternative schedule each month, and that 74% usually comply with parents’ requests.
“Only one vaccine schedule has been shown to be safe and effective,” AAP states in its recommendation. “Any deviation from the recommended schedule may jeopardize benefit and increase the risk of harm.”
Although Baxter says she fully supports the CDC vaccination schedule, she also shares concerns about the long-term effects of unaddressed injection fears. Baxter says pediatricians don’t necessarily have to change the CDC schedule at all, noting that staggering booster injections is still in compliance with the CDC’s recommendations. "Fortunately, we determined that the existing infant and toddler schedule is not associated with increased needle fear. This is one more finding against an alternate schedule when children are the most vulnerable," Baxter says. They do, however, need to find a way to make early vaccines less traumatic in order to reduce the development of later fears and possible noncompliance.
“Needle fear is a logical consequence of the current way we give boosters, and has health consequences,” Baxter says. “Needle fear impacts patients' health choices for life, their likelihood to immunize their own children, and it's iatrogenic. We need to take it seriously.”
There are other considerations to scheduling vaccines, as well, Baxter notes. “Optimizing booster and flu vaccinations requires legislative and payer shifts, and sometimes school district entrance requirements. Ideally flu vaccinations could be done elsewhere to reduce the association of healthcare and anxiety. Ideally, combination vaccines would be approved by all payers,” Baxter says. “We're not in an ideal world, but there are some evidence-based factors to consider if we were. Children at age 4 are the most susceptible to fear; pain is worse when the most painful vaccine is given first. Obviously, you want to err on the side of getting them vaccinated if the family is unreliable.”
Baxter also points out that as children age, they are better able to deal with injections, and any alternative spacing—within CDC recommendations—could be adjusted as children age and are better able to handle their fears.
“What I most hope is that by changing how we give preschoolers injections, we can mitigate the consequences of our patients leaving our practices with needle fear, Baxter says.
“In the most recent US vaccine-preventable death data, there were 40 deaths from pediatric infectious diseases. There were 101 pediatric deaths from flu, and only 26% had been immunized. The CDC estimates 3000 to 12,000 people a year die because they're not vaccinated against the flu,” Baxter notes. “By insisting on giving 4- to 6-year boosters on the same day, we're saving at most 20 lives a year, and causing needle fear in half these kids. If only 20% of those who don't get HPV or flu shots avoid it because of needle fear, that's still 2900 deaths a year. When you throw in that 7% of adults say they won't vaccinate their kids because of their own needle fear, the fact that 63% of kids are now afraid of needles should be a public health emergency.”
1. Baxter AL Cohen LL, Burton M, Mohammed A, Lawson ML. The number of injected same-day preschool vaccines relates to preadolescent needle fear and HPV uptake. Vaccine. 2017; 35(33);4213-4219.
2. Taddio A, Ipp M, Thivakaran S, et al. Survey of the prevalence of immunization noncompliance due to needle fears in children and adults. Vaccine. 2012;30(32):4807-4812.
3. Meissner HC. Do not stretch the immunization schedule. AAP News. Available at: http://www.aappublications.org/news/2017/07/27/IDSnapshot072717. Published July 27, 2017. Accessed January 24, 2018.