The vaccine-hesitant patient

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Contemporary PEDS Journal, November 2021, Volume 38, Issue 11

Best tactics for pediatricians when speaking with patients who resist immunization.

Candice Jones, MD, recently spoke with Charnetta Colton-Poole, MD, and Leila Jerome Clay, MD, about the challenges of vaccine hesitancy and how pediatricians can best get the message across that vaccines are safe, effective, and at times crucial.

Contemporary Pediatrics®: Can you provide a brief overview of the increasing phenomenon of vaccine hesitancy? How did we get here?

Colton-Poole: In the United States, vaccines began to gain traction in the 1800s with the surge of smallpox, a severe, contagious infectious disease known to kill 3 out of every 10 persons with a diagnosis.

Over time, vaccination became widely accepted, and smallpox was eliminated in the United States in 1952. Also during the 1930s, President Franklin D. Roosevelt suffered from polio and lost the use of his legs after infection, making him passionate about finding a cure. This leadership initiative created a culture that was unified in vaccination creation and distribution efforts, despite challenges.

Although history gives an account of countless lives that were saved thanks to vaccines, there have also been adverse events (AEs) that have instilled fear and concern in the population, including hepatitis B’s association with multiple sclerosis; live polio inoculation errors; and the false association of the measles, mumps, and rubella (MMR) vaccine with autism.

In today’s culture, vaccine hesitancy stems not just from history but also from a multitude of factors including celebrity influence, internet misinformation, decreased visibility of vaccine-preventable diseases, knowledge of harmful outcomes after vaccines, lack of knowledge, and government and physician distrust.

As you can see, vaccine hesitancy is not a new phenomenon. In fact, from the 1800s until now, the core of the conflict is still the same.

What factors influence vaccine decision-making? How can health care providers (HCPs) address these factors to minimize vaccine hesitancy in their patients and caregivers?

Colton-Poole: When considering the factors that influence vaccine decision-making, most parental concerns are based on trust, knowledge, and fear. Parents and caregivers have to trust their HCP, have accurate knowledge, and overcome their fears to move from opposition or hesitancy to acceptance. However, this is easier said than done. Many parents have researched vaccines before the child’s visit, often gathering information from noncredible sources, and left feeling confused and fearful when they were bombarded with emotional stories of vaccines causing harm or misinformation about what toxins or chemicals may be present in vaccines. Additionally, there are growing numbers of conspiracy theories related to vaccines, as well as general distrust of government, medical professionals, and pharmaceutical companies.

To overcome these factors, the most important things that we can do as HCPs are establish trust, educate early, and help parents overcome their fears to minimize vaccine hesitancy. Establishing trust begins with a medical home. Being able to see the same staff and provider during visits helps parents feel more comfortable and develop a trusting relationship with their provider.

In my practice, I start providing vaccine education early and often. At the 1-month visit, I begin explaining in great detail what vaccines we plan to give at the next visit, what diseases they prevent, and possible AEs. I use photos and evidence-based medicine to ensure that parents have the correct information. A parent who is armed with the right information can make an informed decision as it relates to vaccines and their child. To truly help parents overcome their fears, providers must be armed with scientific truths and be able to offer that information to parents.

Is there a best approach to explain the importance of immunizations and encourage parents to get their children vaccinated?

Colton-Poole: The best approach is to start early and educate often. Take the time to listen to parents and care- givers. Find out how much they know about vaccines, correct any inaccurate information, and fill in the gaps. This includes discussing the safety and efficacy of the vaccine in a way that is easy for them to understand. Stay up-to- date on the latest in vaccine data, and be aware of misinformation circulating so you can easily dispel myths and refute false claims.

Also, don’t be afraid to share your experiences with vaccine-preventable diseases while also being transparent about possible vaccine AEs, which helps parents and caregivers understand the risks and benefits of vaccination. You can confidently encourage parents to weigh the benefits and risks for themselves and recommend vaccination if the benefits outweigh the risk for them, always leaving the decision in their hands.

More times than not, if there is a healthy doctor-patient relationship and patients don’t feel judged but, rather, heard and informed, they will opt for vaccination, as it is generally the best option for their child.

How can HCPs help caregivers and patients get over the fear and distrust associated with vaccinations?

Colton-Poole: The key to helping caregivers and patients get over the fear and distrust associated with vaccines is creating an environment where questions are welcome and delivering accurate education. Having brochures available, signage in the doctor’s office, and videos in the waiting room are the first steps in helping to educate patients and caregivers.

Moreover, HCPs should ensure that there is ample time during the visit to offer education and truly discuss concerns. It is normal for patients and caregivers to have questions and concerns regarding vaccines. Always encourage questions and answer in a way that they can understand.

For example, many parents worry about giving the MMR vaccine during the 12-month and 4-year visit because of concerns about autism. When discussing vaccinations and possible AEs for this child, we should let the caregivers know that there are no data to support the correlation.

Similarly, when I am discussing meningitis vaccine information with my patients and caregivers, I share the overwhelming benefits of the vaccine after reviewing potential, rare AEs to aid in decision-making. I share statistics so they can make an informed decision.

Patients and caregivers want to feel confident and assured about their decision, not afraid. I often share with my patients that I get vaccinated to protect myself and others, and I chose the same for my son. It is reassuring to parents to know that I wouldn’t give anything to their child that I wouldn’t give to my own.

The most successful vaccination programs in the past have included mass education efforts, and together we can help defuse fear and distrust. However, no matter how welcome the environment and how sage the advice, there will still be some parents that refuse vaccines. Although your approach to these patients should be the same, the seriousness of their decision to not vaccinate must be communicated. Every pediatric practice should have a policy regarding how these patients are addressed. Some offices may refuse to see these patients because they are a danger to other patients in the waiting room. Others may simply choose to thoroughly document that you’ve educated the patient and recommended vaccines as well as have parents sign a refusal form. Whatever you choose, always approach the patients with care and concern.

What are the current recommendations for HCPs when families refuse vaccines based on personal or religious exemptions?

Clay: To maintain an intact public health infrastructure, routine childhood immunizations are vital, as they provide protection against various infectious diseases not only for immunized individuals but also indirectly to children and adults unable to be immunized via the effect of community immunity. The American Academy of Pediatrics (AAP) supports medically indicated exemptions to specific immunizations as determined for each individual child. Medically indicated reasons include allergy to a vaccine component, previous significant adverse reaction to a vaccine or its components, or other underlying health conditions, such as an immunosuppressed organ transplant recipient. The AAP views nonmedical exemptions to immunizations required by schools as inappropriate for individual, public health, and ethical reasons and advocates for their elimination. The current recommendations vary from state to state, with more than a quarter of states requiring parental notarization or affidavit confirming either a religious or personal belief justification in applying for a nonmedical school immunization exemption. A number of states have laws requiring parent/guardian education by health departments or HCPs on the benefits of vaccines and the risks and consequences of not receiving recommended childhood immunizations. Currently, HCPs have reason based on their practice to allow or not allow families who refuse vaccines to join or remain in their practice.

Because children account for 25% of the US population, which strategies should HCPs implement to improve COVID-19 vaccination rates in children?

Clay: It is crucial that children get vaccinated to achieve herd immunity.

As a sickle cell specialist, our clinic ensures families are aware that sickle cell disease is a condition at risk of worse health outcomes with COVID-19 infection. We assess COVID-19 vaccination status and/or encourage families to get the COVID-19 vaccine during every visit. We provide handouts on COVID-19 infection and the COVID-19 vaccine from credible sources, such as the Centers for Disease Control and Prevention and the Sickle Cell Disease Association of America. We collaborate with the St Petersburg chapter, which is a community-based organization, to have COVID-19 discussions during sickle cell support groups, where we cover the importance of getting the vaccine. HCPs should continue to advocate for the administration of COVID-19 vaccines at their practice because families trust their providers most and already receive childhood vaccines there. HCPs should also work with trusted messengers in the community, such as faith-based leaders, school districts, employers, and nonprofit organizations to build trust and reach vulnerable populations. HCPs should consider sending texts or emails to families encouraging vaccination and sharing resources. The nonprofit organization de Beaumont offers advice on how to talk about vaccinations with your patients.

Vaccine passports and mandatory COVID-19 vaccines are under consideration in the United States—what are your thoughts?

Clay: All 50 states require immunizations for children entering public schools. There are currently no mandatory federal vaccination laws. Therefore, if the COVID-19 vaccine were to become mandatory, it would occur at the individual state level. It is also conceivable that employers and certain industries could require the vaccine, especially in higher-risk areas such as health care, entertainment, and travel.

In regard to vaccine passports, proponents highlight allowance of return to normal activities for those who are vaccinated, economic advantages, and incentive to become vaccinated. On the other hand, opponents worry about privacy concerns in digital formats and that vaccine passports could worsen existing inequities. The World Health Organization recently advised against vaccine passports for this reason. Currently, 2 states, Hawaii and New York, have a digital vaccine passport system, whereas several states have implemented laws banning them. The Biden administration is also investigating vaccine passports.

All HCPs should advocate for equitable vaccine distribution and provide data on vaccine documentation. Further roles remain to be seen because this is an ongoing dynamic.