Vaccine refusal

If there is no link between vaccines and conditions such as autism, why do pediatricians spend so much time talking about this topic with parents? Why do parents seek out pediatrician’s opinions about these issues outside of clinical encounters? Why are so many families on "alternative" vaccine schedules? Why are pediatricians less successful in having recommendations acted on compared with other advice given to parents?

For pediatricians, it is important to understand what is the magnitude of the problem surrounding vaccine refusal, why parents refuse or are hesitant about vaccinations, and how to implement time-effective strategies to make the case for vaccination.

Magnitude of vaccine refusal

Despite the known benefits of vaccination, a significant number of parents choose to either allow their children go unimmunized or, more commonly, delay vaccination. Only 70% of children aged between 19 and 35 months are up-to-date for routine vaccinations.¹ As many as 13% of children have been reported to be on some sort of alternative vaccination schedule and are now undervaccinated by parental choice.² Alternative immunization schedules lead to underimmunization and increase the risk of transmitting and acquiring vaccine-preventable illness.^3-5

Recent outbreaks have highlighted problems associated with undervaccination and vaccination refusal. A measles outbreak related to California theme park attendance was associated with 125 confirmed cases (as of February 11, 2015). Among the confirmed 110 California cases, 49 (45%) were unvaccinated and 47 (43%) had unknown or inadequate documentation. Among 37 vaccine-eligible patients in the confirmed cases, 28 (76%) were intentionally unvaccinated because of parental beliefs and 1 child was on an alternative vaccination schedule.⁶ This particular outbreak spurred much discussion in the media and press surrounding how healthcare professionals address undervaccination and how parents address these issues within school systems and with other parents.

Pertussis outbreaks also are more common, with more cases reported in 2010 (27,550) and 2012 (48,277) since the 1950s.⁷ Whereas the pertussis comeback is largely attributed to waning immunity from the acellular pertussis vaccine, undervaccination related to factors such as parental vaccine refusal or other barriers to healthcare are increasingly acknowledged as important factors.^8,9 Based on recent outbreaks and research reports outlining parents increasingly refusing vaccination or requesting alternative schedules, it appears that vaccine refusal and vaccine hesitancy are problems the practicing pediatrician must continue to address.

Why parents refuse or underimmunize

Parents want their concerns to be heard. They seek credible information to make vaccination decisions for their child. Parents want their child to be healthy, and they seek to make rational decisions about healthcare after weighing the benefits and risks. Unfortunately, the public health successes of vaccination make its value invisible to parents today.¹⁰

Given that residents finishing their pediatric training may never have seen some vaccine-preventable illnesses, it is not surprising that parents do not have a personal relationship with any of these diseases. Rather than seeing President Franklin Delano Roosevelt's post-polio state, parents today see celebrity stances against vaccination from the likes of Jenny McCarthy, Alicia Silverstone, Rob Schneider, and Robert Rodriguez. As concern about contracting vaccine-preventable illness declines because of the effectiveness of vaccines, concern about the safety of vaccines seems to have increased. Today, neither parents nor pediatricians commonly have personal experience with the diseases prevented, or the consequences of developing the illnesses that the vaccines prevent.

Parental concerns and reasons for delaying or refusing vaccination include^2,11,12:

•           Potential to experience a long-term complication or adverse effect from vaccines.

•           Immediate short-term adverse effects such as pain or fever.

•           Current illness.

•           Development of autism.

•           Do not perceive their child will contract a vaccine-preventable illness.

•           Do not believe the risk or severity of a vaccine-preventable illness warrants vaccination.

•           Perceived lack of control over their child's health decisions.

•           Are aware of published alternative schedules^13,14 or have friends using an alternative vaccination schedule.

•           Concern that vaccines weaken the immune system.

•           Do not believe vaccine to be effective.

•           Inadequate research.

•           General worry.

Given the lack of tangible experience with the consequences of vaccine-preventable illness, it should not be surprising to the pediatrician that parents question whether they should be giving their children vaccines. Think of the laundry list of screenings and recommendations for the adult patient such as eating a low-fat diet and getting 30 minutes of exercise daily. How many of those recommendations do adults follow?

Problems facing the pediatrician

Vaccine refusal is increasingly common in pediatric practices, with 89% of pediatricians reporting at least 1 parental refusal per month and 10% reporting greater than a 10% refusal rate.¹⁵ Multiple field studies demonstrate that impacted children in epidemics often are not vaccinated or undervaccinated.^9,16-19

Parents generally find pediatricians a preferred and trusted source of information related to vaccination and other health conditions. A 2009 survey by the National Center for Immunization and Respiratory Diseases found that about 85% of parents usually follow and trust advice from their primary care physician.²⁰ A 2011 study in Pediatrics found that only 2% of parents did not trust their child's doctor regarding vaccine safety. Rather, more than 75% of parents trusted their child's doctor in regards to vaccine safety.²¹ However, among parents who refuse or delay vaccination, there appears to be a lack of trust related specifically to vaccine information even though parents may view their pediatrician as a trusted source.²² Further, the problem is exacerbated by celebrity spokespersons and controversy in the media.

Physicians deal with vaccine refusal and alternative schedules in different ways. Although more than two-thirds of physicians report that they agree to spread out vaccinations based on parental requests, large numbers require parents to sign some sort of form (eg, the “Refusal to vaccinate” form provided by the American Academy of Pediatrics [AAP]²³) indicating that they are not vaccinating children per the physician’s recommendation. A smaller number of pediatricians will dismiss patients from their practice if they refuse the primary series of vaccinations.¹⁵

Refusal to vaccinate (English): bit.ly/CP-Vac-refusal-English

Refusal to vaccinate (Spanish): bit.ly/CP-Vac-refusal-Spanish

Physicians also report a significant time burden to discuss vaccination with parents, especially when parents have significant concerns about vaccination. Whereas pediatricians report feeling comfortable having conversations surrounding vaccine refusal and alternative vaccine schedules, the increasing numbers of parents wanting to have these conversations along with the reported time burden is the top-reported barrier to pediatricians.¹⁵ Additionally, some pediatricians report decreased job satisfaction related to the perceived lack of trust and increased demands related to vaccine refusal.¹⁵

Strategies to implement in the pediatric practice

Increasing herd immunity is the best strategy for pediatricians to protect those children at the greatest risk for vaccine-preventable illness. Although pediatricians can and should advocate for health policy that encourages vaccination and discourages nonmedical exemptions, pediatricians will make the biggest impact in their office practices and in the hospital by talking with parents. The pediatrician in an office practice can impact vaccination rates by addressing the following areas:

1.Educate yourself. Vaccine-related education is important. Education ensures that not only is the pediatrician providing appropriate care but he or she also is discussing education with a parent as part of an effective communication strategy. In the California measles epidemic, incorrect assumptions and practices by physicians increased difficulties in controlling the epidemic. Failing to immunize children with minor medical illnesses, spreading out vaccinations, and referring underinsured patients to other facilities all were associated with inadequate vaccination.²⁴ Further, developing nurse-driven or standing protocols and systems helps increase immunization rates and avoid missed opportunities.

2.Educate parents. Pediatricians are a preferred source of health information for parents. Parents seek out information from their pediatrician, but how the information is delivered is important.

3.Develop and plan your communications. Given that parents look to and trust their physician's advice and that parents with concerns about vaccination may not blindly accept their pediatrician’s advice on this subject, the prudent pediatrician will develop a specific communication strategy for parents who refuse or want to delay vaccination. Additionally, the existence of numerous studies clearly demonstrating that there is no link between autism and vaccines would seem to indicate that the problem is with healthcare's communication strategy. The following are suggestions from the Centers for Disease Control and Prevention (CDC) to improve vaccination in your practice²⁵:

• Take time to listen. Restate the parent's concerns, maintain good eye contact, and give parents your full attention. The extent to which a parent feels heard will impact the parent’s decision to choose vaccination or not.

• Ask open-ended questions. If parents express concern or seem reluctant about vaccination, open-ended questions such as "You seem worried about the vaccination" let the parent know you want to address all questions and concerns despite a full schedule.

• Be mindful of nonverbal communication. If parents cannot freely ask questions, think their questions are inappropriate, believe the pediatrician is offended or put out by their vaccine-related questions, or imply any of these feelings from the pediatrician's reactions or facial expressions, parents will stop communicating and trust will be eroded.

• Include less science. Although this can be difficult to measure because every parent is different, some parents may just want to hear a story or the pediatrician’s thoughtful recommendation after listening to parental concern.

• ü Develop specific communication strategies. In practice, physicians report a number of communication strategies they find to be effective when talking with parents who are skeptical of vaccination or who want to delay immunization. These include¹⁵:
• ·      Personal statements about what the physician would do for his or her own child.

• ·      Description of the physician’s personal experience with vaccine safety in his or her patients.

• ·      Stating his or her belief that it is safer to vaccinate than not to vaccinate.

• ·      Discussion of the medical consequences of not vaccinating.

• ·      Discussion of vaccine effectiveness.

Click here for Truven health poll.

The CASE for immunization

Given the time constraints previously mentioned, the pediatrician needs an effective communication strategy that is easily remembered and implemented in practice. One might think of this as an “elevator pitch” or a carefully crafted, high-level, and well-practiced description of why a child should receive a vaccination. It is designed to give enough information so that the parent will want to know more and ask questions, but not so much information that the parent will become overwhelmed and tune out the pediatrician.

One such elevator speech to discuss vaccination has been developed by Alison Singer, executive director of the Autism Science Foundation.²⁶ She suggests the acronym CASE, which stands for Corroborate, About me, Science, and Explain/advise. The CASE model suggests that the pediatrician can effectively address parental concerns about vaccine refusal or hesitancy in an effective and time-efficient manner and easily use the model time and again. The CASE model consists of:

•           Corroborate. Because jumping straight into scientific explanations related to vaccine safety or the lack of an association with diseases such as autism may be deemed by parents as dismissing or challenging, and has not been proven effective, acknowledging the parents’ concern and finding a point of consensus between the parents and the pediatrician is a better first step. Empathize with parents that they are not the only parents with concerns about vaccines. Bringing the pediatrician's own emotional connection sets the tone for a respectful conversation. If the parents offer only vague reasons for refusal, it is often helpful to press them to be more specific. Then, responses such as "That is a valid concern" and "We want your child to be disease free" are statements that get the parents and pediatrician to a point where they all agree and set the stage for a successful discussion.

•           About me. Here the pediatrician moves from acknowledging the parents’ concern to how the pediatrician became an expert on the particular issue. The pediatrician might discuss his or her own research and demonstrate knowledge of both the risks and the benefits of vaccination. Examples include statements such as "I am dedicated to your child's health and have been studying medicine and pediatrics for X years. Vaccines are a major part of my practice and helping prevent disease for your child."

•           Science. Discuss what the science says. Now that the physician has acknowledged parental concern and discussed his or her personal education related to vaccination, parents may be much more likely to hear the informational points related to the science.

•           Explain/advise. The pediatrician must tell the parent why he or she feels strongly about the recommendation to vaccinate or to not "spread out" the primary series. Personal statements about what the physician would do make a powerful impression on parents.

For the CASE video presentation, go to: http://www2.aap.org/immunization/pediatricians/riskcommunication-VIDEOS.html

REFERENCES

1. Elam-Evans LD, Yankey D, Singleton JA, Kolasa M; Centers for Disease Control and Prevention (CDC). National, state, and selected local area vaccination coverage among children aged 19-35 months-United States, 2013. MMWR Morb Mortal Wkly Rep. 2014;63(34):741-748.

2. Kempe A, O'Leary ST, Kennedy A, et al. Physician response to parental requests to spread out the recommended vaccine schedule. Pediatrics. 2015;135(4):666-677.

3. Glanz JM, McClure DL, Magid DJ, et al. Parental refusal of pertussis vaccination is associated with an increased risk of pertussis infection in children. Pediatrics. 2009;123(6):1446-1451

4. Glanz JM, McClure DL, O'Leary ST, et al. Parental decline of pneumococcal vaccination and risk of pneumococcal related disease in children. Vaccine. 2011;29(5):994-999.

5. Glanz JM, Narwaney KJ, Newcomer SR, et al. Association between undervaccination with diphtheria, tetanus toxoids, and acellular pertussis (DTaP) vaccine and risk of pertussis infection in children 3 to 36 months of age. JAMA Pediatr. 2013;167(11):1060-1064.

6. Zipprich J, Winter K, Hacker J, et al; Centers for Disease Control and Prevention (CDC). Measles outbreak-California, December 2014-February 2015. MMWR Morb Mortal Wkly Rep. 2015;64(6):153-154. Erratum in: MMWR Morb Mortal Wkly Rep. 2015;64(7):196.

7. Centers for Disease Control and Prevention National Center for Immunization and Respiratory Diseases. Pertussis cases by year (1922–2014). Available at: www.cdc.gov/pertussis/surv-reporting/cases-by-year.html. Updated March 6, 2015. Accessed May 6, 2015.

8. Cherry JD. Why do pertussis vaccines fail? Pediatrics. 2012;129(5):968-970.

9. Winter K, Glaser C, Watt J, Harriman K; Centers for Disease Control and Prevention (CDC). Pertussis epidemic-California, 2014. MMWR Morb Mortal Wkly Rep. 2014;63(48):1129-1132.

10. Klein MC. Nothing fails like success-the great immunization debate. Birth. March 5, 2015. Epub ahead of print.

11. Freed GL, Clark SJ, Butchart AT, Singer DC, Davis MM. Parental vaccine safety concerns in 2009. Pediatrics. 2010;125(4):654-659.

12. Gust DA, Darling N, Kennedy A, Schwartz B. Parents with doubts about vaccines: which vaccines and reasons why. Pediatrics. 2008;122(4):718-725.

13. Cave S, Mitchell D. What Your Doctor May Not Tell You About Children's Vaccinations. Rev ed. New York: Grand Central Publishing; 2010.

14. Miller DW Jr. A user-friendly vaccination schedule. LewRockwell.com website. Available at: https://www.lewrockwell.com/2004/12/donald-w-miller-jr-md/vaccine-nation/. Published December 10, 2004. Accessed May 6, 2015.

15. Kempe A, Daley MF, McCauley MM, et al. Prevalence of parental concerns about childhood vaccines: the experience of primary care physicians. Am J Prev Med. 2011;40(5):548-555.

16. Centers for Disease Control and Prevention (CDC). Pertussis epidemic-Washington, 2012. MMWR Morb Mortal Wkly Rep. 2012;61(28):517-522.

17. Matthias J, Dusek C, Pritchard SP, et al; Centers for Disease Control and Prevention. Notes from the field: outbreak of pertussis in a school and religious community averse to health care and vaccinations–Columbia County, Florida, 2013. MMWR Morb Mortal Wkly Rep. 2014;63(30):655.

18. Centers for Disease Control and Prevention (CDC). Notes from the field: measles outbreak-Hennepin County, Minnesota, February-March 2011. MMWR Morb Mortal Wkly Rep. 2011;60(13):421.

19. Muñoz-Alía MÁ, Fernández-Muñoz R, Casasnovas JM, et al. Measles virus genetic evolution throughout an imported epidemic outbreak in a highly vaccinated population. Virus Res. 2015;196:122-127.

20. Kennedy A, Basket M, Sheedy K. Vaccine attitudes, concerns, and information sources reported by parents of young children: results from the 2009 HealthStyles survey. Pediatrics. 2011;127(suppl 1):S92-S99.

21. Freed GL, Clark SJ, Butchart AT, Singer DC, Davis MM. Sources and perceived credibility of vaccine-safety information for parents. Pediatrics. 2011;127(suppl 1):S107-S112.

22. Glanz JM, Wagner NM, Narwaney KJ, et al. A mixed methods study of parental vaccine decision making and parent-provider trust. Acad Pediatr. 2013;13(5):481-488.

23. American Academy of Pediatrics. Documenting parental refusal to have their children vaccinated. Refusal to Vaccinate form. Available at: http://www2.aap.org/immunization/pediatricians/pdf/refusaltovaccinate.pdf (English). Also in Spanish: http://www2.aap.org/immunization/pediatricians/pdf/refusaltovaccinateSpanish.pdf. Accessed May 6, 2015.

24. Insel K. Treating children whose parents refuse to have them vaccinated. Virtual Mentor. 2012;14(1):17-22.

25. Centers for Disease Control and Prevention. Talking with parents about vaccines for infants: strategies for health care professionals. Available at: http://www.cdc.gov/vaccines/hcp/patient-ed/conversations/downloads/talk-infants-color-office.pdf. Reviewed March 2012. Accessed May 6, 2015.

26. Singer A; Autism Science Foundation. Making the CASE for vaccines: a new model for talking to parents about vaccines. Immunization: Risk Communication Videos. Available at: http://www2.aap.org/immunization/pediatricians/riskcommunicationvideos.html. Uploaded June 10, 2014. Accessed May 6, 2015.

Dr Bass is chief medical information officer and associate professor of medicine and pediatrics, Louisiana State University Health Science Center–Shreveport. The author has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.