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Rachael Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare Executive, and Medical Economics.
Outbreaks of vaccine-preventable diseases like measles and pertussis have led pediatricians to take a hard line, sometimes dismissing patients who are non-compliant with immunizations. A new study examines the prevalence-and consequences-of patient dismissal.
Vaccination refusal has been in the public eye for awhile-from false fears that vaccines cause autism spectrum disorders to a measles outbreak at Disneyland. As the small minority of anti-vaccine parents continue to emit a loud voice, some physicians are firing back by dismissing patients who refuse immunizations.
According to the Centers for Disease Control and Prevention (CDC), 159 cases of measles were reported in the first quarter of 2015. The largest outbreak originated at Disneyland in California, and accounted for 70% of those early 2015 cases. Additionally, 28,660 cases of pertussis were reported in 2014, up from 28,639 cases in 2013, stressing the importance of children receiving the full set of diphtheria, tetanus, and acellular (DTaP) vaccines, including boosters.
This outbreak and others have illustrated the importance of vaccinating against preventable diseases.
A new study reveals the frequency of patient dismissal, and how vaccine refusal by parents is impacted by state support of immunization through laws opposing philosophical vaccine refusal.
Overall, less than 1% of children received no vaccinations, according to CDC. National coverage met the Healthy People 2020 target of 90% for the full series of the polio vaccine (93.3%), more than 1 dose of measles, mumps, and rubella (91.5%); more than 3 doses of hepatitis B (HepB) (91.6%); and more than 1 dose of varicella (91%). Vaccination rates fell below the goal for more than 4 doses of DTaP, Haemophilus influenza type B, HepB at birth; more than 4 doses of pneumococcal conjugate vaccine; more than 2 doses of hepatitis A; and the full course of the rotavirus vaccine, according to CDC.
In 2014, 23 outbreaks of measles were reported across 27 states, representing more cases than any year since 1994, according to lead study author Sean O’Leary, MD, of Colorado Children’s Hospital in Aurora. Although children living in poverty often fail to receive all of their vaccinations, the study attributes this increase in measles cases to parents who are actively declining vaccination.
Pediatricians report spending significant time in educating parents on the benefits of vaccination and dispelling myths, but there are no best evidence-based strategies identified for effective communication to convince hesitant parents to vaccinate, according to the report.
As a result, some physicians are resorting to dismissing families that refuse vaccinations for their children, even though the American Academy of Pediatrics (AAP) and the CDC discourage such policies.
A 2002 report found that 39% reported they would dismiss families for refusing all vaccines. Since that time, says O’Leary, there has been little investigation into the practice of patient dismissal related to vaccination. For his study, O’Leary specifically examined state exemption policies in relation to the practice of dismissing families for vaccination refusal.
O’Leary’s report found that 83% of pediatricians and family practitioners polled encountered parents on a monthly basis that refused vaccination for their children. Pediatricians in states that did not allow philosophical exemption to vaccination reported less cases of parental refusal.
In terms of prevalence, 63% of physicians reported 1% to 4% of parents refusing vaccines; 15% said 5% to 9% of parents in their practice refuse vaccines; and 5% of physicians reported 10% of parents refused vaccines. Refusal rates were generally higher in pediatric practices than in family practices, according to the report. Looking at trends, 28% of pediatricians reported a decrease in parental refusals over the prior year, compared with 15% of family practitioners, while 14% of pediatricians and 7% of family practitioners reported an increase. An average of 66% of physicians reported no significant change in vaccination refusal, according to the report.
O’Leary found that 14% of the physicians polled dealt with parents who refused vaccinations for their child through dismissal from their practice-21% of pediatricians employed this practice compared to 4% of family practitioners.
Location matters, too, says O’Leary. In states that allowed philosophical exemptions, only 9% of pediatricians reported dismissing patient for infant series vaccine refusal compared to 34% in states that do not allow those exemptions. Additionally, 12% of physicians in states with simple exemption processes dismissed patients, compared to 22% in states where the exemption process was of medium difficulty, and 28% in states with a difficult exemption process.
Physicians in private practices were also more likely to dismiss patients than those in health maintenance organizations, or those working in university or public settings.
There is argument that lower vaccination rates and higher rates of vaccine-preventable illness occurs in states where physicians are less likely to dismiss their patients, but others say that dismissing families can increase vaccine uptake by sending families a strong message on the important of vaccination, according to O’Leary. Little is known about the reaction of families who were dismissed from practices over vaccine refusal, he adds, and no studies have been conducted to examine the larger impact of patient dismissal over vaccination refusal.
Paul A Offit, MD, is director of the Vaccine Education Center at the Children’s Hospital of Philadelphia and is a professor of both vaccinology and pediatrics at the Perelman School of Medicine at the University of Pennsylvania. Recognized as an expert on vaccination, even Offit say there is no easy answer when it comes to dealing with parents who are adamantly against immunizations.
While dismissal of patients who refuse vaccinations may help protect other families within a practice from contracting a vaccine-preventable disease, it carries risk beyond the practice. There is little information about what happens to families after they are dismissed from their pediatric practice, and whether they are educated further by their next physician. Children who continue on to practices that do not continue to education and recommend vaccines will present an increased risk of spreading vaccine-preventable diseases to the many others. Dismissal can sometimes offer the “tough love” some families need to consent to vaccination, but it’s not a tactic to be used lightly.
“At the very least physicians should be more passionate about this issue,” Offit says. “When a parent says they have chosen to hold or delay vaccines, the physician should be emotional. They should say, ‘Look, let me love your child. What you’re really asking me to do is to violate a standard of care. Please don’t put me in that position.’”
Although it’s a somewhat confrontational approach, Offit says physicians need to worried less about taking hard line, and worry more about being an advocate for their patient and other children.
“A choice not to get a vaccine is a choice for other people’s children,” Offit says.
However the decision to dismiss patients or keep seeing them both carry a certain message. “When you continue to see patients [who refuse vaccines], you are passively agreeing that it’s okay. However when you choose not to see a patient anymore, what happens to those children?” Offit says. “[When you dismiss a patient ] you’re saying, ‘It’s so important to me, and you’re making a choice that’s substandard care, and I can’t participate in that position.”
Offit says although he is happy he is not on the front lines, his wife, a practicing pediatrician in Philadelphia, is. When she has encountered parents who refuse vaccines, they do respond to the threat of dismissal, and it usually convinces them to vaccinate. Education, works, too, as many parents who question vaccination aren’t sure, but have heard myths and want clarification.
“They’ve smelled the smoke and they’ve read the articles, and they are wondering about it-but they trust their doctor, Offit says. “Most people are reassurable, and they want to be reassured.”
Physicians who encounter parents against vaccination should first ask the parents about their specific concern or fear. Are they concerned about autism spectrum disorders? Too many vaccines too soon? The frequency of vaccines?
“These are all questions doctors can answer,” Offit says. “The fact is, it’s not hard to understand why we’ve gotten here. We ask citizens in this country to vaccine their children against 14 diseases in the first years of life. It’s not surprising they are pushing back.”
Parents must be counseled on the consequences of not vaccinating, and today’s parents may have little experience with the reality and acute nature of many of the diseases physicians are vaccinating against, like measles.
O’Leary says physicians list having parents sign release forms if they refuse vaccinations, addressing vaccine concerns, and advising parents to inform healthcare workers at emergency visits about their vaccination status as methods in addressing vaccination refusal.
O’Leary says the CDC and a number of organization are all working on ways to develop a message that will be successful is dispelling myths and concerns about vaccination, but it’s hard to find a solution that fits all cases.
In cases where parents are adamantly against vaccination, you aren’t likely to convince them otherwise, and it may be best to focus on other measures of health promotion, O’Leary says. More research needs to be done to understand the decision-making in these populations, he adds.
“People’s risk perceptions are very complicated-even if you show them the risks of the disease are far greater than the risks of the vaccine,” O’Leary says.
In many cases, however, simply talking to the parent about their concerns can go a long way.
“Most parents just have questions. They just have questions about vaccines, they’ve heard some misinformation. For them, it’s about having an open dialogue,” O’Leary says. “Be respectful of their opinions and ask how they came to them, and share how you’ve come to see the issues. Don’t be afraid to say ‘I don’t know’ and seek out more information.”
O’Leary isn’t sure that there should be a strict policy against dismissal. While he acknowledges the negative side of dismissal, he also recognizes that presenting some families with that option pushes them to consent to vaccines. Some pediatricians are also adopting dismissal policies due to demand from other parents, too.
“Parents are saying they don’t want to bring their child to a pediatrician who accepts non-vaccinators because of the risk to their child,” he says.
O’Leary says a big concern in combatting anti-vaccination is that, although the group is a small minority, that it does not get larger.
“Their voice has been larger than their size,” O’Leary says.
Offit says the key is to listen to parents concerns in a non-judgmental way, and education them. When that fails, pediatricians sometimes choose to take a hard line that may or may not include the threat of dismissal.
“Pediatricians are generally trained to be open-minded to a lot of beliefs and it’s great to a point. However when you’re being asked to practice substandard care that could put the children in harms way, it’s not okay,” Offit says. “It’s reasonable to understand the fear, but it’s a decision that should not be tolerated. It’s not fair to the child.”