When parents resist immunizations

When parents resist immunizations By Magna Dias, MD, and Edgar K. Marcuse, MD, MPH Many families feel that pediatricians just don't listen when they try to voice concerns about vaccines. Our recommendation: Identify each family's specific issues, target your response accordingly, and use a nonconfrontational approach. Time-consuming lectures on big subjects like immunology generally aren't needed. Most pediatricians have parents in their practices who are concerned about the safety of vaccinating their children. Explaining the immunologic basis for vaccines, Food and Drug Administration protocols, and vaccine safety monitoringall within the confines of an office visitis a daunting task. Providers often feel frustrated and angry at parents' misconceptions and sometimes offer only quick, even brusque, answers to questions. This leaves families feeling that their worries were not adequately addressed. A recent account in Parenting magazine, for example, says that a mother "read an article in a holistic health magazine that proposed a connection between baby shots and asthma. When she raised with the pediatrician the idea of not vaccinating her second child, since her first had asthma, the doctor was against it" and made her feel "as if I was being a horrible mother." The article goes on to say that this mother eventually switched to another pediatrician who was willing to address her concerns.1 Alleged adverse events associated with vaccines make the 6 o'clock news; immunization successes do not. Most parents and many physicians have never seen a child with diphtheria, tetanus, or polio, but have heard stories about terrible things that have resulted from the vaccines against these diseases. Pictures of children allegedly handicapped because of a vaccine would cause any reasonable parent to question vaccine safety. These allegations most often arise when the adverse event occurred soon after the vaccination. Although a temporal relationship does not prove causation, such stories are hard to forget. Recent experience shows what happens when immunization rates fall. During the antipertussis vaccine movement in the 1970s, Sweden halted DPT immunization in 1979 whereas its neighbor Norway did not. Subsequently, Sweden reported more than 10,000 pertussis cases annually, representing an incidence 100 times that of Norway, even though the countries have similar demographics and climates.2 In 1998 to 1999, Alaska had a measles outbreak when disease introduced by a Japanese child spread among children who had not received two doses of MMR vaccine.3 It is possible to address parents' concerns about vaccine safety even in a busy private practice. Most parents are not looking for extensive facts and figures or long-winded persuasive arguments. Instead, they seek a trustworthy provider who will listen to their apprehensions, acknowledge their fears, answer their questions, and provide personal reassurance that vaccines are right for their child. Vaccines not usually a hard sell Most parents have great faith in their pediatricians and readily accept their recommendations about vaccinating their children. Some parents simply are comfortable doing what everyone else is doing, but most weigh the risks and benefits of vaccines and believe that immunizing their child is the right thing to do, both for themselves and for society. For these parents, the approach is simple. First, provide information on the vaccine and disease by giving the parents the Vaccine Information Statement, as required by law. Then ask the parents a standard set of questions, listed in Table 1, to identify children who should not receive the vaccine, who should receive alternate forms of the vaccine, or who may benefit from acetaminophen with the vaccine. Always make sure that parents have an opportunity to ask questions and never coerce them. TABLE 1 Is today a good day for a routine vaccination? Has the child received a transfusion of blood or plasma, or been given immune (gamma) globulin in the past year? If a parent is concerned about a specific vaccine, try to ascertain exactly what is bothering her, clearly state your recommendation and rationale, voice your respect for the parent's view, and develop a mutually acceptable plan. If possible, administer those vaccines that protect against the diseases for which the child is most at risk based on the child's age, immunization history, and the prevalence of the disease in your community. Be sure to repeat your recommendation on subsequent visits: Parents may change their minds. The change from a sequential OPV/IPV schedule to an all inactivated polio vaccine schedule and the addition of pneumococcal conjugate vaccine have increased the number of injections an infant needs. Simultaneous administration of all routinely recommended childhood vaccines appropriate for the child's age and immunization status is recommended and is not known to affect the efficacy or safety of any of these vaccines. If multiple injections are unacceptable, offer the parent an opportunity to return for an immunization-only visit. Remember that while subsequent doses of the same vaccine must be given four to eight weeks apart and multiple live virus vaccines must be administered simultaneously or four weeks apart, no delay is required between doses of different inactivated vaccines such as DTaP, IPV, Hib, Hep B, or pneumococcal conjugate vaccine. Parents who oppose vaccination For a few parents who question vaccine recommendations, short explanations will not suffice. Like other parents, these mothers and fathers generally view their pediatricians as very credible sources of vaccine information, however, and the mere fact that the pediatrician is confident that giving a vaccine is the right thing to do carries a lot of weight.4 In a 1998 article on the challenges of communicating about vaccine risk, Dr. Leslie Ball categorized three types of risks associated with vaccines that parents often find unacceptable: Risks thought to be imposed or involuntary, such as an immunization that is required for school attendance. Parents prefer to control the decision to take a risk Risks that are man-made. Some people believe that the risk of disease, which is natural, is preferable to the risk posed by a vaccine, which is manufactured Risks associated with memorable or frightening events that occurred in the past apparently as a result of vaccination. Many stories in the antivaccine literature and Web sites fall in this category.5 Parents deal with risk they find unacceptable in various ways. If they hear about a serious adverse event associated with a particular vaccination, for example, they may overestimate the risk of such an event and underestimate the far greater risk of contracting the disease and suffering its complications. Others prefer the risk of the disease to the potential burden of responsibility should their child suffer an adverse effect based on their decision to vaccinate. Still others engage in "free riding": They rely on the protection afforded by living in a highly vaccinated society such as ours to protect their child. Whatever lies behind a parent's objection to immunization, try to understand it and address it in a nonconfrontational manner. Acknowledge parents' right to choose what is best for their child, while at the same time promoting a decision-making partnership. Personalize the information you give the family. For example, parents concerned about very rare vaccine risks may respond best to information about the more common risks of the disease itself. Make sure that responses to all parental questions and worries are balanced and accurate, addressing the benefits as well as the risks of immunization. To identify a family's specific issues, it may be useful to ask three questions represented by the mnemonic CuReS: Do you have any Cultural, religious, or personal beliefs that affect your views on immunizations? Has your child or any child you know ever had a Reaction to an immunization? Do you have any specific concerns about the Safety of vaccines? The first question may elicit a cultural concern or belief system, perhaps because the parent is from a country where any injection is viewed as hazardous. The second question may identify any personal experiences or stories that have affected the parent's views, though it is more likely to reveal that the parent does not know of a child who has suffered from an adverse event. The third question may clarify a specific worryperhaps triggered by the antivaccine literatureand allow a brief targeted response. Much of the antivaccine literature focuses on the pertussis vaccine. It is important to note that the adverse effects attributed to the pertussis vaccine and described on Internet Web sites relate to the old, whole-cell preparation. Parents are unlikely to hear emotional stories about the new acellular vaccines. First licensed in 1993, these vaccines account for only 1% of claims filed with the National Vaccine Injury Compensation Program from 1995 through 1998.6 The whole-cell preparation, on the other hand, accounted for more than 50% of claims under the program. While epidemiologic studies have shown that whole-cell pertussis vaccine is not associated with SIDS or brain damage, arguing this point with parents usually is not productive. It is better to focus on the safety profile of the new vaccines. Once you have dealt with a family's anxieties, you may want to summarize the philosophy behind vaccination by saying something like this: "As your medical advisor, I can give you information and assist you, but you make decisions about what's best for your child. Immunizations, along with better sanitation and nutrition, have made many diseases rare. For example, before the measles vaccine there were half a million cases of measles every year in the United States. Last year there were only 89. Yet more than 1 million children in the world die every year because they can't get the vaccine. In my lifetime, the leading cause of meningitis has been all but wiped out. We used to see kids all the time who got brain damage, were deaf, and died because of Haemophilus meningitis. But now we hardly ever do. All vaccines have some side effects, but serious reactions are rare. The immunizations we usually give at this visit are __________.The most common reaction is ___________________. Do you have any questions?" Information about vaccines is readily available to health-care providers and families. Table 2 lists some resources that are especially helpful. When parents just say no Sometimes, despite your best efforts, parents still say no to routine immunizations. At this point the best you can do is to remind them to remove their child from day care or school during outbreaks of diseases to which they remain susceptible because they have refused immunization. The reminder will not only help keep the nonimmunized child well, but will emphasize the real risks that vaccine-preventable diseases continue to pose. Reopen discussions about vaccination at future visits by asking the parents to repeat their views on immunization. They may welcome a chance to change their minds but may not know that immunization schedules are flexible enough to permit this. Also remember that some vaccines are better than none. Few parents decline Hib vaccine, perhaps because it is not mentioned in the antivaccine literature. Also, parents who refuse the pertussis vaccine may accept the diphtheria and tetanus components. It is important to build trusting relationships with families who don't want their children immunized. Vaccinated or not, all children need good medical care. TABLE 2 Resources for parents and physicians What Every Parent Should Know About Vaccines, by Paul Offit, MD, and Louis Bell, MD A wonderful short book that reviews specific vaccines and the diseases they prevent Six Common Misconceptions and How To Respond To Them, by the Centers for Disease Control and Prevention Targets the most common misconceptions in the antivaccine literature and offers sensible responses for both providers and families Pocket Immunofacts, by John Grabenstein Details on how each vaccine is manufactured and contraindications National Network for Immunization Information: www.immunizationinfo.org National Immunization Program, Centers for Disease Control and Prevention: www.cdc.gov/nip Vaccine information and a link to MMWR National Immunization Coalition: www.immunize.org/stories Stories of families who have suffered from vaccine-preventable diseases REFERENCES 1. Sachs JS: Vaccinesthe real risks and benefits. Parenting, March 1999, p 113 2. Gangarosa EJ, Galazka AM, Wolfe CR, et al: Impact of antivaccine movements on pertussis control: The untold story. Lancet 1998;351(9099):356 3. CDC: Transmission of measles among a highly vaccinated school populationAnchorage, Alaska, 1998. MMWR 1999;48:1109 4. Taylor JA, Darden PM, Slora E, et al: The influence of provider behavior, parental characteristics, and a public policy initiative on the immunization status of children followed by private pediatricians: A study from Pediatric Research in Office Settings. Pediatrics 1997;99(2):209 5. Ball LK, Darden PM, Slora E, et al. Risky business: Challenges in vaccine-risk communication. Pediatrics 1998;101(3):453 6. Richards CA: Vaccine Injury Compensation Program celebrates 10 years protecting children. Infect Dis Child 1998;11(11):16 DR. DIAS is Pediatric Hospitalist, Children's Hospital of Philadelphia, Connection at Shore Memorial Hospital, Somers Point, NJ. DR. MARCUSE is Professor of Pediatrics, University of Washington School of Medicine, Seattle, WA. Magna Chang Dias, Edgar Marcuse. When parents resist immunizations. Contemporary Pediatrics 2000;7:75.