August 29, 2016
The number of pediatricians reporting vaccine refusals increased significantly, with the most common reason given for that refusal is the belief that vaccines are unnecessary.
That finding emerged from a small survey of pediatricians conducted by the American Academy of Pediatrics.
To counteract this trend, AAP issued a clinical report in which it urged open and honest communication by a trusted pediatrician with vaccine-hesitant parents.
Adding some muscle to that advice, the AAP said all non-medical vaccine exemptions should be eliminated. That recommendation came in a separate policy statement.
In 2013, 87% of pediatricians reported experiencing a vaccine refusal — a significant increase compared to 2006 (74.5%, P<0.001), reported Catherine Hough-Telford, MD, of University of Alabama at Birmingham, and colleagues.
The percentage of pediatricians who reported that parents refused vaccines because they considered them unnecessary was also up dramatically from 2006 (73.1% versus 63.4%, respectively, P=0.002), they wrote in Pediatrics.
“To our knowledge, this is the first study to demonstrate the perception among pediatricians of increasing rates of parents who believe vaccines are unnecessary as a reason for refusal,” Hough-Telford and colleagues wrote. “These data represent a significant shift in our understanding of the motivations behind vaccine refusals, [which] has not been recognized in recent literature on the subject.”
They added that other studies have suggested that the “relative rarity” of vaccine-preventable diseases has caused parents to perceive vaccines as “less crucial” to the health of their children. The authors suggested this presented an opportunity to research communication strategies to address these concerns.
Vaccine delays were also quite prevalent, with 87.6% of pediatricians reporting a request for delayed vaccination from a parent. Not surprisingly, 75% of pediatricians reported that a parent wanted to delay a vaccine because of concern for a child’s discomfort and 72.5% reported delays due to “fear that too many vaccines are a burden on their immune system.” Overall, the pediatricians surveyed estimated that 18.7% of parents requested to delay at least one vaccine.
In total, 627 pediatricians who participated directly in patient care and offered age-appropriate immunizations were included in the 2013 survey (similar to 2006, when 629 participated). Vaccine delay questions were only asked in 2013.
Pediatricians reported an increasing number of dismissals for vaccine refusal (11.7% in 2013 versus 6.1% in 2006, P=0.004). The most common reasons for dismissal were a lack of trust between physician and patient, as well as concern for other patients.
However, the authors also found that 31.9% of patients who initially refused a vaccine changed their minds after educational efforts.
“This … illustrates the importance of initiating conversations about vaccines with an understanding of the reasons for parents’ concerns … to best devise effective strategies to promote vaccinations in the refusing and delaying patient,” they wrote.
Strategies for Vaccine Hesitancy
The clinical report on vaccine hesitancy emphasized the importance of the pediatrician as a trusted source of information, and the importance of acknowledging and addressing parental concerns about vaccination, reported Kathryn M. Edwards, MD, and colleagues on the AAP Committee on Infectious Diseases and the Committee on Practice and Ambulatory Medicine.
“The pediatrician is often the only medically trained person available to discuss vaccine matters with parents, and it is incumbent on him or her to provide scientifically based and balanced information when these questions are asked,” Edwards and colleagues wrote. “The clear message parents should hear is that vaccines are safe and effective, and serious disease can occur if your child and family are not immunized.”
In fact, one study found that nearly 80% of parents said their decision to vaccinate was positively influenced by their healthcare provider.
Information was a key component of certain strategies for vaccine-hesitancy — namely that the pediatrician discuss why children need vaccinations on the schedule provided by the CDC’s Advisory Committee on Immunization Practices and the AAP. Another study found that only 55% of practitioners “routinely provide parents with the rationale for why vaccines are administered and their potential adverse effects,” and that nearly half of vaccine-hesitant parents accepted vaccines after this dialog with their provider.
But the parents may not be the only ones who need information. A survey of pediatric residents found that a little under half received training in communication strategies for vaccine-hesitant parents, and 80% wanted more education about a vaccine’s adverse effects.
“A brief educational intervention may not be sufficient to provide physicians with the skills to counteract vaccine hesitancy and … more research is needed to determine the most effective educational interventions,” the authors wrote.
In addition to factual information, the authors suggested “personalizing” the message about the safety and efficacy of vaccines. Prior research suggested that physicians relating that their own children or grandchildren have received all their immunizations was helpful to convince “skeptical parents.”
The authors also addressed the ethical dilemmas involved with dismissing patients who refuse to comply with recommended vaccine schedules. Though they characterized patient dismissal as “an acceptable option,” they encouraged “consistency, transparency and openness” in the process. They also noted certain anecdotal evidence, which showed that given the choice between dismissal or immunization, some parents would opt for immunization.
Non-Medical Exemptions “Inappropriate”
The AAP also argued that non-medical exemptions for vaccinations are not appropriate for children entering school or a community child care facility, in a separate policy statement from the Committee on Practice and Ambulatory Medicine, and several other AAP committees.
“The AAP views non-medical exemptions to school-required immunizations as inappropriate for individual, public health, and ethical reasons and advocates for their elimination,” the authors wrote.
Given the recent ruling against a legal challenge to California’s law eliminating non-medical exemptions, the statement may be especially timely. The AAP called on all states and the District of Columbia to “use their public health authority” and eliminate all non-medical exemptions.
They noted that states offering personal belief exemptions have seen those requests increase over time — and even states who have religious belief exemptions only “have, through regulatory language, broadly defined religion for purposes of obtaining vaccine exemption,” the authors wrote.
In addition to supporting laws requiring immunization to attend child care and school, the AAP recommended that public health authorities provide the community with immunization rates. However, they also recognized the need for medically indicated exemptions “on an individualized basis” for children with rare contraindications for specific vaccines.
Hough-Telford and colleagues were supported in part by grants from the AAP and CDC.
Hough-Telford disclosed no relevant financial relationships.
Kimberlin disclosed serving as site principal investigator on studies conducted by GlaxoSmithKline and Gilead.
Edwards disclosed no relevant financial relationships.
Hackell disclosed that a family member has stock or equity in Glaxo Smith Kline.
The authors of the policy statement disclosed no relevant financial relationships.
Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner
LAST UPDATED 08.29.2016