Pediatrics

The Pediatric Infectious Diseases Society recently issued a position statement that “opposes any legislation or regulation that would allow children to be exempted from mandatory immunizations based simply on their parents, or, in the case of adolescents, their own secular personal beliefs.”

In the statement, Infectious Diseases in Children Editorial Board member Paul A. Offit, MD, and others said any legislation being considered should contain certain provisions; notably, that parents who are claiming exemptions be given counseling about the importance of immunization to their own children, as well as to the community overall. The authors of the statement also recommend that parents should have to sign a statement that they understand the risks of not immunizing their children.

The AAP, meanwhile, urges pediatricians to discuss with parents the importance of having their children immunized and not to dismiss vaccine-hesitant parents out of hand.

The primary reason cited by parents who are reluctant or who refuse to vaccinate is concern over safety and efficacy of vaccines. Lack of trust in the government, the perception that their children were not at great risk and that vaccine-preventable diseases were not severe are additional reasons often given by parents. But many groups, including the Pediatric Infectious Diseases Society (PIDS), said many of these concerns are based on fraudulent scientific data and surrounding media and celebrity hype. The PIDS statement even attributed recent resurgences of diseases, such as the recent measles outbreak, to this type of hype.

Many pediatricians struggle to prepare for a dialogue with vaccine-hesitant parents, and one group, Vax Northwest, is advocating a bottom-up approach that starts with the blogosphere. Vax Northwest is a collaboration of public and private organizations that came together to confront the issue of low immunization rates in Washington.

In an interview with Infectious Diseases in Children, Michele Roberts, MPH, who is the health promotion and communication manager at the Washington State Department of Health and also works with Vax Northwest, said their group began looking at different strategies to address parental concerns about vaccines because Washington has one of the nation’s highest vaccination exemption rates, according to data from the health department.

Until recently, parents in Washington needed only to sign a waiver form to exempt their child from vaccines required for school. However, on May 11, Gov. Chris Gregoire signed into law a bill that legally requires parents seeking non-medical exemptions to include a signature from a vaccine provider on the exemption form, stating that they have been given vaccine benefit and risk information.

Social media as a first step

Vax Northwest developed a social networking-based intervention that included training and a tool kit. These resources led providers to appropriate immunization resources for patients and resources for addressing vaccine-hesitant parents.

The program built on an earlier Vax Northwest statewide campaign for provider offices and clinics that used social marketing to increase timely immunizations among children aged birth to 24 months.

Roberts and one of the program’s partners, Edgar K. Marcuse, MD, MPH, of Seattle Children’s Hospital, said the idea was to use social media strategies to facilitate a dialogue between pediatricians and parents and hopefully reduce the time spent on this subject matter in pediatricians’ offices. Marcuse discussed this intervention during the recent 2011 Pediatric Academic Societies’ Annual Meeting in Denver.

A component of the Vax Northwest intervention, which was pilot-tested in four pediatric care clinics in King County, was to encourage parents to immunize their children as outlined in the CDC/AAP routine immunization schedule. The researchers then collected data via observation, post-training surveys, clinician interviews and project staff interviews.

Roberts, who spoke about the program during the 45th Annual National Immunization Conference in Washington, D.C., said 10 of 14 clinicians reported increased confidence in addressing concerns after completing the intervention training. However, clinicians did not feel that the intervention significantly changed the number of conversations they had with parents or the content of those conversations.

The clinicians also had a number of recommendations for improving the intervention, such as spreading the toolkit outside of pediatrics to other physicians, including family practice and prenatal care providers.

As a result of their study, Roberts said the Washington researchers are enhancing the program and plan to test it in 50 clinics.

“It is not to say there’s not a lot of great conversations going on, it is more of a situation of how can we help make interactions as efficient as possible?” Roberts said. “The research shows, time and again, that parents want to hear the information from their health care providers.”

Roberts stressed that a goal for the organizations that make up Vax Northwest is to work on interventions in the clinic and in the community, “because we know that we need to have a consistent message in all the places where parents are getting immunization information, like friends, providers, media, etc., and that the solution is not just in the provider’s office,” she said. “We’ve also done focus groups with parents who do immunize about what it would take for them to be active in their communities and share that they do immunize.”

Roberts said the next step is to work on how to foster community conversations about the importance of immunization and the benefit to the community, and “to take back the social norm that most people actually do immunize.”

The program plans to pilot this work in community settings such as preschools, parent groups and child care establishments.

In an interview with Infectious Diseases in Children, Offit praised the Vax Northwest approach, calling it one facet of a larger approach. He said that grappling with the issue of vaccine-hesitancy will take a multi-pronged approach, including position statements similar to the ones issued by PIDS, government backing, such as the bills that have been introduced in the state of Washington, and starting from the ground up, such as the Vax Northwest approach.

“Addressing the issue of vaccine-hesitantcy requires a lot of different approaches,” he said. “Educating them peer to peer is just one step.”

Heightened risks

As stated by PIDS, “Even a small number of unimmunized individuals in a community can facilitate the spread of disease.” The risk for measles is 35 times greater for an exempt child than a vaccinated one, 23 times higher for pertussis and nine times higher for varicella, according to the statement.

Parents who follow “alternative” vaccine schedules further complicate the problem. One such schedule, introduced by Robert Sears, MD, in his book, The Vaccine Book: Making the Right Decision for Your Child,offers parents an option in which they can delay, withhold, separate or space out vaccines.

The problem with parents adhering to these types of schedules, according to Marcuse, is that they prolong the time children are exposed to vaccine-preventable illnesses, increasing the likelihood they will get sick.

As a result of this book and others like it, parents are “requesting their child’s vaccines almost like they would order a latte at a coffee house,” Marcuse said. “So new, innovative approaches are needed to reach vaccine-hesitant parents who are susceptible to the messages of the antivaccine folks.”

Response to alternate schedules

Many pediatricians refuse to offer services to parents who only want partial vaccines or who refuse them altogether, according to Infectious Diseases in Children Editorial Board member and practicing pediatrician Richard Lander, MD.

“At issue is the parents’ rights vs. that of the community or that of the minor,” Lander said in an interview, adding that his practice does not refuse parents who choose not to immunize their children. “If a parent decides not to give vaccines, perhaps the insurance companies should charge them higher premiums since their risk of preventable infections is higher; and maybe if someone contracts a preventable illness from their child, the parents should be financially responsible for the health care costs involved. This would place more responsibility upon those parents and really alert them to how their decision doesn’t only affect their child.”

In a published survey, many pediatricians reported at least a single instance of total (85%) or selective (54%) parental refusal of vaccines. Pediatricians asked the families to seek care elsewhere for 28% and 39% of the selective and full refusers, respectively. The reasons to dismiss were “lack of common goals,” lack of trust or fear of litigation.

But refusing parents who refuse vaccines is not ideal, according to recommendations from the AAP, and it continues to urge a dialogue about vaccinations. In a recently published editorial, Larry K. Pickering, MD, and C. Mary Healy, MD, advocated for acknowledging to parents that vaccines are associated with some adverse events and balancing it against the disease risk, as well as addressing specific parental concerns with validated scientific literature.

“Health care professionals need to provide appropriate education and guidance to parents in an effective way to ensure that these decisions are made based on science and not anecdotes,” Pickering told Infectious Diseases in Children.

Lander said the best way to do that is by helping people view vaccines as protecting overall community health, similar to the way other laws are designed to protect community health.

“If a child needs a blood transfusion and is a Jehovah’s Witness, the state will intervene and mandate the transfusion,” Lander said. “No smoking rules are on the books in several states now. These laws were enacted to protect people from the dangers of secondhand smoke. Doesn’t the community have the right to protect itself from diseases that are preventable?”

The problem of addressing vaccine-hesitant parents is not a new concept, and the best approach to reaching these parents continues to be debated, even after decades of proven results with vaccines.

Pickering said in his editorial that “Benjamin Franklin, who was an early anti-vaccination campaigner, regretted his skepticism about vaccination after his 4-year-old son died from smallpox, writing, ‘I long regretted bitterly, and still regret that I had not given it to him by inoculation. This I mention for the sake of parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it, my example showing that the regret may be the same either way, and that, therefore, the safer should be chosen.’”

If only Mr. Franklin had a Twitter account. – by Colleen Zacharyczuk

For more information:

• Healy CM. Pediatrics. 2011;127(Suppl 1):S127-S133.
• Heller G. #I4. Presented at: The 45th Annual National Immunization Conference; March 28-31, 2011; Washington, D.C.
• Marcuse EK. #4230. Presented at: Pediatric Academic Societies’ Annual Meeting 2011; April 30-May 3, 2011; Denver.

Disclosures: Drs. Offit, Pickering and Marcuse report no relevant financial disclosures. Dr. Lander is co-owner of both the National Discount Vaccine Alliance, and Resources in Physician Management Services. He is also a speaker for Merck, Sanofi-Pasteur, Novartis and Pfizer.

What is the best approach to dealing with vaccine-hesitant parents?

All of us in pediatrics know the routine for the 2-month-old checkup. Perform the routine history and physical examination. Dispense routine advice. Administer routine vaccines. Then the impasse begins.

About 75% of parents are totally respectful of and adhere to our immunization recommendations. About 15% are “fence sitters” who can easily be persuaded that vaccines are indeed safe, indeed do not cause autism, and indeed do save innumerable children from death or severe morbidity. The next 5% to 7% of parents will require either our begging, our stern warnings, their signing an informed consent that their infant is at grave risk without vaccinations; or our admonishments that they must receive the vaccines as appropriate — or at least within a minimal schedule alteration, which is a compromise on the part of the pediatrician. But they will receive their vaccines.

It is the remaining 2% to 3% (5% in some areas) who are totally refractory to any advice or warnings or admonishments about the need to immunize. We all know within about 3 to 5 minutes of the vaccine discussion that this is going nowhere. The impasse has been reached.

Many pediatricians will elect to deliver the ultimatum: Come back within a month to receive the child’s vaccines, or else, seek their child’s care elsewhere. Some will be back; most will not. And many of us will coddle them, dispense our sage wisdom at every visit, and spend an extra 15 to 30 minutes of the well-child visits during the first 2 years discussing the child’s need for vaccines — usually without charging any extra fees for our time and energies (think insurance capitation and Medicaid). In addition, there will be no payment for any of several administration fees for vaccines that are never administered during those seven or so visits. Many marginal practices may not be able to really afford to absorb these additional costs.

Then we add the medico-legal risk with continuing to care for these families. What if their child gets the vaccine-preventable disease? What if they spread the disease to an infant or child in your waiting room who is adherent? This is totally unfair to the families who vaccinate their children. Plus, malpractice attorneys love the ambiguity.

The researchers in Washington are to be lauded for their valiant efforts. They are helping the practitioners improve their approach with these difficult families. However, the problem lies not with the practitioners or with their approach (as they told the investigators in Dr. Roberts’ study).

Although the researchers perceived that “parents want to hear the information from their health care provider,” in no way does that apply to this unique 2% to 5% of nay-saying parents.

They are the practitioner’s “mission impossible” for timely vaccinations. These parents know about “herd immunity.” The media hyperbole and the Internet blogs say vaccines are “too dangerous.” As a result of our vaccine successes, many vaccine-preventable diseases have become too uncommon, too far removed and too easy to downplay.

Sadly and ghastly, I think there is only one way to make an impression on them, by showing them the brutal ICU photos or hearing the personal parental testimonials about the devastating nature of these diseases, which is merely a mouse click away. The problem should not be laid at the doorstep of the pediatrician. Peer, social and media pressure on these parents are our only hope to spare innocent victims — their own and other unwitting children – of their vaccine paranoia.

Stan L. Block, MD, is an Infectious Diseases in Children Editorial Board member. Disclosure: Dr. Block reports no relevant financial disclosures.

Suspicious parents can be reassured of vaccine safety with proper communication strategies, openness and empathy.

There are four types of parents when it comes to vaccines: 1) believers — those who believe vaccination is safe and necessary; 2) relaxed — those who are cautious but still trust their physicians; 3) cautious — those who don’t really have a problem with vaccines until seeing media coverage or speaking with friends; and 4) the unconvinced — those who staunchly believe that not getting vaccinated is in the best interest of their child.

Pediatricians should target the cautious parents, who are typically scared but respond to education efforts. Many parents have been put off by physicians whom they felt were condescending. Physicians must maintain proper and sensitive communication habits despite time constraints with each patient.

Break down their fears and see where they’re coming from. Fewer and fewer parents are asking about specific vaccines and instead have this global, vague mistrust. If you ask them to specify their fears, you can respond appropriately.

The most effective pitch for a vaccine is one that is emotional and personal. You can throw out all the science and data and research, but at the end of the day, what really makes families comfortable is that you yourself are vaccinated and that you vaccinate your own kids. You must reassure your patients that you wouldn’t do anything different.

Ari Brown, MD, is an Austin, Texas-based pediatrician and co-author of Baby 411: Clear Answers and Smart Advice for Your Baby’s First Year. Disclosure: Dr. Brown reports no relevant financial disclosures.

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