Tuesday, March 21, 2023
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Disquiet and debate about the safety and effectiveness of vaccines have been around as long as vaccines themselves, dating back to the first smallpox vaccine created by Edward Jenner.[1] The first antivaccination society came into being in 1879, and has existed in one form or another ever since. Vaccine hesitancy is "a delay in acceptance or refusal of vaccination despite availability of vaccination services,"[2] and is viewed as a stance somewhere between full acceptance and outright refusal of some or all vaccines. However, unlike outright, determined refusal of all vaccines, hesitancy leaves the door open to education, compromise, and persuasion. The most common roots of vaccine hesitancy are fear of side effects of vaccination and distrust in the vaccine; a lack of perceived risk for vaccine-preventable diseases; and the influence of antivaccination reports in the media, leading parents to request alternate schedules for vaccines ("vaccine delay") or to refuse some vaccines altogether.[3,4]
Image from National Institutes of Health
The personal and public health impact of vaccine hesitancy, if it culminates in refusal, is substantial. Parents offer many justifications for declining vaccines for their children, and traditionally have not been easily persuaded by statistics about a vaccine's safety and efficacy, or horror stories about children who developed a vaccine-preventable disease. The burden on clinical practice in terms of time alone is significant, and providers must also grapple with such questions as how to provide quality pediatric care to unvaccinated children, how to protect other patients in the practice, and how to protect their own liability for any poor outcomes resulting from continuing to provide care to unvaccinated children.
The reasons behind vaccine hesitancy or refusal range from religious objections to personal beliefs, safety concerns, a preference for "natural" immunity, and a lack of accurate information about vaccines from a trusted source.
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In 2015, a major outbreak of measles in a California theme park focused attention on the problem of vaccine hesitancy and vaccine refusal in general, as well as the effect of low vaccine uptake on herd immunity for vaccine-preventable diseases. In the wake of that outbreak, in a 2015 Medscape survey, clinicians perceived that vaccine acceptance was increasing slightly. Experts wondered whether the increased level of acceptance was merely a reaction to the outbreak—a temporary blip in vaccine acceptance that would return to previous low levels as memory of the measles outbreak faded into history.
This year, questions about the duration of effectiveness of the pertussis vaccine, measles outbreaks among unvaccinated children in Arkansas and Tennessee, and adverse effects reported in association with the HPV vaccine have been prominent in the news, but little is known about how these developments have affected vaccine acceptance.
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In May 2016, 1551 physicians, nurse practitioners, and physician assistants in pediatrics, family medicine, and public health responded to the survey. Only clinicians who worked in a practice setting where vaccines were administered to patients younger than 18 years were included. The survey questions sought to determine the perceptions of these clinicians about current levels of vaccine hesitancy and refusal among patients in their individual practices. Findings were compared, to the extent possible, with a similar Medscape survey conducted in 2015 to identify any trends in vaccine hesitancy, refusal, or acceptance. Respondents were 60% women and 40% men. Practice locations were in the Northeast (13%), Mid-Atlantic (19%), Southeast (15%), Great Lakes (15%), South Central (7%), North Central (5%), Southwest (7%), Northwest (5%), and Western (14%) regions of the United States. (Please note: Totals do not always equal 100%, owing to rounding and because many questions allowed respondents to choose more than one answer.)
When healthcare professionals were asked about vaccine acceptance last year, 42% of respondents perceived that overall vaccine acceptance had increased. This year, 46% believed the same. Although the findings of these surveys are not directly comparable, this degree of vaccine acceptance is encouraging, because it suggests that increasing acceptance is not merely a temporary boost prompted by a major outbreak of vaccine-preventable disease. Overall, vaccine acceptance appears at least to be steady, and trending in the right direction.
However, despite these signals of increased acceptance, 1 in 3 clinicians in our Medscape survey have not perceived any recent changes in the overall willingness of parents to accept vaccines for their children. Vaccine hesitancy remains a significant issue, and vaccine refusal has been associated with outbreaks of invasive Haemophilus influenzae type b disease, varicella, pneumococcal disease, measles, and pertussis.[5]
The top reason for respondents' belief that vaccine acceptance is increasing, cited by 72%, is a general increase in concern about infectious diseases. More than one half (53%) of the respondents believe that increasing vaccine acceptance is motivated by parents' fear of their children acquiring a vaccine-preventable disease, such as pertussis or measles. Concerns about their unvaccinated children being denied admission to school, daycare, or camp were cited by 44% of respondents—a significantly higher proportion than last year, when 33% of respondents believed school requirements to be a key motivating factor. A significant proportion of respondents (39%) believe that increasing acceptance is a consequence of parents becoming more educated about the safety and efficacy of vaccines The influence of other parents ("peer pressure") to have their children vaccinated was cited least often (12%).
Last year, a prominent reason for increasing acceptance of vaccines in general, and the measles-mumps-rubella (MMR) vaccine in particular, may have been the 2015 measles outbreaks in California.[6] This year, measles outbreaks have taken place in several states. Another factor that has come into play is California's new law, effective July 1, 2016, eliminating philosophical/personal belief and religious exemptions to school-mandated vaccines. Parents of children who have not had the 10 vaccines required for school attendance (diphtheria, H influenzae type b, measles, mumps, pertussis, polio, rubella, tetanus, hepatitis B, and chicken pox) may have been scurrying to obtain these before the start of the school year.
Clinicians who report seeing an increase in vaccine refusals blame persistent beliefs on the part of parents about a link between vaccines and autism, and concerns about other ingredients in vaccines. The reasons for vaccine refusal cited by respondents are similar to those in last year's survey and are consistent with other studies on vaccine hesitancy and refusal.[7] These include the fear that children will experience adverse effects from the vaccine that are worse than the diseases they are intended to prevent,[8] or that "natural immunity" from acquiring one of these diseases is to be preferred. More than one half of all clinicians (and 83% of pediatricians) in our study believe that increasing vaccine refusal is based on a fear of overwhelming the child's immune system with too many vaccines.
C. Mary Healy, MD, associate professor of pediatrics, infectious diseases section, at the Baylor College of Medicine in Houston, Texas, says, "Myths persist because it is very difficult to allay fears, once the genie has escaped the bottle. This is especially true when the fear is of a condition such as autism, the cause of which is not yet known, although it is clear that vaccines are not to blame. Vaccines are victims of their own success. Because vaccines have effectively reduced the incidence of vaccine-preventable diseases on a massive scale, saving countless lives and untold misery in the process, parental perception of risk versus benefit has become skewed."
Despite the high degree of vaccine hesitancy reported in this survey, it would be a mistake to assume that this is entirely an "us vs them" issue. Vaccine hesitancy exists among healthcare providers, too, and some share the same concerns about vaccines as vaccine-hesitant parents.[9] A lack of confidence in vaccines can be unconsciously communicated to parents, influencing their vaccine decisions.
Among all vaccines given to children, the three most often refused or requested on an alternate schedule are the human papillomavirus [HPV], influenza, and MMR vaccines. Last year, after sampling differences were accounted for, survey respondents identified the MMR vaccine (52%) as most often refused or given on an alternate schedule, compared with 37% for MMR this year, suggesting that uptake of the MMR vaccine has indeed increased since the 2015 measles outbreak. Slow uptake of the HPV vaccine is consistent with other reports. Nationwide, only 40% of girls and 21% of boys are receiving the recommended three doses of the HPV vaccine.[10]
Many barriers to HPV vaccine uptake have been described, but the reasons for declining the influenza vaccine are not clear. Furthermore, elimination of the nasal spray option for the influenza vaccine this year could pose yet another barrier to vaccine uptake among children.
In the 10 years in which it has been available, uptake of HPV vaccines has not met expectations. Studies indicate that reluctance of parents to consent to the HPV vaccine at the recommended age is common,[11] although the reasons for refusing the HPV vaccine differ from reasons for refusing other childhood vaccines. It is not a mandatory vaccine. It is relatively new, so it doesn't have the long safety record of other vaccines. Even parents who accept other childhood vaccines may hesitate to permit their child to have the HPV vaccine because they have seen news reports from various countries suggesting that the HPV vaccine might be linked with autoimmune or neurologic disorders.
Parents who choose to delay the HPV vaccine because their child is too young for sexual activity should be counseled that the vaccine series must be completed before exposure to HPV, and that the vaccine produces a stronger immune response in preteens than it does in older teens and young women. Several survey respondents suggested focusing on the role of HPV in preventing cancer when counseling parents as a strategy to mitigate resistance to the vaccine.
In examining reasons for the slow uptake of the HPV vaccine, the survey revealed that 7% of all clinicians are ambivalent about the risks and benefits of the HPV vaccine, and do not promote it as much as other vaccines. This ambivalence was slightly stronger among family medicine practitioners than pediatric clinicians (8% vs 2%), and among younger (< 50 years: 8%) vs older (≥ 50 years: 4%) clinicians.
Other research supports the finding that provider ambivalence plays a role in HPV vaccine acceptance. Although most providers reported in a recent study that they usually discuss the HPV vaccine at the 11- or 12-year visit, only about 60% of pediatricians and family practice physicians strongly recommend the vaccine to parents. Without a strong recommendation from clinicians, it is unlikely that parents will be able to overcome other reservations about the vaccine, such as the fear that it will encourage sexual activity, concerns about safety, or relative unconcern about HPV disease.[12]
What strategy do most clinicians use to promote acceptance of vaccines? Asking parents about their specific concerns, and addressing those concerns with the evidence, was the approach that respondents cited most often as a potentially successful strategy. More than one half of the respondents attempt to increase parental confidence in vaccines by sharing that their own children are vaccinated on the recommended schedule. One fourth of respondents find that offering or agreeing to administer vaccines on an alternative schedule satisfies hesitant parents. Other research reports that clinicians are routinely pressured to delay vaccines, and they usually acquiesce to these demands.[13] Like last year, however, in our survey very few clinicians thought that asking families who refuse vaccines to find another healthcare provider was an effective approach to encourage vaccine acceptance.
Rather than a lack of information about vaccines, there is information overload from countless disparate sources.[14] Providing accurate information about vaccines to correct misinformation and misunderstandings is one of the most common strategies used by clinicians to increase parents' confidence in vaccines. However, more than a few respondents were cynical about such strategies as sharing the science or telling "horror stories," which, as one respondent said, "work rarely. Most antivaxxers are not influenced in any way."
Among all specialties, 90% of providers will continue to allow families who refuse required vaccines to remain with the practice, and 10% dismiss such families. Although not recommended by the American Academy of Pediatrics (AAP), pediatric clinicians were more likely than family practice clinicians to dismiss families for refusing vaccines (19% vs 8%)—consistent with other studies.[15] The AAP does not recommend dismissing these families unless distrust develops between provider and parents. Keeping vaccine-hesitant families in the practice allows for repeated opportunities to educate families and convince them to accept vaccines.
According to comments offered by survey respondents, some practices do not immediately dismiss families who request alternate schedules for vaccines, but require the families to adhere to the agreed-on alternate schedules for catch-up vaccinations.
A large majority of respondents (82%) who do not dismiss vaccine-refusing families also make no modification to the clinic or its procedures to protect other children from vaccine-preventable diseases. However, some respondents described how they handle an impending visit from a sick, unvaccinated child:
Many clinicians were proactive about protecting their own liability when they retain vaccine-refusing families in the practice. Almost one half (44%) of all respondents and 60% of pediatric providers require vaccine-refusing parents to sign a waiver stating that they have declined vaccines and are aware of the risks associated with remaining unvaccinated. One in 4 clinicians report that they refuse to sign documents for school or daycare attendance for unvaccinated children. Clinicians who do not require a waiver typically use the electronic health record to document refusal to accept vaccines at each visit. Many clinicians commented that they carefully document all vaccine discussions and education provided during visits.
The AAP has a statement, Responding to Parental Refusals of Immunization of Children,[16] outlining strategies for providers to use with vaccine-refusing parents. Although not considered a legal document, they also provide a sample waiver to have vaccine-refusing parents sign, and information about how to document vaccine refusal and how to code for vaccine counseling when vaccines are refused. With respect to legal liability, healthcare providers who have vaccine-refusing parents in their practices should read Reducing Vaccine Liability: Strategies for Pediatricians.
Clinicians are clearly frustrated about the media's mixed messages about vaccines. They believe that the lay media could support vaccination efforts by disseminating better information to combat the misinformation found on the Web. More than one half of all respondents (and 74% of pediatricians) also believe that laws should be passed or made stronger that mandate vaccines and remove exemptions for all but medical reasons.
The World Health Organization (WHO) maintains that no single intervention strategy can address all reasons for vaccine hesitancy, and that the most effective interventions are multicomponent and should address the specific reasons a parent gives for refusing vaccines. Other strategies recommended by WHO are listed above.
Some experts believe that social media outlets have enormous untapped potential to promote vaccine confidence, increase awareness of the consequences of children remaining unvaccinated, and reverse trends in vaccine refusal.[17]
Image from iStock
In open-ended comments, respondents seem divided on whether attempting to educate parents about the effectiveness, safety, risks, and benefits of vaccines will make any headway with vaccine-hesitant parents. Although many clinicians advocate the educational route to vaccine compliance, many of their comments suggest that they are skeptical that anything they say to these parents will make any difference in their decisions about vaccines. It is viewed by some as an emotional issue that is not susceptible to logic or evidence.
In other research, parental distrust of the government and of healthcare providers plays a significant role in vaccine refusal, and reaching them will require modalities outside of traditional government and healthcare provider communications.[18]
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