Pediatric Vaccination and Vaccine-preventable Disease Acquisition: Associations with Care by Complementary and Alternative Medicine Providers

Lois Downey; Patrick T. Tyree; Colleen E. Huebner; William E. Lafferty


Matern Child Health J. 2010;14(6):922-930. 

In This Article

Abstract and Introduction


This study investigated provider-based complementary/alternative medicine use and its association with receipt of recommended vaccinations by children aged 1–2 years and with acquisition of vaccine-preventable disease by children aged 1–17 years. Results were based on logistic regression analysis of insurance claims for pediatric enrollees covered by two insurance companies in Washington State during 2000–2003. Primary exposures were use of chiropractic, naturopathy, acupuncture, or massage practitioner services by pediatric enrollees or members of their immediate families. Outcomes included receipt by children aged 1–2 years of four vaccine combinations (or their component vaccines) covering seven diseases, and acquisition of vaccine-preventable diseases by enrollees aged 1–17 years. Children were significantly less likely to receive each of the four recommended vaccinations if they saw a naturopathic physician. Children who saw chiropractors were significantly less likely to receive each of three of the recommended vaccinations. Children aged 1–17 years were significantly more likely to be diagnosed with a vaccine-preventable disease if they received naturopathic care. Use of provider-based complementary/alternative medicine by other family members was not independently associated with early childhood vaccination status or disease acquisition. Pediatric use of complementary/alternative medicine in Washington State was significantly associated with reduced adherence to recommended pediatric vaccination schedules and with acquisition of vaccine-preventable disease. Interventions enlisting the participation of complementary/alternative medicine providers in immunization awareness and promotional activities could improve adherence rates and assist in efforts to improve public health.


Experts have hailed vaccination as one of ten great Twentieth Century achievements in public health in the United States (US).[1] Pediatric vaccines have dramatically reduced infectious disease and childhood mortality.[2] The US government's "Healthy People 2010" initiative has set coverage goals for six vaccines recommended for universal use in young children.[3]

However, the recommendations are not without controversy. Some parents choose to delay vaccinating their children or forgo vaccination altogether for at least some of the targeted diseases. Research has consistently found associations between parental support for complementary and alternative medicine (CAM) therapies and opposition to pediatric vaccination. One research group reported an association between family use of CAM providers, particularly chiropractors, and application for nonmedical exemptions from compulsory school entry vaccinations.[4] Another linked parental orientation toward alternative medicine with greater concern for side effects and a likelihood of opting out of vaccinations.[5] Still another found that decisions against pediatric vaccination were more common among parents who preferred obtaining vaccination information from CAM providers instead of conventional providers or public health experts.[6]

Surveys of North American providers have reported mixed findings regarding chiropractors' attitudes toward vaccination. A national study of US chiropractors conducted in the mid-1990s found that two-thirds of respondents agreed that immunizations should never be given to infants under 1-year-old. Almost half believed the chiropractic profession should officially oppose the American Public Health Association's vaccination guidelines. More than one-third believed that immunizations cause more disease than they prevent, that contracting an infectious disease is safer than being immunized against it, and that there is no scientific proof that immunization prevents disease.[7] Researchers since that time have continued to detect vaccination hesitancy among chiropractors.[8] However, two articles concluded that only a minority of the chiropractic profession, fueled by the writings of a handful of vocal opponents, holds extreme anti-vaccination views.[9,10] Surveys of students and practitioners have confirmed that a majority of the rank-and-file offer general support for vaccination and the provision of the full spectrum of risk-benefit information to patients.[11–13] A 1998 survey of Boston family-practice chiropractors found that the majority provided education to parents but made no explicit recommendation, 30% actively recommended in favor, and only 7% actively recommended against pediatric vaccination.[11] Currently neither the American Chiropractic Association (ACA) nor the International Chiropractors Association (ICA) takes an official stand regarding the relative risks and benefits. Both groups oppose mandatory vaccination and emphasize the need for individual freedom of choice. The ACA calls for "informed awareness of the benefits and possible adverse effects of vaccination,"[14] whereas the ICA emphasizes risk over benefit.[15] An early study found significantly greater agreement with anti-vaccination statements among ICA than among ACA members.[7] The International Chiropractic Pediatric Association's position is similar to that of the ICA, focusing on adverse consequences. Its main vaccination web page emphasizes risk information and includes links to additional pages focusing on risks of specific vaccines.[16]

Evidence about associations between naturopathy and pediatric vaccination is less plentiful, but published reports suggest that only a minority of naturopathic physicians actively support full vaccination.[17–20] A survey of naturopathic physicians in Massachusetts found most making no recommendation, 20% actively recommending, and 7% actively opposing pediatric vaccination.[17]

Doubts about vaccination have centered on several arguments. First is a belief that vaccinations do not produce immunity or that they actually cause disease.[4,6–10,12] Second are concerns about vaccine safety, side effects and adverse events, links to autism, and general interference with appropriate development of the immune or nervous systems.[4,5,7–10,21,22] A third argument emphasizes preference for infection-driven immunization as more permanent or less risky than vaccine-induced protection.[7,8,12] Fourth are arguments that minimize risk of disease acquisition[4,6] or effects.[4,6,9] Finally, some vaccination opponents voice disbelief in pro-vaccination information provided by allopathic providers, government agencies, public health experts, and immunization safety and efficacy research.[4,6,7,18]

With increased CAM use in the US during the latter half of the Twentieth Century,[23–25] users' attitudes toward pediatric vaccination have wielded potentially greater influence on vaccination rates. Estimates of pediatric CAM use suggest substantially lower utilization among children than adults, but the estimates vary widely, depending upon the year of data collection, time period considered, study design and sample, geographic area, and types of CAM included. In a 1996 national self-report survey, fewer than 2% of parents reported use of any CAM therapies, broadly defined, in the previous year by their children through age 18 years.[26] Reported rates of use were considerably higher in two 1999 surveys that asked parents whether their children had ever used CAM therapies. When asked about lifetime use, 6% of those seeking care in Detroit-area pediatric practices[27] and 12% seeking care in the emergency department of a Pittsburgh children's hospital[28] reported pediatric CAM use. Data from Washington State insurance claims revealed 6% of pediatric enrollees through age 17 years had used provider-based CAM therapies during calendar year 2002.[29] Estimated rates of pediatric use of chiropractic and naturopathy have typically been higher than estimates for other CAM therapies.[28–31] Despite relatively low pediatric use of provider-based CAM, CAM practitioners may exert direct influence on vaccination rates through information provided to parents who see them strictly for adult care.[32] Additional influence on parents may occur through websites that are affiliated with CAM groups[33] or that refer to CAM literature.[34]

Indications of considerable vaccination hesitancy among CAM users and providers notwithstanding, a study based on the 2002 National Health Interview Survey found that adult users of CAM were more likely than non-users to report having had vaccinations themselves.[35] This finding suggests that CAM users may be more "health conscious" than non-users and may engage in a wide variety of disease-prevention measures. Whether increased health consciousness among adults enhances prevention activities with their children is of interest. To date, however, studies related to pediatric vaccination have typically focused on the following: (1) vaccination attitudes or recommendations rather than uptake rates,[5,7–18] (2) activities related to compulsory vaccination,[4] or (3) rates among localized samples of pediatric CAM users.[19,20] In the current article we examine the use of provider-based CAM therapy and receipt of recommended pediatric vaccinations in a statewide sample. The sample comprised non-Medicaid pediatric enrollees in two large insurance companies in Washington State, where insurance coverage of provider-based CAM therapy is required by law. Because research has shown that exemptions from school immunization requirements are correlated with higher rates of infectious disease,[36] we also examine the association between pediatric CAM use and vaccine-preventable disease occurrence.


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