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

Disclosures

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

In This Article

Discussion

To our knowledge, this is the largest study to date of CAM provider use and immunization rates among young children enrolled in private insurance plans. We found that, among non-Medicaid pediatric enrollees in two Washington State insurance companies, those who received care from naturopathic physicians or chiropractors during the years of their first or second birthdays were significantly less likely to have met the HEDIS schedule for vaccination against measles/mumps/rubella, chickenpox, or H. influenzae type B than were their counterparts. Additionally, children who received care from naturopathic physicians were significantly less likely to have received timely protection against diphtheria/tetanus. Diagnosis with vaccine-preventable diseases among children through age 17 years was rare. However, pediatric use of naturopathy was associated with significantly more diagnoses, and chickenpox was the diagnosis most frequently made.

Although studies over the last quarter century have suggested a lack of support for pediatric vaccination among a subset of CAM practitioners, there has been little information regarding associations between use of provider-based CAM therapies and parents' adherence to national vaccination guidelines. Our study suggests that parents who use naturopathic physicians or chiropractors for pediatric care are less likely to meet recommendations for vaccinations as measured by HEDIS specifications. The national Healthy People 2010 goals use an age range of up to 35 months to assess adherence, and our results, based on the stricter HEDIS standards, provide more conservative estimates of overall vaccination rates. However, our findings, in combination with current evidence of insufficient progress toward Healthy People 2010 goals in Washington State[45] and the US as a whole,[51] underscore the public health importance of improving vaccination rates among CAM providers' pediatric patients.

This study has several limitations. First, we used insurance claims as our sole source of evidence. Previous studies have found that claims underestimate true immunization levels[46] and include inaccuracies in diagnosis.[47] However, our findings are consistent with those based on provider and parent surveys, thus extending the knowledge base with information from insurance claims. Second, our insurance dataset began with the calendar year of the child's first birthday, thereby omitting information for a portion of the first year of life for most children. As a result, we could estimate adherence related to only a portion of the HEDIS vaccination schedule. Moreover, because we did not have precise date-of-birth information, we adopted a generous definition of adherence for even this portion of the standards and almost certainly over-estimated adherence to the schedule. However, we have no reason to believe that these deficits discriminated against CAM users. Third, our results are based on claims for children enrolled in non-Medicaid-funded insurance plans in Washington State. Vaccination rates in this sample may differ from those for the totality of Washington State children. Except for chickenpox, the vaccination coverage levels in our sample were lower than statewide estimates for children aged 19–35 months in 2000–2003.[48] Previous studies have suggested that some children enrolled in private insurance plans may not have full vaccination coverage and that government-sponsored programs may lead to higher uptake rates among children without private insurance.[49,50] We cannot evaluate the extent to which differences between our findings and statewide estimates were the result of our sample's more restrictive age range, private insurance coverage, or other unmeasured factors that differentiated this sample from the one used to estimate statewide rates. Again, however, we have no reason to suspect that this limitation would differentially affect users versus non-users of CAM. Fourth, our data covered too short a time period for determining whether parents chose to delay vaccinations until their children were older or to forgo vaccination altogether. Fifth, although we have shown associations between use of CAM providers and both reduced vaccination and increased disease incidence, our data do not allow attribution of causality. Lower vaccination rates among pediatric CAM users may reflect either a tendency for parents who prefer natural approaches to health and who are already vaccine-hesitant to seek out CAM professionals, or a pattern of direct influence by CAM providers on parents' attitudes. Some researchers have suggested that vaccine-hesitant parents may prefer CAM practitioners, in part, because they are less likely to introduce pro-vaccination pressure.[32] Washington State, where our study took place, has demonstrated strong acceptance of chiropractic and naturopathy into mainstream medical care.[44] Although pediatric vaccination rates in the state have increased dramatically in recent years, Washington currently lags behind 40 other states in childhood vaccination.[45] Our data were not sufficient for evaluating whether these two factors are related. Finally, our insurance data did not include information on factors such as income, education, and racial-ethnic status, which may confound associations between CAM use and both vaccination and diagnosis rates.

Our findings suggest that interventions with CAM practitioners and parents may be needed to increase support for pediatric vaccination. Future research aimed at developing successful interventions must include in-depth studies of parents and CAM providers to assist in understanding more precisely the important provider-related deterrents to vaccination. Intervention protocols will need to be responsive to the extent to which CAM providers are directly instrumental in reducing immunization or merely incidental to the patient population served. Also important will be an understanding of the mechanisms whereby direct influence is exerted (e.g., whether providers explicitly advise against vaccination or influence patients through more indirect means, such as pamphlets made available in waiting rooms or opinions expressed about where to turn for reliable information).

Irrespective of the causal dynamics, interventions with naturopathic physicians and chiropractors to increase active support for vaccination programs may be beneficial. Studies indicate that a majority of CAM practitioners make no explicit recommendations, and only a minority actively recommend against vaccination. Thus, many providers may be open to more active support of vaccination in conversations with parents. A recent survey found chiropractors in Alberta amenable to participation in immunization awareness and promotional activities.[52] Interventions enlisting assistance from CAM providers in the US might be productive, as well.

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