CDC Expert Commentary

Overcoming Vaccine Concerns and Refusals

Anne Schuchat, MD

Disclosures

June 06, 2011

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Hello. I'm Dr. Anne Schuchat, Director of the National Center for Immunization and Respiratory Diseases at the CDC. I am pleased to speak with you today as part of the CDC Expert Commentary Series on Medscape. I want to personally thank you for the work that you and other physicians, nurses, physician's assistants, and office staff do every day to protect our nation's children from vaccine-preventable diseases. You answer parent's questions, schedule and remind them of visits, and address the increasing needs of the families under your care. This is hard but very important work. Today, I would like to provide some tips on effective strategies for talking with parents about infant immunizations as well as highlight new resources that can support you with these conversations.

Let me first say that on the national front we are very reassured by what we have learned about parents' vaccine attitudes and behaviors. We know that the vast majority of parents in the United States believe that vaccines are important for keeping children healthy and nearly all parents are vaccinating their children. Less than 1% of young children have received no vaccines at all. Immunization rates of toddlers are 90% or more for most routine vaccines.[1] We also have found that most parents are confident in vaccine safety. However, that doesn't mean that they have no questions or concerns, and I would bet that many of you have heard some of these concerns.

Research shows that healthcare providers are still parents' most trusted and important source for helping them make vaccine decisions.[2] It seems like you are doing a good job – a recent survey found that 88% of parents felt that their child's healthcare provider was easy to talk to and 84% reported that they trusted their provider's vaccine advice.[2]However, I know that addressing parents' questions and concerns takes time and can be stressful for you, given all that you are trying to do during each well-child visit. Here are some communication tips that should help during your conversations.

Take time to listen. If parents need to talk about vaccines, give them your full attention. Resist the urge to multitask. This can actually save you time in the long run. Maintain eye contact with parents and restate their concerns to be sure you understand their viewpoint. Your willingness to listen will likely play a major role in helping parents choose vaccination.

Solicit and welcome questions. If parents seem concerned about vaccines but are reluctant to talk, ask them open-ended questions to let them know that you want to hear from them. Try putting yourself in parents' shoes and acknowledge their feelings and emotions, including their basic desire to protect their children. Remind them that their infant's health is your priority, too.

Keep the lines of communication open and the conversation going. If parents come to you with a long list of questions or information from the Web or other sources, try not to think of this as a lack of respect. Spending time to research vaccines means that this is an important topic for them. It doesn't mean they won't value your advice.

Use a mix of science and personal experience. Facts can be great, but too much science will frustrate some parents, and starting with the facts often doesn't work. On the other hand, too many anecdotes will frustrate other parents. Try to strike the right balance. Don't be afraid to share stories from your experience about an unprotected child who became ill, or that children in your family have received all of their vaccines.

Talk openly about benefits and risks of vaccines. Always discuss the known side effects associated with vaccines. Your openness helps sustain trust and keeps parents listening. Remind parents of the overwhelming benefit of preventing serious diseases by immunizing. If you are faced with a parent who is considering delaying a shot, tell them that not vaccinating their child leaves them at risk for diseases. Let them know that this is a risk that worries you.

Reduce the stress of immunizations. Give parents some ways that they can make the vaccination visit less stressful for the child. This helps put them in control, and also can make the experience less stressful for the parent. For infants, they can distract the baby during the vaccination with a favorite toy or soothe the baby by making eye contact, and talking softly. After the vaccine is given, suggest that mom cuddle or breastfeed. Toddlers can be distracted by telling a favorite story, singing, or taking deep breaths and "blowing out the pain." Encourage parents to praise their child and reassure them that everything is okay. Stickers or a visit to the treasure chest help, too! Don't forget that it's hard for parents to see their baby in pain. Reassurance helps -- remind them that the pain of the injection is temporary and the protection from disease is long-lasting!

Document and follow up with highly concerned parents. If a parent expresses a high level of concern about vaccines, you may want to document their questions and concerns. This record can be a helpful reference during future visits. Some practices follow up with a call or e-mail a few days after the visit. This will show that you care and reinforce trust.

Unfortunately, a parent may at times decide to delay or decline a vaccine. In these situations, a few things should be considered:

  • CDC doesn't recommend excluding a child from your practice if the parent declines immunizations. We understand that you are trying to protect other children in the practice, but remember that without a medical home, the child is at risk for many different health problems -- not just vaccine-preventable diseases. They need your quality care.

  • We suggest you share our new fact sheet If You Choose Not to Vaccinate Your Child, Understand the Risks and Responsibilities . This tool explains the risks involved with this decision and the additional responsibilities parents need to take on. Many parents don't realize they are putting their children at risk by not vaccinating them, and that they will need to take special precautions when their children are ill and visiting the pediatrician or emergency department, to avoid spreading an infection to others, and to alert clinicians about appropriate diagnoses.

  • Tell the parent that you would like to continue the conversation about vaccines during the next visit, and then make sure to do so.

  • Last, you may wish to have them sign the American Academy of Pediatrics (AAP) Refusal to Vaccinate form . Ask parents to sign this form each time a vaccine is refused so that you have a record in their child's medical file.

CDC, AAP, and the American Academy of Family Physicians have developed new tools to support your communication efforts with parents. They are free and can be downloaded from the CDC Website. You will find materials covering current vaccine safety topics, answers to common questions asked by parents, and more strategies for successful discussions with parents. There are also specific materials that you can give to parents to educate them on vaccines, vaccine-preventable diseases, and vaccine safety. To access the resources and materials I've talked about during my time with you, please refer to Web Resources, below.

I hope that these reminders -- and the materials that you, your staff, and parents can find on our Website -- will help ensure your continued success in immunizing infants and children. Thanks so much for the work you do to keep our nation's children healthy and safe.

Web Resources

Provider Resources for Vaccine Conversations with Parents

Feedback on Provider Resources for Vaccine Conversations with Parents

American Academy of Pediatrics Refusal to Vaccinate Form

Additional resources for healthcare professional on vaccines, vaccine-preventable diseases, and vaccine safety

Dr. Anne Schuchat (pronounced shook-it) joined CDC in 1988 as an Epidemic Intelligence Service Officer. She has made significant contributions to infectious disease prevention through research, surveillance, and policy, developing guidelines and disease monitoring systems, conducting pre- and post-licensure vaccine evaluations, and collaborating with partners to accelerate the availability of vaccines and prevention programs. She worked in West Africa on meningitis and pneumonia vaccine studies, in South Africa on surveillance and prevention projects, in China on SARS emergency response, and as CDC's Chief Health Officer during the H1N1 pandemic response. Dr. Schuchat graduated with highest honors from Swarthmore College and with honors from Dartmouth Medical School. She completed residency training at New York University's Manhattan VA Hospital. She has co-authored more than 180 scientific articles and reports, and received numerous awards including the Public Health Service's Meritorious Service Medal for preventing group B streptococcal infections in newborns. Since December 2005, Dr. Schuchat has served as the Director for the National Center for Immunization and Respiratory Diseases. From February through May 2009 she was CDC's Interim Deputy Director focusing on science and program and in 2008, she was elected to the Institute of Medicine. In 2006, she was promoted to the rank of Assistant Surgeon General within the US Public Health Service, and in 2010 received her second star.

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