Most Pediatricians Accept Alternative Vaccination Schedule

Kate Johnson

November 29, 2011

November 29, 2011 — Pediatricians frequently encounter requests for an alternative childhood vaccination schedule (ACIS), and 61% of them are generally comfortable complying, according to the results of a new survey of pediatricians in Washington state.

However, "pediatricians prioritize specific vaccines over others when considering these ACIS requests," conclude Aaron Wightman, MD, from the University of Washington in Seattle, and colleagues in an article published online November 28 in Pediatrics.

The study, which the authors suggest is the first to capture pediatricians' attitudes about this issue, defined an ACIS as "delaying immunization or not immunizing children" with certain vaccines for reasons other than established medical precautions and contraindications, relative to the Advisory Committee in Immunization Practices recommended schedule.

Dr. Wightman and colleagues included members of the Washington chapter of the American Academy of Pediatrics who were current in 2010 in the email, Internet-based survey if they saw 20 or more patients younger than 2 years of age per week.

Of 311 members who received the survey and responded (65% response rate), a total of 209 met the inclusion criteria and were included in the analysis. Most (57%) respondents were women, white (80%), and practiced in a non–health maintenance organization–based group (63%).

The survey included 9 items pertaining to pediatricians' attitudes towards ACISs, and 7 sociodemographic items. The primary outcomes were frequency of parents' requests for ACISs, pediatricians' comfort in using ACISs when requested, and pediatricians' willingness to consider ACISs for specific vaccines.

A multivariate logistic regression analysis showed independent associations between these primary outcomes and pediatricians' beliefs about immunization, after controlling for sociodemographic characteristics.

The survey found that 11% of respondents reported that parents frequently requested ACISs, 66% of the participants reported that parents sometimes requested them, and 23% reported that parents rarely requested them.

Overall, 61% of pediatricians agreed that they were comfortable using ACISs, if requested. However, just 4% indicated they would offer an ACIS in the absence of such a request.

Moreover, the survey also found that not all parents' requests were equal. Providers reported that they were least willing to delay diphtheria-tetanus toxoids-acellular pertussis vaccine (DTaP), pneumococcal conjugate vaccine (PCV), and Haemophilus influenzae tybe b (Hib) vaccine.

Specifically, more pediatricians were willing to consider ACISs for hepatitis B vaccine (87%), varicella vaccine (76%), and inactivated poliovirus vaccine (74%) than they were for Hib vaccine (36%), DTaP vaccine (39%), and PCV (42%).

When asked whether they would follow the recommended vaccination schedule if they were to become a new parent themselves in 2010, 96% of pediatricians said yes.

Univariate analysis showed that pediatricians who worked in a neighborhood or community clinic were less comfortable using ACISs if requested, compared with those who worked in a single or 2-physician practice (odds ratio, 0.12; 95% confidence interval, 0.03 - 0.53). This finding remained significant in multivariate models, using pediatricians' comfort with ACISs as the dependent variable and sociodemographic characteristics as the predictor variables.

"Perhaps a perception of low continuity of care and administrative and resource constraints may account for the reduced likelihood of pediatricians in some practices being comfortable using ACISs," they write.

The finding that parents' requests for ACISs are common "suggests the need for more-comprehensive studies of the use of ACISs for children throughout the nation, as well as investigations into the safety, efficacy, and potential consequences of delaying immunizations," note the authors.

"Pediatricians must navigate a course that ultimately respects parental authority and decision-making but strives to protect the health of the child," they add. "[P]rimary care clinicians should be recognized for seeking to immunize their patients against common and devastating diseases of infancy while maintaining a therapeutic alliance with parents."

In addition, they suggest that their findings point to a need for flexibility in addressing parental immunization requests "to allow the exercise of individual clinical judgment in managing parental concerns and protecting patients against vaccine-preventable diseases."

The authors acknowledge a number of limitations of the study, including their inability to distinguish between providers who were comfortable with ACISs because they thought this was an effective or superior approach compared with current recommendations and providers who have accepted ACISs because parents insisted on this approach.

Reached for comment, Walter A. Orenstein, MD, a member of the American Adacemy of Pediatrics' Committee on Infectious Diseases, told Medscape Medical News, "Our position is to follow the immunization schedule. We feel strongly that it’s important to get children immunized at the appropriate ages. What pediatricians on the front-lines have to do at times is balance that with the risk of losing the patient and the child receiving no vaccines at all."

Dr. Orenstein, who is also associate director of the Emory Vaccine Center and director of the Emory University of Georgia Influenza Pathogenesis and Immunology Research Center, Atlanta, said pediatricians in the survey sent a clear message about their personal views on the conventional vaccination schedule.

"When the pediatricians were asked if they had their own child in 2010 would they follow the current immunization schedule — and the vast majority would. So I think that tells you immediately what pediatricians think is the best way to go. The difficulties can be in trying to persuade parents of the benefits of the schedule and that’s why a number of them have been willing to accede to parental requests."

Although the optimal is the schedule, he said he would rather have a child receive a delayed vaccine than no vaccine at all.

"[Parents'] concern is the child being overwhelmed by too many vaccines at the same time and so the feeling is if we space them out then it’s safer for the child. I’m not aware of any good scientific data to support that. ...It’s one thing if there was a real trade-off between risk and benefit, but I’m not aware there is. And so you’re trading off benefit and adding risk...The FDA in licensing new vaccines requires that they be evaluated in the context of the current immunization schedule."

He said pediatricians should take a leadership role in convincing parents of the safety of the recommended vaccination schedule.

"I think they should provide leadership in trying to convince the parents to follow the conventional schedule. That is the optimal schedule from the scientific point of view, it’s been the schedule that people have reviewed carefully, and so I think they should try. If they try, and then risk losing the patient or the patient not getting vaccinated at all, there should be room for flexibility — but in my opinion their first effort ought to be to try and convince the parents to follow the routine schedule."

One author has been a paid consultant for Pfizer Pharmaceuticals. The other authors have disclosed no relevant financial relationships.

Pediatrics. Published online November 28, 2011. Abstract

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