Clinicians See Increase in Vaccine Acceptance, Medscape Survey Says

Alicia Ault

August 17, 2015

New survey data from Medscape suggest fewer parents may be refusing to vaccinate their children, especially in western states, which have had some of the highest refusal rates in America.

Forty-two percent of clinicians said they believed more parents are accepting vaccines, and 38% said parents are more accepting of measles vaccination in particular, according to the Medscape Vaccine Acceptance Report, an online survey of 1577 pediatricians, family physicians, public health physicians, nurse practitioners, and physician assistants that was conducted last month.

Even so, a third of those surveyed said they had not seen any changes in parents' willingness to accept vaccinations.

Some states in the Western region of the country, which included California, Alaska, Hawaii, Montana, Wyoming, Idaho, Oregon, and Washington, were the main sites of a well-publicized measles outbreak in 2014. Healthcare professionals in that region reported higher rates of acceptance for measles vaccines (46% vs 36% for the rest of the country) and for all vaccines (51% vs 41%).

"Overall, this is encouraging," Amanda Cohn, MD, deputy director of the Centers for Disease Control and Prevention's (CDC's) Immunization Services Division, told Medscape Medical News. However, she said, "It will take some time to see changes in parental choice in vaccination demonstrated through data."

The CDC will issue its latest National Immunization Survey in late August, but the data will not be up to date enough to reflect changes in parental acceptance in the wake of the 2014 measles outbreak, said Dr Cohn.

According to the Medscape survey, parents were most likely to refuse or request an alternate vaccination schedule for the measles, mumps, and rubella (MMR) and human papillomavirus (HPV) vaccines, 58% of clinicians said. These were followed by the varicella (28%), hepatitis B (23%), hepatitis A (18%), and diphtheria, tetanus, and pertussis (17%) vaccines.

The survey was taken as measles cases continued to increase in the United States. This year and last have been record-setting, with 668 cases from 27 states reported to the CDC's National Center for Immunization and Respiratory Diseases in 2014, and 183 cases in 24 states and Washington, DC, reported through the end of July this year.

A large outbreak (383 cases) occurred among a group of unvaccinated Amish people in Ohio last year, but the outbreak that was traced to a foreign visitor at Disneyland in December 2014 garnered more media attention and may have contributed to some parents' willingness to accept vaccination, according to survey respondents.

"More parents read the news and are open to counseling," said one respondent. Other survey respondents said that parents were asking more questions, but that those who were antivaccination were still hesitant.

Fear Main Driver, but May Not Last

Almost half of clinicians surveyed said they attributed an increase in acceptance to parental fears that their child would contract a vaccine-preventable disease. A fifth said that parents worried about their children being barred from school or camp, and another 20% said that parents had gained more comfort with vaccination after further research.

Fear of disease, especially measles, seemed to be the biggest factor. One nurse practitioner said, "We had a possible measles case that caused some parents who were reluctant to vaccinate call to ask about vaccinating."

Carrie Byington, MD, chair of the American Academy of Pediatrics Committee on Infectious Diseases and the H.A. and Edna Benning Presidential Professor of Pediatrics at the University of Utah School of Medicine, Salt Lake City, said she has seen more acceptance, but that it was likely enhanced in part by the attention to the recent measles cases.

"We've seen this happen every time there have been outbreaks," Dr Byington told Medscape Medical News. "The imminent risk may change their attitudes about immunizing their child," she said.

Mark Fishaut, MD, a pediatrician at San Juan Healthcare in Friday Harbor, Washington, said that a local measles outbreak led to a panic that temporarily increased vaccine acceptance, but that parents who had avoided immunization eventually began refusing again.

Although all states require schoolchildren to be vaccinated, 18 states let parents opt out based on religious or philosophical beliefs, according to the National Conference on State Legislatures. About 3.6% of Washington state kindergartners had a nonmedical (mostly philosophical) exemption from vaccination in the 2013 to 2014 school year, according to the CDC, compared with a national median of 1.8%.

Oregon leads in nonmedical exemptions, at 7.0%, followed by Vermont and Idaho at 6.1%, according to the CDC.

After the Disneyland measles outbreak, which affected at least 100 people, Joseph F. Hagan Jr, MD, and colleagues at their practice in Burlington, Vermont, compiled a list of unimmunized and underimmunized patients and sent a letter to parents asking them to reconsider "in light of the current news." Only two or three of 50 families accepted, Dr Hagan told Medscape Medical News.

There has been no major change in acceptance at his practice, said Dr Hagan. "It's distressing, but not terribly surprising," he said.

"The problem is because we don't see these diseases very often, we've lost perspective," said Dr Hagan, a clinical professor in pediatrics at the University of Vermont College of Medicine.

Dr Fishaut said that the most common reasons for refusals at his practice include fear of autism, conspiracy theories about pharmaceutical companies, and an aversion to all chemical interventions.

That reflects the Medscape survey data. Sixty-four percent of clinicians said parents fear complications, and 61% said parents fear a connection to autism. Half said parents worried about added ingredients such as thimerosal, and 45% said parents expressed concerns about immunization overwhelming a child's immune system.

Dr Byington called the autism and immunity fears myths. "As physicians, we continue to be frustrated by the traction that these myths continue to have," she said, noting that "every one of these myths have been debunked again and again through scientific study."

But parents' fears are easily amped up by specious claims on the Internet, said Dr Byington.

Strategies to Increase Acceptance

A majority of clinicians surveyed (69%) said they provide evidence-based information to address specific parental concerns. Clinicians also said that they create a customized approach and share potential morbidity and mortality statistics on vaccine-preventable diseases.

Eight percent said that they refuse to accept families in their practice who will not adhere to the recommended vaccination schedule. The American Academy of Pediatrics recommends against this, said Dr Byington.

A growing body of literature suggests that parents have wide-ranging reasons for avoiding vaccination, she said. New data indicate that the best approach might be to explain the individual risk to a specific child, Dr Byington said.

The American Academy of Pediatrics is reworking its policy statement on vaccine hesitancy and will publish it later this year, Dr Byington told Medscape Medical News.

"My policy is to not punish children for parental ignorance," said Dr Fishaut. Beyond educating parents, he said he has worked with the school system to ensure that unvaccinated children cannot participate in extracurricular activities. And, he says, he "works with immunizing parents to be the principal public advocates for vaccination."

Washington State is currently considering legislation to repeal the philosophical exemption. California Gov. Jerry Brown (D) signed a bill in June that eliminated religious and philosophical exemptions. And in 2014, Vermont passed a law to eliminate philosophical, but not religious, exemptions beginning in 2016.

Dr Byington said that the California measles outbreak put state lawmakers on notice. She expects "to see a large number of states introducing bills regarding exemptions," she said.

Dr Hagan is coeditor of "The Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents," published by the American Academy of Pediatrics. Dr Fishaut and Dr Byington have disclosed no relevant financial relationships. Clinicians who responded to the survey were eligible for a raffle, but they were not paid for their participation in the survey. The margin of error was plus or minus 2.46%.

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