Many Pediatricians Dismiss Parents Who Veto Infant Vaccines

Diana Swift

November 03, 2015

Almost all physicians encounter parents who refuse infant vaccines, and about 20% of pediatricians dismiss them, contrary to the 2005 American Academy of Pediatrics guideline, which was reaffirmed in 2013, according to a study published online November 2 in Pediatrics.

The dynamics of such refusal and providers' response to it are complicated, vary by region and practice, and need further investigation, according to researchers led by Sean O'Leary, MD, MPH, from the Department of Pediatrics, University of Colorado, Aurora. They conducted a nationally representative mail/internet survey of pediatricians and family physicians from June to October 2012.

With a response rate of 66% (534/815), 83% of all respondents reported that in a typical month, 1% or more of parents refused one or more infant vaccines, whereas 20% of the respondents reported that more than 5% of parents refused the vaccines. By practice type, 21% of pediatricians, but just 4% of family physicians, reported always or often dismissing families for refusing one or more vaccines.

The researchers adjusted for potential confounders including practice setting, whether or not the state allows philosophical exemptions, and region of the United States. Pediatricians who dismissed families were more likely to be in private practice (adjusted odds ratio [aOR], 4.90; 95% confidence interval [CI] 1.40 - 17.19). They were also more likely to be from the South (aOR, 4.07; 95% CI, 1.08 - 15.31) and to reside in a state that does not allow nonmedical philosophical exemptions (OR, 3.70; 95% CI, 1.74 - 7.85).

The majority (64%) of pediatricians reported always or often requiring parents to sign a documentation form if they refused vaccination, whereas just 29% of family doctors did so (P < .0001).

Not surprisingly, pediatricians from states without philosophical exemption or with more stringent exemption policies more often reported no parents refusing vaccines in a typical month than those in states allowing such exemptions (17% vs 8%; P = .03). Surprisingly, this difference did not hold for family physicians.

"Proportionally fewer states in the South (4/17) and Northeast (2/9) have philosophical exemption laws than in the West (8/13) or Midwest (5/12)," the authors write. "It is unclear from these data if this finding is merely an association or if there is a causal relationship in either direction," write Dr O'Leary and colleagues.

Overall, 63% of respondents reported that between 1% and 4% of parents refused vaccines (pediatricians, 68%; family practitioners, 57%), 15% reported 5% to 9% refusals (pediatricians, 16%; family practitioners, 13%), and 5% reported 10% or higher refusals (pediatricians, 4%; family practitioners, 7%; P = .37 for overall comparison between specialties).

When asked to report the current frequency of vaccine refusal vs that 12 months earlier, 23% of physicians reported it had decreased (pediatricians, 28%; family practitioners, 15%), 66% reported that it was about the same (pediatricians 58%; family practitioners, 78%), and 11% reported that it had increased (pediatricians, 14%; family practitioners, 7%; P = .25 for overall comparison between specialties).

In response to vaccine refusal, physicians most often reported requiring parents to sign a waiver form (64%), addressing vaccine concerns at a prenatal visit (55%) and advising parents to inform on-call and urgent care physicians of their children's immunization status (36%). Only about 1% of pediatricians and 4% of family physicians reported often or always advising parents to have children wear a MedicAlert bracelet.

The authors note that although many have decried dismissing families for refusing vaccines on ethical grounds, few have actually studied the practice. "Because many [pediatricians] still dismiss families despite recommendations to the contrary, this practice should be better explored and understood both for its causes and its intended and unintended consequences," they write.

This investigation was funded by the Centers for Disease Control and Prevention and administered through the Rocky Mountain Prevention Research Center, University of Colorado. The authors have disclosed no relevant financial relationships.

Pediatrics. Published online November 2, 2015. Abstract

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