AAP: Patient Dismissal Is Last Resort for Vaccine Refusal

Diana Swift and Rabiya S. Tuma, PhD

August 29, 2016

In a change of course, the American Academy of Pediatrics (AAP) now says pediatricians can dismiss families for vaccine refusal, but only as a last resort. The new clinical report, published online August 29 in Pediatrics, provides clinicians with multiple approaches for dealing with vaccine-hesitant families and stresses the role of pediatrician as educator in these situations.

However, if no approach works and pediatricians need to dismiss a family, they must do so in a thoughtful and professional manner, the authors emphasize. And they must ensure that the family has other options for medical care.

"The decision to dismiss a family who continues to refuse immunization is not one that should be made lightly, nor should it be made without considering and respecting the reasons for the parents' point of view," write Kathryn M. Edwards, MD, and Jesse M. Hackell, MD, from the AAP's Committee on Infectious Diseases and Committee on Practice and Ambulatory Medicine. "Nevertheless, the individual pediatrician may consider dismissal of families who refuse vaccination as an acceptable option. In all practice settings, consistency, transparency, and openness regarding the practice's policy on vaccines is important."

The previous AAP policy was against dismissal, but the authors say that rising refusal rates and clinician frustration led to the change, according to a related news story published by AAP.

Dr Edwards and Dr Hackell emphasize, however, that because pediatricians are often the only medically trained persons to discuss vaccine questions with families, they have a responsibility to provide doubting parents with scientifically based information.

"Pediatricians facing concerned parents…should be prepared to discuss the science behind the current vaccine schedule and the extensive testing of each vaccine before and after licensure, remind the parents of the severity of the diseases being prevented, address the questions that are causing parental concerns and, most importantly, emphasize that infants and children are the ones at greatest risk of disease," they write.

They should also point out that the current vaccine schedule is the only one recommended by the Centers for Disease Control and Prevention and AAP and that other schedules have not been evaluated.

However, pediatricians also need to treat parental concerns seriously. In the case of the human papillomavirus (HPV) vaccine, for example, parents are often concerned not only about adverse effects but also the potential for triggering precocious sexual activity. "Reassuring parents that the vaccine is safe and that there is no evidence that HPV vaccine increases sexual activity may dispel their concerns," they write.

As for the pain and discomfort factor, Dr Edwards and Dr Hackell recommend pain-reducing strategies, such as administering vaccines quickly without aspirating, holding the child upright, administering the most painful vaccine last, and providing tactile stimulation. Other pain-mitigating approaches are breastfeeding, giving sweet solutions or topical anesthetics, and distraction techniques (such as pinwheels, deep breathing exercises, and toys).

The authors also note that parents are often more swayed by anecdotes and personal stories about the safety and power of vaccines than by clinical data, so personalizing the conversation is important.

Ultimately, pediatricians should be prepared to spend a fair amount of time providing vaccine information. Dr Edwards and Dr Hackell cite a 2011 paper by Kempe et al (Am J Prev Med. 2011;40:548-555) reporting that 53% of physicians spent 10 to 19 minutes discussing vaccines with concerned parents and 8% spent at least 20 minutes.

Eliminate Nonmedical Exemptions

In a related policy statement, also published online August 29 in Pediatrics, AAP calls for an end to nonmedical exemptions for immunization.

"The AAP views nonmedical exemptions to school-required immunizations as inappropriate for individual, public health, and ethical reasons and advocates for their elimination," the statement says.

Although the group has previously opposed nonmedical exemptions, a press release says this is the first formal policy statement on the matter.

Pediatrics. Published online August 29, 2016. Clinical report Policy statement

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