How to address vaccine hesitancy: New AAP report says dismissal a last resort

As a practicing pediatrician for decades, Jesse M. Hackell, M.D., FAAP, was tired of trying to convince resistant parents to get their children fully vaccinated. Though his New York practice did not have a large number of families refusing vaccines, they took a lot of time and exposed other patients to vaccine-preventable illnesses.

Several years ago, his practice decided to dismiss families who refused vaccines.

“For years, the Academy position was not to dismiss,” Dr. Hackell said. “Over the years, many of us were frustrated with that being the official policy and not stating that dismissal is also an acceptable option.”

In a new clinical report co-authored by Dr. Hackell, the Academy has officially acknowledged for the first time that dismissal is an option in certain circumstances for patient families who categorically refuse vaccines. The Committee on Infectious Diseases and the Committee on Practice and Ambulatory Medicine issued the report Countering Vaccine Hesitancy, which is available at http://dx.doi.org/10.1542/peds.2016-2146 and will be published in the September issue of Pediatrics.

Address specific concerns

Vaccine hesitancy is on the rise. The percentage of pediatricians encountering parents who refused a vaccine increased from 75% in 2006 to 87% in 2013, according to an AAP Periodic Survey of Fellows. A 2010 telephone survey of parents found that 3% refused all vaccines, though that varied by geography.

The report offers tools to help pediatricians with this population, including online resources to educate families.

One way to educate parents is to address specific concerns directly. For example, if parents are concerned that the number of vaccines given at one time “will overwhelm my child’s immune system,” it may be helpful to show them the table in the clinical report that demonstrates all the preteen vaccines today have about 123-126 immunogenic proteins compared to over 3,200 such proteins in 1960.

Pain is another common reason for vaccine hesitancy, and the report lists several options for pain reduction.

For those worried about safety, the report points out that vaccine testing and licensure is thorough. Post-licensure monitoring includes the Vaccine Adverse Events Reporting System (VAERS), the Vaccine Safety Datalink, the Post-Licensure Rapid Immunization Safety Monitoring system and the Clinical Immunization Safety Assessment Project. In fact, VAERS identified intussusception associated with RotaShield in 1999, leading to withdrawal of the vaccine.

When dismissal is an option

For those who refuse vaccines, another option to consider is patient dismissal. Although the report reflects the Academy’s stance that dismissal is not the preferred choice and encourages pediatricians to continue to work with vaccine-hesitant families, it does discuss dismissal as an option in the right circumstances.

The report originally was written without an option for dismissal, said co-author Kathryn M. Edwards, M.D., FAAP, director of the Vanderbilt Vaccine Research Program.

“But practitioners were having problems,” she said, so dismissal was added as “a very last resort” in the toolbox for pediatricians dealing with vaccine-resistant families.

Drs. Edwards and Hackell emphasize that dismissal should be undertaken only if these conditions are met:

• The pediatrician has exhausted all means of education with the family.
• The family has been made aware of the office policy concerning dismissal of non-vaccinators.
• The geographic area is not in short supply of pediatric providers.
• The practice continues to provide health care until the family finds another provider (usually 30 days).

Pediatricians’ influence

The report notes that pediatricians can have a profound influence on the vaccine-hesitant family. One observational study found that when physicians continued to engage families, up to 47% of parents ultimately agreed to have their children vaccinated after initially refusing.

Dr. Edwards is convinced that if pediatricians focus on the safety of vaccines and accurately relate the burden of disease to parents, many will accept the vaccines.

“Measles is like a four-way stop,” Dr. Edwards said. “If one person doesn’t stop, then we’re fine. But if more than one person doesn’t stop, then we won’t be fine.”

However, the report points out that there is not an evidence-based, reliable way to convince all parents about the value of vaccines and urges more research on communication techniques.

Some families will refuse vaccines no matter what communication method is used (see sidebar). For these families, dismissal now is an AAP-approved option.

For Dr. Hackell, it’s a straightforward decision. “If they won’t accept my advice about vaccinations,” he said, “how are they going to accept my advice on anything else?”

See related story "Facing the dilemma of dismissing vaccine refusers."