Vacunas Up

8/12/2019 Vacunas Up

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Standard childhood vaccines: Parental hesitancy or refusalAuthorsJulie A Boom, MDC Mary Healy, MDSection EditorsMorven S Edwards, MDJan E Drutz, MDDeputy EditorMary M Torchia, MDDisclosures

All topics are updated as new evidence becomes available and ourpeer review process iscomplete.Literature review current through:Mar 2014. | This topic last updated:feb 14, 2014.

INTRODUCTIONThis topic reviews the reasons why some parents refuse or are hesitant to

have their child(ren) immunized; the consequences of vaccine refusal; and an approach to the

management of parents who refuse vaccines for their children. Standard childhood immunizations

for children are discussed separately. (See"Standard immunizations for children and adolescents".)

BACKGROUNDImmunization is one of the most effective preventative health measures and

has saved countless children from death or serious disability (figure 1). Despite this, immunization is

an emotional issue for many parents. As vaccine-preventable diseases become less common and

parents have little familiarity with the devastating effects of vaccine-preventable illnesses, the

benefits of immunization may seem less important than the potential adverse effects [1].

Mainstream media and Internet discussions on vaccines, fueled by celebrity opinion, often give

equal or greater weight to ill-informed opinion or anecdotal claims about the dangers of vaccines

compared with the rigorous scientific studies that prove vaccines are safe and effective [1-4]. The

mainstream media has a limited ability (or perhaps preference) to adequately communicate

scientific data on vaccines, and Internet sites are not subject to constraints regarding scientific

accuracy or fairness of their reporting. The resulting misinformation leads to unnecessary parentalconcerns. Healthcare providers need to understand these concerns in order to effectively address

them and aid parents in choosing immunization for their children. (See'Approach to

management' below.)

STATE LAWS REGARDING VACCINATIONAll 50 states in the United States require some

immunizations for school entry (typically for kindergarten, seventh grade, and college entry).

However, parents can elect to exempt their children from immunizations. There are three types of

exemption:

Medical exemptions are for children who have a valid medical contraindication to a vaccine

or vaccine component (eg, history of anaphylaxis to a previous dose of vaccine).

Religious exemptions are for individuals whose religious beliefs oppose immunizations.

Philosophical exemptions are for individuals with a personal, moral, or philosophical belief

against some or all immunizations.

All states allow medical exemptions; nearly all allow exemptions based upon religious beliefs, and

approximately 40 percent allow philosophical exemptions [5]. TheNational Conference of State

Legislatures provides a comprehensive list of state exemption statutes.
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Observational studies suggest that the ease with which exemptions can be obtained impacts

exemption rates within communities [5-9]. States that allow philosophical and religious exemptions

have significantly higher vaccine exemption rates than those with religious exemptions only [10].

They also have higher rates of vaccine-preventable diseases [6,11,12]. The Pediatric Infectious

Diseases Society is opposed to legislation that permits philosophical exemption to mandatory

immunizations [13]. (See'Consequences of vaccine refusal' below.)

EPIDEMIOLOGY

PrevalenceThe prevalence of vaccine refusal remains low. In a 1999 national survey,

immunizations were rated as extremely important by 87 percent of parents, and 84 percent said

they would not decline any immunizations [14]. In a 2009 national survey of parents or guardians of

children 6 years of age, 93.4 percent indicated that their youngest child had or would receive all

recommended vaccines, but only 80 percent reported believing that immunizations were very

important to childrens health [15].

Although the majority of parents agree to have their children immunized, vaccine refusal appears to

be increasing [5,9,14,16-19]. The proportion of children who are exempted from school

immunization requirements for nonmedical reasons is the primary measure of vaccine refusal in the

United States [5]. Between 1991 and 2004, the mean rate of nonmedical immunization exemptions

at kindergarten entry increased from 0.98 to 1.48 percent at the state level. Among states that

allowed exemptions forphilosophical/personal beliefs, the nonmedical exemption rate increased to

2.5 percent [6]. The rate of nonmedical exemptions at kindergarten entry varies geographically

(ranging from 1.1 to 24.2 percent by county in Washington state for 2010-2011; and from


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Parents who seek vaccine exemptions may have a low level of trust in the government and

healthcare professionals and may use complementary or alternative medicine professionals whom

they consider to be reliable sources of vaccine information [26]. In a 2002 national survey, 12

percent of respondents who had at least one child


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Belief that is it better to be naturally infected than vaccinated

Cost

Belief that the child is not at risk or that the disease is not dangerous is a consequence of the

success of childhood immunization programs (figure 1). As more diseases are successfully

prevented by immunization, the devastating sequelae of vaccine-preventable diseases are forgotten

[1]. Many parents are unaware of the risks to the individual and of the societal consequences of

refusing vaccines. (See'Consequences of vaccine refusal' below.)

Specific objectionsParents (and providers) may have a tendency to selectively protect against

diseases they believe are more severe (eg, Haemophilus influenzaetype b) and refuse vaccines

against diseases that they believe are not dangerous. As an example, varicella vaccine is one of

the more commonly refused vaccines [5,37,38].

Many studies demonstrate that underimmunized children have characteristics reflecting social

inequalities, rather than true philosophical objections to immunization. (See'Demographics' above.)

However, there is some evidence to suggest that parents whose children were underimmunized for

pertussis, hepatitis B, or measles had safety concerns (eg, autism, thimerosal) and wished toselectively immunize their children [23,39].

MMR vaccineConcern regarding the combinationmeasles-mumps-rubella vaccine (MMR) can

be traced to a 1998 study in 12 children from the United Kingdom (UK) alleging that MMR damaged

the intestinal lining, allowing encephalopathic proteins to enter the bloodstream and brain, thereby

leading to the development of autism [40]. The paper was retracted from the public record in 2010,

and exposed as fraudulent in 2011 [41,42]. Despite overwhelming evidence disproving this theory, it

still is highlighted in media reports and on the Internet [2]. Large-scale population studies have

demonstrated that MMR and autism occur independently of each other and that gastrointestinal

disease and autism do not occur after MMR vaccine. This issue is discussed in detail separately.

(See"Autism and chronic disease: Little evidence for vaccines as a contributing factor", section on

'Enterocolitis and regression'.)

Despite the lack of an association between autism and MMR, MMR immunization rates in the UK

declined acutely (from 92 percent in 1995 to 79 percent in 2003) [43,44]. In June 2008, measles

was again endemic in the UK, 14 years after it had been eliminated [45,46].

HPV vaccineHuman papillomavirus (HPV) vaccine is controversial for some patients and

providers. Attitudes of parents, partners, and clinicians influence completion of the vaccine series

[47]. Concerns regarding HPV vaccine are related to the belief that it may encourage sexual

activity, excessive influence by the pharmaceutical industry [48,49], and safety [36]. The 2009 death

of a British girl within hours of receiving HPV vaccine received widespread attention; autopsy

demonstrated that she died of an undiagnosed tumor and that her death was unrelated to HPV [50].

The media focus on the above concerns may have contributed to the number of adverse events

reported to the Vaccine Adverse Event Reporting System (VAERS) between June 2006 and

December 2008 (53.9 per 100,000 doses administered, 6.2 percent serious) [51]. However,

analysis of the VAERS reports shows that the adverse events were similar to those identified before

the vaccine was licensed. They were also similar to background rates of other vaccine-associated

adverse events, except for two categories: syncope and venous thromboembolism. The age group

for whom HPV vaccine is recommended (11 to 26 years) has an excess risk of immunization-
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associated syncope [52]. Two subsequent studies, each including >600,000 doses of HPV, found

either no association with venous thromboembolism [53]or a nonsignificant association that

occurred exclusively among girls with other risk factors (eg, smoking, prolonged hospitalization)

[54]. (See"Recommendations for the use of human papillomavirus vaccines", section on 'Vaccine

safety'.)

Meningococcal conjugate vaccineThe major concern regarding the quadrivalent

meningococcal conjugate vaccine is a possible association with Guillain-Barr syndrome (GBS)

[55]. GBS is an immune-mediated, rapidly evolving polyradiculoneuropathy with an estimated

incidence of 1 to 2 cases per 100,000 person-years. Although GBS has

been temporallyassociated with vaccination, a causalassociation has not been proven. The

possible association between quadrivalent meningococcal conjugate vaccine and GBS is discussed

separately. (See"Meningococcal vaccines", section on 'Possible association with Guillain-Barr

syndrome'.)

InfluenzaParental concerns regarding influenza vaccines may include unknown side effects with

possible long-term problems, Guillain-Barr syndrome (GBS), thimerosal exposure, inadequate

testing to ensure safety in children, and the lack of need for protection against what may bemistakenly thought of as a "mild type" of influenza [56].

Concerns about influenza-vaccine-associated GBS and other neurologic complications were

highlighted by the media during the 2009 H1N1 influenza pandemic. Cases of GBS occurred

following the administration of swine flu vaccine in the United States in 1976 and 1977, and some

commentators erroneously compared the rapid development of H1N1 vaccines to swine flu vaccine

development in 1976. However, monovalent H1N1 vaccine was developed using the same methods

that are used for seasonal influenza vaccine, and the increased risk of GBS following seasonal

influenza vaccine was found to be small or nonexistent [57-59]. (See"Seasonal influenza

vaccination in children", section on 'Adverse reactions' and"Seasonal influenza vaccination in

children", section on 'Adverse effects' and"Pathogenesis of Guillain-Barr syndrome in adults",section on 'Influenza vaccination'.)

ThimerosalThe use of thimerosal (ethylmercury) as a vaccine preservative has been

hypothesized to result in mercury-related neurologic effects, including the development of autism.

Numerous studies refute this hypothesis. Nonetheless, some parents remain unconvinced by the

scientific data. (See"Autism and chronic disease: Little evidence for thimerosal as a contributing

factor".)

CONSEQUENCES OF VACCINE REFUSALVaccine refusal increases the risk of vaccine-

preventable disease among unvaccinated individuals and the risk of vaccine-preventable disease

outbreaks in the general population.

For the individualUnvaccinated children have a higher risk of acquiring vaccine-preventable

illness than their vaccinated peers. In observational studies and mathematical modeling, the

magnitude of the increased risk is approximately ninefold for varicella and ranges from 22- to 35-

fold for measles and 6- to 28-fold for pertussis [60-64].

During January-August 2013, 159 measles cases occurred in residents of the United States

[65]; 82 percent occurred in individuals who were unvaccinated and 9 percent in individuals
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with unknown vaccination status; among those who were unvaccinated, 79 percent had

philosophical or religious objections to vaccination.

Among Colorado children enrolled in a large health plan, 11 percent of pertussis cases were

attributed to vaccine refusal [61].

In a 2008 outbreak of invasiveH. influenzaetype b (Hib) disease in Minnesota, Hib

vaccination was deferred or refused by the guardians of three of the five cases; one of thesechildren died from Hib meningitis [66].

The risks of delaying immunization have not been well studied [5]. As a general rule, young children

are at greater risk for severe disease than older children who contract vaccine-preventable illnesses

(eg, pertussis, influenza). Delaying immunizations increases the duration of vulnerability for these

young children.

For the communityThe public health consequences of vaccine refusal are demonstrated by

multiple outbreaks of vaccine-preventable diseases in unvaccinated individuals, as illustrated

below:

Between 1985 and 1994, 13 disease outbreaks occurred in religious groups opposed toimmunization, resulting in 1200 cases and 9 deaths [67].

A measles outbreak at a college for Christian Scientist students resulted in 125 cases (attack

rate 15 percent) and three deaths (case fatality rate 2.2 percent) [68]. Another measles

outbreak at a camp attended by Christian Scientists had an attack rate of 25.2 percent [68].

Outbreaks of polio, rubella, measles, pertussis (345 cases, attack rate 20 percent), and H.

influenzaetype b (Hib) have been reported in undervaccinated Amish communities [69-75].

Measles outbreaks occur on a regular basis in Europe and were reported across the United

States during 2008, mainly among children whose parents had refused immunization

[45,46,76-78]. (See'MMR vaccine' above and'For the individual' above.)

Suboptimal vaccination rates also result in disease outbreaks and deaths among vaccinatedindividuals [62,79]. Vaccinated children may acquire infection through contact with vaccine

exemptors. Rates of disease among vaccinated individuals increase as vaccinated and

unvaccinated individuals mix in communities [62,63].

In a population-based study of children aged 3 to 18 years, the frequency of vaccine

exemptors directly correlated with the incidence of measles and pertussis in vaccinated

children [62]. Schools with pertussis outbreaks had more vaccine exemptors than schools

without outbreaks (4.3 versus 1.5 percent of students).

In observational studies in Michigan (1993-2004) and California (2010), census tracts with

clusters of nonmedical exemptions were two to three times more likely to overlap with census

tracts with clusters of pertussis than census tracts without clusters of medical exemptions

[11,80].

APPROACH TO MANAGEMENT

Overview of approachParental vaccine refusal may evoke strong emotional responses in

medical providers, ranging from issues of trust in their relationships with patients to medicolegal

concerns [35]. It may be difficult to put aside these initial reactions, but establishing a

nonconfrontational dialogue from the first clinician-parent interaction is essential to ensuring a
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successful result. The healthcare provider is one of the most important influences in decisions about

immunization, even among vaccine-hesitant parents [15,23,26,34,81,82].

When faced with vaccine-hesitant parents, the provider should be guided by the following

recommendations [83]:

Establish open, ongoing, nonconfrontational dialogue to identify concerns.Target education to address specific parental concerns, using a variety of resources (table

1).

Maintain the provider-patient relationship.

Use vaccine schedules that deviate from the recommended schedule (eg, the schedule

recommended by Centers for Disease Control, American Academy of Pediatrics, and

American Academy of Family Physicians in the United States) (figure 2A-B)only when other

options, such as targeted education, have failed and the family would otherwise refuse

vaccination entirely.

Establish dialogueDialogue should begin at the first provider-parent encounter and continue at

every subsequent interaction. The dialogue is more important than the outcome at any one visit

[84]. Providers must listen to their patients' parents to identify the forces that influence vaccine

concerns. Once the concerns are identified, the provider can establish a plan for targeted education

to address them. (See'Why parents refuse vaccines' above.)

Key points in establishing the dialogue include [84]:

Acknowledging a shared goal (what is best for the child)

Acknowledging the large volume of complex, conflicting information about vaccine benefits

and safety

Offering to help them to gather the best information to make an informed decision (table 1)

Identify concernsRespectful listening is critical in identifying the source of parental concerns.

Parents receive vaccine information from media reports that grab audience attention, presentinformation that is easy to understand, and highlight pro- and antivaccine viewpoints in a limited

time frame. A few sensational, anecdotal reports alleging harm may receive equal or greater

attention than large-scale population studies that prove vaccine safety [1]. Erroneous impressions

regarding vaccine safety may be supplemented by stories parents have heard from family or friends

or have read on the Internet. Visual imagery of children allegedly hurt by vaccines is more

compelling than faceless statistics about diseases parents have never seen or experienced.

Some parental concerns may not be immediately obvious. Parents may be concerned that their

infant will suffer during vaccine administration. They may fear committingharm (giving an unsafe

vaccine) more than allowingharm (taking a chance that their child will develop a disease).

Providers must listen carefully and respectfully to understand these concerns, even if it is timeconsuming.

One author provides a practical approach to categorizing vaccine-hesitant parents according to the

source and conviction of their concerns [85]:

The "uninformed but educable" have received an antivaccine message from families or

friends but seek information to counter this.
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The "misinformed but correctable" have been influenced byantivaccine messages from the

media or the Internet but are relatively unaware of medically accurate provaccination

arguments.

The "well-read and open-minded" have explored the pro- and antivaccination messages but

want their provider's input in interpreting the information.

The "convinced and contented" are strongly antivaccination but want to demonstrate theirwillingness to listen to the other side of the argument (often to satisfy a family member).

The "committed and missionary" are strongly antivaccine and want to convince the provider

to agree with their arguments.

The first three groups tend to respond positively to information and dialogue, whereas the latter two

are unlikely ever to change their position, although the "convinced and contented" may moderate

their beliefs over time [85].

Target educationMost parental vaccine concerns are amenable to dialogue and discussion.

Providers should target education to specific parental concerns and/orbeliefs, realizing that some

parents may need information from a variety of resources (table 1). Visual imagery and anecdotes

from parents who are vaccine advocates may be used to support the educational message

(eg,Families Fighting Flu,Meningitis Angels,National Meningitis Association,Vaccine-preventable

disease: The forgotten story).

Focused education that directly addresses the source of vaccine concerns may have an important

impact [17,86]. However, data on the overall success rates of education are limited. The

HealthStyles survey indicates that approximately one-third of parents want more information about

immunizations and that the healthcare provider is one of the most influential factors in decisions

about immunization, even among vaccine-hesitant parents [23,26,81,87].

Targeted immunization materials that provide unbiased, accurate statistical information, avoid scare

tactics, and are not judgmental may be helpful in improving immunization acceptance in certain

groups of vaccine-hesitant parents [39,88]. Parents are skeptical of aggressive pro-and antivaccine

messages [17]. Emphasizing mandatory school entry requirements in an effort to influence parents

is not helpful [89].

The provider must address relevant concerns while fully explaining vaccine benefits and risks.

Potential areas for targeted education include:

Vaccine limitations

Adverseevents

Misconceptions

Pain

Vaccine limitationsIt is important to acknowledge that although vaccines are very safe, they

are not completely risk free or 100 percent effective. Providing this information is important in

establishing credibility, but the information must be placed in a proper context for parents who may

overestimate the risks of vaccines and underestimate the risks from vaccine-preventable diseases

[1]. It may be helpful to reframe the discussion by defining the options in terms of benefits with risks,

rather than emphasizing the risks [35].
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Adverse eventsAdverse events related to vaccines must be put into context. Most vaccine-

associated adverse events are minor and self-limited (eg, local skin reactions, transient low-grade

fever). Serious adverse events from an individual vaccine occur rarely, but these should be weighed

against the risks associated with the natural infection. As examples:

The risk of acquiring measles during an outbreak may be 35 times higher in an unvac cinated

than in a vaccinated person [63].

The risk of measles-associated encephalopathy or subacute sclerosing panencephalitis

following natural measles is 1000 times higher than the risk of encephalopathy from measles

vaccine (1 in 1 million) [90].

MisconceptionsIt is important to dispel myths, correct misinformation, and direct parents to

scientifically sound information (table 1)[35]. Providers should avoid using ambiguous language or

complicated scientific terms when communicating the science supporting vaccine safety and

effectiveness.

Autism The most common vaccine myth, that vaccines cause autism, has suggested a

number of hypotheses to substantiate the link (eg, that MMR or thimerosal [ethylmercury]

cause autism). The myths related to autism and MMR and thimerosal are discussed

separately (see"Autism and chronic disease: Little evidence for vaccines as a contributing

factor" and"Autism and chronic disease: Little evidence for thimerosal as a contributing

factor").

Overwhelming the immune system Parents may worry that multiple vaccines overwhelm

the immune system, possibly causing autism, autoimmune disease, or susceptibility to

infections. The following observations provide evidence against this claim [91-93]:

With manufacturing advances and discontinuation of smallpox immunization, children

are exposed to fewer antigens today than they were in 1980 [35]. The currently

recommended immunizations for children younger than two years in the United States

(figure 2A-B)contain approximately 300 bacterial and viral protein or polysaccharide

antigens, compared with >3000 such antigens in the seven vaccines administered in

1980 [94-96].

Evidence of adverse effects related to exposure to multiple antigens is lacking. In a

cohort of 1047 children who were exposed to an average of >10,000 antigens by age 24

months (predominantly through whole cell pertussis vaccine), there was no association

between increasing antigen exposure and adverse neuropsychologic outcomes (eg,

general intellectual function, speech and language, verbal memory, attention and

executive function, tics, achievement, visual spatial ability, and behavior regulation) [96].

The infant immune system can respond to multiple antigens (conservative estimates

suggest thousands) simultaneously [35,94,97]. This is illustrated by the observations that

mild or moderate illness does not interfere with an infant's ability to generate protectiveimmune responses to vaccines and that combinations of vaccines induce immune

responses comparable to those given individually [97].

Vaccinated and unvaccinated children do not differ in their susceptibility to infectious

diseases for which there are no vaccines (eg, enterovirus, candida) [98-100]. On the

other hand, infection with vaccine-preventable disease can predispose to severe

invasive infections with other pathogens (eg, methicillin-resistant Staphylococcus

aureus) [101,102].
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Vaccines are not necessary As vaccine-preventable diseases become less common and

parents have little familiarity with the devastating effects of vaccine-preventable illnesses,

some parents may believe that vaccines are no longer necessary [1]. These parents must be

educated regarding the persistence of vaccine-preventable diseases and the potential for a

rapid increase in vaccine-preventable disease incidence when immunization rates decline

[35]. (See'Consequences of vaccine refusal' above.)PainProviders can educate parents on available methods to reduce pain when multiple vaccine

injections are required at a single visit. These may include nonpharmacologic options, such as oral

sucrose for infants; stroking, rocking, or "blowing the pain away for older children"; or

pharmacologic management if indicated (eg, topical anesthetics placed 30 to 60 minutes prior to

injection) [103-105].

Maintain relationshipWhen educational efforts fail to persuade parents to immunize their

children, providers may be faced with a dilemma about whether or not to refer the family to another

provider [106,107]. Factors influencing this decision include lack of shared goals, absence of trust in

the clinician-family relationship, and fear of litigation if the child subsequently contracts a vaccine-

preventable disease or transmits a vaccine-preventable disease to an individual with vaccine

contraindications or who was too young to be immunized [107]. Although we recognize that a

provider may choose to dismiss a family form his or her practice when poor communication and

distrust have become insurmountable [108], we encourage providers to maintain relationships with

families who refuse immunization.

The American Academy of Pediatrics (AAP) Committee on Bioethics suggests that pediatricians

should endeavor not to discontinue care for patients solely because their parents refuse or delay

vaccines [83,109]. The decision to immunize belongs, ultimately, to the parents. The benefits of

immunization must be weighed against those of the provider maintaining a positive relationship with

the family. Maintenance of the relationship permits time for ongoing dialogue and targeted

education and ensures that the child has a medical home.

Although the AAP Committee on Bioethics acknowledges that the welfare of the child is paramount,

it advises providers to tolerate parental decisions "not likely to be harmful to the child" [83]. Using

this paradigm, immunization of an individual child is favored when community immunization rates

are low and disease prevalence is high, or if the child has a medical predisposition to a disease.

The risk to the community attributable to unimmunized children infecting children who are unable to

be immunized and the community cost of caring for children with vaccine-preventable diseases

should also be considered [110,111]. Rarely, providers may be obliged to involve state agencies to

provide immunization against parental wishes (eg, when a child is placed at risk during an

epidemic) [83]. (See'Consequences of vaccine refusal' above.)

The AAP advises that dismissing vaccine-refusing families should be an option of last resort but

recognizes that distrust and poor communication may, rarely, make termination of the clinician-

patient relationship advisable [83]. In this unusual situation, the provider should offer sufficient

information to assist families to find another provider and allow adequate time for the transition to

occur, thus avoiding potentially harmful lapses in medical care [106].

Alternative schedulesDeviations from the recommended childhood immunization schedule

should be used only when all other options have failed. Alternative schedules should not be used as

a substitute for establishing parental dialogue or targeted education [1,83].
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Alternative schedules are not founded in science and entail multiple visits to the provider's office. A

committee convened by the Institute of Medicine to study the health outcomes related to the

recommended childhood immunization schedule in the United States found no conclusive evidence

of adverse events related to multiple immunizations or other aspects of the immunization schedule,

suggesting that the current recommended schedule is safe [112]. Alternative schedules increase

the risk of noncompliance and the duration of vulnerability to vaccine-preventable diseases andmay increase the risk of adverse effects [113]. However, the use of an alternative schedule may

allay the fears of some parents enough that they permit their child to be immunized.

The most popular of the alternative immunization schedules are the "selective vaccine schedule"

and "alternative vaccine schedule" published by Dr. Robert Sears [114]. Dr. Sears's book casts

doubt on clinicians' understanding of vaccine research and the motives of the pharmaceutical

industry and suggests that the immunization schedule recommended by the Centers for Disease

Control and Prevention, American Academy of Pediatrics, and American Academy of Family

Physicians is in the public's, but not necessarily the individual's, best interest. His alternative

schedules prioritize immunizations that he considers more important on the basis of his experience

as a pediatrician in private practice, while delaying or skipping others. Only two vaccines are

administered at a time, and only one aluminum-containing vaccine is given at any one visit.

Although Dr. Sears's approach may seem to be a reasonable compromise between hesitant

parents and their providers, there are multiple inherent problems. Critics of Dr. Sears's book explain

in detail how it fails to distinguish good from bad science when discussing vaccine research,

misinterprets vaccine safety data, underestimates the risks to children of vaccine-preventable

diseases by considering only his limited personal experience, is ambiguous regarding the disproven

associations of MMR and thimerosal with autism, and does not fully grasp the scientific method

[115].

Timely receipt of vaccines during the first year of life has no adverse effect on neuropsychologic

outcomes. Review of data from the Vaccine Safety Datalink study, which included 1047 children,indicate that the 47 percent of children who received their vaccines on time (2 hepatitis B, three

diphtheria-tetanus-pertussis, three H. influenzaetype b, and two polio vaccines within 30 days of the

recommended age) performed as well or better at age 7 to 10 years on every measure of

neuropsychologic outcome than the 23 percent of children who received all of the recommended

vaccines, but not on time; and the 20 percent of children who did not receive all of the

recommended vaccines [116].

The schedules proposed in Dr. Sears's book are potentially harmful, extending the duration of

vulnerability for vaccine-preventable diseases that continue to cause outbreaks. For example, under

the "alternative" schedule, it is recommended that MMR be separated into three components:

mumps is given at 12 months, rubella at two years, and measles at three years. Single-antigen

measles vaccine is no longer available in the United States [117]. Under the "selective" schedule,

titers for measles, mumps, and rubella are checked at age 10 years, and vaccination considered if

not immune. Delayed administration of polio, varicella, hepatitis A, and hepatitis B vaccines is also

suggested for reasons that are not founded in science.

Special precautionsChildren who have not been immunized are at risk to develop or transmit

vaccine-preventable disease. Parents of children who refuse immunizations must take special

precautions with respect to these risks. When their child is ill, they must inform the healthcare
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providers that the child has not been vaccinated so that the providers can consider vaccine-

preventable illnesses in their differential diagnosis and take the necessary steps to prevent infection

of other patients. The Centers for Disease Control and Prevention, American Academy of

Pediatrics, and American Academy of Family Physicians has developed a handout for parents to

remind them of these risks and responsibilities [118].

DocumentationProviders should document each discussion with parents about the risks of not

immunizing [83]. The American Academy of Pediatrics (AAP) has developed guidelines for

providers faced with this situation and provides sample waiver documentation to cover this

eventuality (available through theAmerican Academy of Pediatrics ). Another sample waiver is

available through theImmunization Action Coalition.

PREVENTIONSpecific strategies to prevent parental vaccine refusal have not been studied.

However, given that primary care providers are one of the most influential factors in decisions about

immunization [23,26,81], it is reasonable for providers to establish open, honest, nonconfrontational

dialogue about the importance of childhood vaccinations beginning with the first provider-parent

interaction. Providers also should share their own or their practice's philosophy regarding delaying

or refusing vaccination to avoid the potential for future disagreements.

Education should start at the prenatal visit and continue at all subsequent well-child visits. At each

encounter, providers should listen to parental concerns to identify sources of misinformation or

other factors that may lead to vaccine hesitancy. Providers can then provide individualized

education to address specific concerns or misconceptions.

Education should be multifaceted, with providers answering questions unambiguously, avoiding

complicated statistics, and providing information that is easily understood and "personal." Providers

should make full use of the online resources outlined in the table (table 1). Some parents may find

the information on the Vaccine Information Statements adequate to address their needs, but others

may require more detailed scientific information or may find simple question-and-answer pamphlets

or personal testimonials from vaccine advocates more helpful [1,119].

In a randomized trial, vaccine-hesitant parents (defined by a score of 25 on the Parent Attitudes

about Childhood Vaccines [PACV] survey) who received educational information (a video, written

information, and written instructions for finding accurate information on the Internet) at the two-week

health supervision visit had decreased PACV scores at the two-month visit compared with those

who received usual care [120].

How the provider initiates the conversation about vaccines may play a role in vaccine acceptance.

In an observational study in which 93 discussions about vaccines at health supervision visits were

initiated by the provider, 74 percent of providers used a presumptive approach (eg, Hes due for

three shots today) and 26 percent used a participatory approach (eg, What would you like to do

about shots?) [121]. The presumptive approach was associated with decreased parental

resistance to immunizations (26 versus 83 percent).

RESOURCESMost parents trust advice from their child's healthcare provider [23,26,81].

However, it is useful for both parents and providers to access reputable sources where accurate

and easy-to-understand vaccine information is available.
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Focus groups suggest that most parents trust information from the Centers for Disease Control and

Prevention (CDC) or American Academy of Pediatrics (AAP) [88]. A list of additional reputable

vaccine Web sites is provided in the table (table 1). Parents who need more information than the

clinician can provide during an office visit can be directed to these resources.

Many of the organizations in the list provide publications or question-and-answer tear sheets that

can be purchased or downloaded for use in office waiting rooms or for parents to take away and

read. Posters and publications describing the consequences of vaccine-preventable diseases are

also available for download or purchase from some of the sources in the table, which include public

health agencies, organizations specializing in vaccine education, and parent-advocacy groups. The

latter may be particularly useful for vaccine-hesitant parents because they highlight identifiable,

serious, and sometimes fatal consequences of refusing immunization, using anecdotes and visual

imagery to counter those used with such great effect by antivaccine activists [122].

For providers, the CDC, in partnership with the AAP and the American Academy of Family

Physicians (AAFP), has developedProvider Resources for Vaccine Conversations with Parents.

They provide communication tips for providers, current vaccine safety information, answers to

common questions, and disease-specific fact sheets that can be downloaded as a handout forparents to supplement Vaccine Information Statements and guide parent risk-benefit discussions

[1].

SUMMARY AND RECOMMENDATIONS

Immunizations are one of the safest and most cost-effective preventative health measures

(figure 1). However, misinformation may lead parents to hesitate or refuse to immunize their

child(ren). (See'Background' above.)

Concern about vaccine safety is the most common reason for vaccine refusal. (See 'General

objections' above.)

Vaccine refusal may result in vaccine-preventable disease in the individual and/or outbreaks

of vaccine-preventable disease in unvaccinated and vaccinated individuals.

(See'Consequences of vaccine refusal' above.)

The healthcare provider is one of the most influential factors in the decision whether or not to

immunize a child. When faced with vaccine-hesitant parents, the provider should be guided by

the following recommendations (see'Overview of approach' above):

Establish open, ongoing, nonconfrontational dialogue to identify concerns

Target education to specific concerns, using a varietyof resources (table 1)

Maintain the provider-patient relationship

Use vaccine schedules that deviate from the recommended schedule only when other

options have failed and the family would otherwise refuse vaccination entirely

Targeted education may include acknowledgment of vaccine limitations, provision of

accurate estimates of the risks of adverse events and vaccine-preventable disease, correction

of misconceptions, and discussion of techniques to alleviate immunization-related pain.

(See'Target education' above.)

While we recognize that a provider may choose to dismiss a family from his or her practice

when poor communication and distrust have become insurmountable, we encourage providers

to maintain relationships with families who refuse immunization. (See'Maintain

relationship' above.)
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We do not suggest deviation from therecommended immunization schedule (Grade 2C).

(See'Alternative schedules' above.)

Use of UpToDate is subject to theSubscription and License Agreement.

REFERENCES

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immunization laws. Am J Public Health 2001; 91:645.8. Salmon DA, Omer SB, Moulton LH, et al. Exemptions to school immunization requirements: the roleof school-level requirements, policies, and procedures. Am J Public Health 2005; 95:436.

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http://www.uptodate.com.dti.sibucsc.cl/contents/grade/6?title=Grade%202C&topicKey=PEDS/2846http://www.uptodate.com.dti.sibucsc.cl/contents/grade/6?title=Grade%202C&topicKey=PEDS/2846http://www.uptodate.com.dti.sibucsc.cl/contents/grade/6?title=Grade%202C&topicKey=PEDS/2846http://www.uptodate.com.dti.sibucsc.cl/contents/standard-childhood-vaccines-parental-hesitancy-or-refusal?source=search_result&search=vacunas&selectedTitle=3%7E150#H29http://www.uptodate.com.dti.sibucsc.cl/contents/licensehttp://www.uptodate.com.dti.sibucsc.cl/contents/standard-childhood-vaccines-parental-hesitancy-or-refusal/abstract/1http://www.uptodate.com.dti.sibucsc.cl/contents/standard-childhood-vaccines-parental-hesitancy-or-refusal/abstract/1http://www.uptodate.com.dti.sibucsc.cl/contents/standard-childhood-vaccines-parental-hesitancy-or-refusal/abstract/2http://www.uptodate.com.dti.sibucsc.cl/contents/standard-childhood-vaccines-parental-hesitancy-or-refusal/abstract/2http://www.uptodate.com.dti.sibucsc.cl/contents/standard-childhood-vaccines-parental-hesitancy-or-refusal/abstract/3http://www.uptodate.com.dti.sibucsc.cl/contents/standard-childhood-vaccines-parental-hesitancy-or-refusal/abstract/3http://www.uptodate.com.dti.sibucsc.cl/contents/standard-childhood-vaccines-parental-hesitancy-or-refusal/abstract/4http://www.uptodate.com.dti.sibucsc.cl/contents/standard-childhood-vaccines-parental-hesitancy-or-refusal/abstract/4http://www.uptodate.com.dti.sibucsc.cl/contents/standard-childhood-vaccines-parental-hesitancy-or-refusal/abstract/5http://www.uptodate.com.dti.sibucsc.cl/contents/standard-childhood-vaccines-parental-hesitancy-or-refusal/abstract/5http://www.uptodate.com.dti.sibucsc.cl/contents/standard-childhood-vaccines-parental-hesitancy-or-refusal/abstract/6http://www.uptodate.com.dti.sibucsc.cl/contents/standard-childhood-vaccines-parental-hesitancy-or-refusal/abstract/6http://www.uptodate.com.dti.sibucsc.cl/contents/standard-childhood-vaccines-parental-hesitancy-or-refusal/abstract/7http://www.uptodate.com.dti.sibucsc.cl/contents/standard-childhood-vaccines-parental-hesitancy-or-refusal/abstract/7http://w

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