Point-Counterpoint:Responding to Common Reasonsfor Vaccine Refusal

Vaccines have saved more lives than any other single medical advance and are among the most important preventive tools available to clinicians. Nevertheless, pediatricians and other health care providers increasingly find themselves in the difficult position of having to persuade parents that vaccines are safe and necessary. Here, to help you respond effectively in these situations, I offer proven strategies and sample responses to specific objections.

VACCINE REFUSAL: WHY THE INCREASE?
The estimated number of unvaccinated children aged 19 to 35 months increased from 14,700 in 1995 to 24,000 in 2000.¹ Nearly 15% of underimmunization in the United States is attributable to parental concerns about vaccine safety.²

In a survey of parents conducted in 2003, 31% agreed that it is painful for children to get many shots during a single doctor visit, 24% said they believed that the ingredients in vaccines are unsafe, 21% said they believed that vaccines are not sufficiently tested for safety, and 17% expressed concern that vaccines may cause learning disabilities.³

The growth in parental concerns about vaccine safety has several sources:
• An increasingly cynical attitude toward those who make vaccine recommendations.
• The belief that not only pharmaceutical companies but health care providers and the government promote vaccines mainly for profit.
• Lack of awareness of the seriousness of vaccine-preventable diseases, in large measure a result of the remarkably low incidences of these infections.
• Media promotion of high-profile stories about vaccine adverse effects, most notably those that involve a purported link to autism^.4

It is no wonder, especially given the negative media attention, that many parents are refusing to have their children vaccinated.

Today, incidences of vaccine preventable diseases are at or near record lows. However, the very scarcity of these diseases has all but done away with their ability to serve as a reminder of the benefits of vaccination. At the same time, around 10,000 cases of adverse events following vaccination are reported in the United States each year. Thus, both parents and providers are more likely to know someone who has experienced an adverse event following immunization than they are to know someone who has experienced a reportable vaccinepreventable disease. Consequently, parents are shifting from fear of disease to fear of adverse events.⁵

RESPONDING TO PARENTS WHO REFUSE VACCINES: GENERAL TIPS
Try implementing the following strategies when faced with parents who refuse vaccines:

• Listen to the parents’ concerns. Remember that some parents may not employ the same decision-making process or view evidence the same way that a physician does.⁶

• Be familiar with the common myths regarding the dangers of vaccines, and be prepared to respond to these effectively.

• Although vaccines are very safe, they are not risk-free.⁷ Communicate honestly and respectfully what is known about the risks and benefits of the vaccine in question and attempt to correct any misperceptions and misinformation.^8-10

• When discussing vaccine safety, emphasize the balance between the risks and benefits of vaccination. Point out that the risks of the disease are far, far greater than the risk of a serious adverse effect from the vaccine.

• Have print resources on hand from state and local health departments and national agencies, such as the CDC or the American Academy of Pediatrics, to give to parents. Also encourage parents to visit the reputable, databased Web sites in the Box.

• The most effective measure clinicians can use in responding to vaccine refusal is the provision of up-to-date and accurate information regarding the main concerns of vaccine-hesitant parents. Thus, it is of the utmost importance that health care providers educate themselves and continually update their knowledge in these areas. The issues parents raise most often are listed below, followed by brief counters to each concern.

RESPONSES TO SPECIFIC CONCERNS The vaccine-or the thimerosal in the vaccine-may cause autism or other illness.

• The CDC and the Institute of Medicine (IOM) have reviewed multiple studies and concluded that there is no evidence to support a connection between the measlesmumps- rubella (MMR) vaccine and autism. For example, in a study conducted in the United Kingdom,¹¹ the rate of immunization with the MMR vaccine in children who had received a diagnosis of autism (78.1% of 1010 cases) was similar to the immunization rate in children who did not have autism (82.1% of 3671 controls). A US study published in 2004 showed that autism developed in similar proportions of children who received the MMR vaccine by the recommended age (before 18 months) and children who did not receive the vaccine. The authors of this study also stressed that vaccine administration occurred well before the age at which atypical development is usually observed in children with autism (24 to 36 months).¹²

• Several other studies reached similar conclusions, finding no evidence of a link between the MMR vaccine and autism.^13-16

• The onset of autism tends to occur in the second year of life, around the same time that children receive a number of vaccines. Temporal association does not prove causation; just because one event follows another does not mean that the first caused the second.

• The increased incidence of autism may in part reflect greater awareness of the nature of the disease and better recognition of autistic features by pediatricians and other health care providers.

• Even though there is no convincing evidence that the low concentrations of thimerosal in vaccines have caused any harm, none of the vaccines currently used in the United States to protect preschool children against infectious diseases-with the exception of some influenza vaccines- contain thimerosal. There are brands of influenza vaccine that are thimerosal-free.

• Many vaccines, including the MMR and varicella vaccines, never contained thimerosal.

I do not trust the government, the pharmaceutical industry, or doctors. They all just push vaccines for financial gain.

• Vaccines in the United States are held to the highest standard of safety. Normally, years of testing are required by law before a vaccine can be licensed. Once licensed, vaccines are monitored by a comprehensive vaccine safety monitoring system that is run jointly by the FDA and the CDC. Adverse events associated with vaccines are investigated and studied, and action is taken when vaccine recommendations need to be changed. The CDC places a high priority on the integrity and credibility of its vaccine safety research.

• The Advisory Committee on Immunization Practices (ACIP) was established to guide the CDC in vaccine selection and monitoring. The ACIP has 15 voting members who come from diverse backgrounds and who are not employees of the US government. One member of its board is a consumer representative. Vaccines are against my religion because they are made from aborted human fetuses.

• A few of the vaccines available today (those for hepatitis A, rubella, varicella, and rabies) are grown in human embryo fibroblasts because human embryonic cells are the only vehicle that will allow mass replication of these viruses. These cells were initially obtained from an aborted fetus in the early 1960s and have been propagated in tissue cultures since then.¹⁷

Despite their opposition to abortion, several religious organizations, including the United States Conference of Catholic Bishops (USCCB),¹⁸ have permitted the use of these vaccines. The USCCB and the Vatican have used the following arguments:
• Because the person receiving the vaccine took no part in the decision to use a morally unacceptable material to make it, his or her cooperation in the moral evil of abortion is very remote; consequently, no serious sin is involved.

• If forgoing vaccination exposes a person-or the community-to considerable dangers to health, and if no vaccine other than one with moral problems is available, then such vaccines may be used. (The Church does stress, however, that parents should press pharmaceutical companies to develop alternative vaccines.)¹⁹

Vaccine-preventable diseases occur so rarely nowadays; my child is at no risk for acquiring them.

• Vaccine-preventable diseases have not gone away, not even in the United States.

• These diseases are common in most of the rest of world, including, in some cases, in Europe.

• International travel is continually reintroducing these diseases into the United States. Once here, they often spread easily. Between January and July 2008, 131 cases of measles were reported in 15 states, 123 of which were in US residents. Of the 131 reported measles cases, 89% were imported from abroad-mainly from Europe, where several countries reported recent measles outbreaks.^20,21 Of note, 112 (91%) of the US residents in whom measles developed were unvaccinated or had unknown vaccination status, and 63 (66%) of those were unvaccinated because of philosophical or religious beliefs.²²

These recent events show clearly that measles outbreaks can occur in communities with a high number of unvaccinated persons, and they demonstrate the value of high MMR coverage rates.

Vaccine-preventable diseases (eg, chickenpox) are not that serious anyway, and the natural immunity that results from contracting these infections is better than immunity from a vaccine.

• Although natural infection may produce a longer and more lasting immunity than vaccines, there are some diseases for which vaccines actually do a better job of inducing lasting immunity than does natural infection. ¹⁷ An example is infection with Haemophilus influenzae. Natural infection with H influenzae in infants does not produce an effective antibody response because of the inability of the immature immune system to recognize polysaccharide antigens. However, conjugated Hib vaccines have been shown to be effective at facilitating the mounting of a protective immune response in young infants.

• Natural infection with a vaccine-preventable disease may exact a heavy toll. For example, chickenpox caused by wild-type varicella virus (a disease familiar to most parents and generally thought of as “mild”) may be associated with serious complications, such as encephalitis, necrotizing fasciitis, toxic-shock syndrome, or pneumonia. Another example is seasonal influenza, which affects millions of people in the United States each year, causing more than 200,000 hospitalizations and 36,000 deaths.²³ Too many vaccines are given at once; this overloads or weakens a child’s immune system.

• Current research does not support the hypothesis that multiple vaccines overwhelm or weaken the immune system. Several trials have demonstrated that vaccinated children are not at higher risk than unvaccinated children for subsequent infections with other pathogens.^24-26

• Research also demonstrates that infants and young children respond to multiple vaccines given at the same time in a manner similar to the way they respond to vaccines given separately.^27,28 Studies have shown that neonates are capable of producing a protective immune response to vaccines within hours of birth and that young infants are fully capable of generating protective humoral and cellular immune responses to multiple vaccines simultaneously.^29,30

• Although children now receive more vaccines, the number of antigens they receive has declined significantly. In the past, a single vaccine- whole cell pertussis-contained about 3000 proteins; now, the 14 routinely recommended vaccines contain, in total, fewer than 150 components.

• The immunological challenge from vaccines is small compared with what children are exposed to everyday.

I am not altruistic. I don’t care about herd immunity or someone else’s child with leukemia.

• A chronic illness such as leukemia can develop in any child-perhaps someday including one’s own. Children who cannot receive vaccines for medical reasons can only be protected by herd immunity. Moreover, such children are more likely to have serious effects should they contract a vaccine-preventable illness.

• Outbreaks of vaccine-preventable illness occur primarily among unvaccinated children and those who fail to respond to vaccination. Those who are affected include healthy children whose parents choose not to have them vaccinated as well as those with conditions, like leukemia or reception of chemotherapy, that preclude vaccination.

• When the presence of clusters of unvaccinated children allows a vaccine- preventable illness to gain a toehold in an area, the risk of serious infection is increased for a number of populations. In addition to children with leukemia or other conditions that depress the immune system, the following groups are also at increased risk:

•Infants too young to be vaccinated.
•Elderly persons who may not be immune or whose immunity has waned.
•Adults receiving corticosteroids, other immunosuppressive agents, or chemotherapy for cancer.

References:

REFERENCES:

1.

Bennett P, Smith C. Parents attitudinal and socialinfluences on childhood vaccination. Health EducRes. 1992;7:341-348.

2.

Gust DA, Strine TW, Maurice E, et al. Underimmunizationamong children: effects of vaccinesafety concerns on immunization status.

Pediatrics

.2004;114:e16-e22.

3.

Gust DA, Kennedy A, Shui I, et al. Parent attitudestoward immunizations and healthcareproviders the role of information.

Am J Prev Med

.2005;29:105-112.

4.

Offit PA, Moser CA. The problem with Dr Bob’salternative vaccine schedule.

Pediatrics

. 2009;123:e164-e169.

5.

Gust DA, Campbell S, Kennedy A, et al. Parentalconcerns and medical-seeking behavior after immunization.

Am J Prev Med

. 2006;31:32-35.

6.

Meszaros JR, Asch DA, Baron J, et al. Cognitiveprocesses and the decisions of some parents toforgo pertussis vaccination for their children.

J ClinEpidemiol

. 1996;49:697-703.

7.

Maldonado YA. Current controversies in vaccination:vaccine safety.

JAMA

. 2002;288:3155-3158.

8.

Wilson CB, Marcuse EK. Vaccine safety-vaccinebenefits: science and the public’s perception.

NatRev Immunol

. 2001;1:160-165.

9.

Pattison S. Ethical debate: vaccination againstmumps, measles, and rubella: is there a case fordeepening the debate? Dealing with uncertainty.

BMJ

. 2001;323:840.

10.

American Academy of Pediatrics. Parental misconceptionsabout immunization. In: Pickering LK, ed.Red Book: 2003 Report of the Committee on InfectiousDiseases. 26th ed. Elk Grove Village, IL: AmericanAcademy of Pediatrics; 2003:50-53.

11.

Smeeth L, Cook C, Fombonne E, et al. MMRvaccination and pervasive developmental disorders:a case-control study.

Lancet

. 2004;364:963-969.

12.

DeStefano F, Bhasin TK, Thompson WW, et al.Age at first measles-mumps-rubella vaccination inchildren with autism and school-matched controlsubjects: a population-based study in metropolitanAtlanta. Pediatrics. 2004;113:259-266.

13.

Kaye JA, del Mar Melero-Montes M, Jick H.Mumps, measles, and rubella vaccine and the incidenceof autism recorded by general practitioners: atime trend analysis.

BMJ

. 2001;322:460-463.

14.

Taylor B, Miller E, Farrington CP, et al. Autismand measles, mumps, and rubella vaccine: noepidemiological evidence for a causal association.

Lancet

. 1999; 353:2026-2029.

15.

Taylor B, Miller E, Lingam R, et al. Measles,mumps, and rubella vaccination and bowel problemsor developmental regression in children withautism: population study.

BMJ

. 2002;324:393-396.

16.

Hornig M, Briese T, Buie T, Bauman ML, et al.Lack of association between measles virus vaccineand autism with enteropathy: a case-control study.

PLoS On

e. 2008;3:e3140.

17.

Marshall G. The Vaccine Handbook: A PracticalGuide for Clinicians. 2nd ed. West Islip, NY: ProfessionalCommunications, Inc; 2008.

18.

United States Conference of Catholic Bishops.Fact sheet: embryonic stem cell research andvaccines using fetal tissue.

http://www.usccb.org/prolife/issues/bioethic/vaccfac2.shtml

. AccessedSeptember 11, 2009.

19.

Sgreccia E. On vaccines made from cellsof aborted fetuses.

http://www.zenit.org/article-13676?l=english

. Accessed September 11,2009.

20.

EuroSurveillance Editorial Team. Measles onceagain endemic in the United Kingdom. Eurosurveillance.2008;13:1.

http://www.eurosurveillance.org/viewarticle.aspx?articleid=18919

. Accessed September11, 2009.

21.

Filia A, De Crescenzo M, Seyler T, et al.Measles resurges in Italy: preliminary data fromSeptember 2007 to May 2008. Eurosurveillance.2008.

http://www.eurosurveillance.org/viewarticle.aspx?articleid=18928

.

22.

Centers for Disease Control and Prevention(CDC). Update: measles: United States, January-July 2008.

MMWR.

2008;57:893-896.

23.

Centers for Disease Control and Prevention(CDC). Key facts about seasonal influenza (flu).

http://www.cdc.gov/flu/keyfacts.htm

. AccessedSeptember 11, 2009.

24.

Black SB, Cherry JD, Shinefield HR, et al.Apparent decreased risk of invasive bacterial diseaseafter heterologous childhood immunization.

Am J Dis Child.

1991;145:746-749.

25.

Davidson M, Letson W, Ward JI, et al. DTPimmunization and susceptibility to infectiousdiseases. Is there a relationship?

Am J Dis Child

.1991;145:750-754.

26.

Storsaeter J, Olin P, Renemar B, et al. Mortalityand morbidity from invasive bacterial infectionsduring a clinical trial of acellular pertussis vaccinesin Sweden.

Pediatr Infect Dis J

. 1988;7:637-645.

27.

King GE, Hadler SC. Simultaneous administrationof childhood vaccines: an important publichealth policy that is safe and efficacious.

PediatrInfect Dis J

. 1994;13:394-407.

28.

Combination vaccines for childhood immunization:recommendations of the Advisory Committeeon Immunization Practices (ACIP), the AmericanAcademy of Pediatrics (AAP), and the AmericanAcademy of Family Physicians (AAFP).

Pediatrics

.1999;103(5, pt 1):1064-1077.

29.

Siegrist CA. Neonatal and early life vaccinology.

Vaccine

. 2001;19:3331-3346.

30.

Plotkin SA, Orenstein WA, eds.

Vaccines

. 3rd ed.Philadelphia: WB Saunders Co; 1999.