Overcoming Vaccine Reluctance

Vaccine hesitancy made the World Health Organization’s list of 10 threats to global health in 2019.(1) The United States currently has a low prevalence of vaccine-preventable diseases, largely due to widespread vaccination efforts. From 2004 to 2014, only two cases of diphtheria were reported in the United States. These numbers are strikingly different from the 15,000 Americans who died of diphtheria in 1921 before the vaccine was developed. In 1974, 393 cases of whooping cough were reported in Japan, with no related deaths. That year about 80% of Japanese children received the pertussis vaccine. In the following years, vaccination rates dropped, eventually reaching only 10%, with the result that 13,000 people contracted whooping cough, and 41 died of the disease in Japan in 1979. This prompted an increase in vaccination rates, which corresponded to a drop in whooping cough cases.(2) Multiple outbreaks of vaccine-preventable diseases also have occurred, more recently, in the United States. In early 2015, a measles outbreak that began at Disneyland ultimately led to 113 children becoming infected. By the time parents realized their child was sick, they had already returned home from Disneyland, potentially spreading the virus further. This outbreak prompted many states to reevaluate their vaccine exemption laws, and it also shed light on the vaccine mandate laws, especially regarding the measles, mumps, and rubella (MMR) vaccine.

Parents who seek nonmedical exemptions (NMEs) based on personal beliefs often are sure they are doing what is best for their children to protect them.(3) When working with this subgroup of patients, open dialogue and conversations with healthcare workers are imperative. A study highlighted that, of parents who originally resisted specific vaccinations, 47% ended up complying with the physicians’ recommendations if the physician continued to pursue them.(4) This article explores the history of the MMR vaccination and vaccination exemptions in the United States and provides a methodical approach to discussing vaccines with parents, along with ways to approach vaccine hesitancy.

After the introduction of the mumps vaccine, there was a 99% decrease in cases compared with the pre-vaccine era.

The MMR vaccine protects against measles, mumps, and rubella. The year 1912 was the first year that the United State Government required healthcare providers and laboratories to report all diagnosed cases of measles. In the 10 years before the vaccine was widely available (1953–1963), nearly all children were expected to get measles by the age of 15. It is estimated that 3 to 4 million people were infected each year in the United States. In 1963, a vaccine was licensed in the United States, and in 1968 an improved vaccine was developed. Widespread use of the measles vaccine led to drastically reduced rates of the disease. In 1981, the number of reported cases was 80% less than the previous year. In 1989, following an outbreak among vaccinated school-aged children, a second dose of MMR vaccine for children was recommended.(5) Even with widespread vaccination efforts, however, isolated outbreaks of measles are still occurring throughout the United States. The mumps vaccination was introduced in 1967; before the vaccine, mumps was a universal disease of childhood. After the introduction of the vaccine, there was a 99% decrease in cases compared with the pre-vaccine era.(6) Rubella also was common before the introduction of vaccines. The last major rubella epidemic in the United States occurred from 1964 to 1965, with an estimated 12.5 million cases. Due to successful vaccination programs, rubella was declared eliminated from the United States in 2004.(7)

According to the Centers for Disease Control and Prevention (CDC), as of December 29, 2018, there had been 349 individual confirmed cases of measles in the United States in 2018.(8) Due to both state and local requirements on childhood vaccinations, particularly for entering school,(9) an effective way to analyze current trends is to look at vaccination compliance among kindergarten-aged students. In the 2014–2015 school year, the median state-level vaccination rate for MMR was approximately 94.0%.(10) According to the CDC, estimated two-dose compliance for the MMR vaccine for the 2016–2017 school year remained stable, at a median state-level vaccination rate of approximately 94.0%.(11) However, although the national MMR vaccination rate has been stable, this has not been the same for the number of confirmed cases of measles. Since 2016, the number of confirmed cases of measles in the United States has increased, from 86 in 2016, to 120 in 2017, and to 349 in 2018; this represents an increase of nearly 290% from 2017 to 2018.(8) Currently, all states allow exemptions for medical necessity, with almost all states allowing an exemption for religious reasons. Currently, 18 states allow “philosophical exemptions for those who object to immunization because of personal, moral or other beliefs,”(12) which is referred to as a nonmedical exemption. Since 2009, the number of NMEs has increased in 12 of these 18 states. In more recent years, some states have seen a plateau, whereas others continue to see an increase in NME use.(12) Overall there is an inverse relationship between NME rates and MMR vaccination levels, resulting in reduced MMR vaccination coverage.(13)

In January 2019, the state of Washington declared a state of emergency due to a measles outbreak centered in Clark County. As of January 30, 2019, there had been 42 confirmed cases in the state.(14,15) Portland was one of many metropolitan areas cited for having a high number of NMEs for kindergartens during the 2016-2017 school year. Phoenix topped the list, with 2947 NMEs during that year. Other metropolitan areas with more than 400 NMEs for kindergartens in 2016-2017 include Seattle, Salt Lake City, Detroit, and Kansas City, Missouri.(13) To receive an NME in Oregon, a parent must watch an educational module online and submit a certificate of completion to their child’s school or have a healthcare worker sign a “vaccine education certificate.”(16) In Arizona, parents can fill out a one-page personal beliefs exemption form provided by the health department that does not require a signature from a healthcare provider.(17) To receive an NME in Michigan, as of 2014, a parent must go to the local health department and receive education on the vaccinations before a waiver can be signed by the health department.(18) Similarly, in Washington state, a licensed healthcare provider must discuss risks and benefits of vaccinations and sign off on the exemption.(19)

Perceptions Regarding Vaccines

Although concerns about vaccinations are not new, the perception that vaccinations entail an inherent risk is spreading worldwide.(20) This growth in hesitancy to vaccinate is in part due to changes in cultural views, as trust in pharmaceutical companies is low and trends focused on all-natural products continue to grow.(21) Currently, in states that allow NMEs, certain populations are more likely to request and use NMEs rather than vaccinate. Studies have demonstrated that higher exemption rates are common in private schools and are clustered in communities with college-educated, predominantly white population with higher incomes.(22)

Healthcare providers are in a position to influence parents’ perceptions of vaccination.

The U.S. Department of Health and Human Services recommends coverage ranging from 90% to 95% to maintain herd immunity against vaccine-preventable diseases.(23) Those who have not received the MMR vaccination are 35 times more likely to contract measles than vaccinated individuals.(24) Using exemptions to school-age vaccination requirements also places those who are too young to be vaccinated, those who cannot be vaccinated due to medical reasons, and those who were vaccinated but did not develop an adequate response at increased risk.(21) Healthcare providers are in a position to influence parents’ perceptions of vaccination.(11)

Stepwise Approach to Discussing Childhood Vaccines

The CDC has created a stepwise approach for discussing childhood vaccinations with parents. It recommends assuming that all parents will vaccinate and starting the conversation stating that a child needs specific vaccines rather than asking parents for their opinion on vaccines.(25) This approach was found to result in more children receiving the stated vaccines in a cross-sectional observational study.(26) However, some parents will be hesitant and will have questions. The CDC then recommends that physicians give their personal recommendations to receive the vaccination and work to understand and address all concerns that the parent may have.(25) This is where the patient–physician relationship is paramount.

Benin et al.(27) found that parents were more likely to vaccinate in an effort to adhere to social and cultural practices and if they were pleased with the conversation they had with the physician about vaccinations. Parents were less likely to vaccinate if they felt isolated by the physician, if they believed the physician was not trustworthy, if they were close with another person who did not believe in vaccines, if they were worried about vaccine side effects, and if they did not believe that the diseases being vaccinated against were serious. In another study, which collected data on more than 13,000 children, parental concerns about vaccine-related side effects were the most commonly cited barrier to vaccination.(28) If a parent is concerned about possible side effects, the CDC recommends reminding parents that most side effects are mild, but that your office is prepared to handle any serious reactions should they occur. Additionally, physicians can share their own experiences with specific vaccines to reassure the parents that the serious side effects are rare.

Even if all of the correct steps are taken, some parents may still make the choice not to vaccinate their children.

Another common area of parental concern is the number of vaccines that their child will receive in one office visit. It is important to explain what is contained within a vaccine; and, furthermore, that the child is exposed to more antigens in his or her daily environment compared with the amount contained in vaccines. It is also important to explain the reasoning behind the recommended vaccination schedule to help parents understand why multiple vaccines may be needed in one visit. The CDC’s website suggests physician talking points to additional frequently asked questions.(29) The CDC also produces fact sheets that can be printed and put in the office or given to parents who would like more information after an office visit. These two-page handouts include common questions and answers about a specific topic and the science behind it, in addition to listing multiple evidence-based articles that further support the statements in the handout. The handout topics include the immunization schedule, MMR vaccine safety, understanding the use of thimerosal and mercury in vaccines, how vaccines work, vaccine safety, and information about the Advisory Committee on Immunization Practices.(30)

Even if all of the correct steps are taken, some parents may still make the choice not to vaccinate their children. The American Academy of Pediatrics (AAP) recommends that the decision to not vaccinate be respected unless the child is in immediate danger of harm without the vaccine. In each future visit, another conversation should be had about vaccines, with the same opportunity given for the parent to ask questions.(31) The AAP provides a parental refusal form the physician can use if he or she wants to have written proof that vaccinations were denied or delayed. The form provides a brief summary of the risks associated with not vaccinating and can be added to the patient’s chart.(32) Additionally, the AAP recommends against discharging families due to their vaccine refusal unless a “significant level of distrust develops.”(31)

In addition to physicians advocating for patient vaccine compliance, other members of the healthcare team can be advocates for vaccines as well. The CDC offers free Web-based training courses designed for physicians and a variety of providers, including medical assistants, RNs, physician assistants, and administrators. There is a module for the majority of vaccines given to children including diphtheria, tetanus, and whooping cough; Haemophilus influenzae type b; varicella; MMR; and rotavirus, in addition to modules on vaccine administration and general immunization recommendations. Each vaccine-specific module provides background information on the disease, indications and contraindications for the vaccines, potential adverse effects, and vaccine administration and dosing.(33)

References

1. World Health Organization. Ten threats to global health in 2019. www.who.int/emergencies/ten-threats-to-global-health-in-2019. Accessed January 27, 2019.

2. Vaccines & immunizations. Centers for Disease Control and Prevention. March 10, 2017. www.cdc.gov/vaccines/vac-gen/whatifstop.htm . Accessed January 27, 2019.

3. Bowes J. Measles, misinformation, and risk: personal belief exemptions and the MMR vaccine. J Law Biosci. 2016;3:718-725.

4. Opel DJ, Heritage J, Taylor JA, et al. The architecture of provider-parent vaccine discussions at health supervision visits. Pediatrics. 2013;132:1037-1046.

5. Measles history. Centers for Disease Control and Prevention, March 19, 2018. www.cdc.gov/measles/about/history.html . Accessed December 18, 2018.

6. Mumps vaccination. Centers for Disease Control and Prevention, February 2, 2018. www.cdc.gov/mumps/vaccination.html . Accessed December 18, 2018.

7. Rubella vaccination. Centers for Disease Control and Prevention, July 11, 2016. www.cdc.gov/rubella/vaccination.html . Accessed December 18, 2018.

8. Measles cases and outbreaks. Centers for Disease Control and Prevention, December 18, 2018. www.cdc.gov/measles/cases-outbreaks.html . Accessed December 18, 2018.

9. Pottinger HL, Jacobs ET, Haenchen SD, Ernst KC. Parental attitudes and perceptions associated with childhood vaccine exemptions in high-exemption schools. PLloS One. 2018;13(6):e0198655.

10. Kluberg SA, McGinniss DP, Hswen Y, Santilana M, Brownstein JS. County-level assessment of United States kindergarten vaccination rates for measles mumps rubella (MMR) for the 2014–2015 school year. Vaccine. 2017;35:6444–6450.

11. Seither R, Calhoun K, Street EJ, et al. Vaccination coverage for selected vaccines, exemption rates, and provisional enrollment among children in kindergarten — United States, 2016–17 school year. MMWR Morb Mortal Wkly Rep. 2017;66:1073-1080. doi:10.15585/mmwr.mm6640a3.

12. United States, National Conference of State Legislatures. States with religious and philosophical exemptions from school immunization requirements. 20 Dec. 2017. www.ncsl.org/research/health/school-immunization-exemption-state-laws.aspx . Accessed December 18, 2018

13. Olive JK, Hotez PJ, Damania A, Nolan MS. The state of the antivaccine movement in the United States: a focused examination of nonmedical exemptions in states and counties. PLoS Med. 2018 Jun 12;15(6):e1002578.

14. Measles Outbreak 2019. Washington State Department of Health. January 2019. www.doh.wa.gov/YouandYourFamily/IllnessandDisease/Measles/MeaslesOutbreak . Accessed January 28, 2019.

15. Vera A. Washington is under a state of emergency as measles cases rise. CNN.com . January 28, 2019. www.cnn.com/2019/01/26/health/washington-state-measles-state-of-emergency/index.html . Accessed January 28, 2019.

16. Nonmedical vaccine exemptions. Oregon Health Authority. www.oregon.gov/oha/ph/preventionwellness/vaccinesimmunization/gettingimmunized/pages/non-medical-exemption.aspx#option1 . Accessed January 28, 2019.

17. Arizona Immunization Program. Arizona Department of Health Services. www.azdhs.gov/preparedness/epidemiology-disease-control/immunization/index.php#schools-immunization-forms . Accessed January 28, 2019.

18. Immunization waiver information. Michigan Department of Health & Human Services. www.michigan.gov/mdhhs/0,5885,7-339-73971_4911_4914_68361-344843-,00.html . Accessed January 28, 2019.

19. School and child care exemptions from immunization requirements. Washington State Department of Health. www.doh.wa.gov/CommunityandEnvironment/Schools/Immunization . Accessed January 28, 2019.

20. Downs JS, deBruin WB, Fischhoff B. Parents’ vaccination comprehension and decisions. Vaccine. 2008;26:1595-1607. doi:10.1016/j.vaccine.2008.01.011.

21. Siddiqui M, Salmon DA, Omer SB. Epidemiology of vaccine hesitancy in the United States. Hum Vaccin Immunother. 2013;9:2643-2648.

22. Pottinger HL, Jacobs ET, Haenchen SD, Ernst KC. Parental attitudes and perceptions associated with childhood vaccine exemptions in high-exemption schools. PLos One. 2018;13(6), 14 June 2018.

23. Olive JK, Matthews KRW. How too much freedom of choice endangers public health: the effect of nonmedical exemptions from school-entry vaccinations in Texas. Policy brief no. 10.13.16. Rice University’s Baker Institute for Public Policy, Houston, Texas. www.bakerinstitute.org/research/effect-nonmedical-exemptions-school-entry-vaccinations-texas/ . Accessed January 3, 2019.

24. Salmon DA, et al. Health consequences of religious and philosophical exemptions from immunization laws: individual and societal risk of measles. JAMA. 1999;282:47-53. doi:10.1001/jama.282.1.47.

25. Talking with parents about vaccines for infants. Centers for Disease Control and Prevention. December 10, 2018. www.cdc.gov/vaccines/hcp/conversations/talking-with-parents.html#ref01 . Accessed December 18, 2018

26. Opel DJ, Mangione-Smith R, Robinson JD, et al. The influence of provider communication behaviors on parental vaccine acceptance and visit experience. Am J Public Health. 2015;105:1998-2004. doi:10.2105/ajph.2014.302425.

27. Benin AL, Wisler-Scher DJ, Colson E, Shapiro ED, Holmboe ES. Qualitative analysis of mothers’ decision-making about vaccines for infants: the importance of trust. Pediatrics. 2006;117:1532-1541. doi:10.1542/peds.2005-1728.

28. Anderson EL. Recommended solutions to the barriers to immunization in children and adults. Missouri Medicine. 2014;111:344-348.

29. Preparing for vaccine questions parents may ask. Centers for Disease Control and Prevention. December 10, 2018. www.cdc.gov/vaccines/hcp/conversations/preparing-for-parent-vaccine-questions.html . Accessed December 18, 2018.

30. Understanding vaccines and vaccine safety. Centers for Disease Control and Prevention. August 17, 2018. www.cdc.gov/vaccines/hcp/conversations/provider-resources-safetysheets.html#childhood . Accessed December 18, 2018.

31. Meissner HC. Immunizations. In: Kline MW, Blaney SM, Giardino AP, Orange JS, Penny DL, Schutze GE, Shekerdemian LS, eds, Rudolph’s Pediatrics. 23rd ed. New York: McGraw-Hill, 2018.

32. Tan T, Rothstein E. Documenting parental refusal to have their children vaccinated. American Academy of Pediatrics. 2013. www.aap.org/en-us/Documents/immunization_refusaltovaccinate.pdf .

33. You call the shots: Web-based training course. Centers for Disease Control and Prevention. January 2, 2019. www.cdc.gov/vaccines/ed/youcalltheshots.html . Accessed January 3, 2019.