Q&A: Keeping nonimmunizing families in practices

According to a recent study in Pediatrics, the percentage of pediatricians who reported parents refusing vaccines for their children rose from 74.5% in 2006 to 87% in 2013. The proportion of such parents who felt vaccines were unnecessary rose from 63.4% to 73.1% during the same period.

Pediatricians also reported a higher percentage of parents who delayed vaccines because of concerns about discomfort and immune system burden, according to the report. Meanwhile, the percentage of pediatricians who “always” dismissed patients from their practice because of vaccine refusals climbed from 6.1% to 11.7% over the study period.

Kenneth A. Alexander

Also in Pediatrics, several doctors co-authored a paper debating the pros and cons of dismissing families from pediatric practices for refusing to vaccinate their children. In the paper, Kenneth A. Alexander, MD, PhD, chief of infectious diseases at Nemours Children’s Hospital in Orlando, Florida, Thomas A. Lacy, MD, of Nemours Children’s Primary Care in Orlando, Florida, and colleagues wrote that they keep nonimmunizing families in their practices because the benefits outweigh the risks.

“If all we did was immunize, and if we only offered immunization once, we would vote to exclude nonimmunizing families,” they wrote. “But this is not the case.”

To get a better idea of this stance, Infectious Disease News asked Alexander five questions on the topic of vaccine refusals and his decision to keep nonimmunizing families in his practice. – by Gerard Gallagher

Why do you keep nonimmunizing families in your practice?

This question is really at the center of the discussion. Many pediatricians feel angry and saddened when families refuse to accept our advice to immunize their children. Nonimmunizing families can be immensely frustrating, especially when we as pediatricians are vaccine enthusiasts. Furthermore, pediatricians worry that when parents reject our advice to immunize their children, parents will reject other advice that we give as well. In addition, we know that unimmunized children pose a risk to our vulnerable patients. Given that dealing with nonimmunizing families can be frustrating, and that unimmunized children pose a risk to the vulnerable children in our practices, we may feel that excluding nonimmunizing families from our practice will save us a great deal of headache, and may protect our vulnerable children from vaccine-preventable diseases.

But here’s the rub: We as pediatricians do so much more than just immunize. We educate, we screen for disease, we role model, and we do everything within our power to improve the lives of the children we serve. Our good works go far beyond just immunizing. The trick is, if we are to do all these other good things, we have to keep the children coming to our offices, even if parents choose not to immunize them.

What is the principle of double effect, and how does it impact your opinion on whether or not to treat unvaccinated children?

The principle of double effect was articulated by the early Christian philosopher Thomas Aquinas. Aquinas articulated the principle of double effect as he struggled with complex ethical issues like self-defense and the justice of war. The principle of double effect asserts that when an intended positive action carries with it a smaller and unintended negative effect, the action is still positive overall. The principle of double effect requires that:

The intended effect is positive.
The positive effect is intended.
The negative effect is not intended as a means to the positive effect, nor as an end in itself.
The positive effect outweighs the negative effect.
Continual effort is made to minimize the negative effect.

Applying the principle of double effect to the question of excluding nonimmunizing families from our practices, we must ask if the good that we do as pediatricians, even without immunizing, outweighs the risks that nonimmunized children pose to our vulnerable patients. Given all the important nonvaccinating things that we do as pediatricians, I believe that the answer to this question is a resounding “Yes!” Pediatricians do so much more than just immunize, and given the relative rarity of vaccine-preventable diseases, I believe that the good that pediatricians do when we include nonimmunized children in our practices outweighs the risks that nonimmunized children pose to our vulnerable patients.

This is not to say that we take nonimmunization of our patients sitting down. The final part of the double effect principle is that we make continuous efforts to minimize the negative effect. With respect to nonimmunizing families, this means that we continue our efforts to get children immunized. We engage, we advise, we teach, we cajole, we plead and we persist, imploring parents to let us immunize their children, all the while doing the other valuable nonimmunizing things that we do as pediatricians.

It is important to bear in mind that, should we exclude a family from our practices for not immunizing their children, these families may seek care with less effective providers such as chiropractic, homeopathic, or naturopathic practitioners who will offer unproven, ineffective, and potentially dangerous remedies. Even if families don’t let us immunize their children, parents may listen as we talk to them about securing cabinets against toddlers’ prying fingers, wearing bicycle helmets, weight control, avoiding tobacco, preventing substance abuse and practicing safe sex. Even if parents won’t let us immunize their children, we can screen their children for learning disabilities, hearing and vision loss, dyslipidemias, cardiac problems, and depression (none of which can be screened for or treated effectively with a cup of Chinese lemongrass tea or by manipulation of the spine).

How do you educate and encourage nonimmunizing families to vaccinate their children, and what kind of success do you have?

When it comes to encouraging families to vaccinate their children, there are no magic words. Further, there is no single recipe for success. Unfortunately, the decision to vaccinate children is not always made on rational grounds. Facts and logic don’t always carry the day. It is well-established that people make decisions, not always on the basis of facts and logic, but on the basis of experience. People come to our offices with biases and misinformation. The best we can do is engage families; we invest in the relationship for the long haul. We educate, and we persist. Still, research shows that education is not enough. Some parents, as you challenge their erroneous ideas around immunization, cling even more vociferously to their erroneous ideas. Education can backfire when it challenges strongly held notions, even erroneous ones. How to respond to this situation is not well-studied.

Perhaps the best we can do is to counter the thoroughly entrenched immunization-resisting parent is offer an emotional plea. Paul A. Offit, MD, chief of the division of infectious diseases at The Children’s Hospital of Philadelphia, once shared his observation with me that parents bring their children to us because parents love their children. Parents are asking us to love their children as well. To promote vaccination, we need to say to parents that, when you don’t let me immunize your child, you are not allowing me to love your child the way that you are asking me to. As a pediatrician, I believe strongly that immunizing your child is a gesture of love.

How likely is it that an unvaccinated child will transmit a vaccine-preventable disease to a vulnerable child in a pediatric office?

The good news is this: (with the exceptions of HPV infections and influenza) vaccine-preventable diseases are rare. Because most vaccine-preventable diseases are rare, the risk for transmission of vaccine-preventable disease from an unvaccinated child to a vulnerable child in a pediatric office is low. Very likely, the risk for transmission of a vaccine-preventable infection out in the real world (eg, at school, at the grocery store, or at a soccer game) is greater than the risk for acquiring infection in our waiting rooms. In California, even at the height of the measles outbreak, the prevalence of measles infection was still very low.

Where does the issue of vaccine refusal rank in terms of emerging health threats?

The good news here is that most vaccine-preventable diseases are rare in the United States. The bad news is that there are other problems that cause many more deaths than vaccine-preventable diseases. Here in Florida, a child drowns in a swimming pool every 4 days. Children die in motor vehicle accidents, children die of prematurity, children die of toxic ingestions, children die violently. Childhood death by firearms is not rare in this country. These are evils greater than nonimmunization.

This said, there is a dangerous mindset growing in our society. Developing around our coffee tables and internet chat rooms is a growing disdain for the scientific method and for the opinions of qualified experts. Increasingly, we hear parents say “I don’t care what the science says,” and “I have my own opinions.” We live in a country where some people still question the value of fluoridation of community water supplies. Some question the reality of climate change. Some of our parents believe that their individual opinions, however unqualified, must be valued as we value the opinions of our most learned experts. This is tantamount to ascribing the same value to a block of lead and to a bar of gold, only in the case of immunization, something more valuable than gold — the health of our children — is a stake.

Should we keep the children of nonimmunizing families in our practices? Yes! But we have to keep engaging families. Perhaps, given the continued opportunities to talk with parents that each well-child and sick visit affords, we can work our alchemy, turning nonimmunizing parents from the lead of their opinions toward the gold of immunization.

References:

Alexander K, et al. Pediatrics. 2016;doi:10.1542/peds.2016-1597.

Hough-Telford C, et al. Pediatrics. 2016;doi:10.1542/peds.2016-2127.

Disclosure: Alexander reports being a paid speaker and consultant for Merck Vaccines. The other researchers report no relevant financial disclosures.