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When parents say no to vaccines
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A very insightful article recently appeared in The New England Journal of Medicine (2009; 360: 1981-1988) on unvaccinated (NOT) and undervaccinated (UNDER) children.
The authors referred back to an article in Pediatrics that estimated that in 2001, 0.3% of these children were not vaccinated and more than one-third of 19- to 35-month-olds were undervaccinated. “Undervaccinated” is variously defined as missing a single or multiple recommended vaccines. The level of children who are not vaccinated has been rising in recent years. What danger do these children pose to themselves and their communities and what can be done to encourage optimal immunization of these children?
Comparing the parents of the “undervaccinated” children with the “not vaccinated” group is a bit tricky as the comparison depends upon the number of vaccines missed and the age of the children. They also compare the parents of fully immunized with the parents of children who are not or undervaccinated. Parents of the undervaccinated children tended to be poorer, less well-educated and more likely to be minorities. Parents of the “not vaccinated” children are predominately white, college graduates, older than 30, have an income exceeding $75,000 annually, and have more than four children.
Most of those children who fall into the undervaccinated category will be reduced or eliminated when they attend school or preschool, depending on their respective school’s vaccine requirements. The danger, however, as witnessed in the measles epidemic of the late 1980s, is that the undervaccinated children tend to live in communities where there were sufficient numbers of susceptibles to perpetuate an outbreak. In that epidemic of more than 50,000 cases, there were more than 100 deaths and the number of the cases in inner city areas was directly related to the proportion of UNDER in these cities.
Contrary to the belief I have heard expressed by many of my colleagues, parents of children in the not vaccinated group may be frustrating but they are not ignorant. They generally are better educated and better off economically.
Children who are not vaccinated clearly are at increased risk of disease as demonstrated by recent outbreaks among religious groups that do not accept immunization and in communities in which the not vaccinated children tend to cluster. In Ashland, Oregon, 12% and 18.8% of those attending public and preschool, respectively, claimed exemptions, compared with 2.4% for the entire state. In Colorado, the exemption rate was 4.3% in schools with outbreaks, as compared with 1.5% in those that had not. Eleven percent of the non-exempted in those communities who were infected with vaccine-preventable diseases were infected by those with exemptions.
Why do parents choose not to have their children immunized? Religious beliefs, in my opinion, are a non-negotiable reason.
These children clearly pose a risk to the other children and for that reason may be excluded from school in the event of an outbreak. Parenthetically, several hundred thousand children are home-schooled where they are not subject to school-based immunization requirements.
The NOT parents were more likely than the parents of vaccinated children to be concerned about safety and unconvinced of efficacy of vaccines. Lack of trust in the government, the perception that their children were not at great risk and that the vaccine-preventable diseases were not severe were other reasons given (Arch Dis Child Adol Med. 2005;155:470). Some parents objected to vaccines because they were concerned about “overload of the immune system” and others because of the use of human fetal tissues in vaccines, animals for testing and a variety of other reasons. Some were selective in the vaccines they rejected, most commonly varicella. These parents were likely to rely on sources other than physicians, public health officials or government than alternative sources. Parenthetically, some parents whose physicians have dismissed them from their practices because they rejected immunization drifted to alternative medicine providers who support their choices.
Pediatrician response
How have we responded to parental reluctance? In a recent survey, many pediatricians reported at least a single instance of either total, 85%, or selective, 54%, parental refusal of vaccines. Pediatricians asked the families to seek care elsewhere for 28% and 39% of the selective- and full-refusers, respectively. The reasons to dismiss were “lack of common goals,” lack of trust, or fear of litigation. Reimbursement was not an issue.
Of interest was the relative importance pediatricians placed on the particular vaccines. Diptheria-tetanus and acellular pertussis, Haemophilus influenzae type B, measles-mumps-rubella and inactivated polio vaccine ranked very important; seven-valent pneumococcal conjugate vaccine (PCV7), hepatitis B (HBV) and varicella zoster (VZV) ranked less important. Between 2.3% and 6.6% of those surveyed rated VZV, HBV and PCV7 as “optional.”
In a recent presentation at the Pediatric Academic Societies Annual Meeting, Dr. Bonnie Offitt, who practices in suburban Philadelphia, indicated that she would not accept patients into her practice who refused at the onset to have their children immunized. One of the reasons I have heard from pediatricians for not treating patients whose parents refuse is the reluctance to have their other patients, some of whom may be too young to immunize or are unable to receive vaccines, exposed to the unvaccinated in their waiting rooms. Another reason, I suspect, is the unwillingness to devote the time required for exhaustive discussion with refusers.
Most parents rely on their pediatricians for advice on immunization, although they certainly consult other sources. It is our obligation to be able to answer their questions honestly and authoritatively. To my mind, the mercury issue has been settled by the study showing that autism diagnoses continued to rise after its removal from childhood vaccines in 2001. There are similar data from other countries. If parents are concerned about mercury, I would remind them of the mercury content of tuna fish. The major issue has been measles vaccine and autism. Here again, the evidence rejecting an etiologic relationship is overwhelming, including studies not only from the United States but also from Japan, Sweden, Denmark and Canada. I would strongly recommend you try to get a copy of the review in Clinical Pharmacology and Therapeutics (2007;82:756), which has a very critical review of the relationship of both measles and mercury to autism.
The AAP urges us to make an effort to convince parents of the need to have their children immunized and not to dismiss them out of hand. The refusers are and will continue to be a challenging problem. The best way we can prepare ourselves for discussions with these parents is to be able to share with them objectively the available data.