Q&A: How to talk to families about vaccines
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Key takeaways:
- Kindergarten vaccine exemptions are rising, but they are not solely to blame for declining vaccine coverage.
- A highly effective way for providers to improve uptake is through strong, presumptive recommendations.
NEW YORK — Vaccine hesitancy is only one factor leading to a decrease in vaccine coverage in the United States, so pediatric providers may need to try multiple strategies to improve vaccine uptake, according to Sean O’Leary, MD, MPH, FAAP.
In his presentation at the Infectious Diseases in Children Symposium, O’Leary offered advice for improving vaccine communication based on a clinical report he and colleagues published in Pediatrics earlier this year.
The CDC reported in October that DTaP and MMR vaccine coverage fell below 93% this year among kindergarteners, and the rate of exemptions rose from 3% during the 2022-2023 school year to 3.3% during the 2023-2024 school year. This trend is worrying because it could lead to a reemergence of infections like measles. However, O’Leary said exemptions are not solely to blame.
“There is a very small percentage of parents who refuse all vaccines,” O’Leary, a professor of pediatrics at the University of Colorado School of Medicine and chair of the AAP’s Committee on Infectious Diseases, told Healio. “It is roughly around 1%, and it has been stable over many years.
“For many children who have no vaccines, it is not that their parents are refusing — it is that they do not have access to care.”
Healio spoke with O’Leary about his presentation and asked for advice that pediatric providers can use to improve vaccine uptake in their clinics.
Healio: What factors are causing vaccination rates to decrease?
O’Leary: It is a combination of factors. During the pandemic, there were a lot of kids who missed vaccine doses. We saw a precipitous drop in that 3- or 4-month period after March 2020 that started to come back up but never really caught all the way back up. We also know that nonmedical exemptions for kindergarteners have risen slightly but not enough to explain all of the fall that we have seen. Some of it also appears to be access issues — kids who are uninsured and more likely to not be up to date on their vaccines.
I think a lot of people want to explain it all as more people refusing vaccines, but I think it is more complicated than that. We have been following a longitudinal survey here in Colorado, going back before the pandemic, and we did not see a change in overall hesitancy. What we did see was more parents saying they were concerned about the safety of vaccines, even though they were not overall more hesitant about vaccines. We also saw more of a polarization. One specific question asked, “How hesitant do you consider yourself to be about childhood vaccines?” We saw more people saying either they were not hesitant or that they were hesitant, with fewer people saying they were unsure. There have been some other national surveys that have seen similar findings.
Healio: What did you explain to providers during your presentation?
O’Leary: I was generally describing a clinical report that we published with AAP in February 2024, which updated a prior clinical report published in 2012 called Countering Vaccine Hesitancy. The overall gist of both my talk and the clinical report was to help clinicians improve vaccine uptake within their practices and communities.
There is a section in the clinical report on the costs of vaccine refusal. If a child comes down with a vaccine-preventable disease, that costs the family in numerous ways. We describe costs to pediatric practices, like having to contact patients who may have been exposed to a vaccine-preventable disease in their office, and the costs of vaccine counseling, for example. We also described the cost to society, the costs to insurance companies or Medicaid having to pay for diseases that could have been prevented by vaccination.
We had a large section on vaccine safety. We know that a lot of parents who have questions about vaccines have concerns about safety, so there are a lot of facts describing the vaccine safety surveillance mechanisms in place in the U.S., describing prelicensure clinical trials, and we cover a lot of vaccine safety concerns that come up in these conversations and what the facts are around those questions.
This led into a large section on how to communicate those facts. We talk about using presumptive recommendations for vaccination because there is strong evidence that those are effective at increasing vaccination uptake.
Healio: Are there any ways providers can improve vaccine access in their clinics?
O’Leary: This is a systemic problem. This is not something that is easily solved in a pediatric office, but providers should stock vaccines. That is certainly an issue in a lot of rural areas where families may have to drive many, many miles to get vaccines. Sending reminders or even personal phone calls to set up appointments can help reach the kids who do not come in very often.
Healio: How do you recommend pediatric providers approach conversations with parents who are hesitant about vaccinating their child?
O’Leary: First of all, recognize that you are both on the same page. You both want what is best for the child. Go into the conversation in that spirit and not [with] a lecture. There are motivational interviewing techniques that are described in the clinical report.
Pediatricians are consistently identified as the most trusted source of information about vaccines. As pediatricians, we need to recognize that. Do not assume that parents are hesitant. There is a real risk to assuming people are questioning vaccines because one of the things that we know about vaccine communication is that if you give a strong recommendation, parents are much more likely to vaccinate their children. If you go in hesitant about giving a recommendation, parents may sense that hesitancy. Even if they end up even getting their child vaccinated, they may walk out feeling like maybe they should not have because “Gosh, if a pediatrician is not confident about this, should I be?” It is really important to convey that message of confidence that you have in vaccines as a pediatrician, because otherwise you sort of risk making parents feel less confident in their decision to vaccinate.
Healio: What should providers say to parents who refuse to vaccinate their child?
You do sometimes run into these families who are adamantly against vaccines. Often in the clinical encounter, you get a sense of that when you first start the conversation. What I generally recommend is to point out that as a pediatrician, I believe vaccines are one of the most important things I do to ensure children's health, and I am going to bring this up every time you come in, because I think it is so important. And then, move on to other topics. Because when people are that strong in their feelings, you are probably not going to have a productive conversation. You want to be open to it if they have questions, certainly. But often, when you get that sense that these folks really do not want to talk about vaccines, it is probably not productive to push it when trying to build a trusting relationship with that family.
Healio: Where can providers learn more about this?
O’Leary: In the clinical report, we have an exhaustive list of resources and websites for vaccine information. In my talk, I said, “Don’t reinvent the wheel.” If you get a question that you are not sure how to answer, or if you hear a question a lot and you want to create something from your office, you probably should look around first, because I can guarantee it probably already exists.
References:
- Higgins DM, et al. Pediatrics. 2023;doi:10.1542/peds.2023-062927.
- O’Leary ST. Strategies for improving vaccine communication and uptake. Presented at: Infectious Diseases in Children Symposium; Nov. 16-17, 2024; New York.
- O’Leary ST, et al. Pediatrics. 2024;doi:10.1542/peds.2023-065483.
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