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02/20/2015

What should docs do with parents who don’t vaccinate?

by Jenna Lillemoe, B.A.
by Arthur Caplan , Ph.D.

This year has marked the largest measles outbreak in decades with over 102 cases documented since December. This outbreak is a product of the anti-vaccination trend that has dramatically decreased vaccination compliance rates in children. Parents no longer follow the guidance of their pediatricians or believe the scientific evidence that vaccinations work without adverse effects. Pediatricians and family medicine physicians are then tasked with caring for these unvaccinated children. Because there is no set policy of how to manage caring for non-vaccinated children, we were interested in attempting to critically analyze how physicians manage non-vaccinated children.

In July 2014, a survey was distributed electronically to pediatricians and family medicine physicians to assess the frequency with which physicians interact with families who choose not to vaccinate and to uncover the conversations that take place between physicians and parents about vaccine refusal. We reached out to each state director of American Academy of Pediatrics and American Academy of Family Medicine and invited them to invite their members to participate in this IRB approved study. Many doctors agreed to participate and we gathered 539 responses by October 2014 from Maine, Oklahoma, New Jersey, Utah, New York, Kansas, Kentucky, North Carolina, New Mexico, Texas, and Florida. 53% of respondents were pediatricians and 47% were family medicine physicians; 57% were female and 43% were male.

Of the respondents, 86% reported that they had parents refuse one or more CDC-recommended childhood vaccination in the past three years. These physicians were then asked to disclose more information about the conversations with the parents. The main reason parents chose not to vaccinate was due to concerns about a vaccine’s safety. This was closely followed by discomfort over the administration of too many vaccinations at one time. Many physicians cited the rumor that vaccines contribute to autism as a concern raised by parents.

In responding to parents who refused the HPV vaccine (Gardasil), many reported concerns regarding its effectiveness and safety, saying that it was too new and untested. Others felt the vaccine to be unnecessary since their child was not having sex.

Physicians have their own strategies for treating families who do not wish to protect children against preventable diseases. We specifically inquired about persuasive strategies, alternative vaccination schedules, and dismissal of families from practice.

Most physicians attempt to convince “anti-vaxxers” through conversation and reason. Physicians reported that they most often try to conduct an educational discussion with the patients regarding the importance/safety of immunizations, provide refusing parents with educational materials, or provide anecdotal evidence of risk of disease amongst unvaccinated children.

Physicians often feel forced into offering or obliging the administration of vaccinations on a schedule different than the one recommended by the CDC and ACIP. Over 80% of physicians responded in the survey that they typically discuss alternative schedules with refusing parents. Many parents who refuse are afraid to overwhelm the child’s immune system with too many vaccinations at once, therefore an alternative schedule minimizes this concern while ensuring the child receives all vaccinations at some point. This approach did seem to be efficacious as 38.5% of anti-vaxx families gave permission for vaccination at scheduled time and 43.5% gave permission for an alternative schedule.

Many physicians will dismiss parents from their practice if they are unwilling to vaccinate. The difference of beliefs is too stark for some and they feel they can’t properly care for the children who are unvaccinated. 12.3% physicians reported that they dismiss all families who refuse from their practice and 16.3% reported they dismiss some families who do not choose to vaccinate their children. Those that do dismiss families reported doing so because of a strained relationship with the families, staying true to their duty to vaccinate all patients, and a desire to not take on vaccine-preventable diseases within their practice. Of the 71% of physicians who do not dismiss families from their practice, they largely do so due to the desire to provide continued care regardless of parents’ decisions, holding the belief that the decision is not the fault of the child.

Physicians are able to independently choose how to “treat” unvaccinated patients. As we found, approaches vary and it is rare that physicians refuse to treat children who are not vaccinated. In light of this year’s measles outbreak, more and more physicians are either asking un-vaccinated patients to refrain from coming to clinic this season or scheduling certain days for appointments for unvaccinated children.

Ultimately, the United States needs to increase vaccination rates and this begins at the clinic level. Our findings indicated that physicians are able to convince parents to vaccinate, either on the recommended or alternative schedule. Physicians should persistently attempt to talk with parents about the pros and lack of cons for vaccination and urge compliance. If the parents continue to refuse, it is the physicians choice as to how to move forward in the relationship, however unvaccinated patients are an unnecessary risk in waiting rooms and create an unnecessary public health risk.

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