standard childhood vaccines parental refusal

Official reprint from UpToDate®

www.uptodate.com ©2010 UpToDate®

Authors Julie A Boom, MD C Mary Healy, MD

Section Editors Morven S Edwards, MD Jan E Drutz, MD

Deputy Editor Mary M Torchia, MD

Standard childhood vaccines: Parental refusal

Last literature review version 18.3: septiembre 2010 | This topic last updated: octubre 8, 2010

INTRODUCTION — This topic reviews the reasons why some parents refuse or are hesitant to have their child(ren) immunized; the consequences of vaccine refusal; and an approach to the management of parents who refuse vaccines for their children. Standard childhood immunizations for children are discussed separately. (See "Standard childhood immunizations".)

BACKGROUND — Immunization is one of the most effective preventative health measures and has saved countless children from death or serious disability (figure 1). Despite this, immunization is an emotional issue for many parents. As vaccine-preventable diseases become less common and parents have little familiarity with the devastating effects of vaccine-preventable illnesses, the benefits of immunization may seem less important than the potential adverse effects [1].

Mainstream media and Internet discussions on vaccines, fueled by celebrity opinion, often give equal or greater weight to ill-informed opinion or anecdotal claims about the dangers of vaccines compared with the rigorous scientific studies that prove vaccines are safe and effective [1-4]. The mainstream media has a limited ability (or perhaps preference) to adequately communicate scientific data on vaccines, and Internet sites are not subject to constraints regarding scientific accuracy or fairness of their reporting. The resulting misinformation leads to unnecessary parental concerns. Healthcare providers need to understand these concerns in order to effectively address them and aid parents in choosing immunization for their children. (See 'Approach to management' below.)

STATE LAWS REGARDING VACCINATION — All 50 states in the United States require some immunizations for school entry (typically for kindergarten, seventh grade, and college entry). However, parents can elect to exempt their children from immunizations. There are three types of exemption:

Medical exemptions are for children who have a valid medical contraindication to a vaccine or vaccine component (eg, history of anaphylaxis to a previous dose of vaccine).

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Religious exemptions are for individuals whose religious beliefs oppose immunizations.

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Philosophical exemptions are for individuals with a personal, moral, or philosophical belief against some or all immunizations.

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All states allow medical exemptions; nearly all allow exemptions based upon religious beliefs, and approximately 40 percent allow philosophical exemptions [5]. A comprehensive link to state exemption statutes may be found at www.ncsl.org/programs/health/SchoolExempLawsChart.htm.

Observational studies suggest that the ease with which exemptions can be obtained impacts exemption rates within communities [5-8]. States that allow philosophical and religious exemptions have significantly higher vaccine exemption rates than those with religious exemptions only [9]. They also have higher rates of vaccine-preventable diseases [6,10]. (See 'Consequences of vaccine refusal' below.)

EPIDEMIOLOGY

Prevalence — The prevalence of vaccine refusal remains low. In 2001, it was estimated that only 3 per 1000 children aged 19 to 35 months had never received any vaccines [11]. In a national survey, immunizations were rated as extremely important by 87 percent of parents, and 84 percent said they would not decline any immunizations [12].

Although the majority of parents agree to have their children immunized, vaccine refusal appears to be increasing [5,12-15]. The proportion of children who are exempted from school immunization requirements for nonmedical reasons is the primary measure of vaccine refusal in the United States [5]. Between 1991 and 2004, the mean rate of nonmedical immunization exemptions at school entry increased from 0.98 to 1.48 percent at the state level. Among states that allowed exemptions for philosophical/personal beliefs, the nonmedical exemption rate increased to 2.5 percent [6]. The rate of nonmedical exemptions varies geographically (ranging from 0 to 17.7 percent for 2007-2008 in one state) [16]. In the 2003 and 2004 National Immunization Survey (NIS), 6 percent of parents reported having refused at least one vaccine [13]. In another national survey, 11.5 percent of parents reported having refused at least one vaccine in 2009 [15].

Many parents express concerns related to vaccines, even if they choose to vaccinate their children. In a 1999 national survey, 25 percent of parents expressed vaccine concerns [12]. In the 2003 and 2004 NIS, 9 percent of parents reported that they allowed their child to be immunized but were doubtful it was the correct thing to do, and 13 percent reported having delayed a vaccine [13]. Approximately 90 percent of pediatric healthcare providers annually encounter at least one parent who refuses some recommended vaccines, and 54 percent encounter a parent who refuses all recommended vaccines [14,17].

Demographics — There are important racial/ethnic and socioeconomic differences between children who have received fewer than the recommended number of vaccines (undervaccinated children) and children who have received no vaccines (unvaccinated children) [11,18,19]. In the 2001 NIS, undervaccinated children were more likely to be black, live in poverty in a central city, and have an unmarried younger mother without a college education [11]. In contrast, unvaccinated children were more likely to be white, have a married mother with a college degree, and have an annual family income greater than $75,000. Additional studies confirm that parents who refuse vaccines or seek philosophical exemptions are older (36 to 40 years) [20] and have higher levels of education and household incomes [20-22]. Unvaccinated children also tend to live in states that allow philosophical exemption, and cluster in certain counties [11,16].

Parents who seek vaccine exemptions may have a low level of trust in the government and healthcare professionals and may use complementary or alternative medicine professionals whom they consider to be reliable sources of vaccine information [20]. In a



2002 national survey, 12 percent of respondents who had at least one child <18 years of age living in the household were opposed to compulsory vaccination [18]. Many of those opposed to compulsory vaccination believed that vaccines were not necessary for protection against disease and did not plan to fully immunize their youngest child.

Vaccine beliefs — Scientific characterization of parents according to vaccine beliefs is difficult. One study from the Centers for Disease Control and Prevention (CDC) has identified five types of parents, according to clusters of attitudes and beliefs about vaccines [23]:

"Immunization advocates" (33 percent) strongly agree that vaccines are necessary, safe and important

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"Go along to get alongs" (26 percent) agree that vaccines are necessary and safe•"Health advocates" (25 percent) agree that vaccines are necessary but are less sure about their safety

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"Fence-sitters" (13 percent) slightly agree that vaccines are necessary and safe•"Worrieds" (3 percent) slightly disagree that vaccines are necessary and strongly disagree that they are safe

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Parental types also differ in their descriptions of their relationship with their provider, varying from "good," for immunization advocates, to "neutral," for fence-sitters and worrieds [23]. Worrieds are also skeptical that providers have their child's best interest at heart.

WHY PARENTS REFUSE VACCINES

General objections — Parental concerns regarding vaccines can be classified into several major categories that have remained relatively unchanged since the advent of smallpox vaccination in the 18th century: concerns about safety or side effects, religious objections (immunizations are a violation of God's will), and philosophical objections (immunization is "not natural") [14,15,20,24].

Concerns about safety and side effects account for approximately 60 to 70 percent of vaccine exemption requests [20,22]. Specific safety concerns include particular side effects (eg, Guillain-Barré syndrome, intussusception) and concerns that vaccines overload the immune system, possibly causing autism, autoimmune disease, or increased susceptibility to infection [12,20]. Some safety concerns have a factual basis (eg, an early rotavirus vaccine [Rotashield] and intussusception), whereas others are misconceptions (that multiple vaccines overwhelm the immune system) [25]. Concerns about safety are intensified by negative word of mouth and media messages [3,14].

Additional reasons for vaccine refusal include [14,15,20,25]:

Concern that vaccines don't work•Concerns about medical contraindications•Antigovernment sentiment•Belief that their child is not at risk•Belief that the disease is not dangerous•Belief that is it better to be naturally infected than vaccinated•Cost•

Belief that the child is not at risk or that the disease is not dangerous is a consequence of the success of childhood immunization programs (figure 1). As more diseases are successfully prevented by immunization, the devastating sequelae of vaccine-preventable diseases are forgotten [1]. Many parents are unaware of the risks to the



individual and of the societal consequences of refusing vaccines. (See 'Consequences of vaccine refusal' below.)

Specific objections — Parents (and providers) may have a tendency to selectively protect against diseases they believe are more severe (eg, Haemophilus influenzae type b) and refuse vaccines against diseases that they believe are not dangerous. As an example, varicella vaccine is one of the more commonly refused vaccines [5,26,27].

Many studies demonstrate that underimmunized children have characteristics reflecting social inequalities, rather than true philosophical objections to immunization. (See 'Demographics' above.) However, there is some evidence to suggest that parents whose children were underimmunized for pertussis, hepatitis B, or measles had safety concerns (eg, autism, thimerosal) and wished to selectively immunize their children [11,28].

MMR vaccine — Concern regarding the combination measles-mumps-rubella vaccine (MMR) can be traced to a 1998 study in 12 children from the United Kingdom (UK) alleging that MMR damaged the intestinal lining, allowing encephalopathic proteins to enter the bloodstream and brain, thereby leading to the development of autism [29]. The paper was retracted from the public record in 2010 [30]. Despite overwhelming evidence disproving this theory, it still is highlighted in media reports and on the Internet [2]. Large-scale population studies have demonstrated that MMR and autism occur independently of each other and that gastrointestinal disease and autism do not occur after MMR vaccine. This issue is discussed in detail separately. (See "Autism and chronic disease: Little evidence for vaccines as a contributing factor".)

Despite the lack of an association between autism and MMR, MMR immunization rates in the UK declined acutely (from 92 percent in 1995 to 79 percent in 2003) [31,32]. In June 2008, measles was again endemic in the UK, 14 years after it had been eliminated [33,34].

HPV vaccine — Human papillomavirus (HPV) vaccine is controversial. Attitudes of parents, partners, and clinicians influence completion of the vaccine series [35]. Concerns regarding HPV vaccine are related to the belief that it may encourage sexual activity, excessive influence by the pharmaceutical industry [36,37], and safety. The 2009 death of a British girl within hours of receiving HPV vaccine received widespread attention; autopsy demonstrated that she died of an undiagnosed tumor and that her death was unrelated to HPV [38].

The media focus on the above concerns may have contributed to the number of adverse events reported to the Vaccine Adverse Event Reporting System (VAERS) between June 2006 and December 2008 (53.9 per 100,000 doses administered, 6.2 percent serious) [39]. However, analysis of the VAERS reports shows that the adverse events were similar to those identified before the vaccine was licensed. They were also similar to background rates of other vaccine-associated adverse events, except for two categories: syncope and venous thromboembolism. The age group for whom HPV vaccine is recommended (11 to 26 years) has an excess risk of immunization-associated syncope [40]. Studies are ongoing to further quantify the excess risk, if any, of HPV-vaccine-associated thromboembolism. (See "Recommendations for the use of human papillomavirus vaccines", section on 'Vaccine safety'.)

MCV4 — The major concern regarding the quadrivalent meningococcal conjugate vaccine (MCV4) is a possible association with Guillain-Barré syndrome (GBS) [41]. GBS is an immune-mediated, rapidly evolving polyradiculoneuropathy with an estimated incidence of 1 to 2 cases per 100,000 person-years. Although GBS has been temporally associated with vaccination, a causal association has not been proven. (See



"Overview of Guillain-Barré syndrome in children", section on 'Epidemiology'.) The possible association between MCV4 and GBS is discussed separately. (See "Meningococcal vaccines", section on 'Possible association with Guillain-Barré syndrome'.)

Influenza — Parental concerns regarding influenza vaccines may include unknown side effects with possible long-term problems, Guillain-Barré syndrome (GBS), thimerosal exposure, inadequate testing to ensure safety in children, and the lack of need for protection against what may be mistakenly thought of as a "mild type" of influenza [42].

Concerns about influenza-vaccine-associated GBS and other neurologic complications were highlighted by the media during the 2009 H1N1 influenza pandemic. Cases of GBS occurred following the administration of swine flu vaccine in the United States in 1976 and 1977, and some commentators erroneously compared the rapid development of H1N1 vaccines to swine flu vaccine development in 1976. However, monovalent H1N1 vaccine was developed using the same methods that are used for seasonal influenza vaccine, and the increased risk of GBS following seasonal influenza vaccine is small or nonexistent [43]. (See "Seasonal influenza vaccination in children", section on 'Adverse reactions' and "Seasonal influenza vaccination in children", section on 'Adverse effects'.)

Studies regarding adverse effects of monovalent H1N1 vaccines do not indicate an increased incidence of GBS among recipients [44-46]. (See "Treatment and prevention of pandemic H1N1 influenza ('swine influenza')", section on 'Guillain-Barré syndrome'.)

Thimerosal — The use of thimerosal (ethylmercury) as a vaccine preservative has been hypothesized to result in mercury-related neurologic effects, including the development of autism. Numerous studies refute this hypothesis. Nonetheless, some parents remain unconvinced by the scientific data. (See "Autism and chronic disease: Little evidence for thimerosal as a contributing factor".)

CONSEQUENCES OF VACCINE REFUSAL — Vaccine refusal increases the risk of vaccine-preventable disease among unvaccinated individuals and the risk of vaccine-preventable disease outbreaks in the general population.

For the individual — Unvaccinated children have a higher risk of acquiring vaccine-preventable illness than their vaccinated peers. In observational studies and mathematical modeling, the magnitude of the increased risk is approximately ninefold for varicella and ranges from 22- to 35-fold for measles and 6- to 23-fold for pertussis [47-50].

During January-July 2008, 123 measles cases occurred in residents of the United States [33]. Ninety-one percent of these cases occurred in individuals who were unvaccinated or did not have evidence of vaccination; among the 95 cases who were eligible for immunization, two-thirds were unvaccinated because of religious or philosophical beliefs (figure 2).

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Among Colorado children enrolled in a large health plan, 11 percent of pertussis cases were attributed to vaccine refusal [48].

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In a 2008 outbreak of invasive Haemophilus influenzae type b (Hib) disease in Minnesota, Hib vaccination was deferred or refused by the guardians of three of the five cases; one of these children died from Hib meningitis [51].

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The risks of delaying immunization have not been well studied [5]. As a general rule, young children are at greater risk for severe disease than older children who contract



vaccine-preventable illnesses (eg, pertussis, influenza). Delaying immunizations increases the duration of vulnerability for these young children.

For the community — The public health consequences of vaccine refusal are demonstrated by multiple outbreaks of vaccine-preventable diseases in unvaccinated individuals, as illustrated below:

Between 1985 and 1994, 13 disease outbreaks occurred in religious groups opposed to immunization, resulting in 1200 cases and 9 deaths [52].

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A measles outbreak at a college for Christian Scientist students resulted in 125 cases (attack rate 15 percent) and three deaths (case fatality rate 2.2 percent) [53]. Another measles outbreak at a camp attended by Christian Scientists had an attack rate of 25.2 percent [53].

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Outbreaks of polio, rubella, measles, pertussis (345 cases, attack rate 20 percent), and Haemophilus influenzae type b (Hib) have been reported in undervaccinated Amish communities [54-60].

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Measles outbreaks occur on a regular basis in Europe [34,61] and were reported across the United States during 2008, mainly among children whose parents had refused immunization [33,62]. (See 'MMR vaccine' above and 'For the individual' above.)

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Suboptimal vaccination rates also result in disease outbreaks and deaths among vaccinated individuals [49,63]. Vaccinated children may acquire infection through contact with vaccine exemptors. Rates of disease among vaccinated individuals increase as vaccinated and unvaccinated individuals mix in communities [49,50].

In a population-based study of children aged 3 to 18 years, the frequency of vaccine exemptors directly correlated with the incidence of measles and pertussis in vaccinated children [49]. Schools with pertussis outbreaks had more vaccine exemptors than schools without outbreaks (4.3 versus 1.5 percent of students).

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In an observational study, there was significant overlap between census tracts with clusters of pertussis and census tracts with clusters of nonmedical exemptions (odds ratio 2.7, 95% CI 2.2-3.3) [10]

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APPROACH TO MANAGEMENT

Overview of approach — Parental vaccine refusal may evoke strong emotional responses in medical providers, ranging from issues of trust in their relationships with patients to medicolegal concerns [25]. It may be difficult to put aside these initial reactions, but establishing a nonconfrontational dialogue from the first clinician-parent interaction is essential to ensuring a successful result. The healthcare provider is one of the most important influences in decisions about immunization, even among vaccine-hesitant parents [11,20,64].

When faced with vaccine-hesitant parents, the provider should be guided by the following recommendations [65]:

Establish open, ongoing, nonconfrontational dialogue to identify concerns.•

Target education to address specific parental concerns, using a variety of resources (table 1).

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Maintain the provider-patient relationship.•

Use vaccine schedules that deviate from the recommended schedule (eg, the schedule recommended by Centers for Disease Control, American Academy of Pediatrics, and American Academy of Family Physicians in the United States) (figure 3A-B) only when other options, such as targeted education, have failed.

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Establish dialogue — Dialogue should begin at the first provider-parent encounter and continue at every subsequent interaction. The dialogue is more important than the outcome at any one visit [66]. Providers must listen to their patients' parents to identify the forces that influence vaccine concerns. Once the concerns are identified, the provider can establish a plan for targeted education to address them. (See 'Why parents refuse vaccines' above.)

Key points in establishing the dialogue include [66]:

Acknowledging a shared goal (what is best for the child)•Acknowledging the large volume of complex, conflicting information about vaccine benefits and safety

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Offering to help them to gather the best information to make an informed decision (table 1)

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Identify concerns — Respectful listening is critical in identifying the source of parental concerns. Parents receive vaccine information from media reports that grab audience attention, present information that is easy to understand, and highlight pro- and antivaccine viewpoints in a limited time frame. A few sensational, anecdotal reports alleging harm may receive equal or greater attention than large-scale population studies that prove vaccine safety [1]. Erroneous impressions regarding vaccine safety may be supplemented by stories parents have heard from family or friends or have read on the Internet. Visual imagery of children allegedly hurt by vaccines is more compelling than faceless statistics about diseases parents have never seen or experienced.

Some parental concerns may not be immediately obvious. Parents may be concerned that their infant will suffer during vaccine administration. They may fear committing harm (giving an unsafe vaccine) more than allowing harm (taking a chance that their child will develop a disease). Providers must listen carefully and respectfully to understand these concerns, even if it is time consuming.

One author provides a practical approach to categorizing vaccine-hesitant parents according to the source and conviction of their concerns [67]:

The "uninformed but educable" have received an antivaccine message from families or friends but seek information to counter this.

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The "misinformed but correctable" have been influenced by antivaccine messages from the media or the Internet but are relatively unaware of medically accurate provaccination arguments.

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The "well-read and open-minded" have explored the pro- and antivaccination messages but want their provider's input in interpreting the information.

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The "convinced and contented" are strongly antivaccination but want to demonstrate their willingness to listen to the other side of the argument (often to satisfy a family member).

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The "committed and missionary" are strongly antivaccine and want to convince the provider to agree with their arguments.

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The first three groups tend to respond positively to information and dialogue, whereas the latter two are unlikely ever to change their position, although the "convinced and contented" may moderate their beliefs over time [67].

Target education — Most parental vaccine concerns are amenable to dialogue and discussion. Providers should target education to specific parental concerns and/or beliefs, realizing that some parents may need information from a variety of resources (table 1). Visual imagery and anecdotes from parents who are vaccine advocates may be used to support the educational message (eg, www.familiesfightingflu.org, www.meningitis-angels.org, www.nmaus.org, a publication profiling families affected by vaccine-preventable diseases available at www.vaccine.texaschildrens.org).

Focused education that directly addresses the source of vaccine concerns may have an important impact [14,68]. However, data are lacking on the overall success rates of education. The HealthStyles survey indicates that approximately one-third of parents want more information about immunizations and that the healthcare provider is one of the most influential factors in decisions about immunization, even among vaccine-hesitant parents [11,20,64].

Targeted immunization materials that provide unbiased, accurate statistical information, avoid scare tactics, and are not judgmental may be helpful in improving immunization acceptance in certain groups of vaccine-hesitant parents [28,69]. Parents are skeptical of aggressive pro-and antivaccine messages [14]. Emphasizing mandatory school entry requirements in an effort to influence parents is not helpful [70].

The provider must address relevant concerns while fully explaining vaccine benefits and risks. Potential areas for targeted education include:

Vaccine limitations•Adverse events•Misconceptions•Pain•

Vaccine limitations — It is important to acknowledge that although vaccines are very safe, they are not completely risk free or 100 percent effective. Providing this information is important in establishing credibility, but the information must be placed in a proper context for parents who may overestimate the risks of vaccines and underestimate the risks from vaccine-preventable diseases [1]. It may be helpful to reframe the discussion by defining the options in terms of benefits with risks, rather than emphasizing the risks [25].

Adverse events — Adverse events related to vaccines must be put into context. Most vaccine-associated adverse events are minor and self-limited (eg, local skin reactions, transient low-grade fever). Serious adverse events from an individual vaccine occur rarely, but these should be weighed against the risks associated with the natural infection. As examples:

The risk of acquiring measles during an outbreak may be 35 times higher in an unvaccinated than in a vaccinated person [50].

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The risk of measles-associated encephalopathy or subacute sclerosing panencephalitis following natural measles is 1000 times higher than the risk of encephalopathy from measles vaccine (1 in 1 million) [71].

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Misconceptions — It is important to dispel myths, correct misinformation, and direct parents to scientifically sound information (table 1) [25]. Providers should avoid using ambiguous language or complicated scientific terms when communicating the science supporting vaccine safety and effectiveness.

Autism — The most common vaccine myth, that vaccines cause autism, has suggested a number of hypotheses to substantiate the link (eg, that MMR or thimerosal [ethylmercury] cause autism). The myths related to autism and MMR and thimerosal are discussed separately (see "Autism and chronic disease: Little evidence for vaccines as a contributing factor" and "Autism and chronic disease: Little evidence for thimerosal as a contributing factor").

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Overwhelming the immune system — Parents may worry that multiple vaccines overwhelm the immune system, possibly causing autism, autoimmune disease, or susceptibility to infections. The following observations provide evidence against this claim [72-74]:

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With manufacturing advances and discontinuation of smallpox immunization, children are exposed to fewer antigens today than they were in 1980 [25]. The currently recommended immunizations for children younger than two years (figure 3A-B) contain <200 bacterial and viral protein or polysaccharide antigens, compared with >3000 such antigens in the seven vaccines administered in 1980 [75].

The infant immune system can respond to multiple antigens (conservative estimates suggest thousands) simultaneously [25,75,76]. This is illustrated by the observations that mild or moderate illness does not interfere with an infant's ability to generate protective immune responses to vaccines and that combinations of vaccines induce immune responses comparable to those given individually [76].

Vaccinated and unvaccinated children do not differ in their susceptibility to infectious diseases for which there are no vaccines (eg, enterovirus, candida) [77-79]. On the other hand, infection with vaccine-preventable disease can predispose to severe invasive infections with other pathogens (eg, methicillin-resistant Staphylococcus aureus) [80,81].

Vaccines are not necessary — As vaccine-preventable diseases become less common and parents have little familiarity with the devastating effects of vaccine-preventable illnesses, some parents may believe that vaccines are no longer necessary [1]. These parents must be educated regarding the persistence of vaccine-preventable diseases and the potential for a rapid increase in vaccine-preventable disease incidence when immunization rates decline [25]. (See 'Consequences of vaccine refusal' above.)

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Pain — Providers can educate parents on available methods to reduce pain when multiple vaccine injections are required at a single visit. These may include nonpharmacologic options, such as oral sucrose for infants; stroking, rocking, or "blowing the pain away for older children"; or pharmacologic management if indicated (eg, topical anesthetics placed 30 to 60 minutes prior to injection) [82-84].



Maintain relationship — When educational efforts fail to persuade parents to immunize their children, providers may be faced with a dilemma about whether or not to refer the family to another provider [85,86]. Factors influencing this decision include lack of shared goals, absence of trust in the clinician-family relationship, and fear of litigation if the child subsequently contracts a vaccine-preventable disease or transmits a vaccine-preventable disease to an individual with vaccine contraindications or who was too young to be immunized [86].

The American Academy of Pediatrics (AAP) Committee on Bioethics advises against discontinuing care for families who refuse or delay vaccines [65]. The decision to immunize belongs, ultimately, to the parents. The benefits of immunization must be weighed against those of the provider maintaining a positive relationship with the family. Maintenance of the relationship permits time for ongoing dialogue and targeted education and ensures that the child has a medical home.

Although the AAP Committee on Bioethics acknowledges that the welfare of the child is paramount, it advises providers to tolerate parental decisions "not likely to be harmful to the child" [65]. Using this paradigm, immunization of an individual child is favored when community immunization rates are low and disease prevalence is high, or if the child has a medical predisposition to a disease. The risk to the community attributable to unimmunized children infecting children who are unable to be immunized and the community cost of caring for children with vaccine-preventable diseases should also be considered [87,88]. Rarely, providers may be obliged to involve state agencies to provide immunization against parental wishes (eg, when a child is placed at risk during an epidemic) [65]. (See 'Consequences of vaccine refusal' above.)

The AAP advises that dismissing vaccine-refusing families should be an option of last resort but recognizes that distrust and poor communication may, rarely, make termination of the clinician-patient relationship advisable [65]. In this unusual situation, the provider should offer sufficient information to assist families to find another provider and allow adequate time for the transition to occur, thus avoiding potentially harmful lapses in medical care [85].

Alternative schedules — Deviations from the recommended childhood immunization schedule should be used only when all other options have failed. Alternative schedules should not be used as a substitute for establishing parental dialogue or targeted education [1,65].

Alternative schedules are not founded in science and entail multiple visits to the provider's office. They increase the risk of noncompliance and the duration of vulnerability to vaccine-preventable diseases. However, the use of an alternative schedule may allay the fears of some parents enough that they permit their child to be immunized.

The most popular of the alternative immunization schedules are the "selective vaccine schedule" and "alternative vaccine schedule" published by Dr. Robert Sears [89]. Dr. Sears's book casts doubt on clinicians' understanding of vaccine research and the motives of the pharmaceutical industry and suggests that the immunization schedule recommended by the Centers for Disease Control and Prevention, American Academy of



Pediatrics, and American Academy of Family Physicians is in the public's, but not necessarily the individual's, best interest. His alternative schedules prioritize immunizations that he considers more important on the basis of his experience as a pediatrician in private practice, while delaying or skipping others. Only two vaccines are administered at a time, and only one aluminum-containing vaccine is given at any one visit.

Although Dr. Sears's approach may seem to be a reasonable compromise between hesitant parents and their providers, there are multiple inherent problems. Critics of Dr. Sears's book explain in detail how it fails to distinguish good from bad science when discussing vaccine research, misinterprets vaccine safety data, underestimates the risks to children of vaccine-preventable diseases by considering only his limited personal experience, is ambiguous regarding the disproven associations of MMR and thimerosal with autism, and does not fully grasp the scientific method [90].

Timely receipt of vaccines during the first year of life has no adverse effect on neuropsychologic outcomes. Review of data from the Vaccine Safety Datalink study, which included 1047 children, indicate that the 47 percent of children who received their vaccines on time (≥2 hepatitis B, three diphtheria-tetanus-pertussis, three Haemophilus influenzae type b, and two polio vaccines within 30 days of the recommended age) performed as well or better at age 7 to 10 years on every measure of neuropsychologic outcome than the 23 percent of children who received all of the recommended vaccines, but not on time; and the 20 percent of children who did not receive all of the recommended vaccines [91].

The schedules proposed in Dr. Sears's book are potentially harmful, extending the duration of vulnerability for vaccine-preventable diseases that continue to cause outbreaks. For example, under the "alternative" schedule, it is recommended that MMR be separated into three components: mumps is given at 12 months, rubella at two years, and measles at three years. Single-antigen measles vaccine is no longer available in the United States [92]. Under the "selective" schedule, titers for measles, mumps, and rubella are checked at age 10 years, and vaccination considered if not immune. Delayed administration of polio, varicella, hepatitis A, and hepatitis B vaccines is also suggested for reasons that are not founded in science.

Special precautions — Children who have not been immunized are at risk to develop or transmit vaccine-preventable disease. Parents of children who refuse immunizations must take special precautions with respect to these risks. When their child is ill, they must inform the healthcare providers that the child has not been vaccinated so that the providers can consider vaccine-preventable illnesses in their differential diagnosis and take the necessary steps to prevent infection of other patients. The Centers for Disease Control and Prevention, American Academy of Pediatrics, and American Academy of Family Physicians has developed a handout for parents to remind them of these risks and responsibilities [93].

Documentation — Providers should document each discussion with parents about the risks of not immunizing [65]. The American Academy of Pediatrics (AAP) has developed guidelines for providers faced with this situation and provides sample waiver documentation to cover this eventuality (available through the AAP at www.aap.org/immunization/pediatricians/refusaltovaccinate.html).

PREVENTION — Specific strategies to prevent parental vaccine refusal have not been studied. However, given that primary care providers are one of the most influential factors in decisions about immunization [11,20,64], it is reasonable for providers to establish open, honest, nonconfrontational dialogue about the importance of childhood



vaccinations beginning with the first provider-parent interaction. Providers also should share their own or their practice's philosophy regarding delaying or refusing vaccination to avoid the potential for future disagreements.

Education should start at the prenatal visit and continue at all subsequent well-child visits. At each encounter, providers should listen to parental concerns to identify sources of misinformation or other factors that may lead to vaccine hesitancy. Providers can then provide individualized education to address specific concerns or misconceptions.

Education should be multifaceted, with providers answering questions unambiguously, avoiding complicated statistics, and providing information that is easily understood and "personal." Providers should make full use of the online resources outlined in the table (table 1). Some parents may find the information on the Vaccine Information Statements adequate to address their needs, but others may require more detailed scientific information or may find simple question-and-answer pamphlets or personal testimonials from vaccine advocates more helpful [1,94].

RESOURCES — Most parents trust advice from their child's healthcare provider [11,20,64]. However, it is useful for both parents and providers to access reputable sources where accurate and easy-to-understand vaccine information is available.

Focus groups suggest that most parents trust information from the Centers for Disease Control and Prevention (CDC) or American Academy of Pediatrics (AAP) [69]. A list of additional reputable vaccine Web sites is provided in the table (table 1). Parents who need more information than the clinician can provide during an office visit can be directed to these resources.

Many of the organizations in the list provide publications or question-and-answer tear sheets that can be purchased or downloaded for use in office waiting rooms or for parents to take away and read. Posters and publications describing the consequences of vaccine-preventable diseases are also available for download or purchase from some of the sources in the table, which include public health agencies, organizations specializing in vaccine education, and parent-advocacy groups. The latter may be particularly useful for vaccine-hesitant parents because they highlight identifiable, serious, and sometimes fatal consequences of refusing immunization, using anecdotes and visual imagery to counter those used with such great effect by antivaccine activists [95].

For providers, the CDC, in partnership with the AAP and the American Academy of Family Physicians (AAFP), has developed the Provider Resource for Vaccine Conversations with Parents. These materials are available at www.cdc.gov/vaccines/. They provide communication tips for providers, current vaccine safety information, answers to common questions, and disease-specific fact sheets that can be downloaded as a handout for parents to supplement Vaccine Information Statements and guide parent risk-benefit discussions [1].

SUMMARY AND RECOMMENDATIONS

Immunizations are one of the safest and most cost-effective preventative health measures (figure 1). However, misinformation may lead parents to hesitate or refuse to immunize their child(ren). (See 'Background' above.)

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Concern about vaccine safety is the most common reason for vaccine refusal. (See 'General objections' above.)

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Vaccine refusal may result in vaccine-preventable disease in the individual and/or outbreaks of vaccine-preventable disease in unvaccinated and vaccinated individuals. (See 'Consequences of vaccine refusal' above.)

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The healthcare provider is one of the most influential factors in the decision whether or not to immunize a child. When faced with vaccine-hesitant parents, the provider should be guided by the following recommendations (see 'Overview of approach' above):

•

Establish open, ongoing, nonconfrontational dialogue to identify concerns

Target education to specific concerns, using a variety of resources (table 1)

Maintain the provider-patient relationship

Use vaccine schedules that deviate from the recommended schedule only when other options have failed

Targeted education may include acknowledgement of vaccine limitations, provision of accurate estimates of the risks of adverse events and vaccine-preventable disease, correction of misconceptions, and discussion of techniques to alleviate immunization-related pain. (See 'Target education' above.)

•

We do not suggest that families who refuse immunization be dismissed from the practice (Grade 2C). (See 'Maintain relationship' above.)

•

We do not suggest deviation from the recommended immunization schedule (Grade 2C). (See 'Alternative schedules' above.)

•

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

Healy C, Pickering, LK. How to deal with vaccine hesitant parents. Pediatrics 2010; (in press).

1.

Zimmerman, RK, Wolfe, RM, Fox, DE, et al. Vaccine criticism on the World Wide Web. J Med Internet Res 2005; 7:e17.

2.

Leask, JA, Chapman, S. An attempt to swindle nature: press anti-immunisation reportage 1993-1997. Aust N Z J Public Health 1998; 22:17.

3.

Davies, P, Chapman, S, Leask, J. Antivaccination activists on the world wide web. Arch Dis Child 2002; 87:22.

4.

Omer, SB, Salmon, DA, Orenstein, WA, et al. Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases. N Engl J Med 2009; 360:1981.

5.

Omer, SB, Pan, WK, Halsey, NA, et al. Nonmedical exemptions to school immunization requirements: secular trends and association of state policies with pertussis incidence. JAMA 2006; 296:1757.

6.

Rota, JS, Salmon, DA, Rodewald, LE, et al. Processes for obtaining nonmedical exemptions to state immunization laws. Am J Public Health 2001; 91:645.

7.

Salmon, DA, Omer, SB, Moulton, LH, et al. Exemptions to school immunization requirements: the role of school-level requirements, policies, and procedures. Am J Public Health 2005; 95:436.

8.



Thompson, JW, Tyson, S, Card-Higginson, P, et al. Impact of addition of philosophical exemptions on childhood immunization rates. Am J Prev Med 2007; 32:194.

9.

Omer, SB, Enger, KS, Moulton, LH, et al. Geographic clustering of nonmedical exemptions to school immunization requirements and associations with geographic clustering of pertussis. Am J Epidemiol 2008; 168:1389.

10.

Smith, PJ, Chu, SY, Barker, LE. Children who have received no vaccines: who are they and where do they live? Pediatrics 2004; 114:187.

11.

Gellin, BG, Maibach, EW, Marcuse, EK. Do parents understand immunizations? A national telephone survey. Pediatrics 2000; 106:1097.

12.

Gust, DA, Darling, N, Kennedy, A, Schwartz, B. Parents with doubts about vaccines: which vaccines and reasons why. Pediatrics 2008; 122:718.

13.

Fredrickson, DD, Davis, TC, Arnould, CL, et al. Childhood immunization refusal: provider and parent perceptions. Fam Med 2004; 36:431.

14.

Freed, GL, Clark, SJ, Butchart, AT, et al. Parental vaccine safety concerns in 2009. Pediatrics 2010; 125:654.

15.

School Status Data Reports. Washington State Department of Health, 2009. www.doh.wa.gov/cfh/immunize/schools/schooldatarprts.htm. (Accesed November 10, 2009).

16.

Freed, GL, Clark, SJ, Hibbs, BF, Santoli, JM. Parental vaccine safety concerns. The experiences of pediatricians and family physicians. Am J Prev Med 2004; 26:11.

17.

Kennedy, AM, Brown, CJ, Gust, DA. Vaccine beliefs of parents who oppose compulsory vaccination. Public Health Rep 2005; 120:252.

18.

Jessop, LJ, Kelleher, CC, Murrin, C, et al. Determinants of partial or no primary immunisations. Arch Dis Child 2010; 95:603.

19.

Salmon, DA, Moulton, LH, Omer, SB, et al. Factors associated with refusal of childhood vaccines among parents of school-aged children: a case-control study. Arch Pediatr Adolesc Med 2005; 159:470.

20.

Wei, F, Mullooly, JP, Goodman, M, et al. Identification and characteristics of vaccine refusers. BMC Pediatr 2009; 9:18.

21.

Lawrence, GL, Hull, BP, MacIntyre, CR, McIntyre, PB. Reasons for incomplete immunisation among Australian children. A national survey of parents. Aust Fam Physician 2004; 33:568.

22.

Gust, D, Brown, C, Sheedy, K, et al. Immunization attitudes and beliefs among parents: beyond a dichotomous perspective. Am J Health Behav 2005; 29:81.

23.

Wolfe, RM, Sharp, LK. Anti-vaccinationists past and present. BMJ 2002; 325:430.24.

Lyren, A, Leonard, E. Vaccine refusal: issues for the primary care physician. Clin Pediatr (Phila) 2006; 45:399.

25.

Smith, PJ, Santoli, JM, Chu, SY, et al. The association between having a medical home and vaccination coverage among children eligible for the vaccines for children program. Pediatrics 2005; 116:130.

26.

Allred, NJ, Wooten, KG, Kong, Y. The association of health insurance and continuous primary care in the medical home on vaccination coverage for 19- to 35-month-old children. Pediatrics 2007; 119 Suppl 1:S4.

27.

Gust, DA, Strine, TW, Maurice, E, et al. Underimmunization among children: effects of vaccine safety concerns on immunization status. Pediatrics 2004; 114:e16.

28.

Wakefield, AJ, Murch, SH, Anthony, A, et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 1998; 351:637.

29.

Retraction--Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet 2010; 375:445.

30.



Health Protection Agency. COVER programme: January to March 2003. Commun Dis Rep CDR Wkly (serial online) 2003; 13:.

31.

Communicable Disease Surveillance Center. COVER/Korner July to September 1995. CDR Wkly 1995; 5:301.

32.

Centers for Disease Control and Prevention (CDC). Update: measles--United States, January-July 2008. MMWR Morb Mortal Wkly Rep 2008; 57:893.

33.

Measles once again endemic in the United Kingdom. Euro Surveill 2008; 13.pii:18919.

34.

Conroy, K, Rosenthal, SL, Zimet, GD, et al. Human papillomavirus vaccine uptake, predictors of vaccination, and self-reported barriers to vaccination. J Womens Health (Larchmt) 2009; 18:1679.

35.

Rothman, SM, Rothman, DJ. Marketing HPV vaccine: implications for adolescent health and medical professionalism. JAMA 2009; 302:781.

36.

Haug, C. The risks and benefits of HPV vaccination. JAMA 2009; 302:795.37.

O'Dowd, A. Teenager who died after having HPV vaccine had a malignant chest tumour. BMJ 2009; 339:b4032.

38.

Slade, BA, Leidel, L, Vellozzi, C, et al. Postlicensure safety surveillance for quadrivalent human papillomavirus recombinant vaccine. JAMA 2009; 302:750.

39.

Kroger, AT, Atkinson, WL, Marcuse, EK, Pickering, LK, Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention (CDC). General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2006; 55:1.

40.

Centers for Disease Control and Prevention (CDC). Update: Guillain-Barré syndrome among recipients of Menactra meningococcal conjugate vaccine--United States, June 2005-September 2006. MMWR Morb Mortal Wkly Rep 2006; 55:1120.

41.

Bradley, JS, Bernstein, H, Bocchini, A. Allay parents' concerns over safety of 2009 H1N1 flu vaccines. AAP News 2009; 30:.

42.

Haber, P, Sejvar, J, Mikaeloff, Y, DeStefano, F. Vaccines and Guillain-Barré syndrome. Drug Saf 2009; 32:309.

43.

Centers for Disease Control and Prevention (CDC). Update on influenza A (H1N1) 2009 monovalent vaccines. MMWR Morb Mortal Wkly Rep 2009; 58:1100.

44.

Centers for Disease Control and Prevention (CDC). Safety of influenza A (H1N1) 2009 monovalent vaccines - United States, October 1-November 24, 2009. MMWR Morb Mortal Wkly Rep 2009; 58:1351.

45.

Vellozzi, C, Broder, KR, Haber, P, et al. Adverse events following influenza A (H1N1) 2009 monovalent vaccines reported to the Vaccine Adverse Event Reporting System, United States, October 1, 2009-January 31, 2010. Vaccine 2010.

46.

Glanz, JM, McClure, DL, Magid, DJ, et al. Parental refusal of varicella vaccination and the associated risk of varicella infection in children. Arch Pediatr Adolesc Med 2010; 164:66.

47.

Glanz, JM, McClure, DL, Magid, DJ, et al. Parental refusal of pertussis vaccination is associated with an increased risk of pertussis infection in children. Pediatrics 2009; 123:1446.

48.

Feikin, DR, Lezotte, DC, Hamman, RF, et al. Individual and community risks of measles and pertussis associated with personal exemptions to immunization. JAMA 2000; 284:3145.

49.

Salmon, DA, Haber, M, Gangarosa, EJ, et al. Health consequences of religious and philosophical exemptions from immunization laws: individual and societal risk of measles. JAMA 1999; 282:47.

50.

Centers for Disease Control and Prevention (CDC). Invasive Haemophilus influenzae Type B disease in five young children--Minnesota, 2008. MMWR Morb Mortal Wkly Rep 2009; 58:58.

51.



Hinman, AR, Orenstein, WA, Williamson, DE, Darrington, D. Childhood immunization: laws that work. J Law Med Ethics 2002; 30:122.

52.

Novotny, T, Jennings, CE, Doran, M, et al. Measles outbreaks in religious groups exempt from immunization laws. Public Health Rep 1988; 103:49.

53.

Centers for Disease Control (CDC). Outbreaks of rubella among the Amish--United States, 1991. MMWR Morb Mortal Wkly Rep 1991; 40:264.

54.

Fry, AM, Lurie, P, Gidley, M, et al. Haemophilus influenzae Type b disease among Amish children in Pennsylvania: reasons for persistent disease. Pediatrics 2001; 108:E60.

55.

Centers for Disease Control and Prevention (CDC). Poliomyelitis--United States, Canada. MMWR Morb Mortal Wkly Rep 1997; 46:1194.

56.

Jackson, BM, Payton, T, Horst, G, et al. An epidemiologic investigation of a rubella outbreak among the Amish of northeastern Ohio. Public Health Rep 1993; 108:436.

57.

Sutter, RW, Markowitz, LE, Bennetch, JM, et al. Measles among the Amish: a comparative study of measles severity in primary and secondary cases in households. J Infect Dis 1991; 163:12.

58.

Briss, PA, Fehrs, LJ, Hutcheson, RH, Schaffner, W. Rubella among the Amish: resurgent disease in a highly susceptible community. Pediatr Infect Dis J 1992; 11:955.

59.

Centers for Disease Control and Prevention (CDC). Pertussis outbreak in an Amish community--Kent County, Delaware, September 2004-February 2005. MMWR Morb Mortal Wkly Rep 2006; 55:817.

60.

Filia, A, De Crescenzo, M, Seyler, T, et al. Measles resurges in Italy: preliminary data from September 2007 to May 2008. Euro Surveill 2008; 13.

61.

Sugerman, DE, Barskey, AE, Delea, MG, et al. Measles outbreak in a highly vaccinated population, San Diego, 2008: role of the intentionally undervaccinated. Pediatrics 2010; 125:747.

62.

McBrien, J, Murphy, J, Gill, D, et al. Measles outbreak in Dublin, 2000. Pediatr Infect Dis J 2003; 22:580.

63.

Gust, DA, Kennedy, A, Shui, I, et al. Parent attitudes toward immunizations and healthcare providers the role of information. Am J Prev Med 2005; 29:105.

64.

Diekema, DS, American Academy of Pediatrics Committee on Bioethics. Responding to parental refusals of immunization of children. Pediatrics 2005; 115:1428.

65.

Myers, MG, Orenstein, WA, Marcuse, EK. Countering vaccine misinformation. PREP Audio 2009; 4:1.

66.

Halperin, SA. How to manage parents unsure about immunization. Canadian Journal of CME 2000; 12:62.

67.

Dias, M, Marcuse, EK. When parents refuse immunizations. Contemp Pediatr 2000; 17:75.

68.

Gust, DA, Kennedy, A, Wolfe, S, et al. Developing tailored immunization materials for concerned mothers. Health Educ Res 2008; 23:499.

69.

Ball, LK, Evans, G, Bostrom, A. Risky business: challenges in vaccine risk communication. Pediatrics 1998; 101:453.

70.

Maldonado, YA. Current controversies in vaccination: vaccine safety. JAMA 2002; 288:3155.

71.

Offit, PA, Jew, RK. Addressing parents' concerns: do vaccines contain harmful preservatives, adjuvants, additives, or residuals? Pediatrics 2003; 112:1394.

72.

Offit, PA, Hackett, CJ. Addressing parents' concerns: do vaccines cause allergic or autoimmune diseases? Pediatrics 2003; 111:653.

73.

Gerber, JS, Offit, PA. Vaccines and autism: a tale of shifting hypotheses. Clin Infect Dis 2009; 48:456.

74.



Offit, PA, Quarles, J, Gerber, MA, et al. Addressing parents' concerns: do multiple vaccines overwhelm or weaken the infant's immune system? Pediatrics 2002; 109:124.

75.

King, GE, Hadler, SC. Simultaneous administration of childhood vaccines: an important public health policy that is safe and efficacious. Pediatr Infect Dis J 1994; 13:394.

76.

Black, SB, Cherry, JD, Shinefield, HR, et al. Apparent decreased risk of invasive bacterial disease after heterologous childhood immunization. Am J Dis Child 1991; 145:746.

77.

Davidson, M, Letson, GW, Ward, JI, et al. DTP immunization and susceptibility to infectious diseases. Is there a relationship? Am J Dis Child 1991; 145:750.

78.

Storsaeter, J, Olin, P, Renemar, B, et al. Mortality and morbidity from invasive bacterial infections during a clinical trial of acellular pertussis vaccines in Sweden. Pediatr Infect Dis J 1988; 7:637.

79.

O'Brien, KL, Walters, MI, Sellman, J, et al. Severe pneumococcal pneumonia in previously healthy children: the role of preceding influenza infection. Clin Infect Dis 2000; 30:784.

80.

Laupland, KB, Davies, HD, Low, DE, et al. Invasive group A streptococcal disease in children and association with varicella-zoster virus infection. Ontario Group A Streptococcal Study Group. Pediatrics 2000; 105:E60.

81.

Schechter, NL, Zempsky, WT, Cohen, LL, et al. Pain reduction during pediatric immunizations: evidence-based review and recommendations. Pediatrics 2007; 119:e1184.

82.

American Academy of Pediatrics. Managing Injection Pain. In: Red Book: 2009 Report of the Committee on Infectious Diseases, 28th ed, Pickering LK BC, Kimberlin DW, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2009. p.20.

83.

Harrison, D, Stevens, B, Bueno, M, et al. Efficacy of sweet solutions for analgesia in infants between 1 and 12 months of age: a systematic review. Arch Dis Child 2010; 95:406.

84.

Halperin, B, Melnychuk, R, Downie, J, Macdonald, N. When is it permissible to dismiss a family who refuses vaccines? Legal, ethical and public health perspectives. Paediatr Child Health 2007; 12:843.

85.

Flanagan-Klygis, EA, Sharp, L, Frader, JE. Dismissing the family who refuses vaccines: a study of pediatrician attitudes. Arch Pediatr Adolesc Med 2005; 159:929.

86.

Salmon, DA, Omer, SB. Individual freedoms versus collective responsibility: immunization decision-making in the face of occasionally competing values. Emerg Themes Epidemiol 2006; 3:13.

87.

Ross, LF, Aspinwall, TJ. Religious exemptions to the immunization statutes: balancing public health and religious freedom. J Law Med Ethics 1997; 25:202.

88.

Sears, RW. The Vaccine Book: Making the Right Decision for Your Child, Little, Brown and Company, New York 2007.

89.

Offit, PA, Moser, CA. The problem with Dr Bob's alternative vaccine schedule. Pediatrics 2009; 123:e164.

90.

Smith, MJ, Woods, CR. On-time vaccine receipt in the first year does not adversely affect neuropsychological outcomes. Pediatrics 2010; 125:1134.

91.

Kimberlin, DW, Bocchini, JA. Monovalent vaccines no longer available for measles, mumps, rubella. AAP News 2009; 30:9.

92.

If you chooose not to vaccinate your child, understand the risks and resonsibilities. Available at www.cdc.gov/vaccines/spec-grps/hcp/conv-materials.htm#providers. (Accessed on November 9, 2009).

93.



Chen, RT. Vaccine risks: real, perceived and unknown. Vaccine 1999; 17 Suppl 3:S41.

94.

Parikh, RK. Fighting for the reputation of vaccines: lessons from American politics. Pediatrics 2008; 121:621.

95.



GRAPHICS

Effectiveness of routine childhood immunizations

Blue lines indicate the approximate date of routine childhood immunization against the disease. Hib: Haemophilus influenzae type b; PCV7: 7-valent pneumococcal conjugate vaccine. * The time period for this graph precedes the measles outbreaks that occurred across the United States during 2008 (see text for details). • Incidence per 100,000 children under five years of age. Centers for Disease Control and Prevention.



Epidemiology and Prevention of Vaccine-Preventable Diseases, 11th ed. Atkinson W, Wolfe S, Hamborsky J, McIntyre L (Eds). Public Health Foundation, Washington DC 2009.



US residents with measles who were eligible* for vaccination against measles, by reason for not receiving measles vaccine - United States, January-July 2008

* N = 95. Does not include infants aged <12 months, persons born before 1957, foreign visitors, and persons who were vaccinated. • Includes children aged 16 months to 4 years who had not been vaccinated. Δ Includes persons who were age eligible for vaccination but whose vaccination status was unknown or who were unvaccinated for unknown reasons. ◊ Includes eight children eligible for vaccination but not yet vaccinated, and one child whose vaccination status was unknown. § Includes persons who were unvaccinated because of their own or their parents' beliefs. This category includes 61 persons aged ≤18 years and two persons aged 20-50 years. None of the persons in this category cited medical reasons for not having been vaccinated. Centers for Disease Control and prevention. Update: Measles - United States, January-July 2008. MMWR 2008; 57:895.



Online resources regarding vaccines and vaccine safety

Organization/URL Description

Professional organizations/societies

American Academy of Family Physicians

www.familydoctor.org (search on vaccines)

Patient information on childhood vaccines (what they are and why children need them)

American Academy of Pediatrics Childhood Immunization Support Program

www.aap.org/immunization

Compilation of resources for families and providers, including Q&A for families and information on vaccine-preventable illnesses, vaccine ingredients, vaccine safety, and the immunization schedule

Provides information for clinicians on how to communicate with parents about immunization, including responses for common reasons for parental refusal to vaccinate

Canadian Pediatric Society

www.caringforkids.cps.ca/

Provides a parent's guide to immunization information on the Internet

Infectious Diseases Society of America (IDSA)

www.idsociety.org

Provides lists of resources, IDSA position statements, and policy statements

Group on Immunization Education, Society of Teachers and Family

www.immunizationed.org

Provides links to immunization information and resources, including an audio-recording of the pertussis cough in an infant



Academic institutions

Center for Vaccine Awareness and Research, Texas Children's Hospital

www.vaccine.texaschildrens.org

Provides valuable information regarding vaccination. Includes links to resources, including a book that profiles families devastated by vaccine-preventable illness (for purchase).

Institute for Vaccine Safety, Johns Hopkins University

www.vaccinesafety.edu

Provides an independent assessment of vaccines and vaccine safety to guide decision makers and educate physicians, the public, and the media about the safety of vaccines

The Nemours Foundation KidsHealth

kidshealth.org/teen/your_body/health_basics/immunizations.html

Vaccine information targeted to adolescents

The Vaccine Education Center at the Children's Hospital of Philadelphia

www.vaccine.chop.edu

Provides reliable information about vaccines to parents and healthcare professionals

Public health/advocacy groups

Allied Vaccine Group

www.vaccine.org

Links to Web sites dedicated to presenting valid scientific information about vaccines

Program for Appropriate Technology in Health (PATH) Vaccine Resource Library

www.path.org/vaccineresources/

Offers a variety of high-quality, scientifically accurate documents and links to information about vaccine-preventable diseases and vaccines

Every Child by Two

www.ecbt.org

Seeks to raise parental awareness of the need for timely



infant immunizations

Health on the Net Foundation

www.hon.ch

Nonprofit, nongovernmental organization that promotes and guides the deployment of useful and reliable online health information

Immunization Action Coalition (IAC)

www.immunize.org (Search on "immunization safety")

The IAC creates and distributes educational materials and facilitates communication about the safety, efficacy, and use of vaccines

Institute of Medicine

www.iom.edu

Independent, nonprofit organization that works outside the government to provide unbiased and authoritative advice. Provides access to the IOM immunization safety reviews (eg, vaccines and autism, multiple immunizations and immune dysfunction, etc.).

National Alliance for Hispanic Health

www.hispanichealth.org

Advocacy and research forum focused on Hispanic health and well-being. Provides links to information about vaccine-preventable disease and other health issues.

National Foundation for Infectious Diseases

www.nfid.org

Nonprofit organization dedicated to educating the public and healthcare professionals about the causes,



treatment, and prevention of infectious diseases

National Meningitis Association

www.nmaus.org

Nonprofit organization founded by parents whose children have died or have permanent disability from meningococcal disease. Includes links to educational materials, including a video featuring the stories of meningococcal disease survivors and families affected by the disease.

National Network for Immunization Information

www.immunizationinfo.org

Provides science-based information to individuals who need to know the facts about immunization. Publishes a booklet with tips on how to find reliable immunization information on the Internet (for purchase).

The Vaccine Page

www.vaccines.org

Provides access to news about vaccines and annotated database of vaccine resources on the Internet; the vaccine page does not control the content of the news links and encourages readers to validate the news items through reputable resources (eg, the Allied Vaccine Group)

World Health Organization Provides links to information



www.who.int/topics/vaccines/en/ about immunization

Parent/family groups

Families Fighting Flu

www.familiesfightingflu.org

Nonprofit corporation dedicated to educating people about the severity of influenza and the importance of vaccinating children against the flu

Parents of Kids with Infectious Diseases

www.pkids.org/immunizations.php

Provides links to information about vaccines and vaccine safety

Meningitis Angels

www.meningitis-angels.org

Provides education about bacterial meningitis and prevention of bacterial meningitis

Government agencies

United States Centers for Disease Control and Prevention

www.cdc.gov/vaccines

Provides information and links about vaccines and vaccine-preventable diseases

US Food and Drug Administration

www.fda.gov/cber/vaccines.htm

Provides information about vaccines licensed in the United States and information about vaccine safety, including consumer updates

National Institute of Allergy and Infectious Diseases

www3.niaid.nih.gov/topics/vaccines/

Provides information about understanding vaccines, community immunity, and vaccine research

Miscellaneous

Baby 411

www.windsorpeak.com/baby411/

Link to free excerpt on vaccines

Books Publisher



Immunizations and Infectious Diseases: An Informed Parent's Guide by Fisher, MC

American Academy of Pediatrics, Elk Grove Village, IL 2005

Vaccinating Your Child: Questions and Answers for the Concerned Parent by Humiston, SG, Good, C

Peachtree Publishers, Atlanta 2000

Do Vaccines Cause That? A guide for Evaluating Vaccine Safety Concerns by Myers, MG, Pineda, D

Immunizations for Public Health 2008

Vaccines: What Every Parent Should Know by Offit, PA, Bell, LM IDG Books, New York 1999

Autism's False Prophets: bad science, risky medicine, and the search for a cure by Offit, PA

Columbia University Press, New York 2008

Adapted from: American Academy of Pediatrics. Active immunization. In: Red Book: 2009 Report of the Committee on Infectious Diseases, 28th ed, Pickering LK BC, Kimberlin DW, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2009. p.9 and Pickering, LK, Baker, CJ, Freed, GL et al. Immunization programs for infants, children, adolescents, and adults: Clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2009; 49:817.



Recommended immunization schedule for persons aged 0 through 6 years - United States, 2010 (for those who fall behind or start late, see the catch-up schedule)

This schedule includes recommendations in effect as of December 15, 2009. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Considerations should include provider assessment, patient preference, and the potential for adverse events. Providers should consult the relevant Advisory Committee on Immunization Practices statement for detailed recommendations: http://www.cdc.gov/vaccines/pubs/acip-list.htm. Clinically significant adverse events that follow immunization should be reported to the Vaccine Adverse Event Reporting System (VAERS) at http://www.vaers.hhs.gov or by telephone, 800-822-7967. * Hepatitis B vaccine (HepB). (Minimum age: birth) - At birth: Administer monovalent HepB to all newborns before hospital discharge. If mother is hepatitis B surface antigen (HBsAg)-positive, administer HepB and 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth. If mother's HBsAg status is unknown, administer HepB within 12 hours of birth. Determine mother's HBsAg status as soon as possible and, if HBsAg-positive, administer HBIG (no later than age 1 week). - After the birth dose: The HepB series should be completed with either monovalent HepB or a combination vaccine containing HepB. The second dose should be administered at age 1 or 2 months. Monovalent HepB vaccine should be used for doses administered before age 6 weeks. The final dose should be administered no earlier than age 24 weeks. Infants born to HBsAg-positive mothers should be tested for HBsAg and antibody to HBsAg 1 to 2 months after completion of at least 3 doses of the HepB series, at age 9 through 18 months (generally at the next well-child visit). Administration of 4 doses



of HepB to infants is permissible when a combination vaccine containing HepB is administered after the birth dose. The fourth dose should be administered no earlier than age 24 weeks. • Rotavirus vaccine (RV). (Minimum age: 6 weeks) Administer the first dose at age 6 through 14 weeks (maximum age: 14 weeks 6 days). Vaccination should not be initiated for infants aged 15 weeks 0 days or older. The maximum age for the final dose in the series is 8 months 0 days. If Rotarix is administered at ages 2 and 4 months, a dose at 6 months is not indicated. Δ Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP). (Minimum age: 6 weeks) The fourth dose may be administered as early as age 12 months, provided at least 6 months have elapsed since the third dose. Administer the final dose in the series at age 4 through 6 years. ◊ Haemophilus influenzae type b conjugate vaccine (Hib). (Minimum age: 6 weeks) If PRP-OMP (PedvaxHIB or Comvax [HepB-Hib]) is administered at ages 2 and 4 months, a dose at age 6 months is not indicated. TriHiBit (DTaP/Hib) and Hiberix (PRP-T) should not be used for doses at ages 2, 4, or 6 months for the primary series but can be used as the final dose in children aged 12 months through 4 years. § Pneumococcal vaccine. (Minimum age: 6 weeks for pneumococcal conjugate vaccine [PCV]; 2 years for pneumococcal polysaccharide vaccine [PPSV]) PCV is recommended for all children aged younger than 5 years. Administer 1 dose of PCV to all healthy children aged 24 through 59 months who are not completely vaccinated for their age. Administer PPSV 2 or more months after last dose of PCV to children aged 2 years or older with certain underlying medical conditions, including a cochlear implant. See MMWR 1997;46 (No. RR-8). ¥ Inactivated poliovirus vaccine (IPV). (Minimum age: 6 weeks) The final dose in the series should be administered on or after the fourth birthday and at least 6 months following the previous dose. If 4 doses are administered prior to age 4 years a fifth dose should be administered at age 4 through 6 years. See MMWR 2009; 58(30):829-30. ‡ Influenza vaccine (seasonal). (Minimum age: 6 months for trivalent inactivated influenza vaccine [TIV]; 2 years for live, attenuated influenza vaccine [LAIV]) Administer annually to children aged 6 months through 18 years. For healthy children aged 2 through 6 years (ie, those who do not have underlying medical conditions that predispose them to influenza complications), either LAIV or TIV may be used, except LAIV should not be given to children aged 2 through 4 years who have had wheezing in the past 12 months. Children receiving TIV should receive 0.25 mL if aged 6 through 35 months or 0.5 mL if aged 3 years or older. Administer 2 doses (separated by at least 4 weeks) to children aged younger than 9 years who are receiving influenza vaccine for the first time or who were vaccinated for the first time during the previous influenza season but only received 1 dose. For recommendations for use of influenza A (H1N1) 2009 monovalent vaccine. See MMWR 2009; 58(No. RR-10). † Measles, mumps, and rubella vaccine (MMR). (Minimum age: 12 months) Administer the second dose routinely at age 4 through 6 years. However, the second dose may be administered before age 4, provided at least 28 days have elapsed since the first dose. ** Varicella vaccine. (Minimum age: 12 months) Administer the second dose routinely at age 4 through 6 years. However, the second dose may be administered before age 4, provided at least 3 months have elapsed since the first dose. For children aged 12 months through 12 years the minimum interval between doses is 3 months. However, if the second dose was administered at least 28 days after the first dose, it can be accepted as valid. •• Hepatitis A vaccine (HepA). (Minimum age: 12 months) Administer to all children aged 1 year (ie, aged 12 through 23 months). Administer 2 doses at least 6 months apart. Children not fully vaccinated by age 2 years can be vaccinated at subsequent visits. HepA also is recommended for older children who live in areas where vaccination programs target older children, who are at increased risk for infection, or for whom immunity against hepatitis A is desired. ΔΔ Meningococcal vaccine. (Minimum age: 2 years for meningococcal conjugate vaccine [MCV] and for meningococcal polysaccharide vaccine [MPSV]) Administer MCV4 to children aged 2 through 10 years with persistent complement component deficiency, anatomic or functional asplenia, and certain other conditions placing tham at high risk. Administer MCV4 to children previously vaccinated with MCV4 or MPSV4 after 3 years if first dose administered at age 2 through 6 years. See MMWR 2009; 58:1042-3. Reproduced from: Centers for Disease Control and Prevention. Recommended immunization schedule for persons aged 0 through 18 years - United States, 2010. MMWR 2010; 58(51&52).



Recommended immunization schedule for persons aged 7 through 18 years - United States, 2010 (for those who fall behind or start late, see the schedule below and the catch-up schedule)

This schedule includes recommendations in effect as of December 15, 2009. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Considerations should include provider assessment, patient preference, and the potential for adverse events. Providers should consult the relevant Advisory Committee on Immunization Practices statement for detailed recommendations: http://www.cdc.gov/vaccines/pubs/acip-list.htm. Clinically significant adverse events that follow immunization should be reported to the Vaccine Adverse Event Reporting System (VAERS) at http://www.vaers.hhs.gov or by telephone, 800-822-7967. * Tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap). (Minimum age: 10 years for Boostrix and 11 years for Adacel) Administer at age 11 or 12 years for those who have completed the recommended childhood DTP/DTaP vaccination series and have not received a tetanus and diphtheria toxoid (Td) booster dose. Persons aged 13 through 18 years who have not received Tdap should receive a dose. A 5-year interval from the last Td dose is encouraged when Tdap is used as a booster dose; however, a shorter interval may be used if pertussis immunity is needed. • Human papillomavirus vaccine (HPV). (Minimum age: 9 years) Two HPV vaccines are licensed: a quadrivalent vaccine (HPV4) for the prevention of cervical, vaginal and vulvar cancers (in females) and genital warts (in females and males), and a bivalent vaccine (HPV2) for the prevention of cervical cancers in females. HPV vaccines are most effective for both males and females when given before exposure to HPV through sexual contact. HPV4 or HPV2



is recommended for the prevention of cervical precancers and cancers in females. HPV4 is recommended for the prevention of cervical, vaginal and vulvar precancers and cancers and genital warts in females. Administer the first dose to females at age 11 or 12 years. Administer the second dose 1 to 2 months after the first dose and the third dose 6 months after the first dose (at least 24 weeks after the first dose). Administer the series to females at age 13 through 18 years if not previously vaccinated. HPV4 may be administered in a 3-dose series to males aged 9 through 18 years to reduce their likelihood of acquiring genital warts. Δ Meningococcal conjugate vaccine (MCV4). Administer at age 11 or 12 years, or at age 13 through 18 years if not previously vaccinated. Administer to previously unvaccinated college freshmen living in a dormitory. Administer MCV4 to children aged 2 through 10 years with persistent complement component deficiency, anatomic or functional asplenia, or certain other conditions placing them at high risk. Administer to children previously vaccinated with MCV4 or MPSV4 who remain at increased risk after 3 years (if first dose administered at age 2 through 6 years) or after 5 years (if first dose administered at age 7 years or older). Persons whose only risk factor is living in on-campus housing are not recommended to receive an additional dose. See MMWR 2009; 58:1042-3. ◊ Influenza vaccine (seasonal). Administer annually to children aged 6 months through 18 years. For healthy nonpregnant persons aged 7 through 18 years (ie, those who do not have underlying medical conditions that predispose them to influenza complications), either LAIV or TIV may be used. Administer 2 doses (separated by at least 4 weeks) to children aged younger than 9 years who are receiving influenza vaccine for the first time or who were vaccinated for the first time during the previous influenza season but only received 1 dose. For recommendations for use of influenza A (H1N1) 2009 monovalent vaccine. See MMWR 2009; 58(No. RR-10). § Pneumococcal polysaccharide vaccine (PPSV). Administer to children with certain underlying medical conditions, including a cochlear implant. A single revaccination should be administered after 5 years to children with functional or anatomic asplenia or an immunocompromising condition. See MMWR 1997; 46(No. RR-8). ¥ Hepatitis A vaccine (HepA). Administer 2 doses at least 6 months apart. HepA is recommended for children aged older than 23 months who live in areas where vaccination programs target older children, who are at increased risk for infection, or for whom immunity against hepatitis A is desired. ‡ Hepatitis B vaccine (HepB). Administer the 3-dose series to those not previously vaccinated. A 2-dose series (separated by at least 4 months) of adult formulation Recombivax HB is licensed for children aged 11 through 15 years. † Inactivated poliovirus vaccine (IPV). The final dose in the series should be administered on or after the fourth birthday and at least 6 months following the previous dose. If both OPV and IPV were administered as part of a series, a total of 4 doses should be administered, regardless of the child's current age. ** Measles, mumps, and rubella vaccine (MMR). If not previously vaccinated, administer 2 doses or the second dose for those who have received only 1 dose, with at least 28 days between doses. •• Varicella vaccine. For persons aged 7 through 18 years without evidence of immunity (see MMWR 2007; 56[No. RR-4]), administer 2 doses if not previously vaccinated or the second dose if only 1 dose has been administered. For persons aged 7 through 12 years, the minimum interval between doses is 3 months. However, if the second dose was administered at least 28 days after the first dose, it can be accepted as valid. For persons aged 13 years and older, the minimum interval between doses is 28 days. Reproduced from: Centers for Disease Control and Prevention. Recommended immunization schedule for persons aged 0 through 18 years - United States, 2010. MMWR 2010; 58(51&52).



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