More parents refusing to get kids vaccinated

Just the other day, a parent of an autistic patient asked Leslie Ellwood, MD, to delay the boy's measles-mumps-rubella vaccine and split the administration of the vaccines his 15-month-old sister was scheduled to receive into two a visit. "Given her concerns, we try to accommodate her," said Dr. Ellwood, a Kaiser Permanente pediatrician and vice president of the Virginia chapter of the American Academy of Pediatrics.

Dr. Ellwood's experience is not unusual. Getting kids vaccinated is no longer automatic. An increasing number of parents express concerns about rumored ill effects like autism, autoimmune diseases, compromised immunity, learning disabilities, diabetes and paralysis, according to a recent University of Michigan study that surveyed by mail a random national sample of 750 pediatricians and 750 family physicians. Many suspect the upward trend in parental apprehension has been fueled by news stories, Internet sites, and word-of-mouth reports that allege deleterious effects.

"We wanted to quantify the degree to which parents were refusing or expressing concerns," said Gary L. Freed, MD, MPH, the study's lead investigator and director of general pediatrics at the university's health system in Ann Arbor, Mich. "Our findings indicated to me that parental concern and refusal is a relatively common occurrence."

In the Michigan study, published in the January American Journal of Preventive Medicine, 93% of pediatricians and 60% of family physicians said at least one parent had refused a vaccination for his or her child in the last year. Sixty-nine percent of the physicians said that the number of concerns had increased substantially over the past year. Pediatricians were twice as likely as family docs to say that refusals were rising.

When parents refuse vaccines, 74% of physicians said they discuss the refusal with the parent. Many ask parents to sign refusal forms, and 10% said they'd ask parents to find another physician.

"Physicians are in a unique position to both quantify parental concern about vaccine safety and provide information on the impact of those concerns," said Dr. Freed. "All of us must be sensitive to parents' concerns and well-prepared to respond to them."

The context of concerns

Common worries -- fever, rash -- are addressed in vaccine information handouts, and most physicians surveyed had these on hand for parents. But according to the AAP, other information from the Internet and in the media is often flawed or biased and serves to feed public concern, leading to increased refusal rates.

And even if some rare events have merit, they are very hard to track because most allegations are based on anecdote, said Alfred O. Berg, MD, chair of the Dept. of Family Medicine at the University of Washington School of Medicine in Seattle. "There is a consistent body of evidence that shows no relevant correlation," said Dr. Berg, who is also chair of the U.S. Preventive Services Task Force and a member of the Institute of Medicine Immunization Safety Review Committee. "People who argue that vaccines are not safe have very general allegations that are impossible to answer."

Still, Dr. Berg said a better surveillance system for picking up adverse reactions or events is needed. The IOM panel reviewed possible connections between the MMR vaccine and autism. And while they could find no proven biological mechanisms that would explain such a link, the committee recommends more targeted research efforts and more rigorous data-gathering procedures to give scientists a firmer understanding of the vaccine and possible side effects.

Meanwhile, on the front lines of the nation's vaccine delivery system, pediatricians and primary care physicians can help parents understand the benefits of vaccination, the state of knowledge on vaccine safety concerns and the individual and societal risks of leaving children unvaccinated.

"We need to look at parents as partners and help them dispel myths," said Dr. Freed. "Physicians must be aware of current vaccination concerns in their own community and work hard to stay up-to-date with vaccine safety concerns. Parents come to us for real information, and we need to be prepared."

The primary message for physicians, said Dr. Ellwood, is to relate to parents the risk and outcomes if a child is not vaccinated. "Many young parents have no information on the diseases for which vaccines offer protection. They need some orientation to the great polio epidemics of the first half of the 20th century, the rubella babies of the 1950s with severe congenital hearing and vision loss, [as well as outbreaks of] measles encephalitis [and] pertussis."

Dr. Berg's practice offers scientific fact sheets for parents to look at while in the office. "We try to help parents make the decision before going home," he said. "There's tons of great stuff to help parents understand about vaccines. Much is written by the [Centers for Disease Control and Prevention] and is freely available."

Despite parental concern and refusal, vaccines remain the best prevention for serious diseases, and parents need to understand the risk of not vaccinating their children, said Dr. Freed. "We need to make sure there is a source of accurate information for parents to make informed decisions," he said. "This kind of responsiveness needs to increase, especially when it comes to unsubstantiated and rumored risks if we are to continue to be able to protect children from these vaccine-preventable diseases."