Vaccine Hesitancy, a Modern Problem: How to Recognize It and How to Preserve Public and Children’s Health

Healthful Vitality | 08/24/2019 | By Sarah Schulze, MSN, APRN, CPNP | Vaccine Hesitancy, a Modern Problem

The development of vaccines has been one of the most impactful events affecting public health in human history and, in the 21st century, immunizations are credited with minimizing and eradicating multiple contagious illnesses and preventing 2-3 million deaths every year (6). The overwhelming success of vaccines, however, creates a conundrum for modern medicine; as diseases which were previously commonplace become a rarity, their devastation is quickly forgotten and society grows comfortable living without fear of these illnesses, comfortable enough to start to question the efficacy and necessity of the vaccines which created this safety-net in the first place.

This growing trend of skepticism and sometimes downright refusal to vaccinate has created a new hurdle for medical providers to learn to work around, as well as pockets of disease re-emergence in areas where vaccine hesitancy grows large enough. The following discussion will touch on some of the most common reasons for vaccine hesitancy and how best to communicate with vaccine hesitant patients while maintaining a good rapport and striving for the goal of maintaining high vaccine rates and herd immunity.

Vaccine Hesitancy: Trends in Vaccine Opposition

Resistance to vaccines is not a new concept, the Anti-Vaccination Society of America was founded in 1879, though the internet and social media have recently brought the movement more attention and a larger following than in the past (4). Typically, the complaints with vaccines fall into two main groups: the belief that the potential effects of vaccines, both separately and in combination, are more dangerous than the diseases they prevent, and the belief that no mandatory stipulations should surround vaccination status, and that individual rights to choose should supersede public health (6). In the United States, it is estimated that around 1-2% of modern parents refuse all vaccines for their children and as many as 19% are hesitant or request a delayed or altered immunization schedule (1).

Regarding the safety of vaccines, there are several themes parents express concern about: perceived lack of need, fear of adverse effects or belief that vaccine safety is not tested enough, immune system overload, and perceived link to autism.

Perceived lack of need

The success of vaccines means that most of us in a developed country have little to no experience with diptheria, measles, h. flu meningitis, or many other diseases we now prevent through vaccination. Medical professionals are taught about pathophysiology and symptoms of these diseases, but only the most seasoned in the profession have actually seen patients with these illnesses. Most parents and the general public do not even know what these diseases entail and do not usually know anyone who has experienced the disease, erroneously believing that a low incidence of these diseases means they are no longer a threat. This leads many parents to have an “omission bias,” or a preference for the perceived low risk of inaction (not vaccinating) over the risk of actively causing an adverse reaction in their child by choosing to vaccinate (2).

Concern over safety and side effects

When a child is sick and needs to take medication, often those medications come with side effects (most commonly diarrhea with antibiotics), but because parents can also see the intended results of the medication with improvement of symptoms, they are often more accepting of these side effects as mild and necessary for the greater benefit. However, when an otherwise healthy child is given immunizations and then suddenly complaining of soreness at the injection site or running a fever the next day (and with no obvious signs of immunity), it can be difficult for parents to rationalize these symptoms and they sometimes grow suspicious of the vaccine and its necessity.

Vaccines do, of course, come with the risk of side effects. Typically, these are mild reactions, often local irritation/redness/soreness or a low grade fever. Very rarely, there is a more serious reaction, however such reactions are considered much more unlikely than a serious outcome from contracting the disease itself. It is important to discuss with parents the rigor with which vaccines are tested when first approved and that they are consistently monitored for continued safety (2).There is a risk to benefit ratio to be considered with vaccines, however the risks are so low that vaccines are nearly always considered the safer choice (2).

Immune System Overload

A common belief held by parents is that children receive too many immunizations both at one time and across the entire immunization schedule. They believe that so many vaccine components at one time can overwhelm the immune system and some parents prefer their children receive single component vaccines rather than combination vaccines like DTaP and MMR (which are designed to reduce the number of injections received). Parents worry that overwhelming the immune system in young children will cause long term effects such as more illnesses later in life.

Some parents also believe that if their young child is frequently ill with colds, otitis media, and other common childhood illnesses, that their immune system cannot handle introduction to more antigens through immunization (2). Further parent education in both how the immune system works and the prevalence of microorganisms is needed in this area. I often ask parents if their child has ever touched a shopping cart during cold and flu season, and then assure them that they have likely encountered hundreds of disease antigens in a single shopping visit and their immune systems do just fine!

Perceived link to autism

Probably one of the most infamous controversies surrounding vaccines is the 1998 Wakefield article published in The Lancet claiming that the MMR vaccine was directly linked to development of autism spectrum disorders. This article has since been removed from publication, 10 of 13 authors recanted their opinions, and the physician who headed this project had his medical license revoked for falsifying research (2). However, the damage has been done and public opinion about the potential link between autism and vaccines has been difficult to correct.

One of the main concerns is about preservatives in vaccines, specifically thimerosal, which was previously used in multidose vials of vaccines to prevent the growth of bacteria. Thimerosal was taken out of vaccines in the 1990’s in order to reduce exposure to mercury and now most vaccines are available in single dose vials or syringes. Despite this, as well as a multitude of studies disproving any link between vaccines and autism, this misconception has persisted and leads to continued mistrust of the MMR vaccine (2).

In addition to concerns over vaccine ingredients and safety, there is also resistance to regulations regarding immunization status and many people believe the choice to vaccinate should lie solely with a child’s parents. Parents will often enroll their children in private schools or seek out a religious exemption in order to bypass the mandatory vaccination status required to attend most public schools.

Lack of Control Over Vaccine Schedule

The standard CDC schedule leaves some parents feeling as though they have no control over what their child is receiving and when. Many people have questions about why children receive so many vaccines in the first two years of life and feel that they are more actively participating in their child’s health when they propose alternative vaccine schedules. Education about the need for boosters while a child’s immune system develops as well as the increased risk of contracting a disease while on a delayed schedule should be discussed when these concerns are present (2).

Mistrust in Government and Healthcare Providers

There is also a culture of mistrust in the government for some vaccine-hesitant parents. Vaccines and their side effects are managed by the government and some people feel that they may not be completely honest with the true risks of vaccines or that financial involvement with the pharmaceutical industry may create a conflict of interest. There is also a belief that healthcare providers are not educated enough about vaccines or that they only provide information about the benefits and try to hide the risks (2).

Vaccine Hesitancy: Communicating with Vaccine Hesitant Parents

It can be a daunting task to combat the misinformation on the internet and amongst groups of vaccine-hesitant parents. However primary care providers (especially in pediatrics) are in the optimum position to help correct these misconceptions, provide quality information and education, and work with parents to help make the best decisions for their child and public health. Ongoing research indicates that open communication and a rapport of trust between parents and their child’s health care provider can promote the eventual acceptance of vaccines (1).

Of the utmost importance when working with vaccine hesitant parents, is current and thorough education on vaccines, the diseases they protect against, and the common misconceptions or perceptions that are presented against vaccines. If a parent feels that they know more about vaccines than their provider or that the professional is unable to adequately answer questions, this builds a foundation of mistrust and parents may turn to their friends, family members, or the internet for further advice. Staying current on CDC recommendations and learning the factual information behind vaccine misconceptions should be high priority for those in healthcare (5).

Vaccine ambassador program

Another suggested action is to create a vaccine ambassador program, particularly within pediatric office, where parents with vaccinated children can be trained to talk with parents who may be hesitant and share their own experiences with vaccines. This may be especially useful if the ambassadors were formerly hesitant and have now decided to vaccinate as this experience may be very relatable for the non-vaccinating parent. An ambassador program removes the barrier of differing roles that may exist between providers and their patients and allows people to speak openly with peers (5).

Conversation of understanding rather than confrontation

Finally, and most importantly, it is recommended to approach the entire conversation with an attitude of understanding rather than confrontation. In the end, vaccine-hesitant parents do truly believe they are doing what is best for their child and they are making their decisions based on that pressure to make the safest choices. Education is required to help them see what the true best choice is, but condescension, anger, or refusal to listen to their concerns is not likely to be successful in any scenario.

The need to partner with others to achieve the best possible health goals

In my experience, it has been effective to lead by explaining to parents that I know they want to make the best possible choices about their child’s health and that I applaud their desire to gather as much information as possible before making a decision. I then point out that I too want what is best for their child and that healthy, happy children is a common goal for us. Besides, I acknowledge that they are the ones in the “driver’s seat” and I am merely a guide as they navigate parenthood, but that I would love to partner with them to achieve the best possible health goals.

I have found that many parents come into the conversation expecting confrontation, but if they are instead met with respect and understanding, we can often go on into a question and answer section and find that many of their concerns are quite easily handled with further education.

It is worth noting that in some cases, there are parents who are so deeply entrenched in the anti-vaccine community that they cannot be reached and have no desire to listen or change their minds. These particular parents are typically unable or unwilling to have a respectful dialogue about the subject and it is usually best if the healthcare provider recognizes that there is no progress to be made in these situations and simply deal with them as their facility policy dictates (often a no tolerance policy means these parents are dismissed as patients).

Vaccine Hesitancy: Conclusion

There is a wide spectrum of concerns with vaccine hesitant parents and with proper education and sensitive communication, the vast majority of them can be reached and a plan of care can usually be mutually decided upon. It is the responsibility of healthcare workers to familiarize themselves with the common themes in arguments against vaccines and to learn how to communicate openly with families to help correct any misconceptions and to empower parents to make the decision to vaccinate. If approached correctly, there is a good chance of establishing trust with parents and reaching the goal of keeping children an the public healthy through vaccination.

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References:

1. Anderson, V. L. (2015). Promoting childhood immunizations. The Journal for Nurse Practitioners, 11 (1). Retrieved from: https://www.npjournal.org/article/S1555-4155(14)00743-0/fulltext
2. Barrows, M. A., Coddington, J. A., Richards, E. A., & Aaltonen, P. M. (2015). Parental vaccine hesitancy: clinical implications for pediatric providers. Journal of Pediatric Health 29 (4). Retrieved from: https://www.jpedhc.org/article/S0891-5245(15)00157-1/fulltext.
3. Kestenbaum, L. A., and Feemster, K. A. (2015). Identifying and addressing vaccine hesitancy. Pediatric Annals, 44 (4). Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4475845/
4. Schwartz, J. L. (2012). New media, old messages: themes in the history of vaccine hesitancy and refusal. AMA Journal of Ethics, 14 (1). Retrieved from: https://journalofethics.ama-assn.org/article/new-media-old-messages-themes-history-vac cine-hesitancy-and-refusal/2012-01
5. Smith, T. C. (2017). Vaccine rejection and hesitancy: a review and call to action. Open Forum Infectious Diseases, 4 (3). Retrieved from: https://academic.oup.com/ofid/article/4/3/ofx146/3978712
6. World Health Organization (n.d.). Immunization. Retrieved from: https://www.who.int/topics/immunization/en/

Author:

Sarah Schulze is a board-certified pediatric Nurse Practitioner. She earned a B.S. in Nursing from Indiana State University and an M.S. in Nursing from the University of Illinois at Chicago.