Vaccination was hailed as one of the most important medical interventions of the 20th century, preventing up to 3 million pediatric deaths every year ( Diekema DS, 2005). In addition to saving millions of lives from infectious diseases, they prevent certain cancers and save billions of dollars in healthcare costs ( Loria K , September 11, 2014). Yet despite their benefits, a small population of parents refuses to vaccinate their children, believing that some or all of the vaccines are dangerous, resulting in outbreaks of diseases that we have almost eliminated in the United States.
There is a radical difference between families of undervaccinated children and unvaccinated children. A study examining 2001 National Immunization Survey (NIS) data showed that families of undervaccinated children are more likely to be black, with an unmarried younger mother in a household near the poverty level with more than 4 children (Smith PJ, Chu SY, Barker LE, 2004). Then again, groups of unvaccinated children will probably be white, with a wedded school instructed mother in a family surpassing a yearly pay of $75,000 (no information on dads were accumulated in the NIS reviews). Unvaccinated children were additionally more inclined to be male than female and much more probable than undervaccinated kids to originate from a family with in excess of 4 kids. These unvaccinated kids represented 0.3% (17,000) of US children somewhere in the range of 19 and 35 months old in 2001
According to the latest published NIS data, unvaccinated children remain at less than 1% of US population and vaccine coverage on average is high, with over 90% vaccine coverage for MMR, DTaP, polio, and hepatitis B (Figure Depicting Coverage with Individual Vaccines from the Inception of NIS, 1994 Through 2014, Reviewed August 27, 2015). For new routine vaccines like rotavirus and hepatitis A, vaccine coverage has been steadily climbing upward.
That being said, because unvaccinated children tend to be geographically grouped, they are more likely to be the source of vaccine-preventable disease outbreaks. For instance, in Washington state, county-level nonmedical vaccine exemption levels ranged from 1.2% to 26.9% and similar clustering of exemptions has been found in other states (Omer SB, Salmon DA, Orenstein WA, deHart P, Halsey N, 2009). Clustering has been known to be associated with school policies favorable to exemptions and beliefs of school personnel responsible for ensuring vaccine compliance (Salmon DA, Omer SB, Moulton LH, et al, 2005).
As a result of unvaccinated children living in the same community, outbreaks of vaccine-preventable disease occur and spread rapidly. For example, the 2003 outbreak of pertussis (a whooping cough) in New York was traced to four children whose parents decided against vaccination. The outbreak spread to a neighboring county in which five out of the first seven cases were of unvaccinated children (Klein M, October 29, 2003). In total, 54 cases of pertussis were recorded. A high number of those cases were of vaccinated children whose conferred immunity for pertussis had 4 naturally waned over time and were more susceptible to acquiring the disease from unvaccinated children.
This small subset of unvaccinated children has increased since the 1990s. Between 1991 to 2004, mean state-level exemptions for personal beliefs have increased from 0.99% to 2.54% while religious exemptions have remained steady at about 1% ( Omer SB, Pan WK, Halsey NA, et al, 2006). In a study of more than 2,000 parents, the most common reason reported for claiming vaccine exemption was concern that vaccines might cause harm (Salmon DA, Moulton LH, Omer SB, et al, 2005). Physicians have also reported that many have had a parent refuse at least one vaccination for their child and once a parent decides to forego vaccination, they are unlikely to change their decision even after learning that the risks of disease versus the risks of vaccination. As more parents claim personal belief exemptions, the clusters of unvaccinated children will continue to expand and increase the risk of vaccine-preventable disease outbreaks for both unvaccinated and vaccinated children whose immunity have waned, as seen in the case of the 2003 New York pertussis outbreak.
In summary, compared to parents of undervaccinated children who may have problems with healthcare access, parents who refuse vaccination on behalf of their children are well-educated and have the annual income to afford healthcare for their children, but ultimately decide not to vaccinate their children. Unvaccinated children are a small population (0.3%) compared to undervaccinated children (36.9%) but because they tend to live near one another, children without vaccinations become sites of a potential outbreak that affect populations beyond themselves (Smith PJ, Chu SY, Barker LE, 2004).
Along with the increasing number of families opting out of vaccination, some physicians have begun to turn away families who decline vaccination. In a 2012 survey of 282 pediatricians, 21% stated that they often or always dismissed families who refused at least one vaccination (O'Leary ST, Allison MA, Fisher A, et al, 2015). According to a national survey of members of the American Academy of Pediatrics, over 25% of physicians said they would choose to discontinue their provider relationship if parents refused permission for some vaccines (Flanagan-Klygis EA, Sharp L, Frader JE, 2005).
Because the current vaccine safety debate appears to offer two seemingly legitimate options for parents - one to vaccinate and one to not - vaccination becomes one of many 12 choices a parent must make regarding their child’s health. Their final decision to vaccinate, delay vaccination, or refuse vaccination is formed by exposure to public discourse on vaccine safety and of weighing the risks and benefits of possibly skewed evidence. The following two conversations are excerpted from Kaufmann’s parent interviews (Kaufmann SR, 2010). They illustrate the pervasive nature of vaccine safety talk and the resulting responsibility parents feel in making the ‘right’ choice about vaccines.
'It's hard to read about autism without coming across stuff on vaccines. My faith in mainstream medicine began to be significantly eroded when I started reading and through the parent networks. Ninety person of the information that is useful to me has come from parents... Again, I'm a very establishment person. Not on the left. So, for me to be converted says something... So, I'm mad at the pediatrician. I feel she didn't give me accurate information, based on my own research.
'I feel guilty that I didn't do more research on vaccines. You can't get away from the guilt, because you always need to do more reading, research. It goes on and on; it doesn't end. The pressure to interview the doctor, to ask the doctor questions and more questions are always there. Because you have the responsibility, not just of minimizing risk, but also of optimizing the physical, social, and cognitive development of your child.” (mother of a child without developmental problems)
Once a parent has decided not to vaccinate their child, social mechanisms can reinforce like-minded ideas about vaccine refusal (Sobo EJ, 2015). In a 2015 ethnography conducted of California Waldorf private school parents, anthropologist Elisa Sobo shows that increased post-enrollment vaccine refusal was likely linked to the school culture, which embraced alternative views of health and education. After interviewing the primary caregivers of 17 families, Sobo noticed that some families with more than one child showed a drop-off in vaccination for each younger child. When questioned about vaccination, these parents and parents from her focus groups said that as they learned more about vaccines from the Waldorf community, they decided to stop vaccinating their children. Similar social networks like this particular school community may contribute to the geographic clustering of vaccine refusal, as these networks strengthen parents’ opinions and ultimately their decisions about vaccine safety.
In conclusion, a combination of effective public health communication, early and empathetic provider interventions, and restricted personal belief exemption policies may hold the answer to vaccine anxiety. Eliminating personal belief exemptions alone does not address the pervasive underlying vaccine anxiety that many parents have. Much of the work is on the provider to alleviate this anxiety and strengthen the provider-family relationship for future medical decisions. By understanding that vaccine anxious parents are making vaccination decisions based on conflicting information and that their decisions are likely reinforced by peer connections, providers can begin to see that a vaccine anxious parent’s perspective is not unreasonable or illogical. Lastly, by diagnosing the specific worries parents have, providers can start the conversation toward viewing vaccination positively.
References
Diekema DS. (2005). Responding to Parental Refusals of Immunization of Children. Pediatrics, 115(5): 1428-1431.
Loria K. (September 11, 2014). 7 Undeniable Reasons Opposition To Vaccines Is Deadly And Backwards. . . Business Insider.
Omer SB, Pan WK, Halsey NA, et al. (2006). Nonmedical exemptions to school immunization requirements: secular trends and association of state policies with pertussis incidence. JAMA, 296: 1757-63.
Figure Depicting Coverage with Individual Vaccines from the Inception of NIS, 1994 Through 2014. (Reviewed August 27, 2015). Centers for Disease Control and Prevention.
Flanagan-Klygis EA, Sharp L, Frader JE. (2005). Dismissing the family who refuses vaccines: a study of pediatrician attitudes. Arch Pediatr Adolesc Med, 159: 929-34.
Kaufmann SR. ( 2010). Regarding the rise in autism: vaccine safety doubt, conditions of inquiry, and the shape of freedom. Ethos, 38(1): 8-32.
Klein M. ( October 29, 2003). Whooping cough outbreak. Journal News.
O'Leary ST, Allison MA, Fisher A, et al. (2015). Characteristics of Physicians Who Dismiss Families for Refusing Vaccines. Pediatrics, 136(6): 1-9.
Omer SB, Salmon DA, Orenstein WA, deHart P, Halsey N. (2009). Vaccine Refusal, Mandatory Immunization, and the Risks of Vaccine-Preventable Diseases. N Engl J Med. , 360(19): 1981-1987.
Salmon DA, Moulton LH, Omer SB, et al. (2005). Factors associated with refusal of childhood vaccines among parents of school-aged children. Arch Pediatr Adolesc Med, 159(5)470-6.
Salmon DA, Omer SB, Moulton LH, et al. (2005). Exemptions to school immunization requirements: the role of school-level requirements, policies, and procedures. Am J Public Health, 95: 436-40.
Smith PJ, Chu SY, Barker LE. (2004). Children Who Have Received No Vaccines: Who Are They and Where Do They Live? Pediatrics, 114(1): 187-195.
Sobo EJ. (2015). Social cultivation of vaccine refusal and delay among Waldorf (Steiner) school parents. Med Anthropol Q, 29(3): 381-399.