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When the answer to vaccines is “No”
We all know how challenging and time-consuming it can be to convince vaccine-hesitant patients that vaccinations are what is best for them and their children. Patients are bombarded with misinformation through the news and social media that seeds or “confirms” their doubts about vaccines. And for our part, we have only a few minutes during an office visit to refute all of the false claims that are a mere click or scroll away.
To better prepare for this challenge, this article details a practical approach to discussing vaccines with your patients. Using the patient-friendly language and evidence described here, you will be well positioned to refute 13 common vaccine misconceptions and overcome the barriers that stand in the way of these lifesaving interventions.
A few important baseline concepts
In discussing vaccination with our patients, it is important to keep the following in mind:
Patients don’t refuse vaccinations just to make our lives difficult. They truly are trying to make the best decisions they can for themselves and their families. Recognizing this can significantly reduce frustration levels.
Time well spent. While educating patients about the value of vaccines takes time, the return is worth it. The more consistently we offer vaccines, along with the reasons they are important, the more likely patients are to give vaccines a second thought. In fact, studies show that provider recommendation is the most important factor in patients’ decisions to vaccinate.1
Approach matters. In all other aspects of medicine, we attempt to use a participatory approach, involving our patients in decisions regarding their health care. When discussing vaccines, however, a participatory approach (eg, “What do you want to do about vaccines today?”) can introduce doubt into patients’ minds. Studies show that a presumptive approach (eg, “Today we are going to provide the tetanus, human papillomavirus [HPV], and meningitis vaccines”) is a much more effective way to get patients to vaccinate.2
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Continue to: Barriers to counseling
Barriers to counseling. Health care providers report a variety of barriers to effective vaccine counseling (limited time and resources, lack of confidence in addressing patients’ concerns, etc).3 In addition, providers sometimes worry that strong encouragement of vaccination will create an adversarial relationship with vaccine-hesitant patients. Developing a good rapport and trusting relationship, as well as using motivational interviewing approaches, can help communicate the importance of vaccines, while leaving patients with the sense that you have heard them and respect their intentions. (See “Facilitate vaccine discussions using these 2 approaches.” 4-7)
SIDEBAR
Facilitate vaccine discussions using these 2 approaches4-7
C.A.S.E.
Corroborate
Acknowledge concerns and find some point on which you can agree.
Example: "It sounds like we both want to keep your child healthy and safe."
About me
Describe what you have done to build your expertise on the subject.
Example: "I have been practicing medicine for 15 years and have spent a great deal of time researching the data on vaccinations."
Science
Review the data and science behind vaccines.
Example: "Vaccines are more rigorously studied and safer than almost any other intervention we have in medicine."
Explain/advise
Explain your recommendations, based on the science.
Example: "This is why I vaccinate my children, and this is why I recommend this vaccine for your child."
3As
Ask
Don't stop at a patient's first "No." Respectfully dig a bit deeper.
Example: "What questions do you have about the vaccines we are recommending today? Tell me what worries you about them."
Acknowledge
Acknowledge your patient's concerns.
Example: "You are obviously a very devoted parent, and I know that you are trying to make the best decision you can for your child. With everything we see on the news and social media, it's not always easy to know what to believe about vaccines."
Advise
Advise patients/parents of the facts about vaccines and provide a strong recommendation to vaccinate.
Example: "Depending on the year, influenza kills 12,000 to 56,000 people annually; the vast majority of those who die did not receive the flu vaccine.7 My family and I get the flu shot every year, and I strongly encourage you and your children to get this lifesaving vaccine."
Continue to: If at first you don't succeed...
If at first you don’t succeed, try again because patients often have an experience that changes their mind. Perhaps a friend died of throat cancer or a family member developed a complication of the flu that required hospitalization. You never know when something will influence patients’ choices.
Don’t wait for scheduled well visits. Use every patient encounter as a means to catch patients up on missing vaccinations.
Common misconceptions and concerns and how to counter them
1. I’ve heard that vaccines can actually make you sick.
When patients raise this concern, start with an explanation of how vaccines work. Explain that our bodies protect us from foreign invaders (such as viruses and bacteria) by mounting an immune response when we are exposed to these proteins. Vaccinations work by exploiting this immune response; they expose the body to killed or weakened viral or bacterial proteins in a safe and controlled manner. In this way, our immune system will have already developed antibodies to these invaders by the time we are exposed to an active infection.
To use an analogy to war, instead of being subjected to a surprise attack where we suffer large losses in the battle, vaccination prepares us with weapons (antibodies) to defend ourselves so that our bodies are now able to successfully fight off that attack.
Because the majority of vaccines are killed virus vaccines, they cannot cause the illness against which they are meant to protect. Triggering the immune system may make some recipients feel a little “under the weather” for a day or 2, but they do not make us “sick.”
Live attenuated vaccines are similarly safe for those with a healthy immune system. We don’t administer them, however, to people who have a weakened immune system (eg, pregnant women, newborns, people with acquired immunodeficiency virus, or patients receiving chemotherapy or other types of immunosuppression) because these patients could develop the illness that we are trying to protect against.
Continue to: 2. Don't vaccines cause autism? Aren't they toxic to the nervous system?
2. Don’t vaccines cause autism? Aren’t they toxic to the nervous system?
The largest setback to vaccination efforts in recent history was a 1998 study by Andrew Wakefield that suggested that vaccination (specifically the mercury [in the form of thimerosal] present in the measles, mumps, rubella [MMR] vaccine) was linked to the development of autism.8 This research was subsequently debunked,9 and the author of the 1998 study was stripped of his medical license for falsifying data. However, the damage to vaccination efforts had already been done.
Aluminum. Thimerosal is not the only agent that patients may find concerning. Some also worry about the aluminum content of vaccines. Aluminum works as an additive to boost the body’s immune response to a vaccine. It is used only in killed virus vaccines—not in live attenuated ones. The Agency for Toxic Substances and Disease Registry monitors minimum risk levels (MRLs) of aluminum and other compounds in potentially hazardous substances. The amount of aluminum in vaccines is far below the MRL for aluminum, which is 1 mg/kg/d.10 (See “The facts about thimerosal and aluminum in vaccines.”11-16)
SIDEBAR
The facts about thimerosal and aluminum in vaccines
Thimerosal
Ethyl-mercury was used (in the form of thimerosal) as a preservative to prevent bacterial and fungal contamination of vaccines. Since 2001, however, thimerosal has been removed from all US-licensed vaccines—except multidose vials of influenza vaccine—as a precautionary measure (and not for any reproducible evidence of harm). The multidose flu vial contains <0.01% thimerosal.11
Ethyl-mercury is cleared from the body much more rapidly than methyl-mercury (the kind found in certain types of fish) and is less toxic.12
Since the removal of thimerosal from vaccines, the Centers for Disease Control and Prevention notes that the rates of autism have actually increased.13
Even Autism Speaks, the leading organization dedicated to advocacy for patients with autism and their families, denies a link between vaccines and autism.14
Aluminum
We are exposed to aluminum in products we use extensively every day, such as pots and pans, aluminum foil, seasonings, cereal, baby formula, paints, fuels, and antiperspirants.15
Infants are exposed to about 4.4 mg of aluminum in the vaccines typically administered in the first 6 months of life.16 However, infants typically ingest more than that during the first 6 months of life. Breast milk contains about 7 mg over 6 months; milk-based formulas contain about 38 mg over 6 months; and soy-based formulas contain about 117 mg over 6 months.16
Contine to: 3. I'm healthy. I never get sick. Why do I need vaccinations?
3. I’m healthy. I never get sick. Why do I need vaccinations?
A good way to counter this comment is to respond: “Saying you don’t need vaccinations because you never get sick is like saying you don’t need to wear a seat belt because you’ve never been in a car accident.” Advise patients that we seek to vaccinate all members of a community—not just those who are sick or at high risk—to protect ourselves and to provide “herd immunity.” It’s important to explain that herd immunity is resistance to the spread of a contagious disease that results if a sufficiently high number of people (depending on the illness, typically 80%-95%) are immune to the disease, especially through vaccination.17,18 If vaccination levels fall, we see a rise in cases of vaccine-preventable illness (as was seen during the 2017 measles outbreak in a community in Minnesota).19
Even though many of us may not suffer severe consequences of an infection, we can still pass that infection to others. While the whooping cough that a healthy 35-year-old gets may cause only prolonged annoyance or time off from work, it can kill the baby that is sitting next to that adult on the plane or bus.
4. Isn’t it true that we see fewer serious illnesses because of improved hygiene and sanitation, rather than vaccines?
Our current US sanitation standards were established under the Safe Drinking Water Act of 1974.20 While improvements in hygiene, sanitation, nutrition, and other public health measures have undoubtedly decreased the spread of disease and improved survival rates, there is no denying the significant drop in disease that occurs after the introduction of a vaccine for a particular illness or the increase in cases of that disease when vaccination rates drop off.
By the early 1990s, our current sanitation standards were already well established. Yet we didn’t see a significant decrease in the incidence of infections with Haemophilus influenzae type b (Hib) until after the conjugate Hib vaccines were introduced (dropping from about 20,000 cases/year to 1419 cases/year by 1993).21
In Britain, a drop in the rate of pertussis (whooping cough) vaccination in 1974 resulted in an epidemic of more than 100,000 cases and 36 deaths by 1978. There was no decrease in hygiene or sanitation standards to explain this rise.21
Continue to: 5. Vaccines are just another way for "big pharma" to make "big money."
5. Vaccines are just another way for “big pharma” to make “big money.”
Patients may benefit from knowing that in the earlier days of vaccines, pharmaceutical companies actually moved away from production of vaccines because they were not very profitable. These days, with worldwide distribution, drug companies are back in the swing of making vaccines and, as we would expect from all companies, are in business to make a profit.
That said, health care providers receive no payments from drug companies for offering vaccines or for offering one vaccine over another. The reason we recommend vaccination is because we know it is best for our patients’ health and the health of the community.
6. We don’t see polio anymore. Why do I need the vaccine?
One of the factors contributing to the rise in antivaccine sentiment is that we rarely see vaccine-preventable illnesses (such as polio, measles, and mumps). But the absence of these illnesses is precisely due to prior years’ vaccination efforts.
Smallpox, a deadly and disfiguring disease that killed many millions of people and contributed to the downfall of the Roman, Aztec, and Incan empires, was eradicated from the planet in 1979, thanks to focused vaccination efforts by the World Health Organization. Vaccination works, but we have to keep at it.
While we no longer see as many of these vaccine-preventable illnesses in the United States, they are still present in other parts of the world. Our world is much smaller than it used to be. International travel is common, and illnesses can be reintroduced into a community with relative ease. We must remain vigilant.
Continue to: 7. I heard that vaccines are made from aborted fetal tissue.
7. I heard that vaccines are made from aborted fetal tissue.
There are 5 vaccines (varicella, rubella, hepatitis A, shingles, and rabies vaccines) that were originally made using aborted fetal tissue. In 1960, tissue from 2 fetuses aborted by maternal choice (and not for the purpose of vaccine production) was used to propagate cell lines that are still used in vaccine development today.
Human cells provide advantages for vaccine production that other cells do not. Some viruses do not grow well in animal cells. Animal cells can introduce contamination by bacteria and viruses that are not carried in human cell lines. Vaccine production can be hindered or halted, resulting in a vaccine shortage, if animal products used in development are threatened (eg, if an illness strikes egg-producing chickens; eggs are used to make the influenza vaccine).22
Some patients, particularly those who are Catholic, may have concerns about these vaccines. The National Catholic Bioethics Center has prepared a statement regarding the use of these vaccines that may help settle any moral dilemmas.23 It reads:
“The cell lines under consideration were begun using cells taken from one or more fetuses aborted almost 40 years ago. Since that time, the cell lines have grown independently. It is important to note that descendent cells are not the cells of the aborted child.”
“One is morally free to use the vaccine regardless of its historical association with abortion. The reason is that the risk to public health, if one chooses not to vaccinate, outweighs the legitimate concern about the origins of the vaccine. This is especially important for parents, who have a moral obligation to protect the life and health of their children and those around them.”
Continue to: 8. Vaccines aren't studied—or monitored—thoroughly enough.
8. Vaccines aren’t studied—or monitored— thoroughly enough.
Patients would benefit from knowing that vaccines are some of the most thoroughly studied products brought to market. They undergo rigorous testing and oversight, from both public and private organizations, for 10 to 15 years before being released for distribution. Post-licensure monitoring is ongoing, and the manufacturer may voluntarily participate in Phase IV trials to continue to test the safety and efficacy of a vaccine after release to market.
Monitoring adverse effects. In addition, in 1990, the Centers for Disease Control and Prevention (CDC) and the US Food and Drug Administration established the Vaccine Adverse Events Reporting System (VAERS) to “detect possible signals of adverse events associated with vaccines.”24 Most events reported are coincidental, but some common mild adverse events (like redness and swelling at the injection site) are often underreported.
Serious events are always thoroughly investigated and are often found unrelated. However, rare associations have been found. For example, an intestinal problem called intussusception, related to the original rotavirus vaccine, was discovered, and the vaccine causing it was removed from the market.25 A new, safer rotavirus vaccine option is now available. Patients need to know that we do have an effective system of checks and balances in which we can place our trust.
9. People can become paralyzed or stop breathing after receiving a vaccination. Why run those risks?
One of the most feared reactions to vaccination is Guillain-Barré syndrome (GBS), which can cause paralysis. The CDC estimates the risk for GBS associated with the flu vaccine, for example, to be 1 to 2 cases per 1 million people vaccinated.26 Another potential concern is the rate of anaphylaxis following vaccination. However, in a 2016 study in the Journal of Allergy and Clinical Immunology, the rate of anaphylaxis for all vaccines combined was only 1.31 per 1 million vaccines.27
The risk of developing severe complications from an illness is much greater than that of developing complications from the vaccine meant to protect a person against that illness. In the United States, the population-based risk for influenza-related hospitalization in children, for example, is as high as 150 in 100,000 with as many as 125 deaths annually.26
Continue to: 10. Isn't vaccination a personal choice? How does my health/illness impact the community?
10. Isn’t vaccination a personal choice? How does my health/illness impact the community?
Patients may not realize that most viruses are contagious from 1 to 2 days before symptoms appear, which means we can spread an illness before we even know we have it. Protecting oneself also protects those around us.
Economic concerns. There’s also the economic impact of these illnesses to consider. This includes the personal cost of being out of school or work for an extended period and the cost of a patient’s care, which can become astronomical if hospitalization is required and which can become the country’s problem if a person lacks sufficient health insurance coverage.
A study looking at the cost of 4 major adult vaccine-preventable illnesses (influenza, pneumococcal disease, shingles, and whooping cough) in the United States in 2013 estimated the annual cost for these illnesses in adults ≥50 years to be $26.5 billion.28 And that doesn’t include the cost of childhood vaccine-preventable diseases.
Countering 3 concerns about childhood vaccinations
1. I can’t afford vaccines for my child.
The Vaccines for Children program is a federally-funded program that covers the cost of all vaccines for children younger than 19 years of age who are Medicaid-eligible, American Indian, Alaskan Native, uninsured, or underinsured.29 Although there may be a small administration fee charged by the provider’s office, the vaccine is free.
2. Don’t all of the vaccines recommended for children overwhelm their immune systems?
Children are exposed to so many more proteins on a daily basis (by crawling around on the floor, putting their hands in their mouths, attending school or day care, etc) than they are ever exposed to in a series of vaccines.30 Exposure to these proteins in their environment and to those in vaccines only serves to boost their immunity and keep them healthier in the long run.
And thanks to advances in vaccine production, the immunologic load in vaccines is far less than it used to be. The 14 vaccines given today contain <200 bacterial and viral proteins or polysaccharides, compared with the >3000 of these immunologic components in the 7 vaccines administered in 1980.31
Continue to: Influenza vaccine: Patient-friendly talking points
SIDEBAR
Influenza vaccine: Patient-friendly talking points
- Some people think that getting the flu is no big deal. While it is true that the flu takes a greater toll on the very young and very old, the chronically ill, and the immune compromised, even healthy people can become seriously ill or die. The Centers for Disease Control and Prevention estimates that the flu is responsible for 140,000 to 720,000 hospitalizations and 12,000 to 56,000 deaths in the United States every year.7 Of those who die from the flu, approximately 80% did not receive a flu shot.36 Of children who died from the flu between 2004 and 2012, more than 40% had no risk factors for complications.37
- The flu shot is a killed virus vaccine, so it can't give you the flu. People sometimes feel under the weather (achy, low-grade fever) after a vaccine, but this is considered normal and evidence that your body's immune system is "revving up."
- It takes 2 weeks before the vaccine becomes effective so a person can still get the flu during that time. This is why it is so important to get the vaccine earlier in the fall, before the flu season takes hold.
- The "stomach flu" is not the flu. The flu vaccine does not protect against the "stomach flu" or other flu-like illnesses.
- The flu vaccine is not perfect. It is an educated guess as to which strains will be circulating that year. (At its best, the flu vaccine is about 60% effective.38) However, it makes the chance of getting the flu less likely and significantly decreases the odds of severe complications/death.
- Egg allergies are no longer a reason to avoid the flu vaccine. There is an egg-free vaccine called Flublok (for those ≥18 years of age). In 2016-17, the Advisory Committee on Immunization Practices changed the recommendations for flu vaccine in egg-allergic people. The recommendations say that if reactions are mild, or you can eat cooked eggs without a problem, you can receive a flu vaccine. If you have severe reactions, such as trouble breathing or recurrent vomiting, you can still receive the flu vaccine, but must be monitored by a health care provider who can recognize and respond to a severe allergic reaction.39
Continue to: 3. Why don't we adhere to Dr. Sears' vaccine schedule?
3. Why don’t we adhere to Dr. Sears’ vaccine schedule?
There are multiple ways in which Dr. Robert Sears’ book, The Vaccine Book: Making the Right Decision for your Child, published in 2007, misrepresents vaccine science and leads patients astray in making decisions regarding vaccinations.32 Most important to note is that Dr. Sears’ Alternative Vaccine Schedule, which seeks to make it so that children do not receive more than 2 vaccinations per office visit, would require visits to a health care provider at 2, 3, 4, 5, 6, 7, 9, 12, 15, 18, and 21 months, and at 2, 2.5, 3, 3.5, 4, 5, and 6 years of age. This significantly increases the number of office visits and needle sticks, and raises the age at which vaccines are given, increasing the risk of illness outbreaks and decreasing the likelihood that parents would return to the office to complete the full series.
Acceptance of influenza and HPV vaccines remains a challenge
We are significantly less successful at getting parents and patients to agree to influenza and HPV vaccines than to the other vaccines we offer. The influenza vaccine success rate in 2016 was 59% in children and 43.3% in adults.33 Compared to the Tdap vaccine (88%) and the meningococcal vaccine (82%), which are offered at the same age as the HPV vaccine, success rates for HPV vaccine are significantly lower. In 2016, only 60.4% of boys and girls were current on their first HPV injection and only 43.3% were up to date with the full series.34
Newness of vaccines a factor?
Perhaps it is because the recommendations for these 2 vaccines are relatively new, and people don’t yet grasp the seriousness and scope of the diseases. Until 2010, the flu shot was recommended only for the very young, the elderly, and the medically high risk.
Similarly, the HPV vaccine was originally introduced for girls in 2006 and wasn’t recommended for boys until 2011.
Continue to: Human papillomavirus vaccine: Patient-friendly talking points
SIDEBAR
Human papillomavirus vaccine: Patient-friendly talking points
- Human papillomavirus (HPV) causes genital warts and cancer of the cervix, vagina, vulva, anus, rectum, penis, and oropharynx.
- The HPV vaccine is a cancer prevention vaccine. The 9-valent vaccine is active against 2 genital wart-causing strains and 7 cancer-causing strains of HPV.
- HPV is highly prevalent; 79 million Americans are currently infected, nearly 14 million people become newly infected each year, and nearly all of us will be exposed at some point in our sexual lives.40
- There are often no outward signs of infection, so it is a difficult infection to avoid.
- It takes no high-risk sexual activity to be exposed to the HPV virus.
- The HPV vaccine is recommended for both boys and girls usually around age 11 to 12 years (but as early as 9 years and as late as 26 years is acceptable). If the first vaccine is administered before 15 years of age, only 2 injections are needed 6 to 12 months apart. If the first vaccine is administered after 15 years of age, 3 injections are needed at 0, 2 months, and 6 months.41
- Completing the series before sexual activity begins is the best way to protect our children because the vaccine is a preventive measure, not a treatment.
- The HPV vaccine is highly effective with >90% efficacy against high-risk cancer-causing strains.42
- The HPV vaccine offers long-term protection. The vaccine has been on the market since 2006, and immunity has not yet diminished. Further monitoring is ongoing.43
- The HPV vaccine is covered under the Vaccines For Children program until age 19 years. Then it is up to individual insurance plans to cover it.
- The HPV vaccine does not cause infertility.44 HPV infection, on the other hand, can lead to fertility problems if, for example, treatment for cervical precancer or cancer requires partial removal of the cervix or a hysterectomy.
- The HPV vaccine does not cause autoimmune diseases.45,46 Studies show no difference between vaccinated and unvaccinated groups in rates of autoimmune diseases such as systemic lupus erythematosus, rheumatoid arthritis, type 1 diabetes mellitus, multiple sclerosis, Hashimoto's thyroiditis, Graves' disease, and others.
- The HPV vaccine does not encourage earlier sexual activity. There was no earlier incidence of outcomes related to sexual activity (pregnancy, sexually transmitted infection testing or diagnosis, or contraceptive counseling) in vaccinated vs unvaccinated patients studied.47
Continue to: A sensitive subject
A sensitive subject. Discussion of a vaccine related to a child’s sexual health makes some parents uncomfortable. Studies show that focusing on the cancer prevention aspects of the vaccine, rather than on sexual transmission of HPV, results in greater vaccine acceptance.35
However, if discussion of sexual transmission is unavoidable, remind parents to consider their own adolescence and whether they chose to share everything with their parents. Point out that there were probably things they did that they later looked back on and thought, “What was I thinking?” Their children, no matter how wonderful and levelheaded they are, will be no different. And, as much as parents don’t want to think about it, some kids will suffer unwanted sexual contact. Shouldn’t parents protect their children as best as they can?
A teen’s right to choose? Some states have passed a Mature Minor Doctrine, which provides for mature, unemancipated teens to make their own medical decisions regarding such issues as sexuality, mental health, and drug and alcohol use without their parents’ consent. In these states, teens may elect to receive the HPV vaccine without parental permission. (Check your state’s laws for specifics, and see the 2 boxes with patient-friendly talking points for influenza vaccine7,36-39 and human papillomavirus vaccine.40-47)
CORRESPONDENCE
Gretchen LaSalle, MD, MultiCare Rockwood Clinic, 2214 East 29th Avenue, Spokane, WA 99203; [email protected].
1. Paterson P, Meurice F, Stanberry LR, et al. Vaccine hesitancy and healthcare providers. Vaccine. 2016;34:6700-6706.
2. Opel DJ, Heritage J, Taylor J, et al. The architecture of provider-parent vaccine discussions at health supervision visits. Pediatrics. 2013;132:1037-1046.
3. Palmer J, Carrico C, Costanzo C. Identifying and overcoming perceived barriers of providers towards vaccination: a literature review. J Vaccines. 2015;1-7.
4. Autism Science Foundation. Making the CASE for vaccines: a new model for talking to patients about vaccines. Available at: http://autismsciencefoundation.org/wp-content/uploads/2015/12/Making-the-CASE-for-Vaccines-Guide_final.pdf. Accessed April 8, 2018.
5. Jacobson RM, Van Etta L, Bahta L. The C.A.S.E approach: guidance for talking to vaccine-hesitant patients. Minn Med. 2013;96:49-50.
6. Henrickson NB, Opel DJ, Grothaus L, et al. Physician communication training and parental vaccine hesitancy: a randomized trial. Pediatrics. 2015;136:70-79.
7. Centers for Disease Control and Prevention. Key facts about seasonal flu vaccine. Available at: https://www.cdc.gov/flu/protect/keyfacts.htm. Accessed April 8, 2018.
8. Wakefield AJ, Murch SH, Anthony A, et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet. 1998;351:637-641.
9. Taylor LE, Swerdfeger AL, Eslick GD. Vaccines are not associated with autism: an evidence-based meta-analysis of case-control and cohort studies. Vaccine. 2014;32:3623-3629.
10. Agency for Toxic Substances & Disease Registry. Minimal risk levels for hazardous substances. Available at: https://www.atsdr.cdc.gov/mrls/mrllist.asp#34tag. Accessed April 8, 2018.
11. US Food and Drug Administration. Thimerosal and vaccines. Available at: https://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/VaccineSafety/UCM096228. Accessed April 8, 2018.
12. Hviid A, Stellfeld M, Wohlfahrt J, et al. Association between thimerosal-containing vaccine and autism. JAMA. 2003;290:1763-1766.
13. Centers for Disease Control and Prevention. Thimerosal in vaccines. Available at: https://www.cdc.gov/vaccinesafety/concerns/thimerosal/index.html. Accessed May 8, 2018.
14. Autism Speaks. Frequently asked questions. Available at: https://www.autismspeaks.org/what-autism/faq. Accessed April 8, 2018.
15. Agency for Toxic Substances & Disease Registry. Toxic substances portal-aluminum. Public Health Statement for Aluminum, CAS #7429-90-5. Available at: https://www.atsdr.cdc.gov/PHS/PHS.asp?id=1076&tid=34. Accessed April 8, 2018.
16. Children’s Hospital of Philadelphia. Vaccine ingredients-aluminum. Available at: www.chop.edu/centers-programs/vaccine-education-center/vaccine-ingredients/aluminum. Accessed April 8, 2018.
17. Orenstein W, Seib K. Mounting a good offense against measles. N Engl J Med. 2014;371:1661-1663.
18. Plans-Rubió P. The vaccination coverage required to establish herd immunity against influenza viruses. Prev Med. 2012;55:72-77.
19. Hall V, Banerjee E, Kenyon C, et al. Measles outbreak – Minnesota April-May 2017. MMWR Morb Mortal Wkly Rep. 2017;66:713-717.
20. The National Academies of Sciences Engineering Medicine. History of U.S. water and wastewater systems. Privatization of Water Services in the United States: an Assessment of Issues and Experience. Washington, DC: The National Academies Press; 2002:29-40. Available at: https://www.nap.edu/read/10135/chapter/4#35. Accessed May 7, 2018.
21. World Health Organization. Global vaccine safety. Six common misconceptions about immunization. Available at: http://www.who.int/vaccine_safety/initiative/detection/immunization_misconceptions/en/index1.html. Accessed May 7, 2018.
22. The history of vaccines. Human cell strains in vaccine development. Available at: https://www.historyofvaccines.org/content/articles/human-cell-strains-vaccine-development. Accessed April 8, 2018.
23. The National Catholic Bioethics Center. Frequently asked questions. Available at: https://www.ncbcenter.org/resources/frequently-asked-questions/use-vaccines/. Accessed April 8, 2018.
24. Shimabukuro TT, Nguyen M, Martin D, et al. Safety monitoring in the vaccine adverse event reporting system (VAERS). Vaccine. 2015;33:4398-4405.
25. Foster S. Rotavirus vaccine and intussusception. J Pediatr Pharmacol Ther. 2007;12:4-7.
26. Mistry RD, Fischer JB, Prasad PA, et al. Severe complications of influenza-like illnesses. Pediatrics. 2014;134:e684-e690.
27. McNeil MM, Weintraub ES, Duffy J, et al. Risk of anaphylaxis after vaccination in children and adults. J Allergy Clin Immunol. 2016;137:868-878.
28. McLaughlin JM, McGinnis JJ, Tan L, et al. Estimated human and economic burden of four major adult vaccine-preventable diseases in the United States, 2013. J Prim Prev. 2015;36:259-273.
29. Centers for Disease Control and Prevention. Vaccines for Children (VFC) Program. Available at: https://www.cdc.gov/features/vfcprogram/index.html. Accessed April 8, 2018.
30. Plotkin S, Gerber JS, Offit PA. Vaccines and autism: a tale of shifting hypotheses. Clin Infect Dis. 2009;48:456-461.
31. Offit PA, Quarles J, Gerber MA, et al. Addressing parents’ concerns: do multiple vaccines overwhelm or weaken the infant’s immune system? Pediatrics. 2002;109:124-129.
32. Offit PA, Moser CA. The problem with Dr. Bob’s alternative vaccine schedule. Pediatrics. 2009;123:e164-e169.
33. Centers for Disease Control and Prevention. Flu vaccination coverage, United States, 2016-17 influenza season. Available at: https://www.cdc.gov/flu/fluvaxview/coverage-1617estimates.htm. April 8. 2018.
34. Walker TY, Elam-Evans LD, Singleton JA, et al. National, regional, state and selected local area vaccination coverage among adolescents aged 13-17 years – United States, 2016. MMWR Morb Mortal Wkly Rep. 2017;66:874-882.
35. Thomas TL. Cancer prevention: HPV vaccination. Semin Oncol Nurs. 2016:32:273-280.
36. Centers for Disease Control and Prevention. Estimating seasonal influenza-associated deaths in the United States. Available at: https://www.cdc.gov/flu/about/disease/US_flu-related_deaths.htm. Accessed May 8, 2018.
37. Wong KK, Jain S, Blanton L, et al. Influenza-associated pediatric deaths in the United States: 2004-2012. Pediatrics. 2013;132:796-804.
38. Centers for Disease Control and Prevention. Seasonal influenza vaccine effectiveness, 2005-2018. Available at: https://www.cdc.gov/flu/professionals/vaccination/effectiveness-studies.htm. Accessed April 8, 2018.
39. Centers for Disease Control and Prevention. Influenza (flu). Flu vaccine and people with egg allergies. Available at: https://www.cdc.gov/flu/protect/vaccine/egg-allergies.htm. Accessed April 8, 2018.
40. Centers for Disease Control and Prevention. For parents: vaccines for your children. HPV vaccine for preteens and teens. Available at: https://www.cdc.gov/vaccines/parents/diseases/teen/hpv.html. Accessed April 8, 2018.
41. Centers for Disease Control and Prevention. Vaccines and preventable diseases. HPV vaccine recommendations. Available at: https://www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html. Accessed May 7, 2018.
42. Cutts FT, Franceschi S, Goldie S, et al. Human papillomavirus and HPV vaccines: a review. Bull World Health Organ. 2007;85:719-726.
43. De Vincenzo R, Conte C, Ricci C, et al. Long-term efficacy and safety of human papillomavirus vaccination. Int J Womens Health. 2014;6:999-1010.
44. McInerney KA, Hatch EE, Wesselink AK. The effect of vaccination against human papillomavirus on fecundability. Paedeatr Perinat Epidemiol. 2017;31:531-536.
45. Chao C, Klein NP, Velicer CM, et al. Surveillance of autoimmune conditions following routine use of quadrivalent human papillomavirus vaccine. J Intern Med. 2012;271:193-203.
46. Vichnin M, Bonanni P, Klein NP, et al. An overview of quadrivalent human papillomavirus vaccine safety: 2006-2015. Ped Infect Dis J. 2015;34:983-991.
47. Bednarczyk RA, Davis R, Ault K, et al. Sexual activity-related outcomes after human papillomavirus vaccination of 11-to-12-year-olds. Pediatrics. 2012;130:798-805.
We all know how challenging and time-consuming it can be to convince vaccine-hesitant patients that vaccinations are what is best for them and their children. Patients are bombarded with misinformation through the news and social media that seeds or “confirms” their doubts about vaccines. And for our part, we have only a few minutes during an office visit to refute all of the false claims that are a mere click or scroll away.
To better prepare for this challenge, this article details a practical approach to discussing vaccines with your patients. Using the patient-friendly language and evidence described here, you will be well positioned to refute 13 common vaccine misconceptions and overcome the barriers that stand in the way of these lifesaving interventions.
A few important baseline concepts
In discussing vaccination with our patients, it is important to keep the following in mind:
Patients don’t refuse vaccinations just to make our lives difficult. They truly are trying to make the best decisions they can for themselves and their families. Recognizing this can significantly reduce frustration levels.
Time well spent. While educating patients about the value of vaccines takes time, the return is worth it. The more consistently we offer vaccines, along with the reasons they are important, the more likely patients are to give vaccines a second thought. In fact, studies show that provider recommendation is the most important factor in patients’ decisions to vaccinate.1
Approach matters. In all other aspects of medicine, we attempt to use a participatory approach, involving our patients in decisions regarding their health care. When discussing vaccines, however, a participatory approach (eg, “What do you want to do about vaccines today?”) can introduce doubt into patients’ minds. Studies show that a presumptive approach (eg, “Today we are going to provide the tetanus, human papillomavirus [HPV], and meningitis vaccines”) is a much more effective way to get patients to vaccinate.2
[polldaddy:10018427]
Continue to: Barriers to counseling
Barriers to counseling. Health care providers report a variety of barriers to effective vaccine counseling (limited time and resources, lack of confidence in addressing patients’ concerns, etc).3 In addition, providers sometimes worry that strong encouragement of vaccination will create an adversarial relationship with vaccine-hesitant patients. Developing a good rapport and trusting relationship, as well as using motivational interviewing approaches, can help communicate the importance of vaccines, while leaving patients with the sense that you have heard them and respect their intentions. (See “Facilitate vaccine discussions using these 2 approaches.” 4-7)
SIDEBAR
Facilitate vaccine discussions using these 2 approaches4-7
C.A.S.E.
Corroborate
Acknowledge concerns and find some point on which you can agree.
Example: "It sounds like we both want to keep your child healthy and safe."
About me
Describe what you have done to build your expertise on the subject.
Example: "I have been practicing medicine for 15 years and have spent a great deal of time researching the data on vaccinations."
Science
Review the data and science behind vaccines.
Example: "Vaccines are more rigorously studied and safer than almost any other intervention we have in medicine."
Explain/advise
Explain your recommendations, based on the science.
Example: "This is why I vaccinate my children, and this is why I recommend this vaccine for your child."
3As
Ask
Don't stop at a patient's first "No." Respectfully dig a bit deeper.
Example: "What questions do you have about the vaccines we are recommending today? Tell me what worries you about them."
Acknowledge
Acknowledge your patient's concerns.
Example: "You are obviously a very devoted parent, and I know that you are trying to make the best decision you can for your child. With everything we see on the news and social media, it's not always easy to know what to believe about vaccines."
Advise
Advise patients/parents of the facts about vaccines and provide a strong recommendation to vaccinate.
Example: "Depending on the year, influenza kills 12,000 to 56,000 people annually; the vast majority of those who die did not receive the flu vaccine.7 My family and I get the flu shot every year, and I strongly encourage you and your children to get this lifesaving vaccine."
Continue to: If at first you don't succeed...
If at first you don’t succeed, try again because patients often have an experience that changes their mind. Perhaps a friend died of throat cancer or a family member developed a complication of the flu that required hospitalization. You never know when something will influence patients’ choices.
Don’t wait for scheduled well visits. Use every patient encounter as a means to catch patients up on missing vaccinations.
Common misconceptions and concerns and how to counter them
1. I’ve heard that vaccines can actually make you sick.
When patients raise this concern, start with an explanation of how vaccines work. Explain that our bodies protect us from foreign invaders (such as viruses and bacteria) by mounting an immune response when we are exposed to these proteins. Vaccinations work by exploiting this immune response; they expose the body to killed or weakened viral or bacterial proteins in a safe and controlled manner. In this way, our immune system will have already developed antibodies to these invaders by the time we are exposed to an active infection.
To use an analogy to war, instead of being subjected to a surprise attack where we suffer large losses in the battle, vaccination prepares us with weapons (antibodies) to defend ourselves so that our bodies are now able to successfully fight off that attack.
Because the majority of vaccines are killed virus vaccines, they cannot cause the illness against which they are meant to protect. Triggering the immune system may make some recipients feel a little “under the weather” for a day or 2, but they do not make us “sick.”
Live attenuated vaccines are similarly safe for those with a healthy immune system. We don’t administer them, however, to people who have a weakened immune system (eg, pregnant women, newborns, people with acquired immunodeficiency virus, or patients receiving chemotherapy or other types of immunosuppression) because these patients could develop the illness that we are trying to protect against.
Continue to: 2. Don't vaccines cause autism? Aren't they toxic to the nervous system?
2. Don’t vaccines cause autism? Aren’t they toxic to the nervous system?
The largest setback to vaccination efforts in recent history was a 1998 study by Andrew Wakefield that suggested that vaccination (specifically the mercury [in the form of thimerosal] present in the measles, mumps, rubella [MMR] vaccine) was linked to the development of autism.8 This research was subsequently debunked,9 and the author of the 1998 study was stripped of his medical license for falsifying data. However, the damage to vaccination efforts had already been done.
Aluminum. Thimerosal is not the only agent that patients may find concerning. Some also worry about the aluminum content of vaccines. Aluminum works as an additive to boost the body’s immune response to a vaccine. It is used only in killed virus vaccines—not in live attenuated ones. The Agency for Toxic Substances and Disease Registry monitors minimum risk levels (MRLs) of aluminum and other compounds in potentially hazardous substances. The amount of aluminum in vaccines is far below the MRL for aluminum, which is 1 mg/kg/d.10 (See “The facts about thimerosal and aluminum in vaccines.”11-16)
SIDEBAR
The facts about thimerosal and aluminum in vaccines
Thimerosal
Ethyl-mercury was used (in the form of thimerosal) as a preservative to prevent bacterial and fungal contamination of vaccines. Since 2001, however, thimerosal has been removed from all US-licensed vaccines—except multidose vials of influenza vaccine—as a precautionary measure (and not for any reproducible evidence of harm). The multidose flu vial contains <0.01% thimerosal.11
Ethyl-mercury is cleared from the body much more rapidly than methyl-mercury (the kind found in certain types of fish) and is less toxic.12
Since the removal of thimerosal from vaccines, the Centers for Disease Control and Prevention notes that the rates of autism have actually increased.13
Even Autism Speaks, the leading organization dedicated to advocacy for patients with autism and their families, denies a link between vaccines and autism.14
Aluminum
We are exposed to aluminum in products we use extensively every day, such as pots and pans, aluminum foil, seasonings, cereal, baby formula, paints, fuels, and antiperspirants.15
Infants are exposed to about 4.4 mg of aluminum in the vaccines typically administered in the first 6 months of life.16 However, infants typically ingest more than that during the first 6 months of life. Breast milk contains about 7 mg over 6 months; milk-based formulas contain about 38 mg over 6 months; and soy-based formulas contain about 117 mg over 6 months.16
Contine to: 3. I'm healthy. I never get sick. Why do I need vaccinations?
3. I’m healthy. I never get sick. Why do I need vaccinations?
A good way to counter this comment is to respond: “Saying you don’t need vaccinations because you never get sick is like saying you don’t need to wear a seat belt because you’ve never been in a car accident.” Advise patients that we seek to vaccinate all members of a community—not just those who are sick or at high risk—to protect ourselves and to provide “herd immunity.” It’s important to explain that herd immunity is resistance to the spread of a contagious disease that results if a sufficiently high number of people (depending on the illness, typically 80%-95%) are immune to the disease, especially through vaccination.17,18 If vaccination levels fall, we see a rise in cases of vaccine-preventable illness (as was seen during the 2017 measles outbreak in a community in Minnesota).19
Even though many of us may not suffer severe consequences of an infection, we can still pass that infection to others. While the whooping cough that a healthy 35-year-old gets may cause only prolonged annoyance or time off from work, it can kill the baby that is sitting next to that adult on the plane or bus.
4. Isn’t it true that we see fewer serious illnesses because of improved hygiene and sanitation, rather than vaccines?
Our current US sanitation standards were established under the Safe Drinking Water Act of 1974.20 While improvements in hygiene, sanitation, nutrition, and other public health measures have undoubtedly decreased the spread of disease and improved survival rates, there is no denying the significant drop in disease that occurs after the introduction of a vaccine for a particular illness or the increase in cases of that disease when vaccination rates drop off.
By the early 1990s, our current sanitation standards were already well established. Yet we didn’t see a significant decrease in the incidence of infections with Haemophilus influenzae type b (Hib) until after the conjugate Hib vaccines were introduced (dropping from about 20,000 cases/year to 1419 cases/year by 1993).21
In Britain, a drop in the rate of pertussis (whooping cough) vaccination in 1974 resulted in an epidemic of more than 100,000 cases and 36 deaths by 1978. There was no decrease in hygiene or sanitation standards to explain this rise.21
Continue to: 5. Vaccines are just another way for "big pharma" to make "big money."
5. Vaccines are just another way for “big pharma” to make “big money.”
Patients may benefit from knowing that in the earlier days of vaccines, pharmaceutical companies actually moved away from production of vaccines because they were not very profitable. These days, with worldwide distribution, drug companies are back in the swing of making vaccines and, as we would expect from all companies, are in business to make a profit.
That said, health care providers receive no payments from drug companies for offering vaccines or for offering one vaccine over another. The reason we recommend vaccination is because we know it is best for our patients’ health and the health of the community.
6. We don’t see polio anymore. Why do I need the vaccine?
One of the factors contributing to the rise in antivaccine sentiment is that we rarely see vaccine-preventable illnesses (such as polio, measles, and mumps). But the absence of these illnesses is precisely due to prior years’ vaccination efforts.
Smallpox, a deadly and disfiguring disease that killed many millions of people and contributed to the downfall of the Roman, Aztec, and Incan empires, was eradicated from the planet in 1979, thanks to focused vaccination efforts by the World Health Organization. Vaccination works, but we have to keep at it.
While we no longer see as many of these vaccine-preventable illnesses in the United States, they are still present in other parts of the world. Our world is much smaller than it used to be. International travel is common, and illnesses can be reintroduced into a community with relative ease. We must remain vigilant.
Continue to: 7. I heard that vaccines are made from aborted fetal tissue.
7. I heard that vaccines are made from aborted fetal tissue.
There are 5 vaccines (varicella, rubella, hepatitis A, shingles, and rabies vaccines) that were originally made using aborted fetal tissue. In 1960, tissue from 2 fetuses aborted by maternal choice (and not for the purpose of vaccine production) was used to propagate cell lines that are still used in vaccine development today.
Human cells provide advantages for vaccine production that other cells do not. Some viruses do not grow well in animal cells. Animal cells can introduce contamination by bacteria and viruses that are not carried in human cell lines. Vaccine production can be hindered or halted, resulting in a vaccine shortage, if animal products used in development are threatened (eg, if an illness strikes egg-producing chickens; eggs are used to make the influenza vaccine).22
Some patients, particularly those who are Catholic, may have concerns about these vaccines. The National Catholic Bioethics Center has prepared a statement regarding the use of these vaccines that may help settle any moral dilemmas.23 It reads:
“The cell lines under consideration were begun using cells taken from one or more fetuses aborted almost 40 years ago. Since that time, the cell lines have grown independently. It is important to note that descendent cells are not the cells of the aborted child.”
“One is morally free to use the vaccine regardless of its historical association with abortion. The reason is that the risk to public health, if one chooses not to vaccinate, outweighs the legitimate concern about the origins of the vaccine. This is especially important for parents, who have a moral obligation to protect the life and health of their children and those around them.”
Continue to: 8. Vaccines aren't studied—or monitored—thoroughly enough.
8. Vaccines aren’t studied—or monitored— thoroughly enough.
Patients would benefit from knowing that vaccines are some of the most thoroughly studied products brought to market. They undergo rigorous testing and oversight, from both public and private organizations, for 10 to 15 years before being released for distribution. Post-licensure monitoring is ongoing, and the manufacturer may voluntarily participate in Phase IV trials to continue to test the safety and efficacy of a vaccine after release to market.
Monitoring adverse effects. In addition, in 1990, the Centers for Disease Control and Prevention (CDC) and the US Food and Drug Administration established the Vaccine Adverse Events Reporting System (VAERS) to “detect possible signals of adverse events associated with vaccines.”24 Most events reported are coincidental, but some common mild adverse events (like redness and swelling at the injection site) are often underreported.
Serious events are always thoroughly investigated and are often found unrelated. However, rare associations have been found. For example, an intestinal problem called intussusception, related to the original rotavirus vaccine, was discovered, and the vaccine causing it was removed from the market.25 A new, safer rotavirus vaccine option is now available. Patients need to know that we do have an effective system of checks and balances in which we can place our trust.
9. People can become paralyzed or stop breathing after receiving a vaccination. Why run those risks?
One of the most feared reactions to vaccination is Guillain-Barré syndrome (GBS), which can cause paralysis. The CDC estimates the risk for GBS associated with the flu vaccine, for example, to be 1 to 2 cases per 1 million people vaccinated.26 Another potential concern is the rate of anaphylaxis following vaccination. However, in a 2016 study in the Journal of Allergy and Clinical Immunology, the rate of anaphylaxis for all vaccines combined was only 1.31 per 1 million vaccines.27
The risk of developing severe complications from an illness is much greater than that of developing complications from the vaccine meant to protect a person against that illness. In the United States, the population-based risk for influenza-related hospitalization in children, for example, is as high as 150 in 100,000 with as many as 125 deaths annually.26
Continue to: 10. Isn't vaccination a personal choice? How does my health/illness impact the community?
10. Isn’t vaccination a personal choice? How does my health/illness impact the community?
Patients may not realize that most viruses are contagious from 1 to 2 days before symptoms appear, which means we can spread an illness before we even know we have it. Protecting oneself also protects those around us.
Economic concerns. There’s also the economic impact of these illnesses to consider. This includes the personal cost of being out of school or work for an extended period and the cost of a patient’s care, which can become astronomical if hospitalization is required and which can become the country’s problem if a person lacks sufficient health insurance coverage.
A study looking at the cost of 4 major adult vaccine-preventable illnesses (influenza, pneumococcal disease, shingles, and whooping cough) in the United States in 2013 estimated the annual cost for these illnesses in adults ≥50 years to be $26.5 billion.28 And that doesn’t include the cost of childhood vaccine-preventable diseases.
Countering 3 concerns about childhood vaccinations
1. I can’t afford vaccines for my child.
The Vaccines for Children program is a federally-funded program that covers the cost of all vaccines for children younger than 19 years of age who are Medicaid-eligible, American Indian, Alaskan Native, uninsured, or underinsured.29 Although there may be a small administration fee charged by the provider’s office, the vaccine is free.
2. Don’t all of the vaccines recommended for children overwhelm their immune systems?
Children are exposed to so many more proteins on a daily basis (by crawling around on the floor, putting their hands in their mouths, attending school or day care, etc) than they are ever exposed to in a series of vaccines.30 Exposure to these proteins in their environment and to those in vaccines only serves to boost their immunity and keep them healthier in the long run.
And thanks to advances in vaccine production, the immunologic load in vaccines is far less than it used to be. The 14 vaccines given today contain <200 bacterial and viral proteins or polysaccharides, compared with the >3000 of these immunologic components in the 7 vaccines administered in 1980.31
Continue to: Influenza vaccine: Patient-friendly talking points
SIDEBAR
Influenza vaccine: Patient-friendly talking points
- Some people think that getting the flu is no big deal. While it is true that the flu takes a greater toll on the very young and very old, the chronically ill, and the immune compromised, even healthy people can become seriously ill or die. The Centers for Disease Control and Prevention estimates that the flu is responsible for 140,000 to 720,000 hospitalizations and 12,000 to 56,000 deaths in the United States every year.7 Of those who die from the flu, approximately 80% did not receive a flu shot.36 Of children who died from the flu between 2004 and 2012, more than 40% had no risk factors for complications.37
- The flu shot is a killed virus vaccine, so it can't give you the flu. People sometimes feel under the weather (achy, low-grade fever) after a vaccine, but this is considered normal and evidence that your body's immune system is "revving up."
- It takes 2 weeks before the vaccine becomes effective so a person can still get the flu during that time. This is why it is so important to get the vaccine earlier in the fall, before the flu season takes hold.
- The "stomach flu" is not the flu. The flu vaccine does not protect against the "stomach flu" or other flu-like illnesses.
- The flu vaccine is not perfect. It is an educated guess as to which strains will be circulating that year. (At its best, the flu vaccine is about 60% effective.38) However, it makes the chance of getting the flu less likely and significantly decreases the odds of severe complications/death.
- Egg allergies are no longer a reason to avoid the flu vaccine. There is an egg-free vaccine called Flublok (for those ≥18 years of age). In 2016-17, the Advisory Committee on Immunization Practices changed the recommendations for flu vaccine in egg-allergic people. The recommendations say that if reactions are mild, or you can eat cooked eggs without a problem, you can receive a flu vaccine. If you have severe reactions, such as trouble breathing or recurrent vomiting, you can still receive the flu vaccine, but must be monitored by a health care provider who can recognize and respond to a severe allergic reaction.39
Continue to: 3. Why don't we adhere to Dr. Sears' vaccine schedule?
3. Why don’t we adhere to Dr. Sears’ vaccine schedule?
There are multiple ways in which Dr. Robert Sears’ book, The Vaccine Book: Making the Right Decision for your Child, published in 2007, misrepresents vaccine science and leads patients astray in making decisions regarding vaccinations.32 Most important to note is that Dr. Sears’ Alternative Vaccine Schedule, which seeks to make it so that children do not receive more than 2 vaccinations per office visit, would require visits to a health care provider at 2, 3, 4, 5, 6, 7, 9, 12, 15, 18, and 21 months, and at 2, 2.5, 3, 3.5, 4, 5, and 6 years of age. This significantly increases the number of office visits and needle sticks, and raises the age at which vaccines are given, increasing the risk of illness outbreaks and decreasing the likelihood that parents would return to the office to complete the full series.
Acceptance of influenza and HPV vaccines remains a challenge
We are significantly less successful at getting parents and patients to agree to influenza and HPV vaccines than to the other vaccines we offer. The influenza vaccine success rate in 2016 was 59% in children and 43.3% in adults.33 Compared to the Tdap vaccine (88%) and the meningococcal vaccine (82%), which are offered at the same age as the HPV vaccine, success rates for HPV vaccine are significantly lower. In 2016, only 60.4% of boys and girls were current on their first HPV injection and only 43.3% were up to date with the full series.34
Newness of vaccines a factor?
Perhaps it is because the recommendations for these 2 vaccines are relatively new, and people don’t yet grasp the seriousness and scope of the diseases. Until 2010, the flu shot was recommended only for the very young, the elderly, and the medically high risk.
Similarly, the HPV vaccine was originally introduced for girls in 2006 and wasn’t recommended for boys until 2011.
Continue to: Human papillomavirus vaccine: Patient-friendly talking points
SIDEBAR
Human papillomavirus vaccine: Patient-friendly talking points
- Human papillomavirus (HPV) causes genital warts and cancer of the cervix, vagina, vulva, anus, rectum, penis, and oropharynx.
- The HPV vaccine is a cancer prevention vaccine. The 9-valent vaccine is active against 2 genital wart-causing strains and 7 cancer-causing strains of HPV.
- HPV is highly prevalent; 79 million Americans are currently infected, nearly 14 million people become newly infected each year, and nearly all of us will be exposed at some point in our sexual lives.40
- There are often no outward signs of infection, so it is a difficult infection to avoid.
- It takes no high-risk sexual activity to be exposed to the HPV virus.
- The HPV vaccine is recommended for both boys and girls usually around age 11 to 12 years (but as early as 9 years and as late as 26 years is acceptable). If the first vaccine is administered before 15 years of age, only 2 injections are needed 6 to 12 months apart. If the first vaccine is administered after 15 years of age, 3 injections are needed at 0, 2 months, and 6 months.41
- Completing the series before sexual activity begins is the best way to protect our children because the vaccine is a preventive measure, not a treatment.
- The HPV vaccine is highly effective with >90% efficacy against high-risk cancer-causing strains.42
- The HPV vaccine offers long-term protection. The vaccine has been on the market since 2006, and immunity has not yet diminished. Further monitoring is ongoing.43
- The HPV vaccine is covered under the Vaccines For Children program until age 19 years. Then it is up to individual insurance plans to cover it.
- The HPV vaccine does not cause infertility.44 HPV infection, on the other hand, can lead to fertility problems if, for example, treatment for cervical precancer or cancer requires partial removal of the cervix or a hysterectomy.
- The HPV vaccine does not cause autoimmune diseases.45,46 Studies show no difference between vaccinated and unvaccinated groups in rates of autoimmune diseases such as systemic lupus erythematosus, rheumatoid arthritis, type 1 diabetes mellitus, multiple sclerosis, Hashimoto's thyroiditis, Graves' disease, and others.
- The HPV vaccine does not encourage earlier sexual activity. There was no earlier incidence of outcomes related to sexual activity (pregnancy, sexually transmitted infection testing or diagnosis, or contraceptive counseling) in vaccinated vs unvaccinated patients studied.47
Continue to: A sensitive subject
A sensitive subject. Discussion of a vaccine related to a child’s sexual health makes some parents uncomfortable. Studies show that focusing on the cancer prevention aspects of the vaccine, rather than on sexual transmission of HPV, results in greater vaccine acceptance.35
However, if discussion of sexual transmission is unavoidable, remind parents to consider their own adolescence and whether they chose to share everything with their parents. Point out that there were probably things they did that they later looked back on and thought, “What was I thinking?” Their children, no matter how wonderful and levelheaded they are, will be no different. And, as much as parents don’t want to think about it, some kids will suffer unwanted sexual contact. Shouldn’t parents protect their children as best as they can?
A teen’s right to choose? Some states have passed a Mature Minor Doctrine, which provides for mature, unemancipated teens to make their own medical decisions regarding such issues as sexuality, mental health, and drug and alcohol use without their parents’ consent. In these states, teens may elect to receive the HPV vaccine without parental permission. (Check your state’s laws for specifics, and see the 2 boxes with patient-friendly talking points for influenza vaccine7,36-39 and human papillomavirus vaccine.40-47)
CORRESPONDENCE
Gretchen LaSalle, MD, MultiCare Rockwood Clinic, 2214 East 29th Avenue, Spokane, WA 99203; [email protected].
We all know how challenging and time-consuming it can be to convince vaccine-hesitant patients that vaccinations are what is best for them and their children. Patients are bombarded with misinformation through the news and social media that seeds or “confirms” their doubts about vaccines. And for our part, we have only a few minutes during an office visit to refute all of the false claims that are a mere click or scroll away.
To better prepare for this challenge, this article details a practical approach to discussing vaccines with your patients. Using the patient-friendly language and evidence described here, you will be well positioned to refute 13 common vaccine misconceptions and overcome the barriers that stand in the way of these lifesaving interventions.
A few important baseline concepts
In discussing vaccination with our patients, it is important to keep the following in mind:
Patients don’t refuse vaccinations just to make our lives difficult. They truly are trying to make the best decisions they can for themselves and their families. Recognizing this can significantly reduce frustration levels.
Time well spent. While educating patients about the value of vaccines takes time, the return is worth it. The more consistently we offer vaccines, along with the reasons they are important, the more likely patients are to give vaccines a second thought. In fact, studies show that provider recommendation is the most important factor in patients’ decisions to vaccinate.1
Approach matters. In all other aspects of medicine, we attempt to use a participatory approach, involving our patients in decisions regarding their health care. When discussing vaccines, however, a participatory approach (eg, “What do you want to do about vaccines today?”) can introduce doubt into patients’ minds. Studies show that a presumptive approach (eg, “Today we are going to provide the tetanus, human papillomavirus [HPV], and meningitis vaccines”) is a much more effective way to get patients to vaccinate.2
[polldaddy:10018427]
Continue to: Barriers to counseling
Barriers to counseling. Health care providers report a variety of barriers to effective vaccine counseling (limited time and resources, lack of confidence in addressing patients’ concerns, etc).3 In addition, providers sometimes worry that strong encouragement of vaccination will create an adversarial relationship with vaccine-hesitant patients. Developing a good rapport and trusting relationship, as well as using motivational interviewing approaches, can help communicate the importance of vaccines, while leaving patients with the sense that you have heard them and respect their intentions. (See “Facilitate vaccine discussions using these 2 approaches.” 4-7)
SIDEBAR
Facilitate vaccine discussions using these 2 approaches4-7
C.A.S.E.
Corroborate
Acknowledge concerns and find some point on which you can agree.
Example: "It sounds like we both want to keep your child healthy and safe."
About me
Describe what you have done to build your expertise on the subject.
Example: "I have been practicing medicine for 15 years and have spent a great deal of time researching the data on vaccinations."
Science
Review the data and science behind vaccines.
Example: "Vaccines are more rigorously studied and safer than almost any other intervention we have in medicine."
Explain/advise
Explain your recommendations, based on the science.
Example: "This is why I vaccinate my children, and this is why I recommend this vaccine for your child."
3As
Ask
Don't stop at a patient's first "No." Respectfully dig a bit deeper.
Example: "What questions do you have about the vaccines we are recommending today? Tell me what worries you about them."
Acknowledge
Acknowledge your patient's concerns.
Example: "You are obviously a very devoted parent, and I know that you are trying to make the best decision you can for your child. With everything we see on the news and social media, it's not always easy to know what to believe about vaccines."
Advise
Advise patients/parents of the facts about vaccines and provide a strong recommendation to vaccinate.
Example: "Depending on the year, influenza kills 12,000 to 56,000 people annually; the vast majority of those who die did not receive the flu vaccine.7 My family and I get the flu shot every year, and I strongly encourage you and your children to get this lifesaving vaccine."
Continue to: If at first you don't succeed...
If at first you don’t succeed, try again because patients often have an experience that changes their mind. Perhaps a friend died of throat cancer or a family member developed a complication of the flu that required hospitalization. You never know when something will influence patients’ choices.
Don’t wait for scheduled well visits. Use every patient encounter as a means to catch patients up on missing vaccinations.
Common misconceptions and concerns and how to counter them
1. I’ve heard that vaccines can actually make you sick.
When patients raise this concern, start with an explanation of how vaccines work. Explain that our bodies protect us from foreign invaders (such as viruses and bacteria) by mounting an immune response when we are exposed to these proteins. Vaccinations work by exploiting this immune response; they expose the body to killed or weakened viral or bacterial proteins in a safe and controlled manner. In this way, our immune system will have already developed antibodies to these invaders by the time we are exposed to an active infection.
To use an analogy to war, instead of being subjected to a surprise attack where we suffer large losses in the battle, vaccination prepares us with weapons (antibodies) to defend ourselves so that our bodies are now able to successfully fight off that attack.
Because the majority of vaccines are killed virus vaccines, they cannot cause the illness against which they are meant to protect. Triggering the immune system may make some recipients feel a little “under the weather” for a day or 2, but they do not make us “sick.”
Live attenuated vaccines are similarly safe for those with a healthy immune system. We don’t administer them, however, to people who have a weakened immune system (eg, pregnant women, newborns, people with acquired immunodeficiency virus, or patients receiving chemotherapy or other types of immunosuppression) because these patients could develop the illness that we are trying to protect against.
Continue to: 2. Don't vaccines cause autism? Aren't they toxic to the nervous system?
2. Don’t vaccines cause autism? Aren’t they toxic to the nervous system?
The largest setback to vaccination efforts in recent history was a 1998 study by Andrew Wakefield that suggested that vaccination (specifically the mercury [in the form of thimerosal] present in the measles, mumps, rubella [MMR] vaccine) was linked to the development of autism.8 This research was subsequently debunked,9 and the author of the 1998 study was stripped of his medical license for falsifying data. However, the damage to vaccination efforts had already been done.
Aluminum. Thimerosal is not the only agent that patients may find concerning. Some also worry about the aluminum content of vaccines. Aluminum works as an additive to boost the body’s immune response to a vaccine. It is used only in killed virus vaccines—not in live attenuated ones. The Agency for Toxic Substances and Disease Registry monitors minimum risk levels (MRLs) of aluminum and other compounds in potentially hazardous substances. The amount of aluminum in vaccines is far below the MRL for aluminum, which is 1 mg/kg/d.10 (See “The facts about thimerosal and aluminum in vaccines.”11-16)
SIDEBAR
The facts about thimerosal and aluminum in vaccines
Thimerosal
Ethyl-mercury was used (in the form of thimerosal) as a preservative to prevent bacterial and fungal contamination of vaccines. Since 2001, however, thimerosal has been removed from all US-licensed vaccines—except multidose vials of influenza vaccine—as a precautionary measure (and not for any reproducible evidence of harm). The multidose flu vial contains <0.01% thimerosal.11
Ethyl-mercury is cleared from the body much more rapidly than methyl-mercury (the kind found in certain types of fish) and is less toxic.12
Since the removal of thimerosal from vaccines, the Centers for Disease Control and Prevention notes that the rates of autism have actually increased.13
Even Autism Speaks, the leading organization dedicated to advocacy for patients with autism and their families, denies a link between vaccines and autism.14
Aluminum
We are exposed to aluminum in products we use extensively every day, such as pots and pans, aluminum foil, seasonings, cereal, baby formula, paints, fuels, and antiperspirants.15
Infants are exposed to about 4.4 mg of aluminum in the vaccines typically administered in the first 6 months of life.16 However, infants typically ingest more than that during the first 6 months of life. Breast milk contains about 7 mg over 6 months; milk-based formulas contain about 38 mg over 6 months; and soy-based formulas contain about 117 mg over 6 months.16
Contine to: 3. I'm healthy. I never get sick. Why do I need vaccinations?
3. I’m healthy. I never get sick. Why do I need vaccinations?
A good way to counter this comment is to respond: “Saying you don’t need vaccinations because you never get sick is like saying you don’t need to wear a seat belt because you’ve never been in a car accident.” Advise patients that we seek to vaccinate all members of a community—not just those who are sick or at high risk—to protect ourselves and to provide “herd immunity.” It’s important to explain that herd immunity is resistance to the spread of a contagious disease that results if a sufficiently high number of people (depending on the illness, typically 80%-95%) are immune to the disease, especially through vaccination.17,18 If vaccination levels fall, we see a rise in cases of vaccine-preventable illness (as was seen during the 2017 measles outbreak in a community in Minnesota).19
Even though many of us may not suffer severe consequences of an infection, we can still pass that infection to others. While the whooping cough that a healthy 35-year-old gets may cause only prolonged annoyance or time off from work, it can kill the baby that is sitting next to that adult on the plane or bus.
4. Isn’t it true that we see fewer serious illnesses because of improved hygiene and sanitation, rather than vaccines?
Our current US sanitation standards were established under the Safe Drinking Water Act of 1974.20 While improvements in hygiene, sanitation, nutrition, and other public health measures have undoubtedly decreased the spread of disease and improved survival rates, there is no denying the significant drop in disease that occurs after the introduction of a vaccine for a particular illness or the increase in cases of that disease when vaccination rates drop off.
By the early 1990s, our current sanitation standards were already well established. Yet we didn’t see a significant decrease in the incidence of infections with Haemophilus influenzae type b (Hib) until after the conjugate Hib vaccines were introduced (dropping from about 20,000 cases/year to 1419 cases/year by 1993).21
In Britain, a drop in the rate of pertussis (whooping cough) vaccination in 1974 resulted in an epidemic of more than 100,000 cases and 36 deaths by 1978. There was no decrease in hygiene or sanitation standards to explain this rise.21
Continue to: 5. Vaccines are just another way for "big pharma" to make "big money."
5. Vaccines are just another way for “big pharma” to make “big money.”
Patients may benefit from knowing that in the earlier days of vaccines, pharmaceutical companies actually moved away from production of vaccines because they were not very profitable. These days, with worldwide distribution, drug companies are back in the swing of making vaccines and, as we would expect from all companies, are in business to make a profit.
That said, health care providers receive no payments from drug companies for offering vaccines or for offering one vaccine over another. The reason we recommend vaccination is because we know it is best for our patients’ health and the health of the community.
6. We don’t see polio anymore. Why do I need the vaccine?
One of the factors contributing to the rise in antivaccine sentiment is that we rarely see vaccine-preventable illnesses (such as polio, measles, and mumps). But the absence of these illnesses is precisely due to prior years’ vaccination efforts.
Smallpox, a deadly and disfiguring disease that killed many millions of people and contributed to the downfall of the Roman, Aztec, and Incan empires, was eradicated from the planet in 1979, thanks to focused vaccination efforts by the World Health Organization. Vaccination works, but we have to keep at it.
While we no longer see as many of these vaccine-preventable illnesses in the United States, they are still present in other parts of the world. Our world is much smaller than it used to be. International travel is common, and illnesses can be reintroduced into a community with relative ease. We must remain vigilant.
Continue to: 7. I heard that vaccines are made from aborted fetal tissue.
7. I heard that vaccines are made from aborted fetal tissue.
There are 5 vaccines (varicella, rubella, hepatitis A, shingles, and rabies vaccines) that were originally made using aborted fetal tissue. In 1960, tissue from 2 fetuses aborted by maternal choice (and not for the purpose of vaccine production) was used to propagate cell lines that are still used in vaccine development today.
Human cells provide advantages for vaccine production that other cells do not. Some viruses do not grow well in animal cells. Animal cells can introduce contamination by bacteria and viruses that are not carried in human cell lines. Vaccine production can be hindered or halted, resulting in a vaccine shortage, if animal products used in development are threatened (eg, if an illness strikes egg-producing chickens; eggs are used to make the influenza vaccine).22
Some patients, particularly those who are Catholic, may have concerns about these vaccines. The National Catholic Bioethics Center has prepared a statement regarding the use of these vaccines that may help settle any moral dilemmas.23 It reads:
“The cell lines under consideration were begun using cells taken from one or more fetuses aborted almost 40 years ago. Since that time, the cell lines have grown independently. It is important to note that descendent cells are not the cells of the aborted child.”
“One is morally free to use the vaccine regardless of its historical association with abortion. The reason is that the risk to public health, if one chooses not to vaccinate, outweighs the legitimate concern about the origins of the vaccine. This is especially important for parents, who have a moral obligation to protect the life and health of their children and those around them.”
Continue to: 8. Vaccines aren't studied—or monitored—thoroughly enough.
8. Vaccines aren’t studied—or monitored— thoroughly enough.
Patients would benefit from knowing that vaccines are some of the most thoroughly studied products brought to market. They undergo rigorous testing and oversight, from both public and private organizations, for 10 to 15 years before being released for distribution. Post-licensure monitoring is ongoing, and the manufacturer may voluntarily participate in Phase IV trials to continue to test the safety and efficacy of a vaccine after release to market.
Monitoring adverse effects. In addition, in 1990, the Centers for Disease Control and Prevention (CDC) and the US Food and Drug Administration established the Vaccine Adverse Events Reporting System (VAERS) to “detect possible signals of adverse events associated with vaccines.”24 Most events reported are coincidental, but some common mild adverse events (like redness and swelling at the injection site) are often underreported.
Serious events are always thoroughly investigated and are often found unrelated. However, rare associations have been found. For example, an intestinal problem called intussusception, related to the original rotavirus vaccine, was discovered, and the vaccine causing it was removed from the market.25 A new, safer rotavirus vaccine option is now available. Patients need to know that we do have an effective system of checks and balances in which we can place our trust.
9. People can become paralyzed or stop breathing after receiving a vaccination. Why run those risks?
One of the most feared reactions to vaccination is Guillain-Barré syndrome (GBS), which can cause paralysis. The CDC estimates the risk for GBS associated with the flu vaccine, for example, to be 1 to 2 cases per 1 million people vaccinated.26 Another potential concern is the rate of anaphylaxis following vaccination. However, in a 2016 study in the Journal of Allergy and Clinical Immunology, the rate of anaphylaxis for all vaccines combined was only 1.31 per 1 million vaccines.27
The risk of developing severe complications from an illness is much greater than that of developing complications from the vaccine meant to protect a person against that illness. In the United States, the population-based risk for influenza-related hospitalization in children, for example, is as high as 150 in 100,000 with as many as 125 deaths annually.26
Continue to: 10. Isn't vaccination a personal choice? How does my health/illness impact the community?
10. Isn’t vaccination a personal choice? How does my health/illness impact the community?
Patients may not realize that most viruses are contagious from 1 to 2 days before symptoms appear, which means we can spread an illness before we even know we have it. Protecting oneself also protects those around us.
Economic concerns. There’s also the economic impact of these illnesses to consider. This includes the personal cost of being out of school or work for an extended period and the cost of a patient’s care, which can become astronomical if hospitalization is required and which can become the country’s problem if a person lacks sufficient health insurance coverage.
A study looking at the cost of 4 major adult vaccine-preventable illnesses (influenza, pneumococcal disease, shingles, and whooping cough) in the United States in 2013 estimated the annual cost for these illnesses in adults ≥50 years to be $26.5 billion.28 And that doesn’t include the cost of childhood vaccine-preventable diseases.
Countering 3 concerns about childhood vaccinations
1. I can’t afford vaccines for my child.
The Vaccines for Children program is a federally-funded program that covers the cost of all vaccines for children younger than 19 years of age who are Medicaid-eligible, American Indian, Alaskan Native, uninsured, or underinsured.29 Although there may be a small administration fee charged by the provider’s office, the vaccine is free.
2. Don’t all of the vaccines recommended for children overwhelm their immune systems?
Children are exposed to so many more proteins on a daily basis (by crawling around on the floor, putting their hands in their mouths, attending school or day care, etc) than they are ever exposed to in a series of vaccines.30 Exposure to these proteins in their environment and to those in vaccines only serves to boost their immunity and keep them healthier in the long run.
And thanks to advances in vaccine production, the immunologic load in vaccines is far less than it used to be. The 14 vaccines given today contain <200 bacterial and viral proteins or polysaccharides, compared with the >3000 of these immunologic components in the 7 vaccines administered in 1980.31
Continue to: Influenza vaccine: Patient-friendly talking points
SIDEBAR
Influenza vaccine: Patient-friendly talking points
- Some people think that getting the flu is no big deal. While it is true that the flu takes a greater toll on the very young and very old, the chronically ill, and the immune compromised, even healthy people can become seriously ill or die. The Centers for Disease Control and Prevention estimates that the flu is responsible for 140,000 to 720,000 hospitalizations and 12,000 to 56,000 deaths in the United States every year.7 Of those who die from the flu, approximately 80% did not receive a flu shot.36 Of children who died from the flu between 2004 and 2012, more than 40% had no risk factors for complications.37
- The flu shot is a killed virus vaccine, so it can't give you the flu. People sometimes feel under the weather (achy, low-grade fever) after a vaccine, but this is considered normal and evidence that your body's immune system is "revving up."
- It takes 2 weeks before the vaccine becomes effective so a person can still get the flu during that time. This is why it is so important to get the vaccine earlier in the fall, before the flu season takes hold.
- The "stomach flu" is not the flu. The flu vaccine does not protect against the "stomach flu" or other flu-like illnesses.
- The flu vaccine is not perfect. It is an educated guess as to which strains will be circulating that year. (At its best, the flu vaccine is about 60% effective.38) However, it makes the chance of getting the flu less likely and significantly decreases the odds of severe complications/death.
- Egg allergies are no longer a reason to avoid the flu vaccine. There is an egg-free vaccine called Flublok (for those ≥18 years of age). In 2016-17, the Advisory Committee on Immunization Practices changed the recommendations for flu vaccine in egg-allergic people. The recommendations say that if reactions are mild, or you can eat cooked eggs without a problem, you can receive a flu vaccine. If you have severe reactions, such as trouble breathing or recurrent vomiting, you can still receive the flu vaccine, but must be monitored by a health care provider who can recognize and respond to a severe allergic reaction.39
Continue to: 3. Why don't we adhere to Dr. Sears' vaccine schedule?
3. Why don’t we adhere to Dr. Sears’ vaccine schedule?
There are multiple ways in which Dr. Robert Sears’ book, The Vaccine Book: Making the Right Decision for your Child, published in 2007, misrepresents vaccine science and leads patients astray in making decisions regarding vaccinations.32 Most important to note is that Dr. Sears’ Alternative Vaccine Schedule, which seeks to make it so that children do not receive more than 2 vaccinations per office visit, would require visits to a health care provider at 2, 3, 4, 5, 6, 7, 9, 12, 15, 18, and 21 months, and at 2, 2.5, 3, 3.5, 4, 5, and 6 years of age. This significantly increases the number of office visits and needle sticks, and raises the age at which vaccines are given, increasing the risk of illness outbreaks and decreasing the likelihood that parents would return to the office to complete the full series.
Acceptance of influenza and HPV vaccines remains a challenge
We are significantly less successful at getting parents and patients to agree to influenza and HPV vaccines than to the other vaccines we offer. The influenza vaccine success rate in 2016 was 59% in children and 43.3% in adults.33 Compared to the Tdap vaccine (88%) and the meningococcal vaccine (82%), which are offered at the same age as the HPV vaccine, success rates for HPV vaccine are significantly lower. In 2016, only 60.4% of boys and girls were current on their first HPV injection and only 43.3% were up to date with the full series.34
Newness of vaccines a factor?
Perhaps it is because the recommendations for these 2 vaccines are relatively new, and people don’t yet grasp the seriousness and scope of the diseases. Until 2010, the flu shot was recommended only for the very young, the elderly, and the medically high risk.
Similarly, the HPV vaccine was originally introduced for girls in 2006 and wasn’t recommended for boys until 2011.
Continue to: Human papillomavirus vaccine: Patient-friendly talking points
SIDEBAR
Human papillomavirus vaccine: Patient-friendly talking points
- Human papillomavirus (HPV) causes genital warts and cancer of the cervix, vagina, vulva, anus, rectum, penis, and oropharynx.
- The HPV vaccine is a cancer prevention vaccine. The 9-valent vaccine is active against 2 genital wart-causing strains and 7 cancer-causing strains of HPV.
- HPV is highly prevalent; 79 million Americans are currently infected, nearly 14 million people become newly infected each year, and nearly all of us will be exposed at some point in our sexual lives.40
- There are often no outward signs of infection, so it is a difficult infection to avoid.
- It takes no high-risk sexual activity to be exposed to the HPV virus.
- The HPV vaccine is recommended for both boys and girls usually around age 11 to 12 years (but as early as 9 years and as late as 26 years is acceptable). If the first vaccine is administered before 15 years of age, only 2 injections are needed 6 to 12 months apart. If the first vaccine is administered after 15 years of age, 3 injections are needed at 0, 2 months, and 6 months.41
- Completing the series before sexual activity begins is the best way to protect our children because the vaccine is a preventive measure, not a treatment.
- The HPV vaccine is highly effective with >90% efficacy against high-risk cancer-causing strains.42
- The HPV vaccine offers long-term protection. The vaccine has been on the market since 2006, and immunity has not yet diminished. Further monitoring is ongoing.43
- The HPV vaccine is covered under the Vaccines For Children program until age 19 years. Then it is up to individual insurance plans to cover it.
- The HPV vaccine does not cause infertility.44 HPV infection, on the other hand, can lead to fertility problems if, for example, treatment for cervical precancer or cancer requires partial removal of the cervix or a hysterectomy.
- The HPV vaccine does not cause autoimmune diseases.45,46 Studies show no difference between vaccinated and unvaccinated groups in rates of autoimmune diseases such as systemic lupus erythematosus, rheumatoid arthritis, type 1 diabetes mellitus, multiple sclerosis, Hashimoto's thyroiditis, Graves' disease, and others.
- The HPV vaccine does not encourage earlier sexual activity. There was no earlier incidence of outcomes related to sexual activity (pregnancy, sexually transmitted infection testing or diagnosis, or contraceptive counseling) in vaccinated vs unvaccinated patients studied.47
Continue to: A sensitive subject
A sensitive subject. Discussion of a vaccine related to a child’s sexual health makes some parents uncomfortable. Studies show that focusing on the cancer prevention aspects of the vaccine, rather than on sexual transmission of HPV, results in greater vaccine acceptance.35
However, if discussion of sexual transmission is unavoidable, remind parents to consider their own adolescence and whether they chose to share everything with their parents. Point out that there were probably things they did that they later looked back on and thought, “What was I thinking?” Their children, no matter how wonderful and levelheaded they are, will be no different. And, as much as parents don’t want to think about it, some kids will suffer unwanted sexual contact. Shouldn’t parents protect their children as best as they can?
A teen’s right to choose? Some states have passed a Mature Minor Doctrine, which provides for mature, unemancipated teens to make their own medical decisions regarding such issues as sexuality, mental health, and drug and alcohol use without their parents’ consent. In these states, teens may elect to receive the HPV vaccine without parental permission. (Check your state’s laws for specifics, and see the 2 boxes with patient-friendly talking points for influenza vaccine7,36-39 and human papillomavirus vaccine.40-47)
CORRESPONDENCE
Gretchen LaSalle, MD, MultiCare Rockwood Clinic, 2214 East 29th Avenue, Spokane, WA 99203; [email protected].
1. Paterson P, Meurice F, Stanberry LR, et al. Vaccine hesitancy and healthcare providers. Vaccine. 2016;34:6700-6706.
2. Opel DJ, Heritage J, Taylor J, et al. The architecture of provider-parent vaccine discussions at health supervision visits. Pediatrics. 2013;132:1037-1046.
3. Palmer J, Carrico C, Costanzo C. Identifying and overcoming perceived barriers of providers towards vaccination: a literature review. J Vaccines. 2015;1-7.
4. Autism Science Foundation. Making the CASE for vaccines: a new model for talking to patients about vaccines. Available at: http://autismsciencefoundation.org/wp-content/uploads/2015/12/Making-the-CASE-for-Vaccines-Guide_final.pdf. Accessed April 8, 2018.
5. Jacobson RM, Van Etta L, Bahta L. The C.A.S.E approach: guidance for talking to vaccine-hesitant patients. Minn Med. 2013;96:49-50.
6. Henrickson NB, Opel DJ, Grothaus L, et al. Physician communication training and parental vaccine hesitancy: a randomized trial. Pediatrics. 2015;136:70-79.
7. Centers for Disease Control and Prevention. Key facts about seasonal flu vaccine. Available at: https://www.cdc.gov/flu/protect/keyfacts.htm. Accessed April 8, 2018.
8. Wakefield AJ, Murch SH, Anthony A, et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet. 1998;351:637-641.
9. Taylor LE, Swerdfeger AL, Eslick GD. Vaccines are not associated with autism: an evidence-based meta-analysis of case-control and cohort studies. Vaccine. 2014;32:3623-3629.
10. Agency for Toxic Substances & Disease Registry. Minimal risk levels for hazardous substances. Available at: https://www.atsdr.cdc.gov/mrls/mrllist.asp#34tag. Accessed April 8, 2018.
11. US Food and Drug Administration. Thimerosal and vaccines. Available at: https://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/VaccineSafety/UCM096228. Accessed April 8, 2018.
12. Hviid A, Stellfeld M, Wohlfahrt J, et al. Association between thimerosal-containing vaccine and autism. JAMA. 2003;290:1763-1766.
13. Centers for Disease Control and Prevention. Thimerosal in vaccines. Available at: https://www.cdc.gov/vaccinesafety/concerns/thimerosal/index.html. Accessed May 8, 2018.
14. Autism Speaks. Frequently asked questions. Available at: https://www.autismspeaks.org/what-autism/faq. Accessed April 8, 2018.
15. Agency for Toxic Substances & Disease Registry. Toxic substances portal-aluminum. Public Health Statement for Aluminum, CAS #7429-90-5. Available at: https://www.atsdr.cdc.gov/PHS/PHS.asp?id=1076&tid=34. Accessed April 8, 2018.
16. Children’s Hospital of Philadelphia. Vaccine ingredients-aluminum. Available at: www.chop.edu/centers-programs/vaccine-education-center/vaccine-ingredients/aluminum. Accessed April 8, 2018.
17. Orenstein W, Seib K. Mounting a good offense against measles. N Engl J Med. 2014;371:1661-1663.
18. Plans-Rubió P. The vaccination coverage required to establish herd immunity against influenza viruses. Prev Med. 2012;55:72-77.
19. Hall V, Banerjee E, Kenyon C, et al. Measles outbreak – Minnesota April-May 2017. MMWR Morb Mortal Wkly Rep. 2017;66:713-717.
20. The National Academies of Sciences Engineering Medicine. History of U.S. water and wastewater systems. Privatization of Water Services in the United States: an Assessment of Issues and Experience. Washington, DC: The National Academies Press; 2002:29-40. Available at: https://www.nap.edu/read/10135/chapter/4#35. Accessed May 7, 2018.
21. World Health Organization. Global vaccine safety. Six common misconceptions about immunization. Available at: http://www.who.int/vaccine_safety/initiative/detection/immunization_misconceptions/en/index1.html. Accessed May 7, 2018.
22. The history of vaccines. Human cell strains in vaccine development. Available at: https://www.historyofvaccines.org/content/articles/human-cell-strains-vaccine-development. Accessed April 8, 2018.
23. The National Catholic Bioethics Center. Frequently asked questions. Available at: https://www.ncbcenter.org/resources/frequently-asked-questions/use-vaccines/. Accessed April 8, 2018.
24. Shimabukuro TT, Nguyen M, Martin D, et al. Safety monitoring in the vaccine adverse event reporting system (VAERS). Vaccine. 2015;33:4398-4405.
25. Foster S. Rotavirus vaccine and intussusception. J Pediatr Pharmacol Ther. 2007;12:4-7.
26. Mistry RD, Fischer JB, Prasad PA, et al. Severe complications of influenza-like illnesses. Pediatrics. 2014;134:e684-e690.
27. McNeil MM, Weintraub ES, Duffy J, et al. Risk of anaphylaxis after vaccination in children and adults. J Allergy Clin Immunol. 2016;137:868-878.
28. McLaughlin JM, McGinnis JJ, Tan L, et al. Estimated human and economic burden of four major adult vaccine-preventable diseases in the United States, 2013. J Prim Prev. 2015;36:259-273.
29. Centers for Disease Control and Prevention. Vaccines for Children (VFC) Program. Available at: https://www.cdc.gov/features/vfcprogram/index.html. Accessed April 8, 2018.
30. Plotkin S, Gerber JS, Offit PA. Vaccines and autism: a tale of shifting hypotheses. Clin Infect Dis. 2009;48:456-461.
31. Offit PA, Quarles J, Gerber MA, et al. Addressing parents’ concerns: do multiple vaccines overwhelm or weaken the infant’s immune system? Pediatrics. 2002;109:124-129.
32. Offit PA, Moser CA. The problem with Dr. Bob’s alternative vaccine schedule. Pediatrics. 2009;123:e164-e169.
33. Centers for Disease Control and Prevention. Flu vaccination coverage, United States, 2016-17 influenza season. Available at: https://www.cdc.gov/flu/fluvaxview/coverage-1617estimates.htm. April 8. 2018.
34. Walker TY, Elam-Evans LD, Singleton JA, et al. National, regional, state and selected local area vaccination coverage among adolescents aged 13-17 years – United States, 2016. MMWR Morb Mortal Wkly Rep. 2017;66:874-882.
35. Thomas TL. Cancer prevention: HPV vaccination. Semin Oncol Nurs. 2016:32:273-280.
36. Centers for Disease Control and Prevention. Estimating seasonal influenza-associated deaths in the United States. Available at: https://www.cdc.gov/flu/about/disease/US_flu-related_deaths.htm. Accessed May 8, 2018.
37. Wong KK, Jain S, Blanton L, et al. Influenza-associated pediatric deaths in the United States: 2004-2012. Pediatrics. 2013;132:796-804.
38. Centers for Disease Control and Prevention. Seasonal influenza vaccine effectiveness, 2005-2018. Available at: https://www.cdc.gov/flu/professionals/vaccination/effectiveness-studies.htm. Accessed April 8, 2018.
39. Centers for Disease Control and Prevention. Influenza (flu). Flu vaccine and people with egg allergies. Available at: https://www.cdc.gov/flu/protect/vaccine/egg-allergies.htm. Accessed April 8, 2018.
40. Centers for Disease Control and Prevention. For parents: vaccines for your children. HPV vaccine for preteens and teens. Available at: https://www.cdc.gov/vaccines/parents/diseases/teen/hpv.html. Accessed April 8, 2018.
41. Centers for Disease Control and Prevention. Vaccines and preventable diseases. HPV vaccine recommendations. Available at: https://www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html. Accessed May 7, 2018.
42. Cutts FT, Franceschi S, Goldie S, et al. Human papillomavirus and HPV vaccines: a review. Bull World Health Organ. 2007;85:719-726.
43. De Vincenzo R, Conte C, Ricci C, et al. Long-term efficacy and safety of human papillomavirus vaccination. Int J Womens Health. 2014;6:999-1010.
44. McInerney KA, Hatch EE, Wesselink AK. The effect of vaccination against human papillomavirus on fecundability. Paedeatr Perinat Epidemiol. 2017;31:531-536.
45. Chao C, Klein NP, Velicer CM, et al. Surveillance of autoimmune conditions following routine use of quadrivalent human papillomavirus vaccine. J Intern Med. 2012;271:193-203.
46. Vichnin M, Bonanni P, Klein NP, et al. An overview of quadrivalent human papillomavirus vaccine safety: 2006-2015. Ped Infect Dis J. 2015;34:983-991.
47. Bednarczyk RA, Davis R, Ault K, et al. Sexual activity-related outcomes after human papillomavirus vaccination of 11-to-12-year-olds. Pediatrics. 2012;130:798-805.
1. Paterson P, Meurice F, Stanberry LR, et al. Vaccine hesitancy and healthcare providers. Vaccine. 2016;34:6700-6706.
2. Opel DJ, Heritage J, Taylor J, et al. The architecture of provider-parent vaccine discussions at health supervision visits. Pediatrics. 2013;132:1037-1046.
3. Palmer J, Carrico C, Costanzo C. Identifying and overcoming perceived barriers of providers towards vaccination: a literature review. J Vaccines. 2015;1-7.
4. Autism Science Foundation. Making the CASE for vaccines: a new model for talking to patients about vaccines. Available at: http://autismsciencefoundation.org/wp-content/uploads/2015/12/Making-the-CASE-for-Vaccines-Guide_final.pdf. Accessed April 8, 2018.
5. Jacobson RM, Van Etta L, Bahta L. The C.A.S.E approach: guidance for talking to vaccine-hesitant patients. Minn Med. 2013;96:49-50.
6. Henrickson NB, Opel DJ, Grothaus L, et al. Physician communication training and parental vaccine hesitancy: a randomized trial. Pediatrics. 2015;136:70-79.
7. Centers for Disease Control and Prevention. Key facts about seasonal flu vaccine. Available at: https://www.cdc.gov/flu/protect/keyfacts.htm. Accessed April 8, 2018.
8. Wakefield AJ, Murch SH, Anthony A, et al. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet. 1998;351:637-641.
9. Taylor LE, Swerdfeger AL, Eslick GD. Vaccines are not associated with autism: an evidence-based meta-analysis of case-control and cohort studies. Vaccine. 2014;32:3623-3629.
10. Agency for Toxic Substances & Disease Registry. Minimal risk levels for hazardous substances. Available at: https://www.atsdr.cdc.gov/mrls/mrllist.asp#34tag. Accessed April 8, 2018.
11. US Food and Drug Administration. Thimerosal and vaccines. Available at: https://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/VaccineSafety/UCM096228. Accessed April 8, 2018.
12. Hviid A, Stellfeld M, Wohlfahrt J, et al. Association between thimerosal-containing vaccine and autism. JAMA. 2003;290:1763-1766.
13. Centers for Disease Control and Prevention. Thimerosal in vaccines. Available at: https://www.cdc.gov/vaccinesafety/concerns/thimerosal/index.html. Accessed May 8, 2018.
14. Autism Speaks. Frequently asked questions. Available at: https://www.autismspeaks.org/what-autism/faq. Accessed April 8, 2018.
15. Agency for Toxic Substances & Disease Registry. Toxic substances portal-aluminum. Public Health Statement for Aluminum, CAS #7429-90-5. Available at: https://www.atsdr.cdc.gov/PHS/PHS.asp?id=1076&tid=34. Accessed April 8, 2018.
16. Children’s Hospital of Philadelphia. Vaccine ingredients-aluminum. Available at: www.chop.edu/centers-programs/vaccine-education-center/vaccine-ingredients/aluminum. Accessed April 8, 2018.
17. Orenstein W, Seib K. Mounting a good offense against measles. N Engl J Med. 2014;371:1661-1663.
18. Plans-Rubió P. The vaccination coverage required to establish herd immunity against influenza viruses. Prev Med. 2012;55:72-77.
19. Hall V, Banerjee E, Kenyon C, et al. Measles outbreak – Minnesota April-May 2017. MMWR Morb Mortal Wkly Rep. 2017;66:713-717.
20. The National Academies of Sciences Engineering Medicine. History of U.S. water and wastewater systems. Privatization of Water Services in the United States: an Assessment of Issues and Experience. Washington, DC: The National Academies Press; 2002:29-40. Available at: https://www.nap.edu/read/10135/chapter/4#35. Accessed May 7, 2018.
21. World Health Organization. Global vaccine safety. Six common misconceptions about immunization. Available at: http://www.who.int/vaccine_safety/initiative/detection/immunization_misconceptions/en/index1.html. Accessed May 7, 2018.
22. The history of vaccines. Human cell strains in vaccine development. Available at: https://www.historyofvaccines.org/content/articles/human-cell-strains-vaccine-development. Accessed April 8, 2018.
23. The National Catholic Bioethics Center. Frequently asked questions. Available at: https://www.ncbcenter.org/resources/frequently-asked-questions/use-vaccines/. Accessed April 8, 2018.
24. Shimabukuro TT, Nguyen M, Martin D, et al. Safety monitoring in the vaccine adverse event reporting system (VAERS). Vaccine. 2015;33:4398-4405.
25. Foster S. Rotavirus vaccine and intussusception. J Pediatr Pharmacol Ther. 2007;12:4-7.
26. Mistry RD, Fischer JB, Prasad PA, et al. Severe complications of influenza-like illnesses. Pediatrics. 2014;134:e684-e690.
27. McNeil MM, Weintraub ES, Duffy J, et al. Risk of anaphylaxis after vaccination in children and adults. J Allergy Clin Immunol. 2016;137:868-878.
28. McLaughlin JM, McGinnis JJ, Tan L, et al. Estimated human and economic burden of four major adult vaccine-preventable diseases in the United States, 2013. J Prim Prev. 2015;36:259-273.
29. Centers for Disease Control and Prevention. Vaccines for Children (VFC) Program. Available at: https://www.cdc.gov/features/vfcprogram/index.html. Accessed April 8, 2018.
30. Plotkin S, Gerber JS, Offit PA. Vaccines and autism: a tale of shifting hypotheses. Clin Infect Dis. 2009;48:456-461.
31. Offit PA, Quarles J, Gerber MA, et al. Addressing parents’ concerns: do multiple vaccines overwhelm or weaken the infant’s immune system? Pediatrics. 2002;109:124-129.
32. Offit PA, Moser CA. The problem with Dr. Bob’s alternative vaccine schedule. Pediatrics. 2009;123:e164-e169.
33. Centers for Disease Control and Prevention. Flu vaccination coverage, United States, 2016-17 influenza season. Available at: https://www.cdc.gov/flu/fluvaxview/coverage-1617estimates.htm. April 8. 2018.
34. Walker TY, Elam-Evans LD, Singleton JA, et al. National, regional, state and selected local area vaccination coverage among adolescents aged 13-17 years – United States, 2016. MMWR Morb Mortal Wkly Rep. 2017;66:874-882.
35. Thomas TL. Cancer prevention: HPV vaccination. Semin Oncol Nurs. 2016:32:273-280.
36. Centers for Disease Control and Prevention. Estimating seasonal influenza-associated deaths in the United States. Available at: https://www.cdc.gov/flu/about/disease/US_flu-related_deaths.htm. Accessed May 8, 2018.
37. Wong KK, Jain S, Blanton L, et al. Influenza-associated pediatric deaths in the United States: 2004-2012. Pediatrics. 2013;132:796-804.
38. Centers for Disease Control and Prevention. Seasonal influenza vaccine effectiveness, 2005-2018. Available at: https://www.cdc.gov/flu/professionals/vaccination/effectiveness-studies.htm. Accessed April 8, 2018.
39. Centers for Disease Control and Prevention. Influenza (flu). Flu vaccine and people with egg allergies. Available at: https://www.cdc.gov/flu/protect/vaccine/egg-allergies.htm. Accessed April 8, 2018.
40. Centers for Disease Control and Prevention. For parents: vaccines for your children. HPV vaccine for preteens and teens. Available at: https://www.cdc.gov/vaccines/parents/diseases/teen/hpv.html. Accessed April 8, 2018.
41. Centers for Disease Control and Prevention. Vaccines and preventable diseases. HPV vaccine recommendations. Available at: https://www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html. Accessed May 7, 2018.
42. Cutts FT, Franceschi S, Goldie S, et al. Human papillomavirus and HPV vaccines: a review. Bull World Health Organ. 2007;85:719-726.
43. De Vincenzo R, Conte C, Ricci C, et al. Long-term efficacy and safety of human papillomavirus vaccination. Int J Womens Health. 2014;6:999-1010.
44. McInerney KA, Hatch EE, Wesselink AK. The effect of vaccination against human papillomavirus on fecundability. Paedeatr Perinat Epidemiol. 2017;31:531-536.
45. Chao C, Klein NP, Velicer CM, et al. Surveillance of autoimmune conditions following routine use of quadrivalent human papillomavirus vaccine. J Intern Med. 2012;271:193-203.
46. Vichnin M, Bonanni P, Klein NP, et al. An overview of quadrivalent human papillomavirus vaccine safety: 2006-2015. Ped Infect Dis J. 2015;34:983-991.
47. Bednarczyk RA, Davis R, Ault K, et al. Sexual activity-related outcomes after human papillomavirus vaccination of 11-to-12-year-olds. Pediatrics. 2012;130:798-805.
From The Journal of Family Practice | 2018;67(6):348-351,359-364.
PRACTICE RECOMMENDATIONS
› Use a presumptive approach when discussing vaccines with patients/parents. A
› Offer vaccines at every opportunity; provider recommendation is the most important factor in getting patients to vaccinate. A
› Focus on the cancer prevention aspect of the human papillomavirus vaccine to improve rates of vaccine acceptance. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Take time to talk to vaccine refusers
I am writing in response to the article titled “Save your breath” by Dr. William G. Wilkoff.
I am a family medicine physician in Spokane, Wash., and have been in practice for the last 12 years. I take care of patients from infancy to old age and through all stages of life between. As a primary care provider, I sympathize with the concerns of Dr. Wilkoff and many others on the front lines of the vaccine debate.
It takes much time and energy to talk to patients and parents about the benefits and safety of vaccination and about the sound science behind vaccines. It is exceedingly frustrating to expend so much energy and passion, only to be met with refusal – refusal of interventions that we know to be lifesaving. I take issue, however, with the assertion that it is not worth our time and breath to discuss the importance of vaccination with our questioning patients. I feel this assertion verges on being irresponsible. I worry about the impact that such a statement will have on our primary care providers who are fresh out of training and have yet to experience the positive influence that they can have on patients’ opinions regarding vaccines.
There are a multitude of reasons that people refuse vaccines. The origins of vaccine refusal go back to the beginning of vaccinations themselves, when Edward Jenner introduced the smallpox vaccine in the 1800s. Back then, the refusals most often had to do with the fact that vaccinations were made mandatory, and people felt this government requirement infringed on their personal liberties. Today, however, the most common reason for vaccine refusal, at least in my own practice, seems to stem from fear, pure and simple.
Most recently, Dr. Andrew Wakefield, who published an article in the journal The Lancet in the late 1990s suggesting a causal relationship between administration of the MMR vaccine and autism, has stirred up the anti-vaccine movement. Despite the fact that his research has been debunked and he has been stripped of his medical license for falsifying and misrepresenting data, his impact persists.
Our efforts are not aided by celebrity figures (actors and politicians) who have a wide-reaching public voice and use their platforms to disseminate misinformation regarding vaccines. There are also the anecdotal reasons that people refuse vaccines – they know someone who had a serious adverse reaction following vaccination or they themselves got sick following vaccination.
We, as primary care clinicians, are charged with determining the reasons behind each individual vaccine refusal so that we can clear up misunderstandings about vaccines. We are asked to do this in a limited time frame, when we have so many other issues to address in an office visit, and we often are speaking to only one or two people at a time. Does fighting this fight often feel like an uphill battle and an impossible task? Yes. Are there other things I could be doing with my time during that office visit? Absolutely! But this is our job. At our core, we are teachers. We are there to educate our patients about health and illness and prevention. Gone are the days of paternalistic medicine. Patients are more involved in their health care than ever before, and they expect to be part of the conversation and decision making process when it comes to interventions such as vaccines.
I completely disagree with the assertion that we should not waste our time discussing vaccinations with patients who initially decline them. Every single day I am able to talk patients into getting vaccines who initially refused them. Perhaps I have success because I come at the task in a nonjudgmental way.
We have to remember that patients are not trying to be difficult. They are just trying to make the best decisions for themselves and for their family members. People are more open to hearing what I have to say when I acknowledge their concerns.
Perhaps it is just that they respect what their doctor thinks and the fact that I am recommending it, alone, is enough to encourage them.
After all, if I, as a doctor who has been through years of training, believe in vaccines, and take them myself, and give them to my own children, then why shouldn’t they feel safe about getting vaccinated? Perhaps it is because I am, as I like to tell my pleasant but challenging patients, annoyingly persistent.
I will present the same message over and over again every time we see each other, and eventually they understand how important the issue is – or maybe they just get so tired of hearing me say the same thing repeatedly that they give in, just so I will stop talking.
Either way, I win! Or, more seriously, perhaps it is that my patients have had some experience (someone they know had a serious outcome from a vaccine-preventable illness) that changed their minds. If we don’t offer up the topic for conversation, we will never know.
I also take issue with providers who simply refuse to see families who don’t vaccinate. In my mind, this hearkens back to that paternalistic practice of medicine, and it punishes those who are most vulnerable. Children need care, no matter what their parents’ decisions regarding vaccination. It also presumes that the clinician will never be able to impact a family’s opinions regarding vaccination. This is categorically untrue! You’d be amazed at how much you can accomplish if you just take the time to listen, acknowledge, and clarify.
So, if you are one of those new doctors out there, please don’t give up hope that you can make a difference. This is a very worthy fight, and you are up to the task! Keep talking to your patients and their families about the importance of vaccinations. Your voice matters, and patients value what you have to say!
Gretchen LaSalle, M.D.
Spokane, Wash.
Dr. Wilkoff responds: While I have had some successes using the same annoying persistence that Dr. LaSalle suggests, they have been few and far between. I agree that many vaccine-hesitant parents are driven by fear. However, the studies I referred to in my column should give all of us pause as we consider how to invest our limited face-to-face time with patients.
Education may be one of the solutions to the vaccine-refusal problem. However, the question remains as to what point in a parent’s development that education should begin. It may be that in many cases we arrive on the scene too late. As pessimistic as this observation may sound, I agree with Dr. LaSalle that discharging vaccine-refusing families doesn’t help the situation and ignores our primary mission.
I am writing in response to the article titled “Save your breath” by Dr. William G. Wilkoff.
I am a family medicine physician in Spokane, Wash., and have been in practice for the last 12 years. I take care of patients from infancy to old age and through all stages of life between. As a primary care provider, I sympathize with the concerns of Dr. Wilkoff and many others on the front lines of the vaccine debate.
It takes much time and energy to talk to patients and parents about the benefits and safety of vaccination and about the sound science behind vaccines. It is exceedingly frustrating to expend so much energy and passion, only to be met with refusal – refusal of interventions that we know to be lifesaving. I take issue, however, with the assertion that it is not worth our time and breath to discuss the importance of vaccination with our questioning patients. I feel this assertion verges on being irresponsible. I worry about the impact that such a statement will have on our primary care providers who are fresh out of training and have yet to experience the positive influence that they can have on patients’ opinions regarding vaccines.
There are a multitude of reasons that people refuse vaccines. The origins of vaccine refusal go back to the beginning of vaccinations themselves, when Edward Jenner introduced the smallpox vaccine in the 1800s. Back then, the refusals most often had to do with the fact that vaccinations were made mandatory, and people felt this government requirement infringed on their personal liberties. Today, however, the most common reason for vaccine refusal, at least in my own practice, seems to stem from fear, pure and simple.
Most recently, Dr. Andrew Wakefield, who published an article in the journal The Lancet in the late 1990s suggesting a causal relationship between administration of the MMR vaccine and autism, has stirred up the anti-vaccine movement. Despite the fact that his research has been debunked and he has been stripped of his medical license for falsifying and misrepresenting data, his impact persists.
Our efforts are not aided by celebrity figures (actors and politicians) who have a wide-reaching public voice and use their platforms to disseminate misinformation regarding vaccines. There are also the anecdotal reasons that people refuse vaccines – they know someone who had a serious adverse reaction following vaccination or they themselves got sick following vaccination.
We, as primary care clinicians, are charged with determining the reasons behind each individual vaccine refusal so that we can clear up misunderstandings about vaccines. We are asked to do this in a limited time frame, when we have so many other issues to address in an office visit, and we often are speaking to only one or two people at a time. Does fighting this fight often feel like an uphill battle and an impossible task? Yes. Are there other things I could be doing with my time during that office visit? Absolutely! But this is our job. At our core, we are teachers. We are there to educate our patients about health and illness and prevention. Gone are the days of paternalistic medicine. Patients are more involved in their health care than ever before, and they expect to be part of the conversation and decision making process when it comes to interventions such as vaccines.
I completely disagree with the assertion that we should not waste our time discussing vaccinations with patients who initially decline them. Every single day I am able to talk patients into getting vaccines who initially refused them. Perhaps I have success because I come at the task in a nonjudgmental way.
We have to remember that patients are not trying to be difficult. They are just trying to make the best decisions for themselves and for their family members. People are more open to hearing what I have to say when I acknowledge their concerns.
Perhaps it is just that they respect what their doctor thinks and the fact that I am recommending it, alone, is enough to encourage them.
After all, if I, as a doctor who has been through years of training, believe in vaccines, and take them myself, and give them to my own children, then why shouldn’t they feel safe about getting vaccinated? Perhaps it is because I am, as I like to tell my pleasant but challenging patients, annoyingly persistent.
I will present the same message over and over again every time we see each other, and eventually they understand how important the issue is – or maybe they just get so tired of hearing me say the same thing repeatedly that they give in, just so I will stop talking.
Either way, I win! Or, more seriously, perhaps it is that my patients have had some experience (someone they know had a serious outcome from a vaccine-preventable illness) that changed their minds. If we don’t offer up the topic for conversation, we will never know.
I also take issue with providers who simply refuse to see families who don’t vaccinate. In my mind, this hearkens back to that paternalistic practice of medicine, and it punishes those who are most vulnerable. Children need care, no matter what their parents’ decisions regarding vaccination. It also presumes that the clinician will never be able to impact a family’s opinions regarding vaccination. This is categorically untrue! You’d be amazed at how much you can accomplish if you just take the time to listen, acknowledge, and clarify.
So, if you are one of those new doctors out there, please don’t give up hope that you can make a difference. This is a very worthy fight, and you are up to the task! Keep talking to your patients and their families about the importance of vaccinations. Your voice matters, and patients value what you have to say!
Gretchen LaSalle, M.D.
Spokane, Wash.
Dr. Wilkoff responds: While I have had some successes using the same annoying persistence that Dr. LaSalle suggests, they have been few and far between. I agree that many vaccine-hesitant parents are driven by fear. However, the studies I referred to in my column should give all of us pause as we consider how to invest our limited face-to-face time with patients.
Education may be one of the solutions to the vaccine-refusal problem. However, the question remains as to what point in a parent’s development that education should begin. It may be that in many cases we arrive on the scene too late. As pessimistic as this observation may sound, I agree with Dr. LaSalle that discharging vaccine-refusing families doesn’t help the situation and ignores our primary mission.
I am writing in response to the article titled “Save your breath” by Dr. William G. Wilkoff.
I am a family medicine physician in Spokane, Wash., and have been in practice for the last 12 years. I take care of patients from infancy to old age and through all stages of life between. As a primary care provider, I sympathize with the concerns of Dr. Wilkoff and many others on the front lines of the vaccine debate.
It takes much time and energy to talk to patients and parents about the benefits and safety of vaccination and about the sound science behind vaccines. It is exceedingly frustrating to expend so much energy and passion, only to be met with refusal – refusal of interventions that we know to be lifesaving. I take issue, however, with the assertion that it is not worth our time and breath to discuss the importance of vaccination with our questioning patients. I feel this assertion verges on being irresponsible. I worry about the impact that such a statement will have on our primary care providers who are fresh out of training and have yet to experience the positive influence that they can have on patients’ opinions regarding vaccines.
There are a multitude of reasons that people refuse vaccines. The origins of vaccine refusal go back to the beginning of vaccinations themselves, when Edward Jenner introduced the smallpox vaccine in the 1800s. Back then, the refusals most often had to do with the fact that vaccinations were made mandatory, and people felt this government requirement infringed on their personal liberties. Today, however, the most common reason for vaccine refusal, at least in my own practice, seems to stem from fear, pure and simple.
Most recently, Dr. Andrew Wakefield, who published an article in the journal The Lancet in the late 1990s suggesting a causal relationship between administration of the MMR vaccine and autism, has stirred up the anti-vaccine movement. Despite the fact that his research has been debunked and he has been stripped of his medical license for falsifying and misrepresenting data, his impact persists.
Our efforts are not aided by celebrity figures (actors and politicians) who have a wide-reaching public voice and use their platforms to disseminate misinformation regarding vaccines. There are also the anecdotal reasons that people refuse vaccines – they know someone who had a serious adverse reaction following vaccination or they themselves got sick following vaccination.
We, as primary care clinicians, are charged with determining the reasons behind each individual vaccine refusal so that we can clear up misunderstandings about vaccines. We are asked to do this in a limited time frame, when we have so many other issues to address in an office visit, and we often are speaking to only one or two people at a time. Does fighting this fight often feel like an uphill battle and an impossible task? Yes. Are there other things I could be doing with my time during that office visit? Absolutely! But this is our job. At our core, we are teachers. We are there to educate our patients about health and illness and prevention. Gone are the days of paternalistic medicine. Patients are more involved in their health care than ever before, and they expect to be part of the conversation and decision making process when it comes to interventions such as vaccines.
I completely disagree with the assertion that we should not waste our time discussing vaccinations with patients who initially decline them. Every single day I am able to talk patients into getting vaccines who initially refused them. Perhaps I have success because I come at the task in a nonjudgmental way.
We have to remember that patients are not trying to be difficult. They are just trying to make the best decisions for themselves and for their family members. People are more open to hearing what I have to say when I acknowledge their concerns.
Perhaps it is just that they respect what their doctor thinks and the fact that I am recommending it, alone, is enough to encourage them.
After all, if I, as a doctor who has been through years of training, believe in vaccines, and take them myself, and give them to my own children, then why shouldn’t they feel safe about getting vaccinated? Perhaps it is because I am, as I like to tell my pleasant but challenging patients, annoyingly persistent.
I will present the same message over and over again every time we see each other, and eventually they understand how important the issue is – or maybe they just get so tired of hearing me say the same thing repeatedly that they give in, just so I will stop talking.
Either way, I win! Or, more seriously, perhaps it is that my patients have had some experience (someone they know had a serious outcome from a vaccine-preventable illness) that changed their minds. If we don’t offer up the topic for conversation, we will never know.
I also take issue with providers who simply refuse to see families who don’t vaccinate. In my mind, this hearkens back to that paternalistic practice of medicine, and it punishes those who are most vulnerable. Children need care, no matter what their parents’ decisions regarding vaccination. It also presumes that the clinician will never be able to impact a family’s opinions regarding vaccination. This is categorically untrue! You’d be amazed at how much you can accomplish if you just take the time to listen, acknowledge, and clarify.
So, if you are one of those new doctors out there, please don’t give up hope that you can make a difference. This is a very worthy fight, and you are up to the task! Keep talking to your patients and their families about the importance of vaccinations. Your voice matters, and patients value what you have to say!
Gretchen LaSalle, M.D.
Spokane, Wash.
Dr. Wilkoff responds: While I have had some successes using the same annoying persistence that Dr. LaSalle suggests, they have been few and far between. I agree that many vaccine-hesitant parents are driven by fear. However, the studies I referred to in my column should give all of us pause as we consider how to invest our limited face-to-face time with patients.
Education may be one of the solutions to the vaccine-refusal problem. However, the question remains as to what point in a parent’s development that education should begin. It may be that in many cases we arrive on the scene too late. As pessimistic as this observation may sound, I agree with Dr. LaSalle that discharging vaccine-refusing families doesn’t help the situation and ignores our primary mission.
Take time to talk to vaccine refusers
I am writing in response to the article titled “Faced with vaccine refusers? Save your breath” by Dr. William G. Wilkoff.
I am a family medicine physician in Spokane, Wash., and have been in practice for the last 12 years. I take care of patients from infancy to old age and through all stages of life between. As a primary care provider, I sympathize with the concerns of Dr. Wilkoff and many others on the front lines of the vaccine debate. It takes much time and energy to talk to patients and parents about the benefits and safety of vaccination and about the sound science behind vaccines. It is exceedingly frustrating to expend so much energy and passion, only to be met with refusal – refusal of interventions that we know to be lifesaving. I take issue, however, with the assertion that it is not worth our time and breath to discuss the importance of vaccination with our questioning patients. I feel this assertion verges on being irresponsible. I worry about the impact that such a statement will have on our primary care providers who are fresh out of training and have yet to experience the positive influence that they can have on patients’ opinions regarding vaccines.
There are a multitude of reasons that people refuse vaccines. The origins of vaccine refusal go back to the beginning of vaccinations themselves, when Edward Jenner introduced the smallpox vaccine in the 1800s. Back then, the refusals most often had to do with the fact that vaccinations were made mandatory, and people felt this government requirement infringed on their personal liberties. Today, however, the most common reason for vaccine refusal, at least in my own practice, seems to stem from fear, pure and simple. Most recently, Dr. Andrew Wakefield, who published an article in the journal The Lancet in the late 1990s suggesting a causal relationship between administration of the MMR vaccine and autism, has stirred up the anti-vaccine movement. Despite the fact that his research has been debunked and he has been stripped of his medical license for falsifying and misrepresenting data, his impact persists. Our efforts are not aided by celebrity figures (actors and politicians) who have a wide-reaching public voice and use their platforms to disseminate misinformation regarding vaccines. There are also the anecdotal reasons that people refuse vaccines – they know someone who had a serious adverse reaction following vaccination or they themselves got sick following vaccination.
We, as primary care clinicians, are charged with determining the reasons behind each individual vaccine refusal so that we can clear up misunderstandings about vaccines. We are asked to do this in a limited time frame, when we have so many other issues to address in an office visit, and we often are speaking to only one or two people at a time. Does fighting this fight often feel like an uphill battle and an impossible task? Yes. Are there other things I could be doing with my time during that office visit? Absolutely! But this is our job. At our core, we are teachers. We are there to educate our patients about health and illness and prevention. Gone are the days of paternalistic medicine. Patients are more involved in their health care than ever before, and they expect to be part of the conversation and decision making process when it comes to interventions such as vaccines.
I completely disagree with the assertion that we should not waste our time discussing vaccinations with patients who initially decline them. Every single day I am able to talk patients into getting vaccines who initially refused them. Perhaps I have success because I come at the task in a nonjudgmental way. We have to remember that patients are not trying to be difficult. They are just trying to make the best decisions for themselves and for their family members. People are more open to hearing what I have to say when I acknowledge their concerns. Perhaps it is just that they respect what their doctor thinks and the fact that I am recommending it, alone, is enough to encourage them. After all, if I, as a doctor who has been through years of training, believe in vaccines, and take them myself, and give them to my own children, then why shouldn’t they feel safe about getting vaccinated? Perhaps it is because I am, as I like to tell my pleasant but challenging patients, annoyingly persistent. I will present the same message over and over again every time we see each other, and eventually they understand how important the issue is – or maybe they just get so tired of hearing me say the same thing repeatedly that they give in, just so I will stop talking. Either way, I win! Or, more seriously, perhaps it is that my patients have had some experience (someone they know had a serious outcome from a vaccine-preventable illness) that changed their minds. If we don’t offer up the topic for conversation, we will never know.
I also take issue with providers who simply refuse to see families who don’t vaccinate. In my mind, this hearkens back to that paternalistic practice of medicine, and it punishes those who are most vulnerable. Children need care, no matter what their parents’ decisions regarding vaccination. It also presumes that the clinician will never be able to impact a family’s opinions regarding vaccination. This is categorically untrue! You’d be amazed at how much you can accomplish if you just take the time to listen, acknowledge, and clarify.
So, if you are one of those new doctors out there, please don’t give up hope that you can make a difference. This is a very worthy fight, and you are up to the task! Keep talking to your patients and their families about the importance of vaccinations. Your voice matters, and patients value what you have to say!
Gretchen LaSalle, M.D.
Spokane, Wash.
Dr. Wilkoff responds: While I have had some successes using the same annoying persistence that Dr. LaSalle suggests, they have been few and far between. I agree that many vaccine-hesitant parents are driven by fear. However, the studies I referred to in my column should give all of us pause as we consider how to invest our limited face-to-face time with patients. Education may be one of the solutions to the vaccine-refusal problem. However, the question remains as to what point in a parent’s development that education should begin. It may be that in many cases we arrive on the scene too late. As pessimistic as this observation may sound, I agree with Dr. LaSalle that discharging vaccine-refusing families doesn’t help the situation and ignores our primary mission.
I am writing in response to the article titled “Faced with vaccine refusers? Save your breath” by Dr. William G. Wilkoff.
I am a family medicine physician in Spokane, Wash., and have been in practice for the last 12 years. I take care of patients from infancy to old age and through all stages of life between. As a primary care provider, I sympathize with the concerns of Dr. Wilkoff and many others on the front lines of the vaccine debate. It takes much time and energy to talk to patients and parents about the benefits and safety of vaccination and about the sound science behind vaccines. It is exceedingly frustrating to expend so much energy and passion, only to be met with refusal – refusal of interventions that we know to be lifesaving. I take issue, however, with the assertion that it is not worth our time and breath to discuss the importance of vaccination with our questioning patients. I feel this assertion verges on being irresponsible. I worry about the impact that such a statement will have on our primary care providers who are fresh out of training and have yet to experience the positive influence that they can have on patients’ opinions regarding vaccines.
There are a multitude of reasons that people refuse vaccines. The origins of vaccine refusal go back to the beginning of vaccinations themselves, when Edward Jenner introduced the smallpox vaccine in the 1800s. Back then, the refusals most often had to do with the fact that vaccinations were made mandatory, and people felt this government requirement infringed on their personal liberties. Today, however, the most common reason for vaccine refusal, at least in my own practice, seems to stem from fear, pure and simple. Most recently, Dr. Andrew Wakefield, who published an article in the journal The Lancet in the late 1990s suggesting a causal relationship between administration of the MMR vaccine and autism, has stirred up the anti-vaccine movement. Despite the fact that his research has been debunked and he has been stripped of his medical license for falsifying and misrepresenting data, his impact persists. Our efforts are not aided by celebrity figures (actors and politicians) who have a wide-reaching public voice and use their platforms to disseminate misinformation regarding vaccines. There are also the anecdotal reasons that people refuse vaccines – they know someone who had a serious adverse reaction following vaccination or they themselves got sick following vaccination.
We, as primary care clinicians, are charged with determining the reasons behind each individual vaccine refusal so that we can clear up misunderstandings about vaccines. We are asked to do this in a limited time frame, when we have so many other issues to address in an office visit, and we often are speaking to only one or two people at a time. Does fighting this fight often feel like an uphill battle and an impossible task? Yes. Are there other things I could be doing with my time during that office visit? Absolutely! But this is our job. At our core, we are teachers. We are there to educate our patients about health and illness and prevention. Gone are the days of paternalistic medicine. Patients are more involved in their health care than ever before, and they expect to be part of the conversation and decision making process when it comes to interventions such as vaccines.
I completely disagree with the assertion that we should not waste our time discussing vaccinations with patients who initially decline them. Every single day I am able to talk patients into getting vaccines who initially refused them. Perhaps I have success because I come at the task in a nonjudgmental way. We have to remember that patients are not trying to be difficult. They are just trying to make the best decisions for themselves and for their family members. People are more open to hearing what I have to say when I acknowledge their concerns. Perhaps it is just that they respect what their doctor thinks and the fact that I am recommending it, alone, is enough to encourage them. After all, if I, as a doctor who has been through years of training, believe in vaccines, and take them myself, and give them to my own children, then why shouldn’t they feel safe about getting vaccinated? Perhaps it is because I am, as I like to tell my pleasant but challenging patients, annoyingly persistent. I will present the same message over and over again every time we see each other, and eventually they understand how important the issue is – or maybe they just get so tired of hearing me say the same thing repeatedly that they give in, just so I will stop talking. Either way, I win! Or, more seriously, perhaps it is that my patients have had some experience (someone they know had a serious outcome from a vaccine-preventable illness) that changed their minds. If we don’t offer up the topic for conversation, we will never know.
I also take issue with providers who simply refuse to see families who don’t vaccinate. In my mind, this hearkens back to that paternalistic practice of medicine, and it punishes those who are most vulnerable. Children need care, no matter what their parents’ decisions regarding vaccination. It also presumes that the clinician will never be able to impact a family’s opinions regarding vaccination. This is categorically untrue! You’d be amazed at how much you can accomplish if you just take the time to listen, acknowledge, and clarify.
So, if you are one of those new doctors out there, please don’t give up hope that you can make a difference. This is a very worthy fight, and you are up to the task! Keep talking to your patients and their families about the importance of vaccinations. Your voice matters, and patients value what you have to say!
Gretchen LaSalle, M.D.
Spokane, Wash.
Dr. Wilkoff responds: While I have had some successes using the same annoying persistence that Dr. LaSalle suggests, they have been few and far between. I agree that many vaccine-hesitant parents are driven by fear. However, the studies I referred to in my column should give all of us pause as we consider how to invest our limited face-to-face time with patients. Education may be one of the solutions to the vaccine-refusal problem. However, the question remains as to what point in a parent’s development that education should begin. It may be that in many cases we arrive on the scene too late. As pessimistic as this observation may sound, I agree with Dr. LaSalle that discharging vaccine-refusing families doesn’t help the situation and ignores our primary mission.
I am writing in response to the article titled “Faced with vaccine refusers? Save your breath” by Dr. William G. Wilkoff.
I am a family medicine physician in Spokane, Wash., and have been in practice for the last 12 years. I take care of patients from infancy to old age and through all stages of life between. As a primary care provider, I sympathize with the concerns of Dr. Wilkoff and many others on the front lines of the vaccine debate. It takes much time and energy to talk to patients and parents about the benefits and safety of vaccination and about the sound science behind vaccines. It is exceedingly frustrating to expend so much energy and passion, only to be met with refusal – refusal of interventions that we know to be lifesaving. I take issue, however, with the assertion that it is not worth our time and breath to discuss the importance of vaccination with our questioning patients. I feel this assertion verges on being irresponsible. I worry about the impact that such a statement will have on our primary care providers who are fresh out of training and have yet to experience the positive influence that they can have on patients’ opinions regarding vaccines.
There are a multitude of reasons that people refuse vaccines. The origins of vaccine refusal go back to the beginning of vaccinations themselves, when Edward Jenner introduced the smallpox vaccine in the 1800s. Back then, the refusals most often had to do with the fact that vaccinations were made mandatory, and people felt this government requirement infringed on their personal liberties. Today, however, the most common reason for vaccine refusal, at least in my own practice, seems to stem from fear, pure and simple. Most recently, Dr. Andrew Wakefield, who published an article in the journal The Lancet in the late 1990s suggesting a causal relationship between administration of the MMR vaccine and autism, has stirred up the anti-vaccine movement. Despite the fact that his research has been debunked and he has been stripped of his medical license for falsifying and misrepresenting data, his impact persists. Our efforts are not aided by celebrity figures (actors and politicians) who have a wide-reaching public voice and use their platforms to disseminate misinformation regarding vaccines. There are also the anecdotal reasons that people refuse vaccines – they know someone who had a serious adverse reaction following vaccination or they themselves got sick following vaccination.
We, as primary care clinicians, are charged with determining the reasons behind each individual vaccine refusal so that we can clear up misunderstandings about vaccines. We are asked to do this in a limited time frame, when we have so many other issues to address in an office visit, and we often are speaking to only one or two people at a time. Does fighting this fight often feel like an uphill battle and an impossible task? Yes. Are there other things I could be doing with my time during that office visit? Absolutely! But this is our job. At our core, we are teachers. We are there to educate our patients about health and illness and prevention. Gone are the days of paternalistic medicine. Patients are more involved in their health care than ever before, and they expect to be part of the conversation and decision making process when it comes to interventions such as vaccines.
I completely disagree with the assertion that we should not waste our time discussing vaccinations with patients who initially decline them. Every single day I am able to talk patients into getting vaccines who initially refused them. Perhaps I have success because I come at the task in a nonjudgmental way. We have to remember that patients are not trying to be difficult. They are just trying to make the best decisions for themselves and for their family members. People are more open to hearing what I have to say when I acknowledge their concerns. Perhaps it is just that they respect what their doctor thinks and the fact that I am recommending it, alone, is enough to encourage them. After all, if I, as a doctor who has been through years of training, believe in vaccines, and take them myself, and give them to my own children, then why shouldn’t they feel safe about getting vaccinated? Perhaps it is because I am, as I like to tell my pleasant but challenging patients, annoyingly persistent. I will present the same message over and over again every time we see each other, and eventually they understand how important the issue is – or maybe they just get so tired of hearing me say the same thing repeatedly that they give in, just so I will stop talking. Either way, I win! Or, more seriously, perhaps it is that my patients have had some experience (someone they know had a serious outcome from a vaccine-preventable illness) that changed their minds. If we don’t offer up the topic for conversation, we will never know.
I also take issue with providers who simply refuse to see families who don’t vaccinate. In my mind, this hearkens back to that paternalistic practice of medicine, and it punishes those who are most vulnerable. Children need care, no matter what their parents’ decisions regarding vaccination. It also presumes that the clinician will never be able to impact a family’s opinions regarding vaccination. This is categorically untrue! You’d be amazed at how much you can accomplish if you just take the time to listen, acknowledge, and clarify.
So, if you are one of those new doctors out there, please don’t give up hope that you can make a difference. This is a very worthy fight, and you are up to the task! Keep talking to your patients and their families about the importance of vaccinations. Your voice matters, and patients value what you have to say!
Gretchen LaSalle, M.D.
Spokane, Wash.
Dr. Wilkoff responds: While I have had some successes using the same annoying persistence that Dr. LaSalle suggests, they have been few and far between. I agree that many vaccine-hesitant parents are driven by fear. However, the studies I referred to in my column should give all of us pause as we consider how to invest our limited face-to-face time with patients. Education may be one of the solutions to the vaccine-refusal problem. However, the question remains as to what point in a parent’s development that education should begin. It may be that in many cases we arrive on the scene too late. As pessimistic as this observation may sound, I agree with Dr. LaSalle that discharging vaccine-refusing families doesn’t help the situation and ignores our primary mission.