Guest Editorial

Building Relationships With Parents Can Make a Difference in Vaccine Acceptance

June 06, 2012 04:35 pm Richard Feldman, M.D.

Pertussis was big news two years ago, when more than 9,000 cases -- a 60-year high -- were reported in California. Ten infants died, and whooping cough suddenly was headline news.

That epidemic eventually waned, and so did the public's attention. Now, pertussis outbreaks are happening again in multiple states.

[Richard Feldman, M.D.]

Richard Feldman, M.D.

Vaccine-preventable diseases smolder along waiting for a chance to re-emerge in undervaccinated areas. For example, Washington, which has pertussis vaccination rates lower than the 93 percent coverage required for effective herd immunity, is reporting epidemic levels of the disease. And Washington state health officials have cited vaccine-averse parents as part of the problem. Last year, more than 5 percent of the state's kindergartners lacked at least one of the required immunizations because of a parent's choice.

Pertussis is just one example of a preventable disease that we have had to deal with in unexpected frequency in recent years. Reported measles cases hit a 15-year high last year. New York and New Jersey had more than 1,500 cases of mumps just two years ago.

Each year, our national program of childhood vaccinations prevents millions of infections and thousands of deaths, and it saves millions of dollars in health care costs. Immunizations are among our greatest public health achievements. As family physicians, we are in a unique position to use our influence and relationships with patients to convince resistant parents that vaccinations are the medical miracles they truly are.

The very success of vaccinations -- the absence of disease -- has created an unintended problem: Immunizations are undervalued or taken for granted. Few of us can remember when diseases like diphtheria, tetanus, pertussis, measles, mumps, rubella and bacterial meningitis raged across our country; when children were paralyzed by polio; and when there were huge epidemics of smallpox. Relatively few questioned the value of vaccines until after these diseases, which once killed and maimed thousands of children yearly, were virtually eliminated. Smallpox has been eradicated from the world, and polio is all but a memory in the Western Hemisphere.

Most young parents have never seen the diseases that vaccines prevent, and, with no experience to draw on, it's hard for some to appreciate the severity of a disease.

When I was a resident in the 1970s, there were about 20,000 cases of invasive Haemophilus influenzae type b (Hib) disease each year in the United States. But since the first Hib vaccine was introduced in 1985, the incidence of disease in infants and children has decreased 99 percent. A few years ago, the combination of a Hib vaccine shortage and significant numbers of unvaccinated or undervaccinated children led to disease outbreaks and deaths in Minnesota and Pennsylvania.

Despite outbreaks like this that illustrate the value of immunizations, at least half of Americans have concerns about vaccine safety. Roughly one-fourth of parents continue to believe vaccines cause autism in the face of overwhelming evidence to the contrary. A small but growing number of parents are finding ways to legally avoid vaccinating their children, placing their communities at increased risk for vaccine-preventable disease outbreaks, especially among children too young to be immunized.

So what should we say to a vaccine-resistant parent? We can start by listening. If we understand their opinions and concerns, we can anticipate their issues and have responses ready. Even if we disagree, being respectful and positive is important. Patients and parents want to be heard and understood.

Explain the benefits -- and risks -- of immunizations. Stress that side effects typically are minimal, and the most common is a local reaction. Serious adverse events are exceedingly rare.

We have to make it clear that their child's well-being is our priority. We also can draw on our own experience. A couple of years ago, two of my patients who declined the influenza vaccine later died of flu complications. Real-life stories get a parent's attention.

Also, physicians with children can deliver the same powerful message today that I did when my children were young: My own kids are immunized because vaccines are safe and effective. Sharing our passion is important. Several studies have shown that a physician's recommendation can make a huge difference in whether a patient is immunized.

So why do parents reject vaccines? One reason is the sheer number of vaccines. It wasn't that long ago that the childhood immunization schedule contained just three vaccines that prevented seven diseases( Today, the AAFP -- in conjunction with the American Academy of Pediatrics (AAP) and the CDC's Advisory Committee on Immunization Practices -- recommend that from birth to age 6, children receive 10 vaccines that prevent 14 diseases. By age 6, children have received more than 20 vaccine doses.

What parents may not realize is that today's vaccines are more precise and contain fewer antigens. There is no evidence that more vaccinations are dangerous, but sometimes when you've done all you can to convince a parent, you have to compromise to get the shots completed. For example, if a parent of an adolescent doesn't want their child to receive all three of the vaccines recommended for that age group -- tetanus and diphtheria toxoids and acellular pertussis (Tdap), human papillomavirus (HPV) and quadrivalent meningococcal conjugate vaccines (MCV4) -- on the same day, administer two of the immunizations and schedule them to come back in a month for the other.

All medications, including vaccines, have the potential to cause undesirable effects. But our best scientific evidence for vaccines is that they are safe, and that serious adverse events occur very rarely. In 34 years of practice, I've never seen a serious adverse event.

We likely will never convince the hardcore, anti-immunization parents (who think vaccines and autism are linked) of the value and safety of vaccines. They already have chosen to ignore mounting evidence. But with parents who are uncertain of what to do, we can make a huge difference in the health of their children and others with whom they come in contact.

We can use our communication skills over time to build trust in our relationships with patients and parents. Be persistent. Every time you see a patient, ask about immunizations. When they're ready, protect that child and your community.

For more information about talking to parents about vaccination, check out these resources( developed by the CDC, AAFP and AAP.

Richard Feldman, M.D.,( is director of medical education and residency training at Franciscan St. Francis Health in Indianapolis and a member of the AAFP's Commission on Health of the Public and Science.