Your Patient Bucks Parents on Vaccine Request. Now What?

Recent news reports have featured children of vaccine-resistant parents who, on reaching an age at which they may consent to their own medical treatment, seek vaccination and reach out for guidance on social media.

As a family physician, you may have the opportunity to provide immunizations to young adults who are incompletely immunized or have never been immunized. The CDC and its Advisory Committee on Immunization Practices (ACIP), together with the AAFP and other medical professional organizations, release updated vaccine schedules every year. It should be noted that the catch-up vaccine schedule is not identical to the childhood schedule and can be complex.

The notes on the vaccine schedules contain valuable information and explanations regarding the appropriate approach for those who have an incomplete or no history of vaccination. And there are exceptions and special considerations for people with certain medical conditions, such as patients who have compromised immune systems. Patients with a history of, or plans for, international travel and those with chronic conditions also should trigger a careful look at the tables on the schedules for any variation from the usual recommendations.

What about consent when one parent brings in a minor child and it's known that the other parent objects to vaccination? In most jurisdictions, either parent may consent to medical care for their child, even if the other is known to have the opposite opinion. In case of divorced or unmarried parents, agreements regarding guardianship, conservatorship or custody may contain specific consent procedures and rights. County or state medical association legal staff (such as this example from Texas) are often able to provide specific guidance.

Can patients younger than 18 consent to their own immunizations? In some states, they can for vaccines in general, and in some states, they can for HPV and hepatitis B vaccine because these fall under STD prevention/treatment rules. In most jurisdictions, minors who are pregnant, married or legally emancipated may consent for their own care. Also, some states allow physicians to assess a minor as "mature" regarding consent for vaccination. 

Laws vary from state to state, so it's important to know the law in your own state. In Oregon, for example, minors who are 15 or older may consent to medical services, including immunizations, without parental consent. There have been calls for other states to adopt similar policy. The Society for Adolescent Health and Medicine released a position paper in 2013 recommending that states allow minors to consent to vaccination, echoing an opinion published five years earlier in Pediatrics.

The Center for Adolescent Health & the Law has compiled a summary edition of state minor consent laws nationwide, as well as reports from individual states. State medical associations, state public health associations, and local and state health departments also can be sources for information, clarification and updates.

But even after questions of consent are answered, payment for vaccination can be a sticky issue for those without health insurance. The Patient Protection and Affordable Care Act guarantees that all ACIP-recommended vaccines are covered by insurance, and the Vaccines for Children Program provides vaccines free of charge to underinsured children who otherwise could not afford them.

Still, vaccines can be expensive, and not all physician offices stock every vaccine. Partnering with your local or state health department -- or a pharmacist who stocks and administers vaccines -- can be helpful in making vaccination accessible.

Also, a young adult still on a parent's insurance should be informed that the parent may receive an explanation of benefits from the insurance company or a bill from the physician's office that details the vaccines administered. It's important to prepare the patient and offer alternatives to help them avoid being confronted by an angry parent holding an unexpected insurance document, as well as to discuss the possibility of vaccine reaction and related medical care, including how the young adult would want parents to be informed or involved.

For those seeking vaccination without using their parents' insurance, state and local programs such as Texas' Adult Safety Net program, the federal Vaccines for Children program and local health departments may help.

Preserving the parent-child relationship may be another important consideration. Some young adults may choose not to inform their parents about vaccination. Others may ask for guidance about how to talk with their parents about vaccination. Offering to host a family discussion is an option that may be fraught, especially if the physician also cares for the parents, but it could provide a safe environment and facilitation for a compromise or meeting of the minds.

And it's important to note that AAFP policy states that "family physicians should be aware of their community's standards regarding adolescent confidentiality. State laws vary, but in general, in areas of care where the adolescent has the legal right to give consent to health services, confidentiality must be maintained."

The challenges presented by previously unvaccinated or partially vaccinated young adults comprise one small part of the larger issue of vaccine refusal. Health care professionals must continue to seek evidence-based solutions for combating false information that has spread to so many parents and left huge numbers of children and those with compromised immune systems susceptible to entirely preventable illness and so many adults inadequately immunized.

Julie Graves, M.D., M.P.H., Ph.D., is an associate professor and vice chair for education in the Department of Family Medicine at Georgetown University in Washington, D.C.