1. Blendell, Robin L. MSN, CNM
  2. Fehr, Jessica L. MSN, CNM


Data regarding rates of vaccination among children and pregnant women show that there has been a decrease in the number of vaccinations being administered in these vulnerable populations. Surveys of parents elicit a wide variety of concerns and fears driving vaccine refusal, many of which have been refuted by research. It has been demonstrated that healthcare providers are a major source of information for patients who have questions about vaccinations. Given the established vital role of vaccinations in preventing the spread of diseases with serious morbidity and mortality profiles, it is important that healthcare providers understand and feel comfortable discussing the principles of vaccination, the recommended vaccine schedules, and the effects of vaccinations. This article provides an overview of vaccination principles, reviews the potential health and financial costs of nonvaccination, and addresses a number of common concerns cited by parents and pregnant women who are considering vaccine abstention or alternate vaccination scheduling. The information in this article will enable healthcare providers to accurately counsel patients about vaccination choices.


Article Content

Since the introduction of modern vaccination by Edward Jenner in the 1790s,1 there has been a steady decline in the incidence, prevalence, and disease burden of vaccine-preventable diseases. Vaccination has the ability to prevent specific illnesses in individuals, leads to a reduction in long-term disability and sequelae from infection, and improves pregnancy outcomes for women who are immunized. Those who avoid infection as a result of vaccination are able to live longer, healthier, and more productive lives. Twenty-eight diseases are currently vaccine-preventable,2 including previously common diseases with high rates of morbidity and adverse sequelae, such as chicken pox and measles. Roush and Murphy3 demonstrated significant decreases in morbidity rates of diphtheria (100%), measles (99.9%), paralytic poliomyelitis (100%), rubella (99.9%), congenital rubella syndrome (99.3%), smallpox (100%), mumps (95.9%), tetanus (92.9%), and pertussis (92.2%) and mortality from tetanus (99.2%) and pertussis (99.3%), in direct relation to the increase in vaccination.


In addition to protecting themselves against preventable illnesses, people who receive vaccinations protect others in 2 ways. The first is through what is known as "herd immunity." If a large-enough portion of the population is vaccinated against an illness, individuals who are unable to be vaccinated will be protected because of the decreased rate of infection and the subsequent decreased likelihood of exposure.4 Although herd immunity protects individuals who are unable to be vaccinated for any reason, parents who are vaccinated confer a similar protection specifically to infants who are too young to be vaccinated. This is one reason to ensure that pregnant women are up to date on vaccines and receive necessary vaccinations when appropriate.


In the United States, modern immunization laws, enacted in the 1960s and 1970s, require childhood vaccination before beginning school. By the 1980s, vaccination was required for entrance into public schools in all 50 states and the District of Columbia.5 Each state law allows exemptions so that families may make individualized decisions and refuse vaccination on the basis of medical need, religion, or personal philosophy. A comparison of pre- and postvaccination rates of incidence and mortality for 11 common vaccine-preventable diseases is shown in Table 1.

Table 1 - Click to enlarge in new windowTable 1. A comparison of pre- and postvaccination rates of incidence and mortality for 11 common vaccine-preventable diseases

Despite the evidence demonstrating significant declines in communicable diseases due to vaccination, as well as the documented safety of vaccination, rates of vaccine refusal for nonmedical reasons have increased significantly in recent years. Between 1991 and 2004, vaccination refusal rates increased from 0.98% to 1.48% nationwide, with the most significant increase of 2.54% in states that allowed for exemptions other than for religious reasons.5 While the absolute numbers of people who are refusing all vaccinations remain low, parental requests for alternative vaccination scheduling have recently risen to as high as 13%.9


This increase in vaccination refusal and alternative schedules has translated into a significant increase in the rates of several vaccine-preventable illnesses. The number of pertussis cases rose from 7580 in 2001 to 16 858 in 2009.10 The Centers for Disease Control and Prevention (CDC) reported 12 outbreaks of measles in the first 6 months of 2011, the highest incidence rates since 1996.11 Influenza vaccination rates for pregnant women have traditionally been low, with only 15% of pregnant women reporting vaccination in the 2009-2010 influenza season.12 While there has been a significant increase in influenza vaccination in response to the H1N1 outbreak, only 49% of pregnant women reported receiving influenza vaccination in the 2010-2011 influenza season.13 This is still well below the Healthy People 2020 goal of 80% vaccination.14



The CDC maintains a comprehensive schedule of recommended immunizations for infants, children, and adults.15 The schedule is reviewed annually to ensure that it is consistent with the most current evidence base as well as data from the Vaccine Adverse Events Reporting System. The CDC vaccination schedule is approved and recommended by the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, and the American Academy of Family Physicians.


As part of maintaining its recommended vaccination schedule, the CDC collects yearly statistics on schedule completion rates-that is, what percentage of the population receives all of the recommended vaccinations at the recommended time. Although vaccination rates for several individual vaccines meet the Healthy People 2020 goals, the rate of completion of the standard vaccine schedule for children 19 to 35 months of age is consistently below goals. These rates rose from 66% nationwide in 2002 to a high of 77% in 2007 and have trended back down to a national average of 70% in 2009 and 73% in 2010, the last year rates were published.16,17 These rates are of particular concern because the cost of not vaccinating is so high.


To decrease rates of vaccine-preventable diseases and provide appropriate counsel to clients who may be wary of vaccines, it is important for healthcare providers to understand the basics of immunity, the best evidence for vaccination, the actual risks associated with vaccines, and the current CDC vaccination recommendations and schedule. This article identifies the current CDC vaccine recommendations, reviews the benefits of vaccination for children and pregnant women, and uses the current evidence base to answer common questions raised by vaccine-cautious parents. For an overview of disease immunity and the basics of vaccination, refer to Table 2.

Table 2 - Click to enlarge in new windowTable 2. Basics of immunity


There are both immediate and long-term benefits of vaccination for individuals, as well as advantages for the community at large. The community benefits of vaccination stem from reduction in morbidity and mortality, as well as of reduction in cost and loss of productivity due to sick days from work and school, doctor's visits, hospitalizations, and long-term disability.7,8 It is clear from these data that vaccination has had a staggering effect on the public health, reducing the disease burden for both individuals and communities.


Pertussis, also known as whooping cough, is a perfect example both of the success of vaccines in decreasing morbidity and mortality and of the rising rates of disease caused by decreasing vaccination rates. As noted in the introductory paragraph, before routine and mandatory vaccination for pertussis, there were 150 000 to 260 000 annual cases of pertussis and up to 9000 annual deaths reported to the CDC. In 2001, there were only 7580 reported cases of pertussis in the United States; there were 181 pertussis fatalities from 2000 to 2008, with 166 of those deaths in children younger than 6 months.7 Such great reductions in illness and death demonstrate the significant role of vaccination in health promotion. Despite the clear benefits of pertussis vaccination, concerns over vaccine administration have led to a decrease in rates of vaccination. Since this decrease, the United States has seen an increase in pertussis infection rates, which rose to 16 858 in 2009, more than double the 2001 rate.


An analysis of the cost-benefit ratio of vaccination must take into account both the actual monetary cost of the vaccine and the costs of adverse events. These costs must then be weighed against the benefits of disease prevention, including the immediate and long-term costs of illness.7,8 An excellent example of this cost analysis was performed by Carabin et al,23 who found that the average cost per measles case (including complications such as hospitalization) in several industrialized countries was $254 to $307 whereas the average cost per postvaccination adverse event was $1.43 to 1.93. When compared with the costs of vaccine-preventable diseases, the absolute monetary cost of any individual vaccine is quite low, even when the cost of adverse events is included. This is particularly true of combination vaccines such as the measles-mumps-rubella (MMR, $18.98) or diphtheria and tetanus toxoids and acellular pertussis (DTaP, $13.25).8



There are several unique vaccination recommendations specific to women who are pregnant or are trying to become pregnant. There are vaccine-preventable diseases that pose special risks to fetuses and newborns; vaccination of a woman before or during her pregnancy can reduce the incidence of these diseases. There are also vaccinations that should not be given to pregnant women. Healthcare providers have the dual responsibility of understanding the impact of vaccine-preventable diseases on both mother and fetus, as well as knowing the vaccine recommendations for pregnant women and how these differ from nonpregnant adults.


The CDC publishes vaccine guidelines for women before, during, and after pregnancy.24 The 4 specific vaccines with unique implications for pregnant women are rubella, hepatitis B, pertussis, and influenza. These will be discussed individually later, as will specific recommendations for women who are traveling while pregnant. Live vaccines should not be given to pregnant women because there is a theoretical risk to the fetus from these types of vaccinations.21,22 These contraindicated vaccinations include rubella, live attenuated influenza, MMR, varicella, and zoster (shingles). In addition, the human papilloma virus vaccine is "not recommended."22


A preconception healthcare visit is an ideal time to assess a woman's vaccination history, collect titers if necessary, and provide appropriate vaccinations if they are needed. Preconception counseling ensures that women are up to date on vaccinations and enables them to receive "missing" vaccinations before becoming pregnant. This is of particular value in the case of live vaccines such as rubella, which should not be given to pregnant women. Women who are already pregnant should be assessed for vaccination status, including titers, and counseled about which vaccines are safe in pregnancy and which should be given postpartum. Pregnant women should be assured that being up to date on their own vaccinations is the first step in protecting their infants from vaccine-preventable diseases.



Rubella (German measles) is a viral disease that typically causes a fever and skin rash for several days. In young adults, it is usually not a serious illness and is self-limiting in duration.25 The fetus of a pregnant woman infected with rubella is at risk for severe birth defects, including deafness, heart defects, cataracts, damage to the liver and spleen, mental retardation, and termination. The CDC recommends that women who intend to become pregnant be given the MMR vaccine if a titer result is nonimmune; these women should wait to become pregnant for at least 4 weeks after vaccination.24 Since rubella is a live-virus vaccine, it should not be given to pregnant women because of the potential risk to the fetus. Instead, pregnant women who are found to be nonimmune to rubella should be offered the vaccine once they have given birth.


Hepatitis B

Hepatitis B is a viral infection that affects the liver. It can be either acute, lasting several weeks, or chronic and lifelong. It is spread through contact with body fluids. A pregnant woman who has hepatitis B can pass it to her infant during delivery.26 Acute hepatitis B is more likely to develop into chronic hepatitis B the younger it is acquired. It is estimated the 90% of infants affected with hepatitis B will develop chronic infection; most people with chronic hepatitis B were infected as infants or very young children. The CDC recommends that pregnant women be tested for hepatitis B as part of preconception care or upon presenting for prenatal care. Women who are at high risk for hepatitis B and not already immune should be offered the vaccination series. The vaccination may be given during pregnancy.


The CDC also recommends the first dose of hepatitis B vaccine be given to infants within 12 hours of birth, with additional doses per the vaccination schedule for children. This is especially important if the mother has hepatitis B. Infants of these women should also be given hepatitis B immune globulin. The combination of the hepatitis B vaccine and hepatitis B immune globulin given to the infants of hepatitis B-positive women can prevent most cases of chronic hepatitis B.26



Pertussis (whooping cough) is a bacterial illness that causes severe, violent coughing spells. Complications include pneumonia and death. The CDC vaccination schedule recommends infant vaccination at 2, 4, and 6 months of age, after which time most infants are protected.27,28 Since infant vaccination does not begin until 2 months, they are susceptible to pertussis infection before this time and are also at increased risk for complications and death. Adults who are infected with pertussis may not have symptoms, so an infected adult can pass pertussis to an infant without realizing it.23 To protect infants who are too young to be vaccinated, the CDC recommends that all adults who are in contact with an infant younger than 12 months receive the DTaP vaccine; ideally, it should be given at least 2 weeks prior to contact. In addition, pregnant women who have not previously had a DTaP vaccine should receive it in the second or third trimester of pregnancy, which provides some passive immunity against pertussis.27 If she is not given the vaccination during pregnancy, it should be given immediately postpartum.



Influenza is a respiratory virus that causes coughing, sneezing, fever, and body aches. It may lead to secondary infections such as ear or sinus infections or pneumonia. Because different strains of the virus are prevalent at different times, yearly influenza vaccination is recommended for everyone aged 6 months and older. As is the case with pertussis, infants younger than 6 months are at increased risk, both of getting influenza and of suffering complications. For this reason, anyone expecting contact with an infant should receive the influenza vaccine.28


Because of normal physiologic changes in the heart and lungs during pregnancy, a pregnant woman who contracts influenza is at a greater risk for complications, hospitalization, and death.29 Infection with influenza also places pregnant women at higher risk of premature labor and delivery. For these reasons, any woman who is pregnant during influenza season should receive the inactivated influenza vaccination regardless of pregnancy trimester.24 Pregnant women should not receive the live attenuated influenza vaccine, which is administered via nasal spray, because of the theoretical harm to the fetus of a live-virus vaccination.28


Swine influenza or "swine flu" is an influenza virus that causes illness in pigs. Although humans are not usually affected by these viruses, variant viruses have occasionally spread to humans, causing limited disease. Prior to 2009, the CDC recorded infection with these variant strains in approximately 1 person every 1 to 2 years.30 In 2009, a strain of variant swine flu (H1N1) emerged that not only caused illness in humans but was also easily transmissible among humans. This led to a pandemic; from April 2009 to April 2010, the CDC reported mid-level estimates of 61 million H1N1 cases, 274 000 hospitalizations, and 12 470 deaths.31 Since 2009, the seasonal influenza vaccine includes H1N1 and other similar swine influenza variants.30


Vaccinations for travel

International travel presents additional considerations for healthcare providers and pregnant women. There are multiple areas of the world where vaccine-preventable diseases are prevalent. In many of these areas, the prevalent diseases are not common or do not exist in the United States and travelers must be vaccinated before taking a trip. While pregnancy is a precaution against giving some pretravel vaccinations, the CDC recommends vaccination if the risk of exposure outweighs the potential risks of the vaccine. Vaccinations for Japanese encephalitis, meningococcal meningitis (the conjugate vaccine is preferred over the polysaccharide), inactivated polio, rabies, and typhoid (the polysaccharide is preferred to the live attenuated vaccine) should all be given with caution to pregnant women. However, if a woman is traveling to an area with high incidence of these diseases and exposure is likely, the CDC suggests that the benefit of vaccine administration outweighs the potential risks.32


The yellow fever vaccination requires that a risk-benefit analysis be made on a case-by-case basis. In some instances, the risk of vaccination outweighs that of exposure to yellow fever; in these cases, a pregnant woman may be issued a medical waiver, allowing her to travel without receiving the vaccination. If the risk of exposure to yellow fever is greater than the risk of vaccination, the vaccination may be administered.32


Some travel locations may require vaccination against tuberculosis, MMR, or varicella. These vaccinations are contraindicated in pregnant women because of the risks to the fetus. A pregnant woman should delay travel until after delivery rather than receiving these vaccines.32 Women considering travel to countries that require vaccinations should be referred to a healthcare professional familiar with these vaccinations and with international travel.



Parents and pregnant women refuse vaccinations for religious or political reasons as a result of concerns over the safety of vaccines and their ingredients. Some of the most common concerns related to vaccines have been dispelled with scientific research. Despite the evidence base supporting the safety and efficacy of vaccination, the rates of nonvaccination and of requests for alternate vaccination scheduling continue to rise. To discuss vaccine safety with parents and pregnant women, it is vital that healthcare providers be familiar with some of the more common concerns parents may present, and should explain the evidence refuting these concerns.


In August 2011, the Institute of Medicine released a consensus report titled "Adverse Effects of Vaccines: Evidence and Causality."33 This report focused on 8 vaccinations-varicella zoster, influenza (except 2009 H1N1), hepatitis B, human papilloma virus, MMR, hepatitis A, meningococcal, and those containing tetanus-with a focus on the casual relationship between these vaccines and adverse events. This meta-analysis established that while there are links between MMR, varicella zoster, influenza, hepatitis B, meningococcal, and tetanus-containing vaccines and anaphylaxis, this is a rare occurrence. The meta-analysis found no demonstrable link between any of the vaccinations and either autism or asthma.33 The analysis concluded that vaccines cause or are associated with few health problems. Common adverse events of vaccination include injection site reactions or localized pain, fever, and malaise, which are mild and self-limiting.


Ahluwalia et al34 investigated the reasons why pregnant women were not vaccinated for influenza during the 2009-2010 influenza season despite the American Congress of Obstetricians and Gynecologists recommendations35 and the Healthy People 2020 goal of 80% vaccination.14 Using the Pregnancy Risk Assessment and Monitoring System, the most common reasons for not vaccinating for seasonal influenza were "normally don't get" (72.1%), "worried for baby" (47.7%), "worried for me" (45.2%), and "MD didn't mention" (32.6%).32 The high number of patients who were not vaccinated because the vaccine was not presented by their healthcare provider indicates one clear way for providers to increase vaccination rates. The percentages of women who were not vaccinated out of concerns for their own or their infant's health indicate that simple education about the benefits of influenza vaccine may be a catalyst to reaching the Healthy People 2020 vaccination goals.


The rationales cited by parents for decreasing rates of completed vaccination for their children are more complex. Kennedy et al36 examined parental beliefs and concerns regarding vaccination. The primary concerns cited by parents who did not vaccinate their children or elected to follow an alternate vaccination schedule were "pain" (38%), "receiving too many vaccines at one time" (36%), "too many vaccines in the first 2 years" (34%), "potential for fever" (32%), "potential for learning disabilities and autism" (30%), and "unsafe ingredients" (26%). Localized pain and swelling, as well as mild fever and the potential for anaphylaxis, are part of the informed consent and should be discussed with parents and pregnant women. However, it is appropriate and important to emphasize that these are not the reasons to delay or withhold vaccination and the sequelae of infection are more significant and more frequent than those resulting from vaccination. Clients with concerns about learning disabilities, vaccine ingredients, and safety should be reassured and provided evidence demonstrating vaccine safety. In addition, current CDC data about rising rates of vaccine-preventable diseases in the community and the role of vaccination can be useful information for parents.


When making decisions about infant vaccination, Kennedy et al36 found that the most frequently cited sources were trusted healthcare providers (85%), family (46%), and friends (22%), government and professional organizations (28%), the Internet (10%), and traditional media (11%). Omer et al5 emphasized that parents who delay vaccination or select alternate scheduling, such as "Dr Bob's Selective Vaccine Schedule"37 (see further discussion on alternative vaccination schedules later), often do so at the suggestion of their healthcare providers. These reviews indicate that trusted healthcare providers can have a great deal of impact on rates of vaccine administration for infants, children, and pregnant women and on preventing disease outbreaks.



Most parents with concerns about vaccinations are asking similar questions. Some common questions and concerns patients bring to providers are presented, followed by a discussion of the evidence and talking points for providers.


Do vaccines cause autism and developmental delays?

This concern gained momentum and publicity after the publication of an article in Lancet by Wakefield et al38 in 1998. The article featured interviews with the parents of 12 children with a diagnosis of autism spectrum disorder (ASD). The parents of 8 of these children recalled that symptoms of developmental delays had begun with the administration of the MMR vaccine. The article speculated that the MMR vaccine had, in fact, been the cause of these delays and of the children's autism.


As this purported link gained momentum, many in the medical field pointed to the inherent flaws in the article of Wakefield et al, including the very small study population and the reliance on interview and parent recollection as its main data sources. Further research was conducted to examine the suggested causal link between MMR vaccination and ASD. One notable study was performed by Thompson et al in 2007.39 In a large-scale cohort study, 1107 children 7 to 10 years of age were given a series of neurophysical tests designed to assess 42 characteristics, including speech ability, memory, hyperactivity, and tics. These results were compared with levels of thimerosal each child had received in vaccines. There were no associations found between the level of thimerosal exposure and any of the neurophysical outcomes.39


All of these subsequent studies culminated in an Institute of Medicine review, "Immunization Safety Review: Vaccines and Autism,"40 and a 2005 Cochrane Database review, "Vaccines for Measles, Mumps and Rubella in Children."41 At the highest level of scientific evidence, neither review found any evidence of a causal linkage between MMR vaccination and ASD. After review of these findings, Lancet ultimately retracted the original article of Wakefield et al.


The American Psychological Association diagnostic criteria for ASD outline a range of symptoms, varying in severity from "mild" to "requiring very substantial support."42 The onset of symptoms coincides with the recommended age for MMR vaccine administration,43 which has led some parents to infer a causal relationship between receipt of the vaccination and the development of ASD. Concerned parents should be assured that although these events are correlated (ie, occur at similar points in time), there is no evidence showing causation (ie, one event, having autism, happens because of the other event, receiving a vaccination). While acknowledging parent's concerns, healthcare providers can succinctly present the information from the Institute of Medicine and Cochrane Database reviews to sufficiently demonstrate that the evidence demonstrates no connection between vaccination and the development of ASDs.


Do vaccines have lots of chemical additives?

One common criticism of vaccinations is that they contain unknown or unusual ingredients. Those commonly cited by concerned parents and patients include thimerosal or mercury (which is discussed earlier), aluminum, formaldehyde, and antifreeze. Information distributed by antivaccination groups and individuals cites the industrial uses of these chemicals and the adverse effects of exposure in large amounts or over long periods of time as reasons to question the safety of vaccines containing these ingredients.


Aluminum salts are included in vaccines to increase efficacy. They increase the body immune response to the antigen, which decreases the number of shots needed to create immunity. Because aluminum is present in the earth crust, we are exposed to it in food and water and it is present in both breast milk and infant formula. It is estimated that the amount of aluminum found in vaccines is about that present in 33 oz of infant formula.44


Formaldehyde is another vaccine component that often causes concerns because of its better-known uses in industrial trades and as an embalming agent. It is used in vaccines to inactivate viruses and detoxify diphtheria and tetanus. The amount that is left in the actual vaccine is smaller than the amount of formaldehyde found naturally in the human bloodstream. It is also worth noting that formaldehyde can be found in household products such as paper towels and cosmetics and is not harmful in these amounts.44


Antifreeze is often cited as a worrisome vaccine component, although this is based on a misunderstanding. Antifreeze is made up of ethylene glycol, whereas the vaccine component is polyethylene glycol, which is often used in cosmetics and toiletries such as lotion and toothpaste. Safe amounts of polyethylene glycol are used in vaccines to inactivate viruses and as a purifier.44


Concerned parents should be told that small amounts of these preservatives and stabilizers are used in manufacturing vaccines to ensure their safety and sterility. In a 2003 review of the evidence, Offit and Jew45 found that these chemical additives, in the amounts present in vaccinations, are likely not harmful to humans. For parents with more specific concerns related to individual vaccines or individual ingredients, the CDC outlines the ingredients found in each vaccine, as well as the evidence for the safety of these ingredients, in its "Ingredients of Vaccines Fact Sheet."46 Healthcare providers may wish to share this fact sheet with parents to help them make fully informed choices about vaccinating their children.


Of course, persons with known allergies to any vaccine component should not receive vaccines containing these components.


Do vaccines have a lot of adverse effects?

Some common adverse effects of vaccine administration are irritation and redness at the injection site, low-grade transient fever, cold-like symptoms (malaise, cough, stuffy nose, etc), and diarrhea. All of these adverse effects are considered mild and will, unlike the diseases prevented by vaccines, resolve without intervention or long-term sequelae.45 There is a potential for more severe reactions and adverse effects following vaccine administration. These adverse effects most notably include autoimmune reactions (rheumatoid arthritis and Guillain-Barre syndrome), complications of high fevers (encephalopathy and seizures), and anaphylaxis or other allergic responses.47 The potential for these serious adverse effects should be considered in context: the Vaccine Adverse Events Reporting System has received so few reports of these reactions that it is difficult to determine a causal relationship between vaccinations and these extremely rare adverse effects.


The exception for vaccine refusal in the face of potential adverse effects is for the case of patients who are immunocompromised. Live vaccines should not be given to those who are immunocompromised, and their family members should discuss the situation with a healthcare provider before being vaccinated themselves. The most important point to remember and emphasize with patients and families is that the adverse effects from vaccinations are typically mild and transient whereas the diseases they prevent have higher rates of debility and death.


Are these diseases really that bad?

There is a misunderstanding among many parents and pregnant women that vaccine-preventable diseases are not serious illnesses or are not common enough to warrant vaccination. The perception of the benign nature and infrequent morbidity of these diseases ironically stems from the success of vaccination. Since polio has been completely eradicated in the United States and the prevalence of other vaccine-preventable diseases has decreased so significantly, the public health risks of these diseases are not as visible or widespread as they once were. Adults who remember having measles or chickenpox when they were children may not realize the rates of disability and death associated with these diseases, thinking of them instead as routine and harmless childhood illnesses.


Misconceptions about the seriousness and transmissibility of vaccine-preventable diseases may prompt patients to question the relevance of vaccinations based on an erroneous risk-benefit ratio. It is important for healthcare providers to be able to explain how sufficiently high enough levels of vaccination in the community ("herd immunity") work to prevent a rapidly spreading outbreak. Providers can also discuss the prevaccination morbidity and mortality rates for vaccine-preventable diseases to counsel patients on the continued importance of vaccinations for individual health and in the larger social context.


Can the vaccines be given on a different schedule?

Many parents with concerns about vaccines may ask about alternatives to the CDC-recommended vaccine schedules. These "alternate schedules" aim to spread the course of vaccination over a longer time period. This is usually accomplished by giving fewer vaccinations at one time, requires more office visits to give all of the recommended vaccinations, and results in finishing the full vaccination course at a later age. Although alternate schedules may seem to be a good compromise, giving all of the recommended vaccinations while assuaging some fears of vaccine-cautious parents, alternate vaccine schedules create gaps in coverage and are not recommended or endorsed by any expert committees.48 It is important that healthcare providers be able to discuss these schedules and correct misconceptions about their value as substitutes for the CDC-recommended schedule.


One of the most popular variations on the vaccine schedule is "Dr Bob's Alternative Vaccine Schedule," which was created by Dr Robert Sears and explained in his 2011 The Vaccine Book.37 The book has sold more than 40 000 copies and Dr Sears' vaccination schedule has been shared on numerous blogs and Web sites. The Vaccine Book presents 2 vaccination schedules of Dr Sears's creation. The first is an "alternative" schedule that gives all of the CDC-recommended vaccinations over a longer period of time-for example, hepatitis B vaccination is begun at 2.5 years rather than at birth. The second schedule is a "selective" schedule that eliminates the MMR, varicella, hepatitis A, and polio vaccinations and delays the influenza vaccination until 21 months of age.37 In their 2009 article, Offit and Moser48 review the statements made in Dr Sears' book and provide evidence countering these claims. The main arguments in The Vaccine Book are those covered previously in this article-that the safety of vaccinations is suspect, that vaccinations contain toxic ingredients, and that vaccines prevent diseases that are no longer a concern in the United States. In addition to providing evidence against these claims, Offit and Moser48 point to the negative effects of following one of Dr Sears' alternate schedules. While parents may feel that the alternative schedule is an acceptable alternative to the CDC-recommended schedule, a delay of months or years in receiving vaccinations leaves children unprotected at a time when they are most vulnerable. Since children are among the groups more likely to experience severe illness or death when infected with vaccine-preventable diseases, an alternative vaccine schedule that leaves the youngest children unvaccinated increases the risk of illness and disease outbreak.46



Rates of vaccination for children and pregnant women continually fall short of the Healthy People public health campaign goals, and patients are declining or delaying vaccinations because of fears and misunderstandings with increasing frequency. The decrease in vaccination rates is leading to increasing disease rates. Given the enormous body of evidence supporting vaccination as a highly effective weapon against multiple diseases, it is clear that increasing vaccination rates and meeting the Healthy People 2020 goals will have a marked effect on public health.


Evidence also shows that patients look to their healthcare providers for information and guidance when they have questions or concerns about the necessity and safety of vaccination. Healthcare providers are in the position of trusted resource for the families and communities they serve. As such, providers have an obligation to know and understand the basic principles of immunity, the evidence base about vaccination safety, and the current vaccination recommendations from government and professional organizations. They must then be able to use this knowledge to discuss vaccinations with parents and pregnant women, answer their questions, and guide them through the large volume of information available. In the digital age, patients are able to assemble information from a wide body of sources, from evidence-based research articles to personal opinion blogs. While acknowledging and respecting patients' right to autonomy and self-efficacy, healthcare providers are under professional responsibility to correct erroneous information and calm unfounded fears and guide patients in safe, rational, and evidence-based decision making.


Table 3 provides a list of further evidence-based resources about vaccines, their purpose, their adverse effects, and their safety, suitable for sharing with patients who desire more information.

Table 3 - Click to enlarge in new windowTable 3. Vaccination resources for parents and patients



1. Willis NJ. Edward Jenner and the eradication of smallpox. Scott Med J. 1997;42(4):118-121. [Context Link]


2. Centers for Disease Control and Prevention. Vaccines & Preventable Diseases. Atlanta, GA: National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention; 2009. Accessed December 5, 2011. [Context Link]


3. Roush SW, Murphy TV, the Vaccine-Preventable Disease Table Working Group. Historical comparisons of morbidity and mortality for vaccine-preventable diseases in the United States. JAMA. 2007;298(18):2155-2163. [Context Link]


4. Clemens J, Shin S, Ali M. New approaches to the assessment of vaccine herd protection in clinical trials. Lancet Infect Dis. 2011;11:482-487. [Context Link]


5. Omer SB, Salmon DA, Orenstein WA, deHart MP, Halsey N. Vaccine refusal, mandatory immunizations, and the risks of vaccine-preventable diseases. N Engl J Med. 2009;360(19):1981-1988. [Context Link]


6. Haberling DL, Holman RC, Paddock CD, Murphy TV. Infant and maternal risk factors for pertussis-related infant mortality in the United States, 1999 to 2004. Pediatr Infect Dis J. 2009;28(3):194-198. Accessed May 20, 2012.


7. Centers for Disease Control and Prevention. What would happen if we stopped vaccinations? Published 2007. Accessed December 5, 2011. [Context Link]


8. Centers for Diseases Control and Prevention. Pediatric/VFC vaccine price list. Published 2012. Accessed December 5, 2011. [Context Link]


9. Dempsey AF, Schaffer S, Singer D, Butchart A, Davis M, Freed GL. Alternative vaccination schedule preferences among parents of young children. Pediatrics. 2011;128(5):848-856. [Context Link]


10. Atkinson W, Wolfe C, Hamborsky J, eds. Epidemiology and Prevention of Vaccine-Preventable Diseases. 12th ed. Washington, DC: Public Health Foundation; 2011. [Context Link]


11. Centers for Disease Control and Prevention. High number of reported measles cases in the United States in 2011-linked to outbreaks abroad. Published 2011. Accessed December 5, 2011. [Context Link]


12. Fiore AE, Shay DK, Broder K, et al. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. Morb Mortal Wkly Rep. 2009;58:896-897. [Context Link]


13. Centers for Disease Control and Prevention. Influenza vaccination coverage among pregnant women-United States, 2010-11 influenza season. Morb Mortal Wkly Rep. 2011;60(32):1078-1082. [Context Link]


14. US Department of Health and Human Services. Healthy People 2020: goals and objectives. Published 2012. Accessed December 5, 2011. [Context Link]


15. Centers for Disease Control and Prevention. Recommended immunization schedules for persons aged 0-18 years-United States, 2011. Morb Mortal Wkly Rep. 2011;60(5). Accessed December 5, 2011. [Context Link]


16. American Academy of Family Physicians. CDC study shows vaccination rates for kids, teens are up: Nearly all 4:3:1:3:3:1 vaccines reach Healthy People 2010 targets. Published 2009. Accessed December 5, 2011. [Context Link]


17. Centers for Disease Control and Prevention. Estimated vaccination coverage with individual vaccines and selected vaccination series among children 19-35 months of age by state and local area US, National Immunization Survey, Q1/2010-Q4/2010. = Q1/2010-Q4/2010. Published 2011. Accessed December 5, 2011. [Context Link]


18. Centers for Disease Control and Prevention. How vaccines prevent disease. Published 2009. Accessed December 5, 2011.


19. Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red book: Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.


20. PrabhuDas M, Adkins B, Gans H, King C, Levy O, Ramilo O. Challenges in infant immunity: implications for responses to infection and vaccines. Nature Immunol. 2011;12(3):189-194.


21. Bartlett BL, Pellicane AJ, Tyring SK. Vaccine immunology. Dermatol Ther. 2009;22(2):104-109. [Context Link]


22. Centers for Disease Control and Prevention. Guidelines for vaccinating pregnant women. Published 2008. Accessed December 5, 2011. [Context Link]


23. Carabin H, Edmunds WJ, Kou U, van den Hof S, Nguyen VH. The average cost of measles cases and adverse events following vaccination in industrialised countries. BMC Public Health. 2002;2:22-35. [Context Link]


24. Centers for Disease Control and Prevention. Immunizations for pregnant women. Published 2012. Accessed May 20, 2012. [Context Link]


25. Centers for Disease Control and Prevention. Rubella disease in-short. Published 2009. Accessed May 20, 2012. [Context Link]


26. Centers for Disease Control and Prevention. Hepatitis B FAQs for the public. Published 2009. Accessed May 20, 2012. [Context Link]


27. Centers for Disease Control and Prevention. Pertussis prevention. Published 2012. Accessed May 20, 2012. [Context Link]


28. Centers for Disease Control and Prevention. Key facts about influenza (flu) & flu vaccine. Published 2012. Accessed May 20, 2012. [Context Link]


29. Centers for Disease Control and Prevention. Seasonal flu vaccine safety and pregnant women. Published 2011. Accessed May 20, 2012. [Context Link]


30. Centers for Disease Control and Prevention. Key facts about human infections with variant viruses (Swine origin influenza viruses in humans). Published April 2012. Accessed May 20, 2012. [Context Link]


31. Centers for Disease Control and Prevention. Updated CDC estimates of 2009 H1N1 influenza cases, hospitalizations and deaths in the united states, April 2009-April 10, 2010. Published 2012. Accessed May 20, 2012. [Context Link]


32. Sutton MY. Pregnant travelers. In: CDC Health Information for International Travel 2012: The Yellow Book. New York, NY: Oxford University Press; 2012:536-544. [Context Link]


33. Stratton K, Ford A, Rusch E, Clayton EW. Adverse Effects of Vaccines: Evidence and Causality. Washington, DC: The National Academies Press; 2011. [Context Link]


34. Ahluwalia IB, Singleton JA, Jamieson DJ, Rasmussen SA, Harrison L. Seasonal influenza vaccine coverage among pregnant women: pregnancy risk assessment monitoring system. J Womens Health. 2011;20(5):649-651. [Context Link]


35. American College of Obstetricians and Gynecologists. Influenza vaccination during pregnancy: Committee opinion No. 468. Obstetr Gynecol. 2010;116(4):1006-1007. [Context Link]


36. Kennedy A, LaVail K, Nowak G, Basket M, Landry S. Confidence about vaccines in the United States: understanding parents' perceptions. Health Aff. 2011;30(6):1151-1159. [Context Link]


37. Sears R The Vaccine Book: Making the Right Decision for Your Child. 2nd ed. New York, NY: Little Brown & Co; 2011. [Context Link]


38. Wakefield AJ, Murch SH, Anthony A, et al. Ileal lymphoid nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet. 1998;35(1903):637-641. [Retraction in Lancet. 2010;375(9713):445; PMID: 20137807]. [Context Link]


39. Thompson WW, Price C, Goodson B, et al. Early thimerosal exposure and neuropsychological outcomes at 7 to 10 years. N Engl J Med. 2007;357:1281-1292. [Context Link]


40. Institute of Medicine. Immunization Safety Review: Vaccines and Autism. Washington, DC: The National Academies Press; 2004. [Context Link]


41. Demicheli V, Jefferson T, Rivetti A, Price D. Vaccines for measles, mumps and rubella in children. Cochrane Database Syst Rev. 2005;(4):CD004407. [Context Link]


42. American Psychological Association. Autism Spectrum Disorder. Published 2011. Accessed December 5, 2011. [Context Link]


43. Ozonoff S, Iosif A, Baguio F, et al. A prospective study of the emergence of early behavioral signs of autism. J Am Acad Child Adolesc Psychiatry. 2010;49(3):256-266. [Context Link]


44. American Academy of Pediatrics. Questions and answers about vaccine ingredients. Published 2008. Accessed December 5, 2011. [Context Link]


45. Offit PA, Jew RK. Addressing parents' concerns: do vaccines contain harmful preservatives, adjuvants, additives, or residuals? Pediatrics. 2003;112(6):1394-1397. [Context Link]


46. Centers for Disease Control and Prevention. Ingredients of vaccines-fact sheet. Published 2011. Accessed December 5, 2011. [Context Link]


47. Ward BJ. Vaccine adverse events in the new millennium: is there reason for concern? Bull World Health Organ. 2000;78(2):205-215. [Context Link]


48. Offit PA, Moser CA. The problem with Dr. Bob's alternative vaccine schedule. Pediatrics. 2009;123:e164-e169. [Context Link]


49. Childhood vaccines: What they are and why your child needs them. Published 2010. Accessed December 5, 2011.


50. Childhood Influenza Immunization Coalition. 10 reasons to get vaccinated: pediatric flu prevention. Published 2009. Accessed December 5, 2011.


51. Immunization Action Coalition. What if you don't immunize your child? Published 2011. Accessed December 5, 2011.


52. Centers for Disease Control and Prevention. Instant childhood immunization schedule. Published 2012. Accessed December 5, 2011.


53. American Academy of Pediatrics. Immunization: frequently asked questions. Published 2012. Accessed December 5, 2011.


54. Immunization Action Coalition. Vaccine information for the public and health professionals. Published 2011. Accessed December 5, 2011.


55. Immunization Action Coalition. Need help responding to vaccine-hesitant parents? Published 2011. Accessed December 5, 2011.


alternate vaccination schedule; childhood diseases; vaccination; vaccination refusal