1. Balestra, Melanie JD, RN, NP

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Recent outbreaks of measles and pertussis are a reminder that infectious diseases once thought of as "rare" or "eradicated" are making a comeback in the United States. This is due in part to a growing trend of parents refusing to immunize their children due to concerns regarding vaccine safety. As part of this antivaccination movement, various groups are opposed to immunizations for philosophical reasons or because they incorrectly believe that vaccines cause autism, neurodevelopmental disorders, sudden infant death syndrome, and autoimmune diseases, among others. However, according to a new report from the CDC, immunization is one of the most important preventive health measures, responsible for saving millions of lives.1


Although NPs in all practice areas (for example, pediatrics, family, adult-gerontology, and women's health) should be aware of the trend against vaccinations, this issue is of particular concern for pediatric NPs who regularly discuss vaccinations with parents as part of routine patient care. This article discusses potential challenges when interacting with vaccine-hesitant parents and offers NPs strategies for educating reluctant parents about vaccine benefits and risks with the hope that they will change their minds. It also provides NPs with recommendations in order to minimize potential legal exposure when facing parents who refuse vaccination.


Role of vaccinations in preventing infectious diseases

Preventive care is an important part of maintaining good health. This includes immunizations, which protect infants and children from vaccine-preventable diseases. The CDC recently reported that routine childhood vaccinations given between 1994 and 2013 will save an estimated 732,000 lives, prevent 322 million illnesses, and 21 million hospitalizations over the course of the children's lifetimes.1 Vaccination also reduces costs in healthcare, saving $295 billion in direct costs and $1.38 trillion in societal costs due to illnesses prevented from vaccinations.1


These benefits are seen as a direct result of the national Vaccines for Children (VFC) program designed to promote childhood vaccines. Implemented in 1994 to help provide vaccines to children whose parents or guardians may not be able to afford them, the VFC program has contributed directly to a substantial increase in childhood immunization coverage levels and has made a significant contribution to the elimination of disparities in vaccination coverage among young children.1 The CDC estimates that vaccine rates have soared to near or above 90% for several routine vaccines, including the measles, mumps, and rubella vaccine; poliovirus vaccine; hepatitis B vaccine; and varicella vaccine.1


As part of routine care, all parents should be informed about the risks of vaccine-preventable diseases as well as the risks and benefits of immunizations. Pediatric NPs play a key role in this process. Education efforts should include a discussion regarding vaccine-associated adverse reactions and the provision of Vaccine Information Statements (VISs) as required by federal law. The National Childhood Vaccine Injury Act requires that all healthcare providers give parents copies of VISs before administering each dose of the vaccines listed in the schedule.2


The antivaccine movement

Despite education efforts regarding the importance and safety of immunizations, some parents will refuse vaccinations. According to the American Academy of Pediatrics, within a 12-month period, 74% of pediatricians reported encountering a parent who refused to have his or her child vaccinated or delayed one or more vaccines.3 Findings from a 2011 survey of children ages 6 months to 6 years found that 13% of parents followed an alternative vaccination schedule, and of these, 53% of parents refused certain vaccines, and 55% of parents delayed some vaccines until the child was older.3 Additionally, 17% of parents refused all vaccines, and in a 2009 survey, 11.5% of parents of children age 17 and younger reported refusing at least one vaccine.3


Immunization refusal is often due to misinformation perpetuated by the antivaccination movement that includes some well-known celebrities who claim that vaccines cause autism despite the fact that the pivotal British study from which they base their arguments was widely discredited and retracted.4 Unfortunately, this movement continues to make inroads, and there are a growing number of parents who seek nonmedical (personal or religious) exemptions from vaccinations for their children to attend public schools. This is exemplified in California (one of several states that allow nonmedical exemptions for parents before their children enter school), where from 2000 to 2010, nonmedical exemption rates more than tripled from 0.77% to 2.33%, with some schools reporting nonmedical exemption rates as high as 84% in 2010.5


Interestingly, these increases continue despite efforts such as California's recent law requiring that in addition to signing a personal belief exemption form for school entry, parents also are required to obtain a signed form from a pediatric provider stating that they have been counseled about the risks and benefits of vaccines.6 Washington, Oregon, and Vermont also have revised their personal exemption processes. Under Oregon's law, effective March 1, 2014, parents must now ask a healthcare practitioner to review information about the risks and benefits of immunization that is consistent with information published by the CDC or complete an online vaccine education module before receiving a Vaccine Education Certificate that will allow them to claim a nonmedical exemption.7


The unfortunate result of the antivaccination movement is the recurrence of infectious diseases, such as pertussis, measles, and meningitis. According to research published in Pediatrics, California's pertussis epidemic, in 2010, likely spread among unvaccinated children to infect 9,210 children.5 The researchers compared the number of intentionally unvaccinated children who entered kindergarten from 2005 to 2010 to the onset of the pertussis outbreak in 2010, identifying 39 regional clusters of children with nonmedical reasons for being unvaccinated and two clusters that were significantly related to rapid spread of the disease.5


Other examples include a current ongoing measles outbreak-the largest outbreak of measles in the United States since 1996. The CDC reports that from January 1 to August 25, 2014, 592 cases of measles have been reported in 21 states, and the majority of those who contracted measles were not vaccinated.8 This includes 18 outbreaks representing 89% of reported cases for 2014.8


In addition, measles is still common in many parts of the world, including some countries in Europe, Asia, the Pacific, and Africa, and travelers with measles continue to bring the disease into the United States. Several cases from this current outbreak were imported via travel to the Philippines, where a huge outbreak affected 20,000 individuals and caused 69 deaths.9 The measles outbreak in the Philippines is an example of new and emerging issues the United States is facing in regards to immunizations and vaccine preventable diseases, which must be looked at in a global context due to increasing international travel and trade as well as immigration (both legal and undocumented).


Focus on education

As part of daily patient care, NPs can play a key role in shaping parental attitudes toward vaccinations and influencing vaccine-hesitant parents. Effective communication is critical, as it can address parent concerns and change attitudes and behaviors, resulting in acceptance of and compliance with vaccination schedules. With that in mind, the following recommendations are provided to help NPs communicate with parents regarding vaccinations as well as the infectious diseases they prevent.


* Build rapport and listen respectfully, encourage questions, and acknowledge parental concerns.


* Provide accurate information about both risks and benefits of immunizations. This should include a thorough and accurate discussion of risks associated with both remaining unvaccinated and delaying certain vaccines as well as a reminder that vaccinations are important in part because effective treatments do not exist for most vaccine-preventable diseases.10


* Try to dissuade a parent from splitting up combination vaccinations, as it can be difficult to get the parent and child back in the office in a timely manner in order to complete the vaccination regimen.


* Be aware that parents who intentionally do not get their children vaccinated could also create secondary problems by opting out of their own vaccinations, such as those required for pertussis, which is highly contagious and can be severe for infants. Parents (and all family members or caregivers involved with young infants) who are not up to date with the tetanus, diphtheria, pertussis (Tdap) vaccine should get vaccinated at least 2 weeks before coming into close contact with an infant. Pregnant women also are encouraged to get vaccinated in their third trimester. As with concerns regarding immunizations for children, NPs should listen to a parent or other caregiver's concern about their own vaccinations, provide information about the value of a booster, such as the Tdap, and encourage vaccination.


* Avoid adversarial debate. If parents express concerns, follow up with them a few days after the visit or schedule a follow-up appointment.


* Document parents' questions and concerns as well as all of the information provided.



Providing good information is essential. There are numerous resources available, including guides from the National Association of Pediatric Nurse Practitioners and the CDC to help assess parents' needs, identify the role they want to play in making decisions for their child's health, and then communicate in ways that meet their needs.11,12


Legal implications: Refusal to vaccinate

It is inevitable that NPs will encounter parents who refuse to vaccinate their children in their practices. NPs should consider the following suggestions about how to handle parents in this situation:13


* Provide parents with sufficient information about vaccine-preventable diseases (verbally and in writing). This includes information about the clinical presentations of these diseases and early symptoms, especially important for pertussis and measles, which are highly contagious and may present early as a nonspecific respiratory illness. One example is the CDC's fact sheet "If You Choose Not to Vaccinate Your Child, Understand the Risks and Responsibilities."14


* Advise parents of an unimmunized child that if they are taking their ill child to a provider's office, urgent care clinic, or other facility, that they should call in advance so that appropriate isolation precautions can be implemented to protect other patients and staff.


* Similar isolation precautions should be implemented when scheduling an office visit for an ill child who has not received vaccines in order to reduce or eliminate exposure from other ill patients in the waiting area who could endanger the unvaccinated child.


* Advise parents that the dialogue about vaccines is ongoing and will be taken up again at the next office visit, and then make sure to do so.



Finally, while good communication and rapport are a key part of the interactions with parents who refuse to vaccinate their children, it also is important to document all medical actions and discussions as part of a sound risk management strategy and to mitigate liability. If, after discussions with parents, they choose to skip vaccines for their children, the parents should sign a Refusal to Vaccinate form (have a new form signed each time a vaccine is refused so there is a record in the child's medical file). The American Academy of Pediatrics has a form that could be easily incorporated into practice.3


Vaccines are one of the largest public health success stories in the United States-a preventive health measure that is responsible for savings millions of lives. Refusing immunizations can put a child at risk for contracting a preventable disease as well as transmitting the disease to others, including those too young to be vaccinated or those with immune problems. For some diseases, such as measles, one case is enough to cause concern. Pediatric and family NPs can work with vaccine-hesitant parents by using clear language to present accurate evidence of disease risks and vaccine benefits. The goal is to ensure timely and full compliance with the recommended vaccine schedule in order to protect children from vaccine-preventable diseases.




1. Whitney CG, Zhou F, Singleton J, Schuchat A. Benefits from immunization during the vaccines for children program era-United States, 1994-2013. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2014;63(16):352-355. [Context Link]


2. Centers for Disease Control and Prevention. Vaccine Information Statements (VIS). Facts about VISs. [Context Link]


3. American Academy of Pediatrics. Documenting parental refusal to have their children vaccinated. [Context Link]


4. Wakefield AJ, Murch SH, Anthony A, et al RETRACTED: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet. 1998;351(9103):637-641. [Context Link]


5. Atwell JE, Van Otterloo J, Zipprich J, et al. Nonmedical vaccine exemptions and pertussis in California, 2010. Pediatrics. 2013;132(4):624-630. [Context Link]


6. California Legislative Information. AB-2109 Communicable disease: immunization exemption. [Context Link]


7. Education Week. States tightening loopholes in school vaccine laws. Aim is to limit opt-outs. [Context Link]


8. Centers for Disease Control and Prevention. Measles (Rubeola). Measles cases and outbreaks. [Context Link]


9. Centers for Disease Control and Prevention. CDC Newsroom. Press briefing transcript. CDC Telebriefing: Report shows 20-year U.S. immunization program spares millions of children from diseases. [Context Link]


10. Diekema DS. Improving childhood vaccination rates. N Engl J Med. 2012;366(5):391-393. [Context Link]


11. National Association of Pediatric Nurse Practitioners. Addressing parental objections to vaccinations. [Context Link]


12. Centers for Disease Control and Prevention. Provider resources for vaccine conversations with parents. [Context Link]


13. Centers for Disease Control and Prevention. Talking with parents about vaccines for infants. [Context Link]


14. Centers for Disease Control and Prevention. If you choose not to vaccinate your child, understand the risks and responsibilities. [Context Link]