ASD, autism spectrum disorder, diphtheria, tetanus, pertussis vaccine, DTaP vaccine, DTP vaccine, measles, mumps, rubella vaccine, MMR vaccine, thimerosol, vaccination, vaccine hesitancy, vaccines



  1. Anderson, Pamela MSN, RN
  2. Bryson, Jaylynn MSN, RN


Abstract: This article reviews the origins of vaccine hesitancy, explores common misconceptions about vaccines, and discusses strategies for overcoming vaccine hesitancy.


Article Content

AMID RECORD-BREAKING cases of vaccine-preventable diseases such as measles and pertussis, social media are overflowing with posts debating the safety and efficacy of vaccinations. The public has important decisions to make. On the front lines of this battle stand RNs, syringes in hand. Nurses must be prepared to address the immunization debate and understand how to educate the public on the importance of vaccinations. This article reviews the origins of vaccine hesitancy and discusses strategies for combating it (see Defining vaccine hesitancy).

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Far-reaching fraud

Much of today's vaccine hesitancy can be traced to a fraudulent study published in 1998 by The Lancet. In it, Andrew Wakefield, a gastroenterologist, and colleagues linked the measles, mumps, rubella (MMR) vaccine to autism. The study included a sample of only 12 subjects, had no controls, and was funded by lawyers for parents who were suing vaccine manufacturers.1 Exhaustive research and investigations revealed that the study was entirely fraudulent.2The Lancet formally retracted the article in 2010 and Wakefield's medical license was revoked, but he has continued to promote his discredited views in books and films.3 However, no scientific research has found any correlation between the MMR vaccine and autism spectrum disorder (ASD).4,5


The debate over the MMR vaccine and autism centered on thimerosal, a mercury-based substance used in certain vaccines as a preservative and added to multidose vials to prevent contamination. Research has consistently shown that thimerosal does not cause autism.6 Since 2003, nine studies conducted or funded by the CDC have found no link between ASD and thimerosal-containing vaccines or the MMR vaccine.7


In 2001, thimerosal was removed or reduced to trace amounts in all childhood vaccines as a precaution to minimize exposure to all types of mercury in children. Interestingly, the MMR vaccine has never contained thimerosal.8


In the late 1970s, the diphtheria, tetanus, pertussis (DTP) vaccine was thought to cause encephalitis in some patients. The rate of encephalitis was 1 to 10 cases per 1 million patients receiving the vaccine. It is believed that the whole-cell pertussis portion of the vaccine caused more severe local reactions and fever that increased the risk of seizures. In 1991, the whole-cell pertussis vaccine was discontinued and the acellular DTaP version was introduced. Studies have shown no evidence of postvaccine encephalopathy and a much lower incidence of febrile seizures with the acellular version.9


Factors underlying hesitancy to immunize

Many patients and parents hesitate to vaccinate due to misconceptions concerning vaccine safety and unfounded fears that vaccination may trigger autism, diabetes, arthritis, autoimmune diseases, or neurodevelopmental disorders in children (see Promoting childhood vaccines). Believing that the risk of adverse vaccine reactions outweighs the vaccine's benefits, they may worry about potential vaccine-associated pain and fever as well as severe but very uncommon complications such as Guillain-Barre syndrome and encephalitis.10


Another factor is the belief that contracting a disease naturally will build a healthy immune system. Some patients see the risk of contracting a vaccine-preventable disease as very small in the US and misjudge the risks of complications related to these diseases. They may feel safer relying on "herd immunity" to protect them from harm.7 Herd immunity occurs when most members of a community are immune from a contagious disease, halting disease transmission.


In addition, some parents are concerned that a child's immune system will become overwhelmed with combination childhood vaccines.10 Parents may also refuse to vaccinate their children entirely based on religious objections. Some studies show that the number of religious exemptions has been increasing, leading to disease outbreaks.11


Finally, some patients and parents distrust the federal government, pharmaceutical companies, and healthcare providers.12 Often, patients do not feel they are involved in the decision-making process when it comes to vaccination. They may lack the time and resources needed to make an informed decision about the safety and efficacy of vaccines.13


Far-reaching impact

When parents make the decision to not vaccinate their child, they impact many more people than just that child. Infants, older adults, and immunocompromised patients may be unnecessarily exposed to potentially life-threatening illnesses such as measles. Consider the following: The measles virus is shed from the nasopharynx beginning with the prodromal phase and shedding lasts until 3 to 4 days after the onset of the rash.14 The incubation period of measles ranges from exposure to the prodromal phase-an average of 10 to 12 days.15 The average days a person is contagious is 14 days, from exposure to rash onset. In those 10 to 12 days, the infected child could potentially expose many vulnerable people to the virus. In the San Diego measles outbreak in 2015, an unvaccinated child with measles exposed two immunocompromised children who could not be vaccinated. Both contracted the disease and died.16


Similarly, pertussis vaccination declined significantly in the United Kingdom in the 1970s due to allegations that the vaccine caused brain damage.17 This led to a nationwide epidemic of pertussis. The outbreak demonstrated the efficacy of the vaccine, which would have prevented the epidemic. It took several years to prove the safety of the vaccine after case control studies were conducted.17


Professor Elizabeth Miller, a leading expert in immunization research and key advisor on vaccination policies, recommends that healthcare professionals promote transparency to better convey the substantial health benefits of immunizations.17 As the examples described above illustrate, the health consequences of nonvaccination can be dire.


Because diseases such as pertussis and measles have become uncommon, many people are not familiar with the morbidity and mortality associated with vaccine-preventable diseases. Nurses can inform patients that the risks of vaccine-preventable diseases far outweigh possible adverse reactions to vaccines. For example, parents need to know about the potentially serious consequences of contracting pertussis: About half of infants younger than 1 year will require hospitalization, and of those infants hospitalized, 1 out of 4 will develop pneumonia, 1 out of 100 will have seizures, 3 out of 5 will have apnea, 1 out of 300 will have encephalopathy, and 1 out of 100 will die.18


Nursing implications

As frontline caregivers, nurses can help educate the public regarding the history and efficacy of vaccination, thereby alleviating concerns regarding vaccination risks. By improving public understanding, nurses can teach facts about vaccine safety with the hope of raising public vaccine confidence and reduce the rate of adverse reactions and vaccine hesitancy or refusal. For example, nurses can reassure patients that vaccines, like other pharmaceutical products, undergo extensive testing and reviews for safety, immunogenicity, and efficacy. They can also be instrumental in monitoring for and reporting adverse reactions, thus contributing to the development of safer vaccines with fewer adverse effects (see Resources for patients and nurses).


To create a trusting relationship, use open dialogue and active listening to determine the patient's knowledge deficits.19 One important tool to educate patients is the Vaccine Information Statement (VIS). Created by the CDC, it is required to be given to patients (or their parents) at the time of vaccination. This information helps patients or their primary caregivers make an informed decision concerning a vaccine's risks and benefits. Inform patients that information from friends, family, and social media may not be reliable and guide them to reputable sources.20


Nurses should also teach parents who hesitate to vaccinate that they should not rely on herd immunity to protect their children. Because many parents are refusing or delaying vaccination, the risk of disease transmission has increased, and the incidence of disease outbreaks is higher in communities that allow more exemptions and have a lower rate of immunization. Herd immunity can significantly reduce transmission of a disease only if the "herd" is immunized. Unfortunately, this group is getting smaller.21 Steps can be taken to increase immunization rates in communities by improving access to vaccinations, providing small incentive rewards such as gift cards or baby products, mandating vaccines for admission to school, establishing guidelines for not vaccinating, and engaging community with influential groups.22,23


Ways in which nurses can improve completion of a vaccination series includes using patient registries, automated patient reminders, reminder-recall systems, and home visits. These interventions have shown to be effective in achieving immunization for those who do not consistently seek medical care.23 Telephone calls and home visits have proven to be the most effective but are also the most costly. However, letters have been more productive than phone calls in bringing patients for immunizations.22 Vaccine compliance improves with campaigns, information in newspapers, social media, back to school nights, and flu season awareness.24


Education is key

The primary approach to improving vaccination rates is education. Nurses can take time to listen, interact, and inform the patient of the purpose, safety, and efficacy of vaccines in preventing infectious diseases.


Evidence has shown that nurses are the most important source of information for patients making decisions about vaccinations.16,25 Patients need to feel that their fears are being heard and acknowledged, and that they can receive answers to their concerns. Putting pressure on patients can lead to vaccine refusal. The best thing nurses can do is to listen, build trust, maintain acceptance, and work with the patient to make informed decisions. Nurses can also advise patients about community resources, such as free clinics.25


Nurses have the potential to truly make a difference in stopping the reemergence of vaccine-preventable diseases through patient education on the front lines, and they should take advantage of their trusted position and the opportunity to save lives.


Promoting childhood vaccines12,26,27

Recommended childhood vaccines prevent many life-threatening illnesses, including, in the case of the human papillomavirus vaccine, many forms of cancer. The American Academy of Pediatrics reiterates that immunization protects children's health and prevents unnecessary deaths.


Reassure parents that combination vaccines are safe and that the FDA requires rigorous clinical testing for safety and efficacy before licensing. Infants and young children have immune systems capable of processing many vaccines. Vaccines are given on a schedule that mirrors how the immune system develops, and some vaccines require boosters for full protection. When the series is completed, lifelong protection is provided for that disease, with the exception of tetanus and influenza vaccines, which require updates during the patient's lifetime.


Defining vaccine hesitancy28

The World Health Organization Strategic Advisory Group of Experts (SAGE) Working Group on Vaccine Hesitancy describes vaccine hesitancy as a "delay in acceptance or refusal of vaccines despite availability of vaccination services." It is influenced by factors such as:


* complacency, or the perception that the risks of vaccine-preventable diseases are low.


* convenience, or the availability, affordability, and accessibility of vaccines.


* confidence in the safety and effectiveness of vaccines, healthcare system, and policymakers who recommend vaccines.



Resources for patients and nurses

Besides reviewing the Vaccination Information Statement with patients, nurses can utilize reputable media resources for patient education. These include:


* American Academy of Pediatrics. Immunizations: Vaccine Hesitant Parents


* American Academy of Pediatrics. Vaccine Safety: The Facts


* Centers for Disease Control and Prevention. Vaccine Information Statements


* Centers for Disease Control and Prevention/Food and Drug Administration. Vaccine Adverse Event Reporting System


* National Foundation for Infectious Diseases. Ten Reasons to Get Vaccinated


* Vaccines on the Go: What You Should Know (a free app)





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