Vaccine Refusal: A Growing Problem

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Vaccine Refusal A Growing Problem

• Adele Young RN, PNP-BC, PhD
• Maggie Venzke RN, FNP-BC, MSN

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The Polio Crusade- What Can We Learn From History?

• http//www.pbs.org/wgbh/americanexperience/polio/

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Vaccination a Public Health Success

• Smallpox vanquished
• Polio limited
• Major reductions of all other vaccine preventable
  diseases.
• So what is the problem?

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Approximation of Recommended Childhood
Immunization Schedule 1985
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Rates of Refusal

• One study found a rate of 7.2 children per 1000
  vaccinated
• 84 of a sample of Family and Pediatric
  Physicians reported a partial refusal and 54
  reported one or more total refusals in the last
  year.
• School exemptions have increased steadily

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Reasons for Refusal

• Erroneous beliefs about contraindications
• Perceived dangers of vaccination
• Preference in making errors of omission vs.
  commission

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Reasons Continued

• Natural Risk vs. Manmade risk
• Disagree with western or conventional medicine
• Infringement of rights

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Reasons cont.

• Overloading the immune system
• Moral objections over how the vaccines are made.
  Use of fetal tissue.
• Lack of knowledge of the diseases that the
  immunization is targeted for. Underestimation of
  the risks of the disease.

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Vaccines most often refused

• Varicella (not seen as serious)
• Dtap
• Hepatitis B (why in children)
• One study showed MMR to be the fifth most likely
  to be refused despite all the controversy

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Who is most likely to refuse

• White ( 9.8 vs. 2.8 Black and 1.5 Hispanic)
• Better educated
• Higher economic status
• Willing and able to breast feed into toddler age
  group
• Willing and able to keep child out of day care
  and home school

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Role of school exemptions

• All states allow medical exemptions
• 48 states allow religious exemptions
• 19 states allow philosophical
• Some states make it easier. In Maryland a simple
  signature on the school physical form is all that
  is required. In fact it is easier to get an
  exemption then it is to fill in the vaccine
  record. California also is easy

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Results of school exceptions

• States that allow easy exemptions have a 50
  higher rate of pertussis
• Also more likely to have measles out break

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Vaccination Refusal Rates in Kindergarten
Students 2006-2007
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Alternative Schedule
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Dr. Bob Selective Vaccination Schedule

• 2 months DTaP, Rotavirus
• 3 months Pc, Hib
• 4 months DTap, Rotavirus
• 5 months Pc, HIB
• 6 months DTaP, Rotavirus
• 7 months Pc, HIB
• 15 months Pc, HIB

• 5 years tetanus booster
• 10 years titers for MMRV, Hep A
• 11 years 3 doses HPV for girls
• 12 years Hep B 3 doses

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Dr. Bobs Alternative Schedule

• 2 months DTaP, Rotavirus
• 3 months Pc, Hib
• 4 months DTap, Rotavirus
• 5 months Pc, HIB
• 6 months DTaP, Rotavirus
• 7 months Pc, HIB
• 9 months Polio, Flu
• 11 months Flu
• 12 months Mumps, Polio
• 15 months Pc, HIB
• 18 months Dtap, Varicella

• 21 months Flu
• 2 years Rubella, Polio
• 2 ½ years Hep B, Hep A
• 3 years Hep B, Measles, Flu
• 4 years DTaP, Polio, Flu
• 5 years MMR, Flu
• 6 years Varicella
• 12 years Tdap, HPV
• 12y 2 mo. HPV
• 13 years HPV, Meningococcal

The Vaccine Book- Making the Right Decision for
your Child by Robert W. Sears, M.D.,F.A.A.P
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Dr. Sears and the Alternate Schedule

• Pros According to Dr. Bob
• 1 aluminum containing vaccine
• No more than two at a time spreading out
• Chemical exposure
• Potential side effects
• Starts out with most important vaccines and
  delays those with less risk because they are
  milder or not around.
• Allows parents who would not vaccinate an
  alternative that would protect the child

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Cons Not Considered by Dr. Bob

• By offering this schedule implies that parents
  concerns over autism, chemicals, weakening the
  immune system are real and have valid scientific
  support.
• Requires 7 additional office visits which will
  probably lead to less compliance, increased cost
  to the parents, further delay in vaccination, and
  increased stress on practices for tracking and
  administering vaccines.
• Delays immunization for Polio, Varicella, Hep B,
  Hep A, Rubella, and especially measles leaving
  infants at risk for extended periods of time.
  (measles would be another two years).
• Safety of the children in his groups depends on
  the current level of herd immunity, which in turn
  depends on most children following the
  recommended schedule.
• For a more in depth discussion see Offit,P.,
  Moser,C. (2009). The problem with Dr. Bobs
  alternative vaccine schedule. Pediatrics.
  123e164-169.
• http//pediatrics.aappublications.org/cgi/content/
  full/123/1/e164

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Themes from the Anti-vaccine Groups

• Vaccines are ineffective and harm the immune
  system
• Vaccine adverse effects are under reported
• Vaccine preventable diseases are not that serious
• Vaccine supporters are all profit driven
• Mandatory vaccination is a violation of civil
  rights
• Vaccines are immoral
• Diseases have declined homeopathic alternative

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Where do they get information

• Preference is for internet and alternative
  medicine sources

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Anti-vaccine Web sites

• Shootem up thedocumentary.com
• Thinktwice Global Vaccine Insitute
• Generation Rescue
• Mothers Against Mercury
• Nature News.com

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KNOW THE FACTSFACT Autism began by affecting 1
in 10,000 it now affects 1 in 166 - a direct
correlation to the rise in vaccines added to the
schedule. (most of which contained mercury)
www.Shootemupthedocumentary.com
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Internet and the Media

• Jenny McCarthy- Generation Rescue

• Campbell Brown CNN on Vaccines

• http//www.generationrescue.org/green-our-vaccines
  .html

• http//www.youtube.com/watch?vqoi6QmcU9IM

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Paul Offit, author of Autism's False Prophets

• http//www.youtube.com/watch?vMTr-HLz7dPc

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What Strategies Can Be Used to Limit Refusal and
Delay
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In Your Practice

• Put up posters clearly supporting vaccination
  including pictures of children with the disease
• Provide visual aids that indicate where these
  diseases still occur emphasizing that they are
  only a plan ride away.
• Provide information on any current outbreak in
  the USA.
• Making the choice not to vaccinate not be
  passive. Have parent sign a form out lining the
  consequences of choosing not to vaccinate.

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In Your Practice Cont.

• Respectfully listen and provide information.
• Show your personal support by indicating that you
  vaccinated your own children
• Use combination vaccines and comfort measures
• Point out that vaccination is a public health
  issue and choosing not to vaccinate puts other
  children at risk.

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In your practice continued

• Dismissing the refusing family from the practice
• A recent study showed that 39 of physicians
  would ask refusing families to seek health care
  else where due to
• Lack of shared goals
• Lack of trust
• Fear of litigation

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Broader Strategies

• Vaccine media campaigns
• Reduce exemptions and make more difficult to
  obtain
• Mandatory education for refusing families

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DO THE S.W.O.T.
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What is the immunization Issue for Adults?

• Vaccine refusal is not the major issue for adults
• It often that the provider did not address the
  need!

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Strategies to Improve Adult Immunization Rates
Short Term

• Effective Evidence-Based Strategies
• Reminders
• Provider and Patient
• Education
• Staff, Provider and Patient
• Offer alternative sites for vaccine
  administration

NFID. A Call To Action Improving Influenza And
Pneumococcal Immunization Rates Among High-risk
Adults
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Strategies to Improve Adult Immunization Rates-
Long Term

• Effective Evidence-Based Strategies
• Organizational change
• Standing orders, standardized procedures,
  preprinted orders
• Expanded access to vaccinations
• Financial incentives
• Provider and Patient, including reducing
  out-of-pocket costs
• Assessment and feedback

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Key Messages The Problem

• Adult vaccination rates fall far below Healthy
  People 2010 leaving thousands of adults at risk
  for vaccine preventable diseases.
• Many barriers contribute to low immunization
  rates.
• Many adults are not aware of their need to
  receive immunizations as a preventive care
  measure.

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Vaccine Refusal is Dangerous

• Recent out breaks of measles, mumps, haemophilus
  influenza and pertussis both here and abroad has
  emphasized the seriousness of the current trend
  toward vaccine refusal.

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Anti-vaccine Web sites

• Shootem up thedocumentary.com
• Thinktwice Global Vaccine Insitute
• Generation Rescue
• Mothers Against Mercury
• Nature News.com

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Websites for Providers

• Immunization Action Coalition
• http//www.immunize.org/
• California Distance Learning Health Network
• http//www.cdlhn.com/default.htm
• American Academy of Pediatrics
• http//www.aap.org
• Pkids ,Project Immunize Virginia, CDC

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References

• Consultant for Pediatricians Supplement Issue
• Oct. 2006 (vol 5 10) and Sept. 2008 (vol 7, 9)
• Clarkson-Keller, V., Siktberg ,L.,
  Hodson-Carlton,K.,(2008). Overcoming obstacles
  to vaccination. American nurse today. 23-29.
• Diekema, D. (2005). Responding to parental
  refusals of immunization of children.
  Pediatrics. 115(5)1428-1431.
• Offit,P., Moser,C.,(2009) The problem with Dr.
  Bobs alternative schedule. Pediatrics. 123
  e164-e169