Aug. 17, 2015 -- Fewer parents may be refusing to vaccinate their children, especially in western states, which have had some of the nation’s highest refusal rates, according to new survey data from Medscape.
Forty-two percent of health care professionals said they believed more parents are accepting vaccines, and 38% said parents are more accepting of measles vaccination in particular, according to the Medscape Vaccine Acceptance Report. The online survey of 1,577 pediatricians, family doctors, public health doctors, nurse practitioners, and physician assistants was conducted last month.
Even so, a third of those surveyed said they had not seen any changes in parents' willingness to accept vaccinations.
Some states in the Western region of the country, which included Alaska, California, Hawaii, Idaho, Montana, Oregon, Washington, and Wyoming, were hit by a well-publicized measles outbreak in 2014. Health care professionals in that region reported higher rates of acceptance for measles vaccines (46% vs 36% for the rest of the country) and for all vaccines (51% vs 41%).
"Overall, this is encouraging," said Amanda Cohn, MD, deputy director of the CDC's Immunization Services Division. But, she said, "It will take some time to see changes in parental choice in vaccination demonstrated through data."
According to the Medscape survey, parents were most likely to refuse or request an alternate vaccination schedule for the measles, mumps, and rubella (MMR) and human papillomavirus (HPV) vaccines, 58% of clinicians said. These were followed by the varicella (28%), hepatitis B (23%), hepatitis A (18%), and diphtheria, tetanus, and pertussis (17%) vaccines.
The survey was taken as measles cases continued to increase in the United States. This year and last have been record-setting, with 668 cases from 27 states reported to the CDC's National Center for Immunization and Respiratory Diseases in 2014, and 183 cases in 24 states and Washington, DC, reported through the end of July this year.
A large outbreak (383 cases) happened among a group of unvaccinated Amish people in Ohio last year, but the outbreak that was traced to a foreign visitor at Disneyland in December 2014 garnered more media attention and may have contributed to some parents' willingness to accept vaccination, according to survey respondents.
"More parents read the news and are open to counseling," said one respondent. Other survey respondents said that parents were asking more questions, but that those who were against vaccines were still hesitant.
Fear Main Driver, but May Not Last
Almost half of clinicians surveyed said they believe parental fears that their child would contract a vaccine-preventable disease was driving the increased acceptance. A fifth said that parents worried about their children being barred from school or camp, and another 20% said that parents had gained more comfort with vaccination after further research.
Fear of disease, especially measles, seemed to be the biggest factor. One nurse practitioner said, "We had a possible measles case that caused some parents who were reluctant to vaccinate call to ask about vaccinating."
"We've seen this happen every time there have been outbreaks," said Carrie Byington, MD, chair of the American Academy of Pediatrics Committee on Infectious Diseases. "The imminent risk may change their attitudes about immunizing their child," she said.
Mark Fishaut, MD, a pediatrician at San Juan Healthcare in Friday Harbor, WA, said that a local measles outbreak led to a panic that temporarily increased vaccine acceptance, but that parents who had avoided immunization eventually began refusing again.
Although all states require schoolchildren to be vaccinated, 18 states let parents opt out based on religious or philosophical beliefs, according to the National Conference of State Legislatures. About 3.6% of Washington state kindergartners had a nonmedical (mostly philosophical) exemption from vaccination in the 2013 to 2014 school year, according to the CDC, compared with a national average of 1.8%.
Oregon leads in nonmedical exemptions, at 7.0%, followed by Vermont and Idaho at 6.1%, according to the CDC.
After the Disneyland measles outbreak, which affected at least 100 people, Joseph F. Hagan Jr., MD, and colleagues at their practice in Burlington, VT, compiled a list of unimmunized and underimmunized patients and sent a letter to parents asking them to reconsider "in light of the current news." Only two or three of 50 families accepted, Hagan told Medscape Medical News.
There has been no major change in acceptance at his practice, he said. "It's distressing, but not terribly surprising.
"The problem is because we don't see these diseases very often, we've lost perspective," Hagan said.
Fishaut said that the most common reasons for refusals at his practice include fear of autism, conspiracy theories about pharmaceutical companies, and an aversion to all chemical interventions.
That reflects the Medscape survey data. Sixty-four percent of clinicians said parents fear complications, and 61% said parents fear a connection to autism. Half said parents worried about added ingredients such as thimerosal, and 45% said parents expressed concerns about immunization overwhelming a child's immune system.
Byington called the autism and immunity fears myths. "As physicians, we continue to be frustrated by the traction that these myths continue to have," she said, noting that "every one of these myths have been debunked again and again through scientific study."
But parents' fears are easily amped up by misleading claims on the Internet, she said.
Strategies to Increase Acceptance
A majority of survey respondents (69%) said they provide evidence-based information to address specific parental concerns. They also said that they create a customized approach and share statistics on vaccine-preventable diseases.
Eight percent said they refuse to accept families in their practice who will not adhere to the recommended vaccination schedule.
The American Academy of Pediatrics recommends against this, Byington said. The group is reworking its policy statement on vaccine hesitancy and will publish it later this year, she said.
"My policy is to not punish children for parental ignorance," Fishaut said. Beyond educating parents, he said he has worked with the school system to ensure that unvaccinated children cannot participate in extracurricular activities. And, he says, he "works with immunizing parents to be the principal public advocates for vaccination."
The state of Washington is considering legislation to repeal the philosophical exemption. California Gov. Jerry Brown (D) signed a bill in June that eliminated religious and philosophical exemptions. And in 2014, Vermont passed a law to eliminate philosophical, but not religious, exemptions beginning in 2016.
Byington said that the California measles outbreak put state lawmakers on notice. She expects "to see a large number of states introducing bills regarding exemptions," she said.
Clinicians who responded to the survey were eligible for a raffle, but they were not paid for their participation in the survey. The margin of error is plus or minus 2.46%.