The problem with Dr Bob's alternative vaccine schedule

The Case for Assessing the Drivers of Measles Vaccine Uptake

Global measles cases are on the rise following disruptions to routine immunisation programs during the COVID-19 pandemic, with devastating consequences. According to the World Health Organization, the behavioural and social drivers of vaccination include what people think and feel about vaccines, social processes, motivation to vaccinate and practical barriers to vaccination. However, the drivers of measles vaccine uptake are not necessarily the same as those for other childhood vaccines, and we lack data on how these drivers specifically have changed during and since the COVID-19 pandemic. Without accurately measuring the behavioural and social drivers for measles vaccination, and ideally measuring them serially over time, countries cannot design, target and implement interventions that effectively increase and sustain measles vaccine coverage. This paper outlines what is and is not known about the behavioural and social drivers of measles vaccination and provides recommendations for improving their post-pandemic assessment.

Strategies for Improving Vaccine Communication and Uptake

Vaccines have led to a significant decrease in rates of vaccine-preventable diseases and have made a significant impact on the health of children. However, some parents express concerns about vaccine safety and the necessity of vaccines. The concerns of parents range from hesitancy about some immunizations to refusal of all vaccines. This clinical report provides information about the scope and impact of the problem, the facts surrounding common vaccination concerns, and the latest evidence regarding effective communication techniques for the vaccine conversation. After reading this clinical report, readers can expect to: Understand concepts and underlying determinants of vaccine uptake and vaccine hesitancy.Understand the relationship between vaccine hesitancy and costs of preventable medical care.Recognize and address specific concerns (eg, vaccine safety) with caregivers when hesitancy is present.

Strategies for Working With Parents With Vaccination Hesitancy

The purpose of this article is to provide an overview of effective strategies for working with parents' vaccination hesitancy or refusal. An overview of historical and current trends in vaccination hesitancy and factors that contribute to and strategies for addressing vaccine hesitancy are discussed. This includes an emphasis on the critical role played by health care providers, as trusted advisors and a primary source of health care information, in encouraging vaccine acceptance. Legal and ethical implications are also considered. Vaccination hesitancy strategies are most effective if they are timely, multifaceted, and collaborative.

Why are people antiscience, and what can we do about it?

From vaccination refusal to climate change denial, antiscience views are threatening humanity. When different individuals are provided with the same piece of scientific evidence, why do some accept whereas others dismiss it? Building on various emerging data and models that have explored the psychology of being antiscience, we specify four core bases of key principles driving antiscience attitudes. These principles are grounded in decades of research on attitudes, persuasion, social influence, social identity, and information processing. They apply across diverse domains of antiscience phenomena. Specifically, antiscience attitudes are more likely to emerge when a scientific message comes from sources perceived as lacking credibility; when the recipients embrace the social membership or identity of groups with antiscience attitudes; when the scientific message itself contradicts what recipients consider true, favorable, valuable, or moral; or when there is a mismatch between the delivery of the scientific message and the epistemic style of the recipient. Politics triggers or amplifies many principles across all four bases, making it a particularly potent force in antiscience attitudes. Guided by the key principles, we describe evidence-based counteractive strategies for increasing public acceptance of science.

Parental vaccine attitudes, beliefs, and practices: initial evidence in California after a vaccine policy change

Senate Bill 277 (SB277) eliminated nonmedical exemptions for school-entry vaccines in California, but the impact of parental vaccine knowledge, attitudes, and beliefs on vaccine decision-making has not been extensively examined within the post-SB277 context. This study generates preliminary understanding and discussion of the vaccination knowledge, attitudes, and beliefs among a pilot population of parents of kindergarten students in California after the implementation of SB277. School officials administered a cross-sectional survey to parents of kindergarten children in California from April to July 2019. Parents reported their perceptions of diseases and vaccines, key immunization beliefs, and confidence in different sources of vaccine information. Most parents (92%) had fully vaccinated their children post-SB277 and generally perceived vaccines to be safe and effective, but about 44% reported they were hesitant about childhood vaccines. The majority of parents (87%) rated vaccine information from their doctor as highly credible. This pilot group of kindergarten parents was generally supportive of vaccination and had fully vaccinated their children, but most parents still harbored concerns and misconceptions about vaccines and about public health authorities. This indicates a disconnect between parental vaccine compliance and confidence, and suggests that educational interventions could impact parental vaccine behavior and decision-making.

Vitamin K Deficiency Bleeding: An Ounce of Prevention

Vitamin K is a fat-soluble vitamin essential for the formation of factors in the clotting cascade. Newborns are born with insufficient levels of vitamin K, resulting in high risk for vitamin K deficiency bleeding (VKDB). Vitamin K deficiency bleeding can occur in the first week of life ("classic" VKDB) and also between 2 weeks and 3 months of age ("late" VKDB). Vitamin K deficiency bleeding can present as bleeding in the skin or gastrointestinal tract, with as many as half of affected neonates experiencing intracranial bleeding. A single intramuscular injection of vitamin K effectively prevents both classic and late VKDB. Although intramuscular vitamin K is safe and effective, VKDB has reemerged because of decreased utilization. Parents refuse intramuscular vitamin K for a variety of reasons, including a disproven association with childhood cancer, the desire to avoid exposure to additives, and valid concerns about early neonatal pain. Many parents request oral vitamin K, an inferior alternative strategy that requires multiple doses utilizing products not designed for neonatal oral administration. In this setting, health care professionals must understand the epidemiology of VKDB and compassionately counsel parents to assuage concerns. Delivery of intramuscular vitamin K to all newborns remains a public health imperative, benefitting thousands of infants annually.

Beliefs towards vaccination and trust in the scientific community in Italy

BACKGROUND

In 2017 the Italian government introduced compulsory vaccination for Italian school children for ten diseases, in response to an alarmingly decrease in coverage and measles outbreak. A hot social debate arose around the issue of the law. Studies on the opinion of Italians on this topic are rare, so we investigated the socio-cultural profile of Italians about beliefs towards vaccination.

METHODS

Data were extracted from the Italian section of the European Social Survey (ESS), conducted by the Italian National Institute for Public Policies Analysis during 2017. The main outcome assessed was the opinion about the supposed harmfulness of vaccines. We analysed the association between the outcome and a selected group of socio-cultural characteristics, with a specific interest in examining the interaction between our main outcome and the perceived trust in the scientific community in regards to vaccines. A principal component analysis was then performed for determining the socio-cultural profile of respondents.

RESULTS

Among the 2,626 subjects interviewed face to face, 19% believed that vaccines were harmful and 10% did not have trust in the scientific community in regards to vaccines. Out of the respondents who believed in the harmfulness of vaccines, 29% neither had trust in the scientific community. Principal Component Analysis suggested that this group (Anti-vax/science sceptic) was characterised by low participation in political and cultural life, being male, older of age and politically oriented towards the right. People agreeing about harmfulness of vaccines are mostly males, have a lower education level, poor attendance in political and cultural life and are politically oriented to the right.

CONCLUSIONS

The ESS survey is unique in its capacity to deal with emerging themes of the social debates. Results paint a picture of the opinions of Italians on vaccines. This profile may be useful for policymakers to design targeted vaccination campaigns and to intervene more efficaciously in the public debate.

Opinions and Knowledge of Parents Regarding Preventive Vaccinations of Children and Causes of Reluctance toward Preventive Vaccinations

Background: Despite the stability of global vaccination coverage, over 19 million children worldwide do not currently receive basic vaccines. Over the past several years, there has been a dramatic drop in the number of vaccinated children worldwide. The implementation of the vaccination program and the scope of protection depend on the parents or legal guardians, who decide whether to vaccinate their child or not. Studies were conducted to assess parents’ knowledge, attitudes, and beliefs about vaccines, as well as the role of healthcare providers in parents’ decisions. Methods: A population survey was conducted in 2018–2019. Parents or legal guardians of the children were invited to participate in the study during their visits to the clinic for healthy or sick children. The method used in the research was a diagnostic survey. Results: According to the conducted research, men and women constituted 45% and 55% of participants, respectively. The average age of men was 44, while, for women, it was 41. Internal research showed that as much as 71% of parents declared the need for vaccination, although 41% of parents vaccinated their children according to the vaccination calendar. The most frequently mentioned concerns included the possibility of adverse vaccination reactions (22%), the occurrence of autism (7%), and child death (6%). General practitioners had, by far, the greatest impact on the use of protective vaccination in children (73% women and 80% men), although there were cases of discouraging the performance of compulsory vaccinations (41%), and mentioning a doctor (38%) or nurse (3%). Conclusions: Modifiable determinants of the negative attitude toward vaccinations are caused mainly by the lack of knowledge. These obstacles in vaccinations can be overcome by improving health education in terms of the vaccination program.

Vaccine Safety: Myths and Misinformation

The World Health Organization has named vaccine hesitancy as one of the top ten threats to global health in 2019. The reasons why people choose not to vaccinate are complex, but lack of confidence in vaccine safety, driven by concerns about adverse events, has been identified as one of the key factors. Healthcare workers, especially those in primary care, remain key influencers on vaccine decisions. It is important, therefore, that they be supported by having easy access to trusted, evidence-based information on vaccines. Although parents and patients have a number of concerns about vaccine safety, among the most common are fears that adjuvants like aluminum, preservatives like mercury, inactivating agents like formaldehyde, manufacturing residuals like human or animal DNA fragments, and simply the sheer number of vaccines might be overwhelming, weakening or perturbing the immune system. As a consequence, some fear that vaccines are causing autism, diabetes, developmental delays, hyperactivity, and attention-deficit disorders, amongst others. In this review we will address several of these topics and highlight the robust body of scientific evidence that refutes common concerns about vaccine safety.

Perspectives of public health nurses on the ethics of mandated vaccine education

BACKGROUND

Since 2015, Michigan has required parents who request nonmedical exemptions (NMEs) from school or daycare immunization mandates to receive education from local public health staff (usually nurses). This is unlike most other US states that have implemented mandatory immunization counseling, which require physicians to document immunization education, or which provide online instruction.

PURPOSE

To attend to the activity and dispositions of the public health staff who provide "waiver education".

METHOD

This study reports results of focus group interviews with 39 of Michigan's vaccine waiver educators (37 nurses), conducted during 2016 and 2017, and analyzed in 2018.

FINDINGS

Four themes emerged from analysis of the transcripts of these interviews: Participants had (1) complex and nuanced observations and evaluations of parents' judgments and feelings about vaccines and vaccine education; (2) sympathetic attitudes about alternative vaccine schedules; (3) critical and supportive evaluations of institutional policies and the background political context of immunization education; and (4) consistent commitments to respect parents, affirm their values, and protect their rights.

DISCUSSION

These results show that public health nurses are sensitive to the burdens mandatory immunization education places on families, the motivations for parents' requests for nonmedical exemptions, and the values implicated by personal immunization decisions and government immunization policies. In light of the unique training, experiences, and public reputation of nurses, there is good reason for additional investigation into the roles that nurses can play in immunization education and in vaccine mandate policies, more generally.

Perceptions of vaccination within a Christian homeschooling community in Pennsylvania

BACKGROUND

More than 1.8 million American children ages 5-17 are being educated at home. The percentage of school-aged children in the United States who are homeschooled increased from 1.7% in 1999 to 3.4% in 2012. Every state has established school-entry vaccination requirements for kindergarten students, but most states exempt homeschoolers from these regulations. The goal of this study was to use qualitative methods to examine the vaccination perceptions and practices of Christian homeschooling families in Pennsylvania.

METHODS

A qualitative study (focus groups) of Christian homeschooling parents representing a diversity of vaccination practices (full, partial/delayed, and no vaccination) was conducted in south-central Pennsylvania in 2017. An analysis using a grounded theory approach identified themes that strongly aligned with constructs from the Health Belief Model.

RESULTS

Many of the perspectives expressed by the study population aligned with those of the general American population, including uncertainty about the risk from vaccine-preventable diseases, concerns about the efficacy and safety of vaccines, and confusion about conflicting vaccine information. The Christian homeschooling parents expressed two especially prominent perceptions: a belief that they had a very low risk of contracting infectious diseases because God has provided them with the natural tools necessary for health and a stronger-than-typical sense of empowerment related to parental decision-making and autonomy. Participants expressed that they were generally open to honest communication about vaccination with physicians who respect parental authority.

CONCLUSIONS

Homeschooling families have diverse vaccination practices. Pediatricians and other healthcare practitioners should not make assumptions about health beliefs in this community, and should instead engage parents in conversations about their risk perceptions and vaccine decisions.

Mistrust in Medicine: The Rise and Fall of America's First Vaccine Institute

In 1813, the American government passed An Act to Encourage Vaccination, the first federal endorsement of a medical practice in American history. The law tasked a federal agent with maintaining a supply of the smallpox vaccine and distributing it nationwide. James Smith, a well-respected physician and proponent of vaccination, was appointed as vaccine agent. Smith was skeptical of claims that only well-trained physicians should be allowed to perform vaccination; he felt it was a simple procedure that should be available to all American citizens. In 1822, he made a tragic error that caused several deaths and left him vulnerable to criticism from political opponents and his medical peers. This ended Smith's professional career and led to the repeal of the act itself. In this article, we use the rise and fall of James Smith to provide a historical perspective on contemporary debates surrounding delayed vaccination schedules. We explain how physicians-in the 19th century and today-have worked to build public trust in vaccination in an American culture suspicious of medical expertise.

Using Pathfinder networks to discover alignment between expert and consumer conceptual knowledge from online vaccine content

This study demonstrates the use of distributed vector representations and Pathfinder Network Scaling (PFNETS) to represent online vaccine content created by health experts and by laypeople. By analyzing a target audience's conceptualization of a topic, domain experts can develop targeted interventions to improve the basic health knowledge of consumers. The underlying assumption is that the content created by different groups reflects the mental organization of their knowledge. Applying automated text analysis to this content may elucidate differences between the knowledge structures of laypeople (heath consumers) and professionals (health experts). This paper utilizes vaccine information generated by laypeople and health experts to investigate the utility of this approach. We used an established technique from cognitive psychology, Pathfinder Network Scaling to infer the structure of the associational networks between concepts learned from online content using methods of distributional semantics. In doing so, we extend the original application of PFNETS to infer knowledge structures from individual participants, to infer the prevailing knowledge structures within communities of content authors. The resulting graphs reveal opportunities for public health and vaccination education experts to improve communication and intervention efforts directed towards health consumers. Our efforts demonstrate the feasibility of using an automated procedure to examine the manifestation of conceptual models within large bodies of free text, revealing evidence of conflicting understanding of vaccine concepts among health consumers as compared with health experts. Additionally, this study provides insight into the differences between consumer and expert abstraction of domain knowledge, revealing vaccine-related knowledge gaps that suggest opportunities to improve provider-patient communication.

Parents' concerns about vaccine scheduling in Shanghai, China

BACKGROUND

Several new vaccines have been introduced into China in recent years, but some parents in China have shown concerns about the scheduling of vaccinations for young infants. This study explores caregiver concerns about children receiving multiple vaccines during a single visit and about vaccine administration in infants <6months, and assesses the degree to which these concerns are associated with ratings of the importance of different sources of vaccine information in Shanghai.

METHODS

Caregivers of children 8months to 7years presenting at immunization clinics in Shanghai completed a survey about vaccine co-administration and vaccine administration <6months of age. Respondents provided ratings of information from different sources (Internet, family/friends, other parents) and trust in doctors. We analyzed vaccine concerns using linear regression analyses that included these information sources after adjusting for socioeconomic variables.

RESULTS

Among 618 caregivers, 64% were concerned about vaccine co-administration and 31% were concerned about vaccine administration to infants <6months of age. Higher ratings of Internet as an important source of information were associated with greater concern about co-administration (β=0.11, 95% CI: 0.00, 0.22) and concern about administration at <6months of age (β=0.17, 95% CI: 0.05, 0.28). Higher ratings given to information from other parents corresponded to 0.24 points greater concern about vaccine co-administration (95% CI: 0.04, 0.44). More trust in doctors and ratings of information from friends and family were not associated with vaccine concerns.

CONCLUSIONS

Caregiver concerns about vaccine scheduling may limit China's flexibility to add vaccines to its official immunization schedule. Reporting information about vaccine safety on the Internet and bringing groups of parents together to discuss vaccines might help to ameliorate concerns about vaccine scheduling.

Childhood vaccine status and correlation with common nonvaccine-preventable illnesses

BACKGROUND AND PURPOSE

Current trends in parental decision making involve alteration from vaccine schedules in children, citing concerns for altered immune function. The purpose of this study was to determine if there is a difference in incidence of common childhood illnesses dependent on vaccination status.

METHODS

An investigator-designed survey was administered to parents of children aged 12 months to 7 years. Participants were separated into one of three groups: fully vaccinated, partially vaccinated, and unvaccinated. There were 111 total participants. Power analysis indicated a minimum of 30 participants per group to detect an 80% effect. Descriptive statistics were applied to variables with chi-square for group comparison.

CONCLUSIONS

The results indicated a statistically significant difference between all three groups in the categories of ear infections, influenza, and common colds. Fully immunized group had significantly more ear infections than partial or unimmunized. The unimmunized group had significantly more colds and flu.

IMPLICATIONS FOR PRACTICE

Nurse practitioner practice implications relate directly to further education of parents, support, and trust building. Many parents question the possible association between childhood vaccines and immune function and have a distrust of current research. This study showed that most common childhood illnesses are equitable across the population and not dependent on vaccine status.

Vaccine Rejecting Parents' Engagement With Expert Systems That Inform Vaccination Programs

In attempting to provide protection to individuals and communities, childhood immunization has benefits that far outweigh disease risks. However, some parents decide not to immunize their children with some or all vaccines for reasons including lack of trust in governments, health professionals, and vaccine manufacturers. This article employs a theoretical analysis of trust and distrust to explore how twenty-seven parents with a history of vaccine rejection in two Australian cities view the expert systems central to vaccination policy and practice. Our data show how perceptions of the profit motive generate distrust in the expert systems pertaining to vaccination. Our participants perceived that pharmaceutical companies had a pernicious influence over the systems driving vaccination: research, health professionals, and government. Accordingly, they saw vaccine recommendations in conflict with the interests of their child and "the system" underscored by malign intent, even if individual representatives of this system were not equally tainted. This perspective was common to parents who declined all vaccines and those who accepted some. We regard the differences between these parents-and indeed the differences between vaccine decliners and those whose Western medical epistemology informs reflexive trust-as arising from the internalization of countering views, which facilitates nuance.

Vaccine hesitancy: More than a movement

Vaccines are some of if not the most successful public health endeavors ever put into practice. Countless lives have been saved and the occurrences of vaccine preventable diseases are at a fraction of the rate experienced before vaccines. Vaccines and the realization of their compulsory scheduling are highly studied, safe, and purposeful. Despite these realities, there are an alarming number of parents who do not permit the vaccination of their children as scheduled. This is known in the health community as vaccine hesitancy and commonly portrayed in popular media as anti-vaccination sediment. This analysis opens with the topic as it was addressed during a September 2015 debate for the Republic Party's 2016 presidential nomination. Some key historical aspects of vaccine hesitancy are presented. This history leads to a description of the 2014-2015 measles outbreak in California. The factors that aide in the recruitment of under vaccination are then explored. Finally, select strategies to control, combat, and potentially attenuate vaccine hesitancy are presented.

Countering Vaccine Hesitancy

Immunizations have led to a significant decrease in rates of vaccine-preventable diseases and have made a significant impact on the health of children. However, some parents express concerns about vaccine safety and the necessity of vaccines. The concerns of parents range from hesitancy about some immunizations to refusal of all vaccines. This clinical report provides information about addressing parental concerns about vaccination.

Pediatric Care Provider Density and Personal Belief Exemptions From Vaccine Requirements in California Kindergartens

OBJECTIVES

To understand contextual associations between medical care providers-pediatricians, family medical practitioners, and alternative medicine practitioners-and personal belief exemptions (PBEs) from mandated school entry vaccinations.

METHODS

Data on kindergarten PBEs from the California Department of Public Health were analyzed for 2010, 2011, and 2012, with each school sorted into Primary Care Service Areas (PCSAs). Provider data from federal sources and state records of alternative medicine providers, alongside controls for school factors, were used to estimate panel models.

RESULTS

Each 10% increase in the relative proportion of pediatricians in a given PCSA was associated with a statistically significant 11% decrease in PBE prevalence. The same increase in the proportion of family medical practitioners was associated with a 3.5% relative increase. Access to alternative medicine practitioners was also associated with a significantly higher PBE prevalence.

CONCLUSIONS

Medical provider contexts are associated with PBEs, reflecting a combination of contextual effects and self-selection of families into schools and PCSAs that share their preferences. The geographic distribution of child primary care services may be a key factor in a school's health risk associated with lack of immunization or underimmunization.

Vaccine hesitancy: More than a movement

Vaccines are some of if not the most successful public health endeavors ever put into practice. Countless lives have been saved and the occurrences of vaccine preventable diseases are at a fraction of the rate experienced before vaccines. Vaccines and the realization of their compulsory scheduling are highly studied, safe, and purposeful. Despite these realities, there are an alarming number of parents who do not permit the vaccination of their children as scheduled. This is known in the health community as vaccine hesitancy and commonly portrayed in popular media as anti-vaccination sediment. This analysis opens with the topic as it was addressed during a September 2015 debate for the Republic Party's 2016 presidential nomination. Some key historical aspects of vaccine hesitancy are presented. This history leads to a description of the 2014-2015 measles outbreak in California. The factors that aide in the recruitment of under vaccination are then explored. Finally, select strategies to control, combat, and potentially attenuate vaccine hesitancy are presented.

Vaccine myths and misconceptions

Communicable diseases are on the rise worldwide. Some of the increase in prevalence of these nearly eradicated diseases is due to a decrease in vaccination rates. This decrease is primarily due to parental concerns over vaccine safety and the increasing rates of autism spectrum disorders. Medical providers must address the growing antivaccine movement and misconceptions about immunizations. Physician assistants are in a unique position to offer evidence-based medical advice and encourage immunizations in order to prevent disease outbreaks.

Factors contributing to suboptimal rates of childhood vaccinations in Vermont

Childhood immunizations are invaluable in preventing contagious diseases. Nonetheless, vaccines have become increasingly controversial with growing numbers of caregivers refusing to vaccinate their children. The percentage of fully vaccinated children in Vermont is one of the lowest nationally. This study set out to determine Vermont caregivers' attitudes toward immunizations to better explain why the percentage of fully vaccinated children has fallen in Vermont. A survey regarding caregivers' health care knowledge about children, their vaccination concerns, and their children's vaccination status was sent to participants in the Vermont Women, Infants and Children's Program from two districts. In total, 83% (n = 379) of respondents reported their children received all recommended vaccinations for their age. Respondents who considered themselves highly knowledgeable regarding their children's health care and confident about the safety of vaccinations were significantly associated with reporting their children as being current on vaccinations and with their intent to continue vaccinations. Respondents indicated highest concern regarding the safety and number of vaccinations administered during one visit. Primary care providers were indicated as important resources for addressing concerns about vaccinations and health care knowledge of children. The results help to understand low vaccination rates in Vermont and can be used for targeting health campaigns to improve vaccination rates.

Vaccine Hesitancy

Vaccine refusal received a lot of press with the 2015 Disneyland measles outbreak, but vaccine refusal is only a fraction of a much larger problem of vaccine delay and hesitancy. Opposition to vaccination dates back to the 1800 s, Edward Jenner, and the first vaccine ever. It has never gone away despite the public's growing scientific sophistication. A variety of factors contribute to modern vaccine hesitancy, including the layperson's heuristic thinking when it comes to balancing risks and benefits as well as a number of other features of vaccination, including falling victim to its own success. Vaccine hesitancy is pervasive, affecting a quarter to a third of US parents. Clinicians report that they routinely receive requests to delay vaccines and that they routinely acquiesce. Vaccine rates vary by state and locale and by specific vaccine, and vaccine hesitancy results in personal risk and in the failure to achieve or sustain herd immunity to protect others who have contraindications to the vaccine or fail to generate immunity to the vaccine. Clinicians should adopt a variety of practices to combat vaccine hesitancy, including a variety of population health management approaches that go beyond the usual call to educate patients, clinicians, and the public. Strategies include using every visit to vaccinate, the creation of standing orders or nursing protocols to provide vaccination without clinical encounters, and adopting the practice of stating clear recommendations. Up-to-date, trusted resources exist to support clinicians' efforts in adopting these approaches to reduce vaccine hesitancy and its impact.

"Everybody just wants to do what's best for their child": Understanding how pro-vaccine parents can support a culture of vaccine hesitancy

BACKGROUND

Although a large majority of parents vaccinate their children, vaccine hesitancy has become more widespread. It is not well understood how this culture of vaccine hesitancy has emerged and how it influences parents' decisions about vaccine schedules.

OBJECTIVE

We sought to examine how attitudes and beliefs of parents who self-report as pro-vaccine are developed and contribute to immunization decisions, including delaying or spacing vaccines.

METHODS

Open-ended, in-depth interviews (N=23) were conducted with upper-middle class parents with young children living in Philadelphia. Interview data were coded and key themes identified related to vaccine decision-making.

RESULTS

Parents who sought out vaccine information were often overwhelmed by the quantity and ambiguity when interpreting that information, and, consequently, had to rely on their own instinct or judgment to make vaccine decisions. In particular, while parents in this sample did not refuse vaccines, and described themselves as pro-vaccine, they did frequently delay or space vaccines. This experience also generated sympathy for and tolerance of vaccine hesitancy in other parents. Parents also perceived minimal severe consequences for deviating from the recommended immunization schedule.

CONCLUSION

These findings suggest that the rise in and persistence of vaccine hesitancy and refusal are, in part, influenced by the conflicts in the information parents gather, making it difficult to interpret. Considerable deviations from the recommended vaccination schedule may manifest even within a pro-vaccine population due to this perceived ambiguity of available information and resulting tolerance for vaccine hesitancy.

Addressing Parental Vaccination Questions in the School Setting: An Integrative Literature Review

School nurses work in a unique environment with key opportunities to address parental concerns and questions regarding their child's health. A common concern for parents during school enrollment is childhood vaccination safety and efficacy. As public health leaders, school nurses are well respected among parents, therefore school nurses are in a prime position to educate parents and promote childhood vaccinations while also dispelling common vaccination myths. The purpose of this integrative literature review is to synthesize evidence-based answers to common parental questions regarding childhood vaccinations.

What do we know about how to improve vaccine uptake?

Over the past 100 years, an increasing array of vaccines has been introduced into the Canadian market and yet optimal use depends on public demand and acceptance of these products. In the 1990s, research focused on key barriers to vaccine uptake, highlighting the importance of barriers to access and "missed opportunities" for vaccination. In this century the focus is on vaccine hesitancy, which is influenced by factors such as complacency, convenience and confidence. This phenomenon is not new but some of its drivers include an increasingly crowded immunization schedule, heightened societal concerns about risk over benefit, and a rise in health consumerism. Understanding and addressing vaccine hesitancy will be critical to preventing it from undermining the success of immunization in the future. While more research is needed, there are both practitioner-based resources to optimize dialogue with vaccine-hesitant parents and program-based resources to address vaccine hesitancy at a population-based and societal level.

Immune overload: Parental attitudes toward combination and single antigen vaccines

Parental concerns have led to a recent decline in immunization coverage, resulting in outbreaks of diseases that were once under control in the US. As the CDC vaccination schedule continues to increase in complexity, the number of required injections per office visit increases as well. Some parents perceive that there is trauma associated with the administration of multiple injections, and research shows that having multiple vaccines due in a single visit is associated with delays and lower immunization rates. Combination vaccines make vaccination more efficient by incorporating the antigens of several different diseases into a single injection, but many parents worry that they may overload the child's developing immune system and leave him or her susceptible to secondary infections. This literature review synthesizes current evidence regarding the parental fear of vaccine-induced immune system overload and the fear of vaccine-associated trauma, in an attempt to understand the scope and nature of these fears. Despite the wealth of knowledge about each of these fears individually, it is still unknown which is of greater concern and how this affects parental decision-making.

Commentary on "Parental vaccine-hesitancy: Understanding the problem and searching for a resolution"

The increasing numbers of vaccine-hesitant parents poses a threat to personal and public health through a resurgence of vaccine-preventable diseases. Understanding the factors underlying vaccine-hesitant parents' fears is a necessary step toward designing interventions to overcome them. Educational interventions appear more successful when combined with personal interactions. Providers are the most important influence on parental vaccine decisions. Research should focus on designing effective interventions that facilitate effective parent-provider communication around this issue.

What are the factors that contribute to parental vaccine-hesitancy and what can we do about it?

Parental refusal or delay of childhood vaccines is increasing. Barriers to vaccination among this population have been described, yet less is known regarding motivating factors. Researchers are beginning to evaluate various approaches to address the concerns of "vaccine-hesitant" parents, but few studies have evaluated the effect of interventions on timely vaccine uptake. Several models for communicating with vaccine-hesitant parents have been reported for healthcare providers; however, the effectiveness and utility of these strategies has not been quantified. This article reviews the known barriers to vaccination reported by vaccine-hesitant parents and the current evidence on strategies to address parental vaccine hesitancy.

Perceptions of personal belief vaccine exemption policy: a survey of Arizona vaccine providers

BACKGROUND

As exemptions to school-entry requirements rise, vaccination rates in Arizona school children are approaching levels that may threaten public health. Understanding the interactions physicians have with vaccine-hesitant parents, as well as the opinions physicians hold regarding vaccination, exemption, and exemption policies, are critical to our understanding of, and ability to affect, vaccination exemption rates among children.

METHODS

Survey responses were elicited from practitioners listed in The Arizona Partnership for Immunization and the Arizona Medical Association databases using a multi-pronged recruitment approach. Respondents provided data regarding their practice, comfort with parental refusal of individual vaccines, opinions about the beliefs held by parents that seek exemptions, parent education strategies, issues regarding providing care to unvaccinated children, and potential changes to Arizona policy.

RESULTS

A total of 152 practitioners providing care to a wide geographic and economic population of Arizona responded to the survey. Respondents were generally strong advocates of all immunizations but were more accepting of parents' desires to refuse hepatitis B and rotavirus vaccines. Almost all providers indicated that they see patients whose parents request to refuse or delay from vaccinations at least occasionally (88% and 97%, respectively). Only 37% of respondents indicated that they would be supportive of a policy requiring them to sign off on a parent's decision to refuse vaccination.

CONCLUSIONS

Vaccination providers in Arizona are generally very supportive of childhood immunizations but have varying comfort with exemption from individual vaccines. Responding providers tended to not support a requirement for a physician's signature for vaccine exemptions due to varying concerns regarding the implementation of such a practice.

Parents who refuse to vaccinate their infants: paediatricians' feelings and treatment intentions

AIM

The aim of this study was to evaluate paediatricians' attitudes and emotions towards parents who refuse to vaccinate their infants and to assess their reactions, suggestions and practices.

DESIGN

The study group consisted of 376 paediatricians in Israel, who completed the emailed research questionnaire anonymously.

RESULTS

Although the vast majority of paediatricians agreed that vaccination was in the baby's best interest (92.2%), only a small percentage (3.5%) felt that there should be some scientific justification behind a parent's refusal. The majority (70.7%) of those surveyed expressed negative feelings towards refusing parents. Despite this, more than a third (36.9%) agreed that parents have the right to decide (28.9% disagreed) and a third (36.8%) agreed that vaccinations should be officially enforced (35.8% disagreed). Only a very small percentage of the paediatricians (1.8%) said they would object to treating infants who had not been vaccinated.

CONCLUSION

Paediatricians face a conflict between two opposing values: the importance of immunization versus the parents' rights to decide what is best for their own child. Therefore, they are in favour of gentle persuasion or official enforcement. We believe that experts in modern communication could help paediatricians to convey the positive benefits of vaccination to parents.

Addressing heterogeneous parental concerns about vaccination with a multiple-source model: a parent and educator perspective

Previous models of vaccine education have not addressed differences in levels and motives of vaccine concerns in parents. These differences may require changes in education approaches based on type of parental concern. Addressing vaccine concerns will require a multi-modal approach involving more than just a pediatrician or primary health care provider, as well as more than one educational approach.

Parental vaccine concerns, information source, and choice of alternative immunization schedules

Alternative immunization schedules increase the time a child is unvaccinated and require greater resources from providers. Understanding what drives interest in alternative immunization schedules can potentially inform the design of effective, targeted messages that help to reduce time spent counseling and decrease requests for alternative immunization schedules. This study used the Theory of Planned Behavior to explore associations between sources of vaccine information, parental vaccine concerns, peer norms for vaccine behavior and intentions to follow an alternative immunization schedule. We performed logistic regression using medical record data from a private pediatric practice in a large northeastern city. Routine data were recorded in the EMR by the pediatrician during an initial vaccine counseling conversation with the parent(s). Parents who received vaccine information from doctors were less likely to have immunization concerns while parents who got vaccine information from friends and family or from books were more likely to report specific vaccine concerns. Our multivariate analysis shows that number of reported vaccine concerns and concerns about the utility or necessity of vaccines are strongly associated with alternative immunization intentions. We also find a direct relationship between sources of information about vaccines and alternative immunization intentions. Our results suggest that vaccine concerns and non-physician information sources play an important role in alternative immunization intentions while communication from physicians may play an important role in addressing vaccine concerns and promoting adherence to the ACIP immunization schedule.

Challenges in comparing the safety of different vaccination schedules

As vaccine hesitancy has increased in the United States, various authors have begun proposing alternatives to the Advisory Committee on Immunization Practices' recommended childhood immunization schedule. Because parents may believe the safety claims made by such authors, evaluations of the safety of alternative vaccination schedules are needed. However, comparing the safety of different vaccination schedules has numerous methodologic challenges. These challenges include defining vaccination history, defining safety, appropriately modeling interactions between vaccines, and appropriately handling age effects. Failure to properly address these challenges can result in biased results.

Autism spectrum disorders: a pediatric overview and update

PURPOSE OF REVIEW

To provide an updated overview of autism spectrum disorders (ASDs), with particular attention to the pediatrician's role in assessing and managing patients with ASDs.

RECENT FINDINGS

Clinical perspectives on ASDs continue to evolve. The prevalence of ASDs in the United States continues to rise, and pediatricians are being tasked with the responsibility for universal screening. Further changes in its epidemiology will undoubtedly result from anticipated changes in the diagnostic criteria put forth in the upcoming revision to the Diagnostic and Statistical Manual (5th edition). Although there have been considerable advances in identifying a genetic cause in many more cases, the cause remains elusive in most cases. Recent studies of concordant twins suggest there is a stronger environmental component than previously believed. Research suggests earlier diagnosis may be feasible in some cases, and a new treatment approach has been shown to be effective in very young children. Although there have not been any large-scale advances in the medical treatment, some isolated successes have been reported and other promising therapies are now being investigated.

SUMMARY

Clinical guidelines for ASDs are evolving, with updated diagnostic criteria expected and revised recommendations for evaluation also imminent. This article provides pediatricians with a clinical overview of ASD - with an emphasis on the clinical considerations relating to screening, evaluation, and management.

Discussing vaccination with concerned patients: an evidence-based resource for healthcare providers

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.

Frequency of alternative immunization schedule use in a metropolitan area

OBJECTIVES

Recent studies have described an increase in parental hesitancy regarding vaccines as well as increases in parental adoption of vaccine schedules that delay or limit receipt of recommended vaccines. This study quantifies potential prevalence and trends in alternative schedule compliance by measuring consistent shot-limiting in a metropolitan area of Oregon.

METHODS

Retrospective cohort analysis using the Oregon ALERT Immunization Information System to track children born between 2003 and 2009 in the Portland metropolitan area. Joinpoint regression was used to analyze prevalence trends in consistent shot-limiting during that time period. The 2007-2009 Haemophilus influenzae type b vaccine shortage and increased availability of combination vaccines were also examined for their effects on shot-limiting rates.

RESULTS

A total of 4502 of 97,711 (4.6%) children met the definition of consistent shot-limiters. The proportion of consistent shot-limiters in the population increased from 2.5% to 9.5% between 2006 and 2009. Compared with those with no or episodic limiting, consistent shot-limiters by 9 months of age had fewer injections (6.4 vs 10.4) but more visits when immunizations were administered (4.2 vs 3.3). However, only a small minority of shot-limiters closely adhered to published alternative schedules.

CONCLUSIONS

The percentage of children consistently receiving 2 or fewer vaccine injections per visit between birth and age 9 months increased threefold within a 2-year period, suggesting an increase in acceptance of non-Advisory Committee on Immunization Practices vaccine schedules in this geographic area.

The clinician's guide to the anti-vaccinationists' galaxy

In this paper we briefly review three common immunological misconceptions that feature prominently among anti-vaccinationists, and in turn, fuel patient and parental concerns, questions, and fears about vaccines. In particular, this Perspective covers a brief history of the anti-vaccine movement, and three common false immunological claims, namely, concerns over "antigenic overload," the induction of autoimmunity by vaccines, and the value of "natural immunity" versus vaccine-induced immunity. This is followed by a review of the harms that have been done by anti-vaccinationists, and a call to action. Regardless of the motivation behind such fears and anti-vaccine sentiment, common fears and concerns relevant to vaccines are evident and therefore are the subject of this Perspective. It is hoped that clinicians will find this information useful in answering concerns and misconceptions about vaccines, and in educating their patients.

Washington State pediatricians' attitudes toward alternative childhood immunization schedules

OBJECTIVE

To determine the frequency of parents' requests for alternative childhood immunization schedules (ACISs) and pediatricians' comfort with and willingness to use ACISs.

METHODS

Washington State primary care pediatricians were asked to complete an Internet-based survey on ACISs. The main outcome measures were the frequency of parents' requests for ACISs, pediatricians' comfort with their use, and pediatricians' willingness to use ACISs for individual vaccines. In addition, respondents were asked to characterize their practices and to provide demographic information.

RESULTS

Of the 311 respondents (response rate: 65%), 209 met inclusion criteria and were included in analyses. Overall, 77% of eligible respondents reported that parents sometimes or frequently requested ACISs, and 61% were comfortable using an ACIS if requested by a parent. Pediatricians were least willing to consider using ACISs for diphtheria-tetanus toxoids-acellular pertussis vaccine, Haemophilus influenzae type b vaccine, and pneumococcal conjugate vaccine. Pediatricians who practiced in a neighborhood or community clinic were less comfortable using ACISs than were those in a 1- or 2-physician practice (odds ratio: 0.10).

CONCLUSIONS

Washington State pediatricians are regularly being asked to use ACISs, and most of them are comfortable using them if requested. Pediatricians are least willing to delay H influenzae type b vaccine, diphtheria-tetanus toxoids-acellular pertussis vaccine, and pneumococcal conjugate vaccine, which suggests prioritization of immunizations that protect against potentially devastating bacterial infections of infancy and early childhood.

Childhood immunization: when physicians and parents disagree

Persistent fears about the safety and efficacy of vaccines, and whether immunization programs are still needed, have led a significant minority of parents to refuse vaccination. Are parents within their rights when refusing to consent to vaccination? How ought physicians respond? Focusing on routine childhood immunization, we consider the ethical, legal, and clinical issues raised by 3 aspects of parental vaccine refusal: (1) physician counseling; (2) parental decision-making; and (3) continuing the physician-patient relationship despite disagreement. We also suggest initiatives that could increase confidence in immunization programs.

Confidence about vaccines in the United States: understanding parents' perceptions

The United States has made tremendous progress in using vaccines to prevent serious, often infectious, diseases. But concerns about such issues as vaccines' safety and the increasing complexity of immunization schedules have fostered doubts about the necessity of vaccinations. We investigated parents' confidence in childhood vaccines by reviewing recent survey data. We found that most parents--even those whose children receive all of the recommended vaccines--have questions, concerns, or misperceptions about them. We suggest ways to give parents the information they need and to keep the US national vaccination program a success.