Provider dismissal policies and clustering of vaccine-hesitant families: an agent-based modeling approach

Challenging the 'acceptable option': Public health's advocacy for continued care in the case of pediatric vaccine refusal

BACKGROUND

In the United States, nearly half of pediatricians dismiss or refuse to accept families that withhold consent from the administration of childhood vaccines. Since 2016, the American Academy of Pediatrics has called patient dismissal in these cases "an acceptable option." Clinician dismissal and non-acceptance pose a problem to public health because they cluster under-vaccinated children in the practices that remain willing to treat such children, and they decrease access to routine care for children who cannot find practices willing to accept or retain them. This paper reports the emergence of a new consciousness about dismissal and non-acceptance policies in the leadership of a local health department (LHD) of a populous metropolitan county.

OBJECTIVES

To understand the prevalence and diversity of patient dismissal within Oakland County, Michigan and to measure shifts in clinicians' attitudes about dismissal following an educational intervention.

METHODS

A preliminary community survey was distributed to immunizing providers during April 2023 with 61 responses measuring the frequency and reasoning for dismissal policies. The results of the survey were used to inform a brief, evidence-backed educational intervention which was delivered in June 2023 to 82 participants from local pediatric medical offices.

RESULTS

The initial survey was completed by 61 immunizing providers, representing an estimated 37% of vaccinating practices in the county. Half said their practice "always" or "sometimes" dismisses patients due to vaccine refusal. After the educational intervention, the proportion of participants who agreed/strongly agreed with the statement "I believe patient dismissal for vaccine refusal is a good choice for public health" decreased from 36% to 18%.

CONCLUSION

The changes that we observed between the pre- and post-intervention surveys demonstrate the opportunity that exists for LHD leaders to enter the conversation around patient dismissal and nonacceptance and shed new light on this issue.

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.

Characteristics of Oklahoma Pediatricians Who Dismiss Families for Refusing Vaccines

Vaccine refusal is increasing. Objectives were to assess frequency of declining or dismissing patients who refuse vaccines, which vaccine(s) prompt pediatricians to decline/dismiss patients, and demographics of pediatricians who decline/dismiss patients. Active members of the Oklahoma American Academy of Pediatricians (AAP) were surveyed. Chi-square tests with non-overlapping 95% confidence intervals compared proportions of providers across various metrics. In all, 47% (48/103) versus 35% (34/98) reported declining versus dismissing patients for refusing vaccines, respectively. Pediatricians were unlikely to decline/dismiss patients if they refused influenza, human papilloma virus (HPV), or MenB vaccines. Pediatricians with more years in practice were less likely to decline 15% (9/62) versus 44% (16/36), P = 0.002 and dismiss 8% (5/62) versus 33% (12/36), P = 0.002 patients. Rural pediatricians were less likely than urban to decline 12% (2/17) versus 29% (26/89), P = NS and dismiss patients 0% (0/17) versus 21% (19/89), P = 0.04. Dismissing/declining patients for vaccine refusal is more common among Oklahoma pediatricians than nationally reported. Patterns differ by practice setting, years in practice, and specific vaccine refused.

Considering a COVID-19 vaccine mandate for pediatric kidney transplant candidates

The world continues to face the effects of the SARS-CoV-2 pandemic. COVID-19 vaccines are safe and effective in protecting recipients, decreasing the risk of COVID-19 acquisition, transmission, hospitalization, and death. Transplant recipients may be at greater risk for severe SARS-CoV-2 infection. As a result, transplant programs have begun instituting mandates for COVID-19 vaccine for transplant candidacy. While the question of mandating COVID-19 vaccine for adult transplant candidates has garnered attention in the lay and academic press, these discussions have not explicitly addressed children who may be otherwise eligible for kidney transplants. In this paper we seek to examine the potential ethical justifications of a COVID-19 vaccine mandate for pediatric kidney transplant candidacy through an examination of relevant ethical principles, analogous cases of the use of mandates, differences between adult and pediatric kidney transplant candidates, and the role of gatekeeping in transplant vaccine mandates. At present, it does not appear that pediatric kidney transplant centers are justified to institute a COVID-19 vaccine mandate for candidates. Finally, we will offer suggestions to be considered prior to the implementation of a COVID-19 vaccine mandate.

A qualitative study examining pediatric clinicians' perceptions of delayed vaccine schedules

OBJECTIVE

To explore pediatric clinicians' attitudes, beliefs, and perceived social norms about the impact of delayed vaccine schedules on the clinical management of their patients.

METHODS

We conducted 30 semi-structured qualitative interviews with academic (Infectious Diseases, Emergency Medicine) and community pediatric clinicians (General Pediatrics) to explore clinicians' perspectives on how delayed schedules influence their clinical management of patients. The interview guide was based on the Theory of Planned Behavior. We analyzed interview transcripts using both an inductive and deductive thematic approach.

RESULTS

The pediatric clinicians in our study overwhelmingly supported the recommended schedule, sought guidance on approaches to navigating conversations with vaccine hesitant families, and desired more evidence to effectively promote on-time vaccination. Clinicians described how delayed schedules have consequences for sick children (e.g., increased antibiotics, laboratory tests, emergency department visits) and healthy children (e.g., increased vaccine visits, out-of-pocket costs, fears among children receiving frequent shots). Clinicians stated that delayed schedules also negatively impact pediatric practices (e.g., increased time counseling patients, staff burden, clogged clinic space, unpredictable vaccine utilization, costs).

CONCLUSIONS

Pediatric clinicians perceive that delayed vaccine schedules negatively affect patients, pediatric practices, the healthcare system, and society. Future research should quantify the consequences of delayed schedules and identify strategies that promote vaccine adherence. Results from future studies can better support clinician-parent conversations about vaccine hesitancy, guide decision-makers about practice-level approaches to vaccine schedules, and advise payors and policymakers regarding vaccine-related policies.

Nurses' Perspectives on the Dismissal of Vaccine-Refusing Families From Pediatric and Family Care Practices

PURPOSE

Dismissal of families who refuse mandated childhood vaccines from pediatric practices has become more common among US pediatricians over the past 2 decades. While nurses (registered nurses [RNs] and advanced practice registered nurses [APRNs]) often are the first health-care professional to encounter parents' vaccine hesitancy and serve as a primary source of information, there are no published data on nurses' perspectives on dismissal as a response to vaccine refusal. This study examined nurses' perspectives on dismissal of vaccine-refusing families from primary care practices.

DESIGN

Cross-sectional survey administered electronically from February to September 2018. Data analysis was conducted from November 2018 to March 2019.

SETTING

Data were collected electronically from a national sample of nurses.

SUBJECTS

A convenience sample of 488 primary care nurses (74% APRNs) was recruited and enrolled in the study through collaboration with 4 professional nursing associations.

MEASURE AND ANALYSIS

A cross-sectional survey was conducted from February to September 2018. We explored correlates of nurses' (n = 488) attitudes toward dismissal by modeling attitude scores as a function of practice and respondent characteristics. We also modeled odds of encountering vaccine refusal and odds of reporting dismissal of a vaccine-refusing family in the last 12 months, each as a function of respondents' practice characteristics.

RESULTS

Eighty-four percent of respondents encountered vaccine refusal in the previous 12 months, and 22% reported that their practice had dismissed a vaccine-refusing family within the previous 12 months. Twenty-eight percent agreed/strongly agreed that they would dismiss or support a decision to dismiss families who refuse all vaccines, and 12% supported dismissal of families for refusal of some but not all vaccines. Thirty-nine percent of respondents disagreed/strongly disagreed with dismissing families who refuse all vaccines, and 50% disagreed/strongly disagreed with dismissal for refusal of some but not all.

CONCLUSION

Almost all nurses working in primary care encounter vaccine refusal, and most consider all Centers for Disease Control and Prevention-recommended childhood vaccines to be important to public health. There is significant polarization of nurses' attitudes toward the appropriateness of dismissal as a response to vaccine refusal. We recommend the development of professional nursing guidelines for responding to vaccine refusal. However, because there are no data on the community health impact of dismissal policies, we recommend further research on outcomes of dismissal policies to inform such guidelines.

Dismissal policies for vaccine refusal among US physicians: a literature review

Childhood vaccination is one of the greatest public health achievements of the 20th century, yet increasingly, parents question the safety of and need for vaccines. This has led to increased rates of vaccine delay and refusal and outbreaks of vaccine-preventable diseases. Physicians struggle with how to respond to families who refuse vaccines, as there are few known effective interventions to convince a family to vaccinate. In the United States, the practice of dismissing families for vaccine refusal appears to be increasing as a strategy for dealing with vaccine refusal. In this review, we review the literature surrounding this controversial practice, starting with the impact that vaccine-refusing families have on medical practices, followed by a review of dismissal policies of US physicians, and ending with a discussion of the ethics of this practice.

Is physician dismissal of vaccine refusers an acceptable practice in Canada? A 2018 overview

Despite robust evidence that routine immunization is effective and safe, some parents refuse some or all vaccines for their children. In 2007, concern that Canadian paediatricians and family physicians might be considering dismissal of vaccine refusers from their practices prompted an ethical, legal, and public health analysis which concluded that dismissal was professionally problematic. We now reassess this important issue in the Canadian context updating ethical, legal, and public health considerations highlighting changes since 2007. In light of the recent strengthening of Ontario's school immunization requirements that include stiffer steps to qualify for a medical, conscience, or religious belief exemption, physicians and health care workers may be under more pressure from vaccine refusers in their practice leading some to contemplate dismissal or even consider no longer offering immunizations at all in their practice. Given the challenges that vaccine refusers may present, we offer an overview for managing vaccine refusal by parents/patients in a medical practice.

Implementing vaccine hesitancy screening for targeted education

BACKGROUND AND PURPOSE

Little research has been performed investigating the effect of using a vaccine hesitancy (VH) screening tool to address specific vaccination concerns. The purpose of this study was to determine whether using a VH screening tool in conjunction with provider discussions addressing parental concerns affected the parental intent to vaccinate (ITV).

METHODS

This study used a pretest/posttest design to measure and categorize VH and ITV.

CONCLUSIONS

The total sample size was 89. Differences between previsit and postvisit questionnaires showed mean responses for questions that measured specific VH categories had slight increases in the level of VH. A regression analysis was conducted to predict the postvisit ITV. Questions measuring parental trust in the provider, beliefs on vaccine efficacy, and beliefs about the prevalence of vaccine preventable disease (VPD) in the community predicted 72% of the postvisit ITV responses.

IMPLICATIONS FOR PRACTICE

The utilization of a VH screening tool used in conjunction with provider education in an educated and mildly VH population did not positively affect the level of VH or the parental ITV. Additional research should investigate the role of parental trust in the provider, beliefs on vaccine efficacy, and the prevalence of VPD in the community affect parental ITV.

Provider-parent Communication When Discussing Vaccines: A Systematic Review

PROBLEM

Expert literature on communication practices with vaccine hesitant parents posits that a non-confrontational/participatory discussion with the parent would be the best approach to improve compliance. A prior literature review found limited evidence to recommend any particular face to face intervention other than to incorporate communication about vaccination effectiveness during an encounter. Hence, a systematic review was performed in an attempt to determine the most efficacious communication practices to use with parents with vaccination concerns.

ELIGIBILITY CRITERIA

Quantitative and qualitative studies written in English that assessed the communication framework/style of the provider-parent interaction and studies where provider communication was listed as an intervention were reviewed.

SAMPLE

Nine articles were included in the sample.

RESULTS

The majority of the studies were descriptive and qualitative in nature with only one randomized controlled trial. Five of the 9 studies utilized a descriptive cross-sectional design. Two main themes included message types recommended or given by the provider and message types that were requested by the parent.

CONCLUSIONS

Overall, findings showed that there is currently not enough information to definitively state the type of provider-parent communication style that should be employed to affect the parents' vaccination viewpoint. However, recurring themes of trust in the provider and a personalized provider-parent interaction were evident, which promotes a participatory type of interaction.

IMPLICATIONS

The literature indirectly supports providers engaging with vaccine hesitant parents in a more individualized, participatory format, though higher quality and more rigorous studies that focus specifically on provider-parent communication practices are needed.

Characteristics of Physicians Who Dismiss Families for Refusing Vaccines

BACKGROUND AND OBJECTIVES

Physicians dismissing families who refuse vaccines from their practices is controversial. We assessed the following among pediatricians (Peds) and family physicians (FPs): (1) reported prevalence of parental refusal of 1 or more vaccines in the infant series; (2) physician response to refusal; and (3) the association between often/always dismissing families and provider/practice characteristics and state exemption laws.

METHODS

Nationally representative survey conducted June to October 2012. A multivariable analysis assessed association of often/always dismissing families with physician/practice characteristics, state philosophical exemption policy, and degree of difficulty obtaining nonmedical exemptions.

RESULTS

The response rate was 66% (534/815). Overall, 83% of physicians reported that in a typical month, ≥1% of parents refused 1 or more infant vaccines, and 20% reported that >5% of parents refused. Fifty-one percent reported always/often requiring parents to sign a form if they refused (Peds 64%, FP 29%, P < .0001); 21% of Peds and 4% of FPs reported always/often dismissing families if they refused ≥1 vaccine. Peds only were further analyzed because few FPs dismissed families. Peds who dismissed families were more likely to be in private practice (adjusted odds ratio [aOR] 4.90, 95% confidence interval [CI] 1.40-17.19), from the South (aOR 4.07, 95% CI 1.08-15.31), and reside in a state without a philosophical exemption law (aOR 3.70, 95% CI 1.74-7.85).

CONCLUSIONS

Almost all physicians encounter parents who refuse infant vaccines. One-fifth of Peds report dismissing families who refuse, but there is substantial variation in this practice. Given the frequency of dismissal, the impact of this practice on vaccine refusers and on pediatric practices should be studied.

Comparative Safety of Vaccine Adjuvants: A Summary of Current Evidence and Future Needs

Use of highly pure antigens to improve vaccine safety has led to reduced vaccine immunogenicity and efficacy. This has led to the need to use adjuvants to improve vaccine immunogenicity. The ideal adjuvant should maximize vaccine immunogenicity without compromising tolerability or safety. Unfortunately, adjuvant research has lagged behind other vaccine areas such as antigen discovery, with the consequence that only a very limited number of adjuvants based on aluminium salts, monophosphoryl lipid A and oil emulsions are currently approved for human use. Recent strategic initiatives to support adjuvant development by the National Institutes of Health should translate into greater adjuvant choices in the future. Mechanistic studies have been valuable for better understanding of adjuvant action, but mechanisms of adjuvant toxicity are less well understood. The inflammatory or danger-signal model of adjuvant action implies that increased vaccine reactogenicity is the inevitable price for improved immunogenicity. Hence, adjuvant reactogenicity may be avoidable only if it is possible to separate inflammation from adjuvant action. The biggest remaining challenge in the adjuvant field is to decipher the potential relationship between adjuvants and rare vaccine adverse reactions, such as narcolepsy, macrophagic myofasciitis or Alzheimer's disease. While existing adjuvants based on aluminium salts have a strong safety record, there are ongoing needs for new adjuvants and more intensive research into adjuvants and their effects.

Physician Dismissal of Families Who Refuse Vaccination: An Ethical Assessment

Thousands of U.S. parents choose to refuse or delay the administration of selected vaccines to their children each year, and some choose not to vaccinate their children at all. While most physicians continue to provide care to these families over time, using each visit as an opportunity to educate and encourage vaccination, an increasing number of physicians are choosing to dismiss these families from their practice unless they agree to vaccinate their children. This paper will examine this emerging trend along with the reasons given by those who advocate such an approach. I will argue that the strategy of refusing to allow families into a clinic unless they agree to vaccinate their children is misguided, and the arguments for doing so fail to stand up to close scrutiny. Such a strategy does not benefit the child or the health of the community, and may have a negative impact on both. Furthermore, some of the arguments in support of dismissal policies ignore the importance of professional obligation and appear to favor self-interest over the interest of the patient.

Nonmedical exemptions from school immunization requirements: a systematic review

We summarized studies describing the prevalence of, trends in, and correlates of nonmedical exemptions from school vaccination mandates and the association of these policies with the incidence of vaccine-preventable disease. We searched 4 electronic databases for empirical studies published from 1997 to 2013 to capture exemption dynamics and qualitatively abstracted and synthesized the results. Findings from 42 studies suggest that exemption rates are increasing and occur in clusters; most exemptors questioned vaccine safety, although some exempted out of convenience. Easier state-level exemption procedures increase exemption rates and both individual and community disease risk. State laws influence exemption rates, but policy implementation, exemptors' vaccination status, and underlying mechanisms of geographical clustering need to be examined further to tailor specific interventions.

Ready or not? School preparedness for California's new personal beliefs exemption law

OBJECTIVE

This paper describes elementary school officials' awareness of and preparedness for the implementation of California's new exemption law that went into effect on January 1, 2014. The new law prescribes stricter requirements for claiming a personal beliefs exemption from mandated school-entry immunizations.

METHOD

We used cross-sectional data collected from a stratified random sample of 315 schools with low, middle, and high rates of personal beliefs exemptions. We described schools' awareness and specific knowledge of the new legislation and tested for differences across school types. We additionally tested for associations between outcome variables and school and respondent characteristics using ordered logit and negative binomial regression. Finally, we described schools' plans and needs for implementing the new legislation.

RESULTS

Elementary school staff reported an overall low level of awareness and knowledge about the new legislation and could identify few of its features. We observed, however, that across the exemption-level strata, respondents from high-PBE schools reported significantly higher awareness, knowledge and feature identification compared to respondents from low-PBE schools. Multivariate analyses revealed only one significant association with awareness, knowledge and identification: respondent role. Support staff roles were associated with lower odds of having high self-rated awareness or knowledge compared to health workers, as well as with a reduced log count of features identified. Though most school officials were able to identify a communication plan, schools were still in need of resources and support for successful implementation, in particular, the need for information on the new law.

CONCLUSION

Schools need additional information and support from state and local agencies in order to successfully implement and enforce California's new school immunization law. In particular, our results suggest the need to ensure information on the new law reaches all levels of school staff.

"Model" patients and the consequences of provider responses to vaccine hesitancy

The manner in which providers respond to parental concerns about the recommended childhood vaccination schedule is an area of increasing interest in pediatrics and medical ethics. Like many aspects of vaccination policy and practice, evaluating the reactions of providers to parental vaccine hesitancy--including the potential dismissal of such families from their practices--requires an appreciation of the twin character of vaccination as both a public health program as well as an individual preventive intervention. Accordingly, the ethics of vaccination combine many aspects of traditional medical ethics, such as respect for patient autonomy, the primacy of informed consent, and concern for the doctor-patient relationship, with the relatively newer discourse of public health ethics, one that directs particular attention to the health of populations and the pursuit of social justice. When parents are hesitant about vaccination for their children, providers may face a significant challenge reconciling their commitment to the health of those children, their respect for the perspectives of parents, and their interest in the health of their other patients and their communities. The tensions and potential conflicts among these considerations help to explain why provider responses to vaccine hesitancy have emerged as a frequent topic of discussion among practitioners, public health advocates, and ethicists alike.

Provider dismissal of vaccine-hesitant families: misguided policy that fails to benefit children

Some health care providers have adopted the policy of refusing to accept into their practices families who refuse to vaccinate their children according to the standard vaccine schedule. While the frustration that drives these policies is understandable, the practice of refusing to see these families is misguided. Such a strategy does not benefit the child or the health of the community, and may have a negative impact on both. Physicians represent the best opportunity to influence the vaccine-hesitant parent, but only if physicians are willing to care for these families will that be possible. Maintaining a relationship of open communication and trust remains the best strategy for addressing the problem of parental vaccine hesitancy.

Overview: special focus vaccine acceptance

At the World Economic Forum in 2010, The Gates Foundation announced the “Decade of Vaccines,” a $10 billion commitment to increase access to existing and new childhood vaccines. It is estimated that this effort could save 6.4 million lives and avert 426 million illnesses [1, 2] Achieving these goals will require a significant effort among global health agencies, non-governmental organizations, industry and national governments to support vaccine development and ensure a strong infrastructure for sustainable vaccine delivery. Vaccines are one of the most important public health achievements in history, resulting in significant decreases in the prevalence of many childhood diseases. However, persistent disparities exist in the adoption of new vaccines and sustained vaccination rates in both developed and developing countries. Decreasing vaccination rates in some communities have resulted in outbreaks of vaccine-preventable diseases. Disparities may be due to vaccine supply, poor infrastructure, or low prioritization of vaccines for public health spending. However, another crucial contributor to the success of vaccination programs is vaccine acceptance.