Patient Dismissal Is Last Resort for Vaccine Refusal
Written by Editor   
Monday, September 26, 2016 07:14 AM

The American Academy of Pediatrics (AAP) has changed its position and now says pediatricians can dismiss families for vaccine refusal, but only as a last resort. The new clinical report provides clinicians with multiple approaches for dealing with vaccine-hesitant families and stresses the role of pediatrician as educator in these situations.  However, if no approach works and pediatricians need to dismiss a family, they must do so in a thoughtful and professional manner. And they must ensure that the family has other options for medical care.

“The decision to dismiss a family who continues to refuse immunization is not one that should be made lightly, nor should it be made without considering and respecting the reasons for the parents’ point of view. Nevertheless, the individual pediatrician may consider dismissal of families who refuse vaccination as an acceptable option. In all practice settings, consistency, transparency, and openness regarding the practice's policy on vaccines is important."

The previous AAP policy was against dismissal, but the authors say that rising refusal rates and clinician frustration led to the change. Pediatricians believe that THEY are often the only medically trained persons to discuss vaccine questions with families, they have a responsibility to provide doubting parents with scientifically based information.  “Pediatricians facing concerned parents…should be prepared to discuss the science behind the current vaccine schedule and the extensive testing of each vaccine before and after licensure, remind the parents of the severity of the diseases being prevented, address the questions that are causing parental concerns and, most importantly, emphasize that infants and children are the ones at greatest risk of disease.” 

They should also point out that the current vaccine schedule is the only one recommended by the Centers for Disease Control and Prevention and AAP and that other schedules have not been evaluated.  However, pediatricians also need to treat parental concerns seriously. In the case of the human papillomavirus (HPV) vaccine, for example, “reassuring parents that the vaccine is safe and that there is no evidence that HPV vaccine increases sexual activity may dispel their concerns,” they write.  As for the pain and discomfort pain-reducing strategies, such as administering the most painful vaccine last. Other pain-mitigating approaches are breastfeeding, giving sweet solutions or topical anesthetics, and distraction techniques (such as pinwheels, deep breathing exercises, and toys).

The authors also note that parents are often more swayed by anecdotes and personal stories about the safety and power of vaccines than by clinical data, so personalizing the conversation is important.  Ultimately, pediatricians should be prepared to spend a fair amount of time providing vaccine information. A 2011 paper reports that 53% of physicians spent 10 to 19 minutes discussing vaccines with concerned parents and 8% spent at least 20 minutes.

AAP also calls for an end to nonmedical exemptions for immunization.  “The AAP views nonmedical exemptions to school-required immunizations as inappropriate for individual, public health, and ethical reasons and advocates for their elimination,” the statement says.  Although the group has previously opposed nonmedical exemptions, a press release says this is the first formal policy statement on the matter.