CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Countering Vaccine Hesitancy Kathryn M. Edwards, MD, Jesse M. Hackell, MD, THE COMMITTEE ON INFECTIOUS DISEASES, THE COMMITTEE ON PRACTICE AND AMBULATORY MEDICINE

Immunizations have led to a signifi cant decrease in rates of vaccine- abstract preventable diseases and have made a signifi cant 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. This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have fi led confl ict of interest statements with the American Academy of Pediatrics. Any confl icts have been resolved through a process approved by the Board of Directors. The American Academy of INTRODUCTION Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Immunizations have had an enormous impact on the health of children, Clinical reports from the American Academy of Pediatrics benefi t from and the prevention of disease by vaccination is one of the single greatest expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of public health achievements of the last century. However, over the past Pediatrics may not refl ect the views of the liaisons or the organizations decade acceptance of vaccines has been challenged by individuals and or government agencies that they represent. groups who question their benefit. 1 Increasing numbers of people The guidance in this report does not indicate an exclusive course of are requesting alternative vaccination schedules 2, 3 or postponing or treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. declining vaccination. 4 In a national telephone survey of 1500 parents of All clinical reports from the American Academy of Pediatrics children 6 to 23 months of age conducted in 2010 with a response rate automatically expire 5 years after publication unless reaffi rmed, of 46%, approximately 3% of respondents had refused all vaccines and revised, or retired at or before that time. 19.4% had refused or delayed at least 1 of the recommended childhood DOI: 10.1542/peds.2016-2146 vaccines.5 A study conducted in a metropolitan area of Oregon reported PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). that rates of alternative immunization schedule usage have increased nearly fourfold in recent years, 3 and in some parts of the country the use Copyright © 2016 by the American Academy of Pediatrics of “personal belief exemptions” from vaccinations has grown to rates in FINANCIAL DISCLOSURE: Dr Hackell has indicated excess of 5% of the school-aged population. 6 that a family member has stock or equity in Pfi zer and GlaxoSmithKline. The Periodic Survey of Fellows (PS#66) conducted by the American Academy of Pediatrics (AAP) in 2006 revealed that 75% of pediatricians FUNDING: No external funding. surveyed had encountered parents who refused a vaccine, 7 and a POTENTIAL CONFLICT OF INTEREST: The authors have follow-up survey in 2013 (PS#84) revealed that this figure had increased indicated they have no potential confl icts of interest to to 87% of pediatricians. 8 According to the survey, pediatricians stated disclose. that the proportion of parents who refused 1 or more vaccines increased from 9.1% to 16.7% during the 7-year interval between surveys. 7, 8 To cite: Edwards KM, Hackell JM, AAP THE COMMITTEE ON Physicians stated that the most common reasons parents refused INFECTIOUS DISEASES, THE COMMITTEE ON PRACTICE AND vaccines were that they believed that vaccines are unnecessary (which AMBULATORY MEDICINE. Countering Vaccine Hesitancy. Pediatrics. 2016;138(3):e20162146 showed an increase over the 7-year span) and that they had concerns

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 :e 20162146 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 1 Categorization of Parental Attitudes Toward Vaccines12, 14 Immunization advocate Parents agree that vaccines are necessary and safe. Parents have a strong relationship with their health care provider. Go along to get along Parents do not question vaccines, would like to vaccinate their children, but may lack a detailed knowledge of vaccines. Cautious acceptor Parents may have minor concerns about vaccines but ultimately vaccinate their children. Fence-sitter Parents have signifi cant concerns about vaccines and tend to be knowledgeable about vaccines. Parents may vaccinate their child or may refuse or delay vaccines. Parents may have signifi cant concerns about vaccines and may have a neutral relationship with their health care provider. Refuser Parents refuse all vaccines for their child. Their reasons for refusal may include distrust in the medical system, safety concerns, and religious beliefs.

The concept that parental vaccine hesitancy is a spectrum has been confirmed in several studies 4, 14, 15 and was well described in a recent review by Leask et al 12 (Table 1). Some parents who totally refuse vaccines may be fixed and unswayable in their beliefs and may not respond to the pediatrician attempting to change their views. The AAP recommends that pediatricians continue to engage with vaccine-hesitant parents, provide other health care services to their children, and attempt to modify FIGURE 1 their opposition to vaccines. 16 – 18 Vaccine pipeline: prelicensure and postlicensure vaccine development activities. From Hardt K, Fortunately, most vaccine-hesitant Schmidt-Ott R, Glismann S, Adegbola RA, Meurice F. Sustaining vaccine confi dence in the 21st century. Vaccines. 2013;1(3):204–224. Copyright © 2013 by the authors; licensee MDPI, Basel, Switzerland. parents are responsive to vaccine Reproduced under the terms and conditions of the Creative Commons Attribution license (http:// information, consider vaccinating creativecommons. org/ licenses/ by/ 3. 0/ ). their children, and are not opposed to all vaccines. Responding to vaccine- about autism (which declined of parental attitudes toward hesitant parents is the focus of this between survey years). In both 2006 vaccines. 1 Vaccine hesitancy has clinical report. and 2013, pediatricians reported been characterized recently by a that they were able to convince committee at the World Health VACCINES ARE TESTED THOROUGHLY approximately 30% of parents Organization as “a behavior, to vaccinate their children when influenced by a number of factors they initially refused. Another including issues of confidence (do Vaccine development is a long observational study found that when not trust a vaccine or a provider), and arduous process, often lasting physicians continued to engage complacency (do not perceive a need many years and involving a parents, up to 47% of parents for a vaccine or do not value the combination of public and private ultimately accepted vaccines after vaccine), and convenience (access).” 11 partnerships. The current system for initially refusing them.9 Although the Vaccine-hesitant individuals are developing, testing, and regulating majority of parents accept vaccines, a heterogeneous group who hold vaccines requires that the vaccines the increasing frequency of refusal varying degrees of indecision demonstrate both safety and efficacy and the requests for alternative about specific vaccines or about before licensure and that long-term vaccine schedules indicate that vaccinations in general. Vaccine- safety is monitored (http:// www. there are still significant barriers to hesitant individuals may accept historyofvaccines . org/ content/ overcome.10 all vaccines but remain concerned articles/ vaccine- development- about them, they may refuse or delay testing- and- regulation; Fig 1). some vaccines but accept others, or The first step in vaccine discovery TERMINOLOGY they may refuse all vaccines. The involves the identification of a The term vaccine hesitancy has latter group refusing all vaccines is need for a vaccine and an emerged to depolarize the “pro” estimated at approximately 3% of understanding of the mechanism versus “anti” vaccination alignment parents, although the prevalence of protective immunity against and to express the spectrum may vary geographically. 4, 12, 13 that disease.

Downloaded from www.aappublications.org/news by guest on September 26, 2021 e2 FROM THE AMERICAN ACADEMY OF PEDIATRICS If the vaccine appears promising events associated with vaccines CDC and the FDA. In rare instances in in preclinical studies, the vaccine (http:// vaers. hhs. gov/ index). which safety concerns are identified, sponsor submits an application for Anyone who suspects an association regulatory or other actions to an Investigational New Drug to the between a vaccination and an safeguard public health are taken. US Food and Drug Administration adverse event can report the event (FDA). Law requires that the sponsor to VAERS. The CDC and the FDA describe the manufacturing and then investigate the event. 19 VAERS HISTORICAL VACCINE OPPOSITION testing processes, summarize the has successfully identified several Before discussing the recent increase laboratory reports, and describe the adverse events related to vaccination in vaccine hesitancy, it is valuable to proposed studies to evaluate the in the past, such as intussusception recall that opposition to vaccination vaccine. As with therapeutic drugs, after administration of the RotaShield is not a new occurrence. In the early vaccine evaluation includes phase (Wyeth Laboratories Inc, Marietta, 1800s in Europe, Jenner promoted I through phase III testing. Phase PA) rotavirus vaccine, which was vaccination against smallpox by I trials are intended to assess the identified in 1999, leading to the using material obtained from safety of the candidate vaccine and ultimate withdrawal of that vaccine cowpox lesions. 25 However, over to determine the type and extent of from the market. 20 the next several decades, increasing immune response that the vaccine In 1990, the CDC also established rates of opposition to smallpox provokes. the Vaccine Safety Datalink (VSD) vaccination were seen in the United Phase II testing involves several to monitor vaccine safety. The VSD Kingdom, requiring vaccination to be hundred volunteers, some of whom is composed of a number of large mandated by law. 25 Similar obstacles belong to groups at risk for acquiring health provider groups with linked to universal smallpox vaccination the disease. These trials generally databases with comprehensive were also encountered in the United are randomized and controlled and information about vaccines States. In the 1850s, a number of usually include a placebo group or administered and health care parents and physicians challenged a standard licensed vaccine when a encounters. 21 Because the VSD mandatory smallpox vaccination, new vaccine for that disease is being involves millions of individuals, it and in 1905 in the case Jacobson tested. can be used to detect rare events and v Massachusetts, the US Supreme Phase III vaccine trials are designed was used to study the possible, but Court supported the rights of states to determine whether the vaccine subsequently disproven, association to pass laws mandating smallpox 6 will prevent the disease in question between Guillain–Barré syndrome vaccine. However, although vaccine 22 and to assess the vaccine’s safety and meningococcal vaccination. hesitancy is not a new phenomenon, when administered to a large Another parallel system to the it may have a greater effect on number of subjects. These studies VSD is the Post-Licensure Rapid public health today. With the ease of often involve thousands or tens of Immunization Safety Monitoring global travel, vaccine-preventable 23 thousands of participants, depending system. This system uses health diseases are spread more quickly and on the incidence of disease and insurance claims data from 107 may unexpectedly appear in areas the rates of adverse events to be million individuals to actively where health care professionals detected. If these studies show the monitor vaccine safety. In addition, are unfamiliar with their clinical vaccine to be effective and safe, it is the CDC has also established the presentation. then licensed. Clinical Immunization Safety Assessment Project, a group of academic health care centers, to CURRENT VACCINE EXEMPTIONS address specific questions about VACCINE SAFETY IS ACTIVELY Herd immunity is a fundamental MONITORED AFTER LICENSURE vaccine safety from individual health concept that contributes to the care providers (http:// www. cdc. gov/ Once vaccines are licensed, a success of many vaccination vaccinesafety/ activities/ cisa. html). 24 number of processes are in place to programs. Control of many vaccine- ensure that the safety of vaccines In summary, vaccines are preventable diseases is contingent is monitored. In 1990, the Centers comprehensively evaluated before on a significant proportion of for Disease Control and Prevention their licensure. They are developed the population in a community (CDC) and FDA established the and tested in large numbers of being immune. 26 Depending on Vaccine Adverse Events Reporting subjects, regulated by the FDA, and the disease, the percentage of System (VAERS), a voluntary passive carefully monitored after licensure individuals required to achieve herd reporting system that serves as a through a comprehensive safety immunity in a community ranges signal detection system for adverse surveillance system funded by the from 30% to 95%.27 Traditionally,

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 e3 immunization rates have been not received measles vaccine (45%) 1994 article by Chen et al 19 (Fig 2), maintained in the United States or had unknown vaccination status which succinctly outlines many through mandatory vaccination (38%).37 Of the cases in unvaccinated of the pivotal factors that must be requirements for entry into and children, 43% of parents cited considered when discussing vaccine advancement through licensed child philosophical or religious objects hesitancy. As shown in Fig 2, disease care centers and schools. However, to vaccine. An additional 40% of incidence is highest before the recent years have seen a marked unvaccinated children could not development and implementation of increase in the availability and use receive the vaccine because they a vaccine program. At this time, the of “philosophical” or “personal were too young. This outbreak, public generally is eager to accept belief” exemptions from vaccination. which spread to multiple states, has a new vaccine, particularly if the Over the period from 2005 through sparked intense debate about vaccine morbidity and mortality associated 2011, Omer et al 28 reported that the exemptions and the government’s with the disease are considerable. unadjusted rates for nonmedical role in limiting nonmedical Then, after the vaccine is developed exemptions in states that allowed exemptions. Whether the 2015 and proven efficacious, individuals for philosophical exemptions were outbreak and legislation resulting are eager to be vaccinated, and 2.5 times higher than in states that from this outbreak will have a long- coverage increases, with subsequent allowed only religious exemptions. lasting effect on public policy and declines in disease incidence In Arkansas, rates of overall parental choices is not clear at this (“increasing coverage” phase). exemptions increased an average time. For these reasons, we believe However, as vaccine uptake peaks, of 23% per year once philosophical the better approach is to work to the disease incidence declines, and exemptions were allowed. 29 Studies eliminate all nonmedical exemptions the total number of adverse events have demonstrated that parents for childhood vaccines, a position that after vaccination increases. Whether who refuse vaccines are more likely to is shared by the American Medical the adverse events were causally be white and more highly educated Association and the Infectious related or only temporally associated than those who do not.4, 6, 30, 31 In Diseases Society of America and with vaccine administration can addition, the prevalence of vaccine- is currently the basis of a policy be difficult to determine, but these hesitant parents seems to vary statement being developed by the adverse events may lead to loss geographically. 6,32 It is unclear AAP. There has also been greater of confidence in the vaccine as whether requiring a mandatory recognition among pediatricians that the public perceives the risk of physician visit or educational delayed or incomplete vaccination vaccination to outweigh the risk module for parents who apply for schedules are probably responsible, of disease (“loss of confidence” vaccine exemption in states with at least in part, for the spread of phase). This, in turn, may increase philosophical exemptions is effective measles in that outbreak. 38 – 40 As vaccine refusal and ultimately lead in reducing refusals. 32 a result, more pediatricians are to disease resurgence. Then, after becoming concerned about the disease resurgence or an outbreak, Children who are philosophically risk unimmunized children pose as the public again appreciates exempted from vaccination not only to other children in their practices, the increasing burden of disease, are at greater risk of developing both immunized children and those vaccine acceptance is restored vaccine-preventable disease but too young or otherwise unable to and vaccination rates increase also put vaccinated children and be immunized. Some are electing to (“resumption of confidence” phase). medically exempt children who dismiss families who refuse vaccines Unfortunately, a recent study during live in the same area at risk. 33 – 35 from their practices. 7 The ethical an outbreak of pertussis in the Vaccine-preventable diseases considerations of patient dismissal state of Washington suggested that, occurring in vaccinated children may are complex and are discussed in a despite an increase in pertussis cases, result from waning immunity after subsequent section of this statement parents did not have a “resumption immunization or may be attributable as well as in a comprehensive review in vaccine confidence” and did not to an ineffective immune response by Diekema.41 increase pertussis vaccine uptake. 42 to vaccine initially. In January 2015, In the rare incidents in which a measles outbreak occurred in disease is eradicated by vaccine, as California, where an estimated 3.1% FACTORS INVOLVED IN VACCINE occurred with smallpox, vaccination of kindergartners had a nonmedical ACCEPTANCE can stop (“eradication” phase). exemption from receiving the The evolution of vaccine confidence This conceptual framework is more measles–mumps–rubella (MMR) over the course of vaccine applicable to diseases for which the vaccine. 36 The majority of cases introduction is summarized in time between exposure and infection occurred in children who either had a figure that first appeared in a is short, such as measles, pertussis,

Downloaded from www.aappublications.org/news by guest on September 26, 2021 e4 FROM THE AMERICAN ACADEMY OF PEDIATRICS or polio, and less relevant to, for example, vaccines against human papillomavirus (HPV), for which the benefits of immunization in preventing cancer may take years or decades to become apparent. Figure 2 clearly highlights the delicate balance between perceived risk and benefit for each vaccine and how this balance is linked integrally to vaccine acceptance.

PARENTS’ VARIED CONCERNS ABOUT VACCINES SHOULD BE ADDRESSED

A number of studies have attempted to define the reasons why parents are FIGURE 2 vaccine hesitant, and these factors Evolution of a vaccine program. Reproduced with permission. Chen RT, Orenstein WA. Epidemiologic are summarized in Table 2. 1, 4, 5,15, 43 – 45 methods in immunization programs. Epidemiol Rev. 1996;18(2):102. Copyright © 1996 by the Oxford In 1 study, 44% of parents reported University Press. concern over pain associated with receiving multiple injections during TABLE 2 Parental Concerns About Vaccines a single visit, 34% expressed unease Vaccine safety about receiving too many vaccines Too many vaccines at a single visit, 26% worried about Development of autism the development of autism or other Vaccine additives (thimerosal, aluminum) Overload the immune system potential learning difficulties after Serious adverse reactions receiving vaccines, 13.5% expressed Potential for long-term adverse events concern that vaccines could lead to Inadequate research performed before licensure chronic illnesses, and 13.2% stated May cause pain to the child that vaccines were not tested enough May make the child sick 45 Necessity of vaccines for safety before their use. Concerns Disease is more “natural” than vaccine about vaccine safety and questions Parents do not believe diseases being prevented are serious about the necessity of vaccines are Vaccine-preventable diseases have disappeared often cited as reasons for vaccine Not all vaccines are needed refusal.43, 46 – 48 One survey found that Vaccines do not work Freedom of choice parents who decide to not vaccinate Parents have the right to choose whether to immunize their child their children have a greater distrust Parents know what’s best for their child of health care professionals and the Believe that the risks outweigh the benefi ts of vaccine government and are more likely to Do not trust organized medicine, public health use complementary and alternative Do not trust government health authorities Do not trust pharmaceutical companies medicine, compared with parents Ethical, moral, or religious reasons who vaccinate their children. 47 Freed et al43 also conducted an online survey of several thousand that vaccines could cause autism was that there is no evidence that HPV 43 parents to identify vaccine concerns. often cited as a reason for refusal. vaccine increases sexual activity Most of the surveyed parents may dispel their concerns. 50 Some agreed that vaccines protected their Parental concerns must be addressed, parents are concerned primarily children from diseases; however, and concerns will vary among about the pain associated with more than half expressed concerns parents. For example, vaccine safety immunizations. Strategies to reduce regarding serious adverse effects of and triggering early sexual activity pain include administering vaccines vaccines. Overall, 11.5% of parents are often cited as parental concerns quickly without aspirating, holding in that study had refused at least 1 about the HPV vaccine. 49 Reassuring the child upright, administering recommended vaccine, and the fear parents that the vaccine is safe and the most painful vaccine last, and

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 e5 TABLE 3 Number of Immunogenic Proteins and Polysaccharides Contained in Vaccines Over the Past 100 Years 1890 1960 1980 2000 Vaccine Proteins Vaccine Proteins Vaccine Proteins Vaccine Proteins and Polysaccharides Smallpox ~200 Smallpox ~200 Diphtheria 1 Diphtheria 1 Total ~200 Diphtheria 1 Tetanus 1 Tetanus 1 Tetanus 1 WC-pertussis ~3000 AC-pertussis 2–5 WC-pertussis ~3000 Polio 15 Polio 15 Polio 15 Measles 10 Measles 10 Total ~3217 Mumps 9 Mumps 9 Rubella 5 Rubella 5 Total ~3041 Hib 2 Varicella 69 Pneumococcus 8 Hepatitis B 1 Total 123–126 Adapted from Offi t et al. 52 AC-pertussis, acellular pertussis vaccine; WC-pertussis, whole cell pertussis vaccine. providing tactile stimulation. 51 cell lines in vaccine production does the diseases prevented by MMR Breastfeeding, feeding sweet-tasting not prohibit the use of these vaccines vaccine, showing visual images solutions, and topical anesthetics are many years after the fetal cells were of children who have diseases other tools that can be used before obtained. 53 prevented by MMR vaccine, vaccine administration to decrease A specific response to the parental providing a dramatic audio narrative pain. Distraction strategies, including concern of “too many vaccines” and about an infant who almost died pinwheels, deep breathing exercises, the potential for “overwhelming the of measles, and no intervention. and toys, can be used in older immune system” was provided by None of the interventions increased children to decrease anxiety and Offit et al. 54 As shown in Table 3, the parental intent to vaccinate a pain. Although rigorously controlled number of immunogenic proteins future child. Thus, the authors studies of these techniques have not and polysaccharides contained concluded that current public health been performed, studies of other in currently licensed vaccines is communications about vaccines painful procedures lend support to significantly smaller than the number may not be effective, and for some 51, 52 their use in vaccination. of antigens contained in earlier vaccine-hesitant parents, they may actually increase misperceptions Providers should address specific vaccines and in naturally circulating and reduce vaccination intention. parental questions about the organisms that infected children However, a limitation of this study production and composition of the before universal vaccination. Sharing was that it was Web based and did vaccines by directly providing the a copy of Table 3 could provide the not examine the effect of direct one- information requested. For example, necessary reassurance to parents to-one personal communication for concerns about the presence of who have concerns regarding “too between the pediatrician and the mercury (thimerosal) in vaccines, many vaccines.” parent. parents can be reassured that currently, none of the single-dose Providing vaccine information is vaccine preparations given to infants COUNTERING VACCINE HESITANCY CAN time consuming. Kempe et al 56 found contain any mercury. The opposition BE CHALLENGING that 53% of physicians spend 10 to the presence of aluminum as an Even the use of targeted discussion to 19 minutes discussing vaccines adjuvant in some vaccines can be strategies may not be adequate to with concerned parents, and 8% addressed by providing evidence for counter vaccine hesitancy. A recent of physicians spend 20 minutes both the necessity of the aluminum study reported by Nyhan et al 55 or more with these parents. They for a vigorous immune response and recruited a nationally representative also reported that pediatricians the lack of evidence for its toxicity. sample of parents through random experienced decreased job The religious argument that vaccines digit dialing and address-based satisfaction because of time spent contain cells derived from aborted sampling and randomly assigned with parents with significant vaccine human fetuses can be answered in them to 1 of 5 groups: providing concerns. Physicians have several statements from major religious textual information explaining the options to deal with this problem, denominations either acknowledging lack of evidence that MMR vaccine ranging from scheduling longer that the vaccines do not contain such causes autism, supplying textual well-care visits, with some loss of cells or that the earlier use of fetal information about the dangers of overall efficiency; simply not having

Downloaded from www.aappublications.org/news by guest on September 26, 2021 e6 FROM THE AMERICAN ACADEMY OF PEDIATRICS the discussion and acceding to a another study, Smith et al59 clearly the current recommended vaccine parent’s request to defer, delay, or demonstrated that parents whose schedule and support it as the skip a vaccination; or dismissing children were vaccinated listed their only evidence-based schedule that such families from their practice. pediatrician as a strong influence on has been tested and approved by Permitting alternative vaccine their decision to vaccinate. A well- multiple authoritative experts for schedules reduces vaccine timeliness informed pediatrician who effectively safety and efficacy. 60 No alternative and complicates an already complex addresses parental concerns and vaccine schedules have been vaccine schedule. 57 A study by strongly supports the benefits of evaluated and found to provide Robison et al 3 demonstrated that vaccination has enormous influence better safety or efficacy than the children whose parents chose to limit on parental vaccine acceptance. recommended schedule, supported vaccinations had more total visits by the Advisory Committee for immunizations and by both 9 and on Immunization Practices of 19 months of age were substantially ATTENTIVENESS TO PARENTS’ the CDC and the Committee on less likely to be caught up on their CONCERNS IS IMPORTANT WHILE Infectious Diseases of the AAP (the immunization series. The additional CORRECTING MISCONCEPTIONS committee that produces the Red time and costs associated with longer After acknowledging the varied Book). Pediatricians who routinely and more frequent well-child and concerns of vaccine-hesitant recommend limiting the numbers of immunization visits for parents with parents, the pediatrician needs to vaccines administered at a single visit vaccine concerns are substantial, communicate with the parents about such that vaccines are administered and by decreasing the efficiency of the development and safety testing of late are providing care that deviates primary care providers, they may vaccines, the reasons for immunizing, from the standard evidence-based have a significant effect on access to and the risks of not doing so. An schedule recommended by these health care services for all children. important aspect of communication bodies. Situational deviation from with vaccine-hesitant parents is to these recommendations may be clearly articulate the message that considered a last resort if, after PEDIATRICIANS PLAY AN IMPORTANT vaccines are safe and effective, and reasonable attempts to convince ROLE serious disease can occur if your child hesitant parents, it is the only With all the challenges acknowledged, and family are not immunized. The way to achieve the ultimate goal the single most important factor in safety of the currently recommended of immunizing a child. All who getting parents to accept vaccines vaccines administered according provide vaccines must be capable of remains the one-on-one contact with to their established schedules was articulating the safety and efficacy an informed, caring, and concerned strongly affirmed by the Institute of of the standard schedule and refrain pediatrician.58 In a study reported Medicine in 2013. 60 A recent report from suggesting that delaying or in Pediatrics, parents of more than commissioned by the Agency for deferring vaccines may be safer or 7000 children 19 to 35 months of age Healthcare Research and Quality, more effective, because there is no were surveyed to determine whether on behalf of the National Vaccine evidence to support this viewpoint. they believed vaccines were safe and Program Office, and an accompanying what influence their primary care editorial also affirmed the safety of Pediatricians should not providers had on their decisions to vaccines recommended for routine overestimate parental vaccine vaccinate.45 Nearly 80% of parents immunization of children. 61, 62 It hesitancy or mistake a simple lack stated that their decision to vaccinate is important to present this safety of knowledge for hesitancy or was positively influenced by their information in a nonconfrontational opposition. 64 Opel et al 9 reported that primary care provider. The study dialogue with the parents while only 55% of practitioners routinely concluded, “Health care providers listening to and acknowledging their provide parents with the rationale for have a positive influence on parents concerns. Misconceptions should be why vaccines are administered and to vaccinate their children, including corrected, because both parents and their potential adverse effects. They parents who believe that vaccinations pediatricians are in agreement in reported that nearly half of parents are unsafe. Physicians, nurses, and wanting the best for the children’s who were initially vaccine hesitant other health care professionals health and well-being. 63 ultimately accepted vaccines after should increase their efforts to build practitioners provided a rationale honest and respectful relationships for vaccine administration. Parental with parents, especially when parents THE CURRENT VACCINE SCHEDULE IS education can be provided through express concerns about vaccine safety THE ONLY RECOMMENDED SCHEDULE Vaccine Information Statements or have misconceptions about the It is extremely important that the (VISs) given to parents before benefits and risks of vaccinations.” In pediatrician remain up to date on vaccine administration, through

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 e7 an online review of the VIS before demonstrated that recent graduates success convincing skeptical parents the routine immunization visit, or were less likely to believe that using messages that relied on their through referral to authoritative Web vaccines were safe and efficacious personal choices and experiences. sites, such as that of the CDC (http:// than their older colleagues 66; Physicians relating that they have www. cdc. gov/ vaccines/ vpd- vac/ whether this is attributable to lack of immunized all of their children, default. htm). One study reported that first-hand experience with vaccine- their grandchildren, or themselves the majority of mothers preferred preventable diseases or lack of provide a compelling message that receiving vaccine information before comprehensive vaccine education they are confident in the safety of the the initial immunization visit. 65 is unclear. Educational efforts vaccines. The provision of a VIS is required during residency training programs Other techniques, such as the use at each immunization encounter should provide trainees with a of parent-centered motivational for each vaccine, and counseling comprehensive understanding of the interviewing, have been suggested about vaccine-preventable diseases effect of vaccines on disease burden as an effective way to personalize and vaccine adverse effects is and the knowledge to evaluate communication. Having parents required to correctly bill for vaccine the safety of vaccines as well as verbalize their questions and administration. If parents refuse effective communication strategies. concerns, followed by a focused vaccination, a vaccine refusal Only 48.5% of 303 US pediatric response to their concerns, may waiver, used by many pediatricians residents surveyed reported training be an effective communication in the event of deviations from the in communication strategies for strategy. However, the effect of recommended vaccine schedule, vaccine-hesitant patients during motivational interviewing and other can be obtained from the AAP Web residency, and nearly 80% requested communication techniques requires site (https:// www. aap. org/ en- us/ more education about the adverse careful assessment. It is encouraging advocacy- and- policy/ aap- health- effects of vaccines. 67 One study that both AAP Periodic Surveys initiatives/ immunization/ Pages/ found that a brief single educational of Fellows from 2006 and 2013 refusal- to- vaccinate. aspx), and intervention may not be sufficient indicated that one-third of parents parents may be asked to sign it. to provide physicians with the skills who initially refused ≥1 vaccines to counteract vaccine hesitancy ultimately changed their minds and and suggested that more research gave permission for vaccination. is needed to determine the most PRESUMPTIVE DELIVERY STRATEGY Although these conversations may effective educational interventions. 68 be difficult and frustrating, they Another effective communication clearly represent time well spent. approach is the presumptive A summary of points that may be delivery strategy. Opel et al 9 PERSONALIZING THE MESSAGE THAT useful in these conversations is found demonstrated that the majority of VACCINES ARE SAFE AND EFFECTIVE CAN BE POWERFUL in Table 4. parents accepted the provider’s vaccine recommendations when The presentation of basic medical they were presented as required information may not be sufficient to DISMISSAL OF PATIENTS WHO REFUSE immunizations to maintain optimal reassure parents about the safety and VACCINATION disease prevention. This approach necessity of vaccines. Developing a may not work well with some trusting relationship with parents Some families still will not be parents, however, and pediatricians is key to influencing parental persuaded to vaccinate. 56 After may use it selectively based on their decision-making around vaccines. 69 multiple attempts to convince experience. In addition, pediatricians Parents often are more likely to be families to vaccinate have failed, who began practicing medicine persuaded by stories and anecdotes some pediatricians have chosen to before the introduction of many of about the successes of vaccines. dismiss families as a last resort. 7, 8, 70 today’s routinely recommended Personal examples of children who Arguments have been made vaccines have first-hand knowledge were sick with vaccine-preventable that these families should not of these preventable diseases illnesses can be much more effective be dismissed on the basis of and often use that experience to than simply reading the numbers of public health principles, because effectively communicate the need children infected with a disease each nonvaccinating families might cluster for vaccines and the rationale for year in the VIS. The Web site www. in certain practices, making them the their administration according to immunize. org/ reports is an excellent focal point for outbreaks.71 Ethical established recommendations. One source of such cases. A recent study arguments against dismissal have study conducted among 542 primary by Kempe et al 56 demonstrated that also been made. 41, 72, 73 In addition, care providers in the United States physicians reported the greatest there are dilemmas for the many

Downloaded from www.aappublications.org/news by guest on September 26, 2021 e8 FROM THE AMERICAN ACADEMY OF PEDIATRICS pediatricians who continue to TABLE 4 Communication Highlights care for these families, including Vaccines are safe and effective, and serious disease can occur if your child and family are not potentially exposing other patients immunized. to vaccine-preventable diseases Vaccine-hesitant individuals are a heterogeneous group, and their individual concerns should be from those who are unimmunized. respected and addressed. Vaccine are tested thoroughly before licensure, and vaccine safety assessment networks exist to Finally, many pediatricians may monitor vaccine safety after licensure. feel obligated to continue to care Nonmedical vaccine exemptions increase rates of unvaccinated children. for children in families who refuse Unvaccinated children put vaccinated children and medically exempt children who live in that same area immunizations. at risk. Pediatricians and other health care providers play a major role in educating parents about the safety There are no published data and effectiveness of vaccines. Strong provider commitment to vaccination can infl uence hesitant or regarding the eventual outcome of resistant parents. strict “vaccinate or be dismissed” Personalizing vaccine acceptance is often an effective approach. policies on the eventual acceptance of The majority of parents accepted the provider’s vaccine recommendations when they were presented as required immunizations to maintain optimal disease prevention. vaccines, and additional studies are The current vaccine schedule is the only one recommended by the CDC and the AAP. Alternative needed. However, there is anecdotal schedules have not been evaluated. evidence that when pediatricians give parents the choice between these situations, the pediatrician of the available resources to aid the immunizing their child or being should continue to provide care to pediatrician. dismissed, some parents accept the patient and family. vaccination, even when other efforts The pediatrician should also at persuasion have failed. The decision to dismiss a family who appreciate that vaccine-hesitant It should be noted that the same continues to refuse immunization is parents are a heterogeneous group legal and ethical constraints exist not one that should be made lightly, and that specific parental vaccine to dismissal for any permissible nor should it be made without concerns should be individually reason, including failure to vaccinate. considering and respecting the identified and addressed. Although Dismissal must be conducted in a reasons for the parents’ point of many techniques for working with manner consistent with applicable view. 44 Nevertheless, the individual vaccine-hesitant parents have been state laws prohibiting abandonment pediatrician may consider dismissal suggested, scant data are available of patients. Although these laws of families who refuse vaccination as to determine the efficacy of these vary from state to state, official an acceptable option. In all practice methods. 77 Additional research notification of the parents or legal settings, consistency, transparency, on communication techniques is guardian is required, along with the and openness regarding the needed. The clear message parents provision of information for finding practice’s policy on vaccines is should hear is that vaccines are safe a new physician. Furthermore, the important. and effective, and serious disease dismissing physician is obligated can occur if your child and family to continue current treatment are not immunized. Pediatricians and provide emergency care for a CONCLUSIONS should keep in mind that many, if not most, vaccine-hesitant parents reasonable period of time, usually 30 Vaccine discussions continue to 74,75 are not opposed to vaccinating their days. occupy the media and Internet, and children; rather, they are seeking Certain practice settings may also every parent of a child for whom guidance about the issues involved, limit the ability to dismiss a patient. vaccination is recommended is beginning with the complexity of the Employees of hospitals and large exposed to these messages on a schedule and the number of vaccines health care organizations are often regular basis. Data have shown proposed. Parents may be unsure of unable to dismiss patients by official that participation in social media the need for vaccines, because most organizational policy. In areas of reinforces one’s beliefs about have never experienced the diseases the country where there may be vaccination, no matter what those vaccines are designed to prevent, and limited access to pediatric care, the beliefs are. 76 The pediatrician is often they have concerns about possible pediatrician should carefully evaluate the only medically trained person adverse effects of these vaccines. the availability of other qualified available to discuss vaccine matters providers for the family. If there with parents, and it is incumbent on Pediatricians facing concerned are no other qualified physicians in him or her to provide scientifically parents on a regular basis should the area, the pediatrician is faced based and balanced information be prepared to discuss the science with the problem of leaving a family when these questions are asked. behind the current vaccine schedule without adequate health care. In Table 5 provides a summary of some and the extensive testing of each

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 e9 TABLE 5 Vaccine Resources Tools AAP refusal to vaccinate form: https://www. aap. org/ en- us/ Documents/ immunization_ refusaltovaccinat e. pdf Risk communication videos: https://www. aap. org/ en- us/ advocacy- and- policy/ aap- health- initiatives/ immunization/ Pages/ vaccine- hesitant- parents. aspx#Video Navigating Vaccine Hesitancy: https://www. aap. org/ en- us/ Documents/ immunization_ hesitancy. pdf (will be available soon) Education Pedialink modules: https://pedialink. aap. org/ visitor Adolescent Immunizations: Strongly Recommending the HPV Vaccine: http:// shop. aap. org/ Adolescent-Immunizations- Strongly-Recommending- the- HPV- Vaccine Challenging Cases: Vaccine Hesitancy: http://bit.ly/cc-vaccinehesitancy. This module is the educational component of the clinical report. AAP Immunization Web site: https://www. aap. org/ en- us/ advocacy- and- policy/ aap- health- initiatives/ immunization/ Pages/ default. aspx (The following are some of the specifi c pages within the above site) Parental Refusal Resource Page: https://www. aap. org/ en- us/ advocacy- and- policy/ aap- health- initiatives/ immunization/ Pages/ refusal- to- vaccinate. aspx Vaccine-Hesitant Parents: https://www. aap. org/ en- us/ advocacy- and- policy/ aap- health- initiatives/ immunization/ Pages/ vaccine- hesitant- parents. aspx Information for families: https://www. healthychildren. org/ english/ safety- prevention/ immunizations/ pages/ default. asp x Common Parental Concerns: https://www. aap. org/ en- us/ advocacy- and- policy/ aap- health- initiatives/ immunization/ Pages/ Common- Parental- Concerns. aspx HealthyChildren.org (for parents): http://www. healthychildren. org/ English/ safety- prevention/ Pages/ default. aspx (same as above) CDC/AAP Provider Resources for Vaccine Conversations With Parents: http:// www. cdc. gov/vaccines/ hcp/ patient-ed/ conversations/index. html Immunization Action Coalition: http:// www. immunize. org/ Children’s Hospital of Philadelphia: http://www. chop. edu/ service/ vaccine- education- center/ home. html National Foundation for Infectious Diseases: http:// www. nfi d. org/ Families Fighting fl u: www. familiesfi ghtingfl u.org Vaccine Resource library: www. path. org/ vaccineresources Every Child by Two: www. ecbt. org Parents of Kids With Infectious Diseases: www. pkids. org Policy Responding to Parental Refusals of Immunization of Children: http:// pediatrics. aappublications.org/ content/ 115/5/ 1428.full Medical Versus Nonmedical Immunization Exemptions for Child Care and School Attendance: http://www. pediatrics. org/ cgi/doi /10. 1542/ peds. 2016. 2146 2016 Immunization Schedules: http://www2. aap. org/ immunization/ IZSchedule. html COID Policy Collection page: http://pediatrics. aappublications. org/ cgi/ collection/ committee_ on_ infectious_ diseases Red Book Discussing Vaccines With Patients and Parents Discussing Vaccines With Patients and Parents (pp. 7–9) Addressing Parents’ Questions About Vaccine Safety and Effectiveness (p. 9) Common Misconceptions About Immunizations and the Institute of Medicine Findings (pp. 10–11) Resources for Optimizing Communications With Parents About Vaccines (p. 12) Parental Refusal of Immunizations (pp. 12–13) Assessing the State of Vaccine Confi dence in the United States: Recommendations From the National Vaccine Advisory Committee: http://www. hhs. gov/ sites/ default/fi les/nvpo/ nvac/ reports/ nvac- vaccine- confi dence-public- health- report- 2015. pdf Journal articles Childhood Immunization: When Physicians and Parents Disagree: http:// pediatrics. aappublications.org/ content/ 128/Suppleme nt_4/ S167. full Safety of Vaccines Used for Routine Immunization of US Children: A Systematic Review: http://pediatrics. aappublications.org /content/ early/ 2014/ 06/ 26/ peds. 2014-1079. full. pdf+html Commentary in Pediatrics: Vaccines: Can Transparency Increase Confi dence and Reduce Hesitancy? http:// pediatrics.aappublications. org/content/ early/2014/ 06/26/ peds. 2014- 1494. full. pdf+html Children whose parents refused vitamin K at birth are 14.6 times more likely to be unimmunized by age 15 mo. This provides an opportunity to identify a subset of likely vaccine-hesitant parents at birth and engage them with targeted information. News release: http://www. aap. org/ en- us/ about- the- aap/ aap- press- room/ Pages/ Parents- Who- Refuse- Vitamin- K- for- Newborn- Also- More- Likely- to- Refuse- Vaccines.aspx Study: http://pediatrics. aappublications. org/ content/ early/ 2014/ 08/ 12/ peds. 2014- 1092 A survey found that parents who were informed about the MMR vaccine’s direct benefi ts to their child, rather than the vaccine’s benefi ts to society as a whole, were more likely to immunize. News release: http://www. aap. org/ en- us/ about- the- aap/ aap- press- room/ Pages/ Emphasizing- MMR- Vaccine%27 s- Benefi ts-for- Children- Increases- Parents%27 - Intent-to- Immunize. aspx Study: http://pediatrics. aappublications. org/ content/ early/ 2014/ 08/ 12/ peds. 2013- 4077 MedScape story: http://www. medscape. com/ viewarticle/ 830062? src= rss A pertussis epidemic in Washington State did not increase parents’ intent to vaccinate their children. Study: http://pediatrics. aappublications. org/ content/ early/ 2014/ 08/ 12/ peds. 2013- 3637. full. pdf+html Commentary: http://pediatrics. aappublications. org/ content/ early/ 2014/ 08/ 12/ peds. 2014- 1883. full. pdf+html HealthDay story: http://health. usnews. com/ health- news/ articles/ 2014/ 08/ 18/ doctors- id- new- ways- to- get- more- kids- vaccinated Research Periodic Survey #66 (2006): Vaccine Refusals: http://www. aap. org/ en- us/ professional- resources/ Research/ Pages/ PS66_ Executive_ Summary_ PediatriciansAtti tudesandPracticesSurroundingtheDel iveryofImmunizati onsPart2. aspx Periodic Survey #84(2013) Vaccine Delays/Refusals and Risk–Benefi t Information Abstracts Vaccine Refusals and Requests for Alternate Vaccine Schedules (AVS): National Surveys of Pediatricians Pediatric Academic Societies (PAS) May 2014

Downloaded from www.aappublications.org/news by guest on September 26, 2021 e10 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 5 Continued Images Red Book Online Visual Library: http:// aapredbook.aappublications. org/ site/ visual Photos, videos, and family stories regarding vaccine-preventable diseases: http:// www2. aap.org/ immunization/ illnesses/il lnesses.html vaccine before and after licensure, COMMITTEE ON INFECTIOUS DISEASES, Natasha Halasa, MD, MPH, FAAP – Pediatric remind the parents of the severity 2015–2016 Infectious Diseases Society Joan L. Robinson, MD – Canadian Paediatric of the diseases being prevented, Carrie L. Byington, MD, FAAP, Chairperson Society address the questions that are Yvonne A. Maldonado, MD, FAAP, Vice Chairperson Geoffrey R. Simon, MD, FAAP – Committee on causing parental concerns and, Elizabeth D. Barnett MD, FAAP Practice Ambulatory Medicine most importantly, emphasize that H. Dele Davies, MD, MS, MHCM, FAAP Jeffrey R. Starke, MD, FAAP – American Thoracic Kathryn M. Edwards, MD, FAAP Society infants and children are the ones at Ruth Lynfi eld, MD, FAAP greatest risk of disease. The on-time Flor M. Munoz, MD, FAAP STAFF administration of vaccines is the most Dawn Nolt, MD, MPH Jennifer M. Frantz, MPH effective way to prevent what have Ann-Christine Nyquist, MD, MSPH, FAAP in the past been severe and often Mobeen H. Rathore, MD, FAAP COMMITTEE ON PRACTICE AND fatal childhood illnesses. Delaying Mark H. Sawyer, MD, FAAP AMBULATORY CARE, 2015–2016 William J. Steinbach, MD, FAAP any vaccine past the recommended Geoffrey R. Simon, MD, FAAP – Chair Tina Q. Tan, MD, FAAP Cynthia N. Baker, MD, FAAP administration date greatly increases Theoklis E. Zaoutis, MD, MSCE, FAAP the period of time that a child Graham A. Barden III, MD, FAAP Oscar “Skip” W. Brown III, MD, FAAP remains susceptible to disease FORMER COMMITTEE MEMBERS Jesse M. Hackell, MD, FAAP and also exposes even vaccinated Dennis L. Murray, MD, FAAP Amy P. Hardin, MD, FAAP 35,78 Kelley E. Meade, MD, FAAP children to additional risk. Gordon E. Schutze, MD, FAAP Scot B. Moore, MD, FAAP Rodney E. Willoughby Jr, MD, FAAP Countering vaccine hesitancy can Julia E. Richerson, MD, FAAP best be accomplished in the course EX OFFICIO STAFF of clinical practice through open Henry H. Bernstein, DO, MHCM, FAAP – Red Book Elizabeth Sobczyk, MPH, MSW communication and discussion Online Associate Editor The AAP acknowledges the signifi cant between the pediatrician and the Michael T. Brady, MD, FAAP, Red Book Associate contributions of Annabelle de St Maurice MD, parents. Because most parents Editor FAAP – Vanderbilt University. agree to vaccinate their children, Mary Anne Jackson, MD, FAAP, Red Book Associate Editor this dialogue, which can be started ABBREVIATIONS David W. Kimberlin, MD, FAAP – Red Book Editor as early as the prenatal interview Sarah S. Long, MD, FAAP – Red Book Associate AAP: American Academy of visit79 if possible, should be an Editor Pediatrics ongoing process. Continued research H. Cody Meissner, MD, FAAP – Visual Red Book CDC: Centers for Disease Control is needed on the best methods Associate Editor and Prevention to communicate the safety and FDA: US Food and Drug Adminis- CONTRIBUTOR effectiveness of vaccines. Providing tration vaccine-related information before Annabelle de St Maurice, MD, FAAP – Vanderbilt HPV: human papillomavirus the first immunization visit may University MMR: measles–mumps–rubella permit parents to clearly formulate VAERS: Vaccine Adverse Events LIAISONS their concerns so that they can be fully Reporting System addressed by the pediatrician. Most Douglas Campos-Outcalt, MD, MPA – American VIS: Vaccine Information Academy of Family Physicians Statement parents need and want education Amanda C. Cohn, MD, FAAP – Centers for Disease about the best way to provide care for Control and Prevention VSD: Vaccine Safety Datalink their children, including vaccinations. Jamie Deseda-Tous, MD – Sociedad Dealing with vaccine hesitancy is a Latinoamericana de Infectologia Pediatrica (SLIPE) REFERENCES wonderful opportunity to continue Karen M. Farizo, MD – US Food and Drug 1. Larson HJ, Jarrett C, Eckersberger E, to provide this information and Administration Smith DM, Paterson P. Understanding education to families. Marc Fischer, MD, FAAP – Centers for Disease Control and Prevention vaccine hesitancy around vaccines and vaccination from a global perspective: LEAD AUTHORS Bruce G. Gellin, MD, MPH – National Vaccine Program Offi ce a systematic review of published Kathryn M. Edwards, MD, FAAP Richard L. Gorman, MD, FAAP – National Institutes literature, 2007–2012. Vaccine. Jesse M. Hackell, MD, FAAP of Health 2014;32(19):2150–2159

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Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 e13 63. Healy CM, Pickering LK. How to hesitancy: a randomized trial. 74. Lippman H, Davenport J. Patient communicate with vaccine-hesitant Pediatrics. 2015;136(1): dismissal: the right way to do it. J Fam parents. Pediatrics. 2011;127(suppl 70–79 Pract. 2011;60(3):135–140 1):S127–S133 69. Benin AL, Wisler-Scher DJ, Colson E, 75. American Academy of Pediatrics. 64. Healy CM, Montesinos DP, Middleman Shapiro ED, Holmboe ES. Qualitative Medicolegal Issues in Pediatrics. 7th AB. Parent and provider perspectives analysis of mothers’ decision- ed. Elk Grove Village, IL: American on immunization: are providers making about vaccines for infants: Academy of Pediatrics; 2012:58–59 overestimating parental concerns? the importance of trust. Pediatrics. 76. Salathé M, Khandelwal S. Assessing Vaccine. 2014;32(5):579–584 2006;117(5):1532–1541 vaccination sentiments with online 65. Vannice KS, Salmon DA, Shui I, et al. 70. Block SL. The pediatrician’s social media: implications for infectious Attitudes and beliefs of parents dilemma: refusing the refusers of disease dynamics and control. PLOS concerned about vaccines: impact of infant vaccines. J Law Med Ethics. Comput Biol. 2011;7(10):e1002199 timing of immunization information. 2015;43(3):648–653 77. Sadaf A, Richards JL, Glanz J, Salmon Pediatrics. 2011;127(suppl 71. Halperin B, Melnychuk R, Downie J, DA, Omer SB. A systematic review of 1):S120–S126 Macdonald N. When is it permissible interventions for reducing parental 66. Mergler MJ, Omer SB, Pan WK, et al. to dismiss a family who refuses vaccine refusal and vaccine hesitancy. Are recent medical graduates more vaccines? Legal, ethical and Vaccine. 2013;31(40):4293–4304 skeptical of vaccines? Vaccines public health perspectives. 78. Luman ET, Barker LE, Shaw KM, (Basel). 2013;1(2):154–166 Paediatr Child Health. 2007;12(10): McCauley MM, Buehler JW, Pickering 67. Williams SE, Swan R. Formal 843–845 LK. Timeliness of childhood training in vaccine safety to 72. Chervenak FA, McCullough LB, Brent vaccinations in the United States: address parental concerns not RL. Professional responsibility and days undervaccinated and number routinely conducted in US pediatric early childhood vaccination. J Pediatr. of vaccines delayed. JAMA. residency programs. Vaccine. 2016;169(2):305–309 2005;293(10):1204–1211 2014;32(26):3175–3178 73. Diekema DS. Physician dismissal of 79. Cohen GJ; Committee on Psychosocial 68. Henrikson NB, Opel DJ, Grothaus L, families who refuse vaccination: an Aspects of Child and Family Health. et al. Physician communication ethical assessment. J Law Med Ethics. The prenatal visit. Pediatrics. training and parental vaccine 2015;43(3):654–660 2009;124(4):1227–1232

Downloaded from www.aappublications.org/news by guest on September 26, 2021 e14 FROM THE AMERICAN ACADEMY OF PEDIATRICS Countering Vaccine Hesitancy Kathryn M. Edwards, Jesse M. Hackell and THE COMMITTEE ON INFECTIOUS DISEASES, THE COMMITTEE ON PRACTICE AND AMBULATORY MEDICINE Pediatrics originally published online August 29, 2016;

Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2016/08/25/peds.2 016-2146 References This article cites 71 articles, 28 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2016/08/25/peds.2 016-2146#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Infectious Disease http://www.aappublications.org/cgi/collection/infectious_diseases_su b Vaccine/Immunization http://www.aappublications.org/cgi/collection/vaccine:immunization _sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

Downloaded from www.aappublications.org/news by guest on September 26, 2021 Countering Vaccine Hesitancy Kathryn M. Edwards, Jesse M. Hackell and THE COMMITTEE ON INFECTIOUS DISEASES, THE COMMITTEE ON PRACTICE AND AMBULATORY MEDICINE Pediatrics originally published online August 29, 2016;

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2016/08/25/peds.2016-2146

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2016 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

Downloaded from www.aappublications.org/news by guest on September 26, 2021