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Providers hoping to counteract the anti-vaccine movement can cultivate trust by setting aside time for vaccine discussions and using effective, empathetic communication to encourage vaccine compliance.
By Trudie Mitschang
Over the past decade, perceptions and concerns about vaccine safety have steadily increased vaccine refusal rates in the United States. Currently, several states allow for “personal belief” exemptions from school vaccination requirements, in addition to exemptions for religious or medical reasons. What is the cause for concerns about vaccines, and how can healthcare providers overcome them?
The rise in parental resistance to once-routine vaccinations is, in many cases, directly tied to concerns linking vaccines to rising instances of childhood autism. This theory first gained ground in 1998 after a study was published in the British medical journal The Lancet, despite an editorial published in the same issue that discussed concerns about the validity of the study, the dismissal of the study by medical professionals, as well as a host of new research. Since then, what has been dubbed the “anti-vaccine movement” has garnered increased attention and momentum, and several scientific studies have debunked the connection between thimerosal, a mercury-based preservative that was once used in most vaccines, and autism. Vaccine opponents believe this ingredient has helped trigger the growing number of autism cases and other neurological disorders in vaccinated children.
Clinicians hoping to educate the public, particularly parents, about the safety and benefits of vaccines have faced an uphill battle. In recent years, celebrity parents whose own children have been diagnosed with autism have lent their support to the anti-vaccine movement by speaking out on national talk shows and using social media tools, like blogs, Facebook and Twitter, to get their messages out. This increased media focus has helped catapult the anti-vaccine movement from a somewhat fringe discussion to a mainstream debate, with heated opinions on both sides.
Another setback for healthcare providers occurred in March 2008 when the U.S. government awarded compensation to a Georgia family that claimed vaccines had caused their daughter’s autism. The decision rallied anti-vaccine groups and created even more confusion for parents grappling with questions about the safety of vaccinations.
Recent events may help to turn the table on the battle. Last year, reports surfaced that the author of the study that was published in The Lancet, Dr. Andrew Wakefield, may have altered data after being paid $1 million to examine autistic children whose parents blamed the measles, mumps, rubella (MMR) vaccine for the illness. Then, this past February, that same article highlighting this study was retracted by the editor of the journal just days after the United Kingdom’s General Medical Council ruled that Dr. Wakefield acted improperly during his research. According to a statement by the Centers for Disease Control and Prevention (CDC), The Lancet ’s decision to retract the article “builds on the overwhelming body of research by the world’s leading scientists that concludes there is no link between MMR vaccine and autism. We want to remind parents that vaccines are very safe and effective, and they save lives. Parents who have questions about the safety of vaccines should talk to their pediatrician or their child’s healthcare provider.”
Unfortunately, anecdotal information and Internet-gleaned research seems to resonate louder than physician opinion for parents who remain on the fence. These days, it seems many in the medical community are viewed with increasing skepticism.
“I’ve spoken to my pediatrician about vaccine safety, and she assures me there is no proven correlation between vaccinations and autism. But how can I ignore people who noticed a change in their child after vaccination?” asks April Jace, a Los Angeles school teacher and mother of three. “My older boys have had all their vaccinations, but so far I have not scheduled my 14-month-old for his recommended 15-month shots. I have to wait until I read more and get more educated about it. I don’t want to be paranoid, but I also don’t want to just blindly trust my pediatrician either.”
One of the challenges physicians face in adequately addressing parental concerns regarding vaccines is a practical one: With a busy caseload of both well-child visits and sick children who need immediate attention, pediatricians are often thrown off guard when hit with a list of vaccine questions that they may not be prepared to answer. Dr. Bob Sears, pediatrician and author of The Vaccine Book, says he has made it a policy not to discuss vaccine safety during regular checkups, preferring to schedule a separate consultation for parents who have a lot of unanswered questions.
“When you have about 15 minutes to complete a regular checkup and a parent hits you with 20 minutes’ worth of questions about vaccines, there is simply no way to adequately address their concerns,” he explains. “I’ve found that scheduling a separate vaccine consultation allows for a much more focused and, hopefully, informative discussion. That way I’m not frustrated by time constraints, and the parent has my undivided attention. This is an emotional issue for many people, and it’s important that they feel as if they’ve been heard.”
According to the CDC website, effective, empathetic communication is critical in responding to parents who are considering not vaccinating their children. And, it says, “parents should be helped to feel comfortable voicing any concerns or questions they have about vaccination, and providers should be prepared to listen and respond effectively.”
The debate over vaccine safety is a polarizing one, pitting parent against parent, patient against physician, and leaving vaccine manufacturers and administrators caught in the middle. For some, refusing to vaccinate a child is a personal decision that should not come under scrutiny by anyone outside of the immediate family. But vaccine proponents argue that a decision against immunization puts entire communities at risk. In reality, even children whose parents do not refuse vaccination can be put at risk because “community immunity” normally protects children who are too young to be vaccinated, who can’t be vaccinated for medical reasons, or whose immune systems do not respond sufficiently to vaccination. When higher numbers of people go unvaccinated, once-obscure diseases like measles and whooping cough begin making a comeback, and for the most vulnerable members of society, the consequences can be deadly.
To achieve community immunity, more than 95 percent of a community would need immunization, which means childhood vaccinations need to go from being viewed as a personal decision to more of a larger social obligation. This moral consideration is a missing component in many discussions between physicians and parents, but it’s an important one. The CDC stresses that education is key when it comes to achieving vaccine compliance, and encourages physicians to inform parents who defer vaccination of their responsibilities to protect other family and community members, including people who may be immunocompromised. The CDC also suggests parents be advised of state school or childcare entry laws that might require that unimmunized children stay home from school during outbreaks of vaccine-preventable diseases.
In an article published in the New England Journal of Medicine, lead author Saad B. Omer, MBBS, PhD, MPH, assistant professor of global health and epidemiology at Emory University’s Rollins School of Public Health, reviewed evidence from several states that vaccine refusal puts children at substantially higher risk for infectious diseases such as measles and pertussis. Omer stated, “The implication of recent research findings is that everyone who is living in a community with a high proportion of unvaccinated individuals has an elevated risk.”
Few of today’s parents can recall the devastation of diseases such as smallpox, mumps or polio, which makes communicating the value of vaccines a difficult prospect for physicians. Educating parents about the risks of such diseases is important, but equally important is the need to honestly address perceived vaccine risks. A workshop on risk communication and vaccination sponsored by the Institute of Medicine’s Vaccine Safety Forum covered various discussion dynamics between the general public and healthcare providers. Among the findings:
Several resources are available to assist healthcare providers in addressing the benefits and risks of vaccination. Federal law requires all healthcare providers who administer vaccines in the United States to provide Vaccine Information Statements (VIS) to vaccine recipients (or their parent or guardian) prior to each dose. VIS are developed by the CDC and contain information on the disease, as well as the risks and benefits associated with immunization. Since the technical and medical language in these statements can sometimes be difficult for lay people to understand, discussing the information contained in the VIS with the parent/patient is also an excellent way to bridge the communication gap and encourage the administration of scheduled vaccines.
Omer, SB, Salmon, DA, Orenstein, WA, deHart, MP, and Halsey, N. Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases. N. New England Journal of Medicine, 360: 1981-8 (2009).
Centers for Disease Control and Prevention. Provider’s Guide: Helping Parents Who Question Vaccines. Accessed at http://www.cdc.gov/vaccines/pubs/providers-guide-parents-questioning-vacc.htm.
Immunization Action Coalition. Communicating About Vaccines. Accessed at http://www.immunize.org/concerns/comm_talk.asp.
Shapiro, JF. The History Behind the MMR Vaccine Controversy. Daily Strength. Accessed at http://www.dailystrength.org/experts/dr-jeremy/article/the-history-behind-the-mmr-vaccine-controversy.
The Centers for Disease Control and Prevention (CDC) suggests using the following guidelines during vaccine consultations:
Source: Centers for Disease Control and Prevention. Provider’s Guide: Helping Parents Who Question Vaccines. Accessed at http://www.cdc.gov/vaccines/pubs/providers-guide-parents-questioning-vacc.htm.
With the recent retraction of an article that appeared in the February 1998 British medical journal The Lancet, there are no proven data to suggest that the measles, mumps, rubella (MMR) vaccine will increase the risk of developing autism or any other behavioral disorder. However, there is plenty of scientific research to suggest that there is no causal association at all.
This research begins with the study reported on in The Lancet, which was based on data from 12 patients. Dr. Andrew Wakefield and colleagues speculated that MMR vaccine may have been the possible cause of bowel problems that led to a decreased absorption of essential vitamins and nutrients that resulted in developmental disorders like autism. However, no scientific analyses were reported to substantiate the theory. For instance, there is no clinical data that support the theory that autism may be caused by poor absorption of nutrients due to bowel inflammation. Plus, in at least four of the 12 cases in the study, behavioral problems appeared before the onset of symptoms of inflammatory bowel disease. What’s more, Dr. Wakefield and his colleagues later published another study in which highly specific laboratory assays in patients with inflammatory bowel disease were negative for measles virus.
In an investigation conducted in 1999 by a Working Party on MMR Vaccine of the United Kingdom’s Committee on Safety of Medicines, several hundred reports of autism, Crohn’s disease or similar disorders developing after receipt of MMR or MR vaccines were evaluated. The Working Party concluded that the results of their investigation did not support the suggested causal associations or give cause for concern about the safety of MMR or MR vaccines. The American Medical Association has since reached the same conclusion.
In a study conducted in certain districts in London, England, researchers investigated 498 known cases of autism spectrum disorders (ASD), which includes classical autism, atypical autism and Asperger’s syndrome, born in 1979 or later and linked to an independent regional vaccination registry. They found that while the known number of ASD cases has been increasing since 1979, there was no jump after the introduction of MMR vaccine in 1988. Those vaccinated before 18 months of age had similar ages at diagnosis as did cases who had been vaccinated after 18 months or not vaccinated. At 2 years old, the MMR vaccination coverage among ASD cases was nearly identical to coverage in children in the same birth cohorts in the whole region. Further, the first diagnosis of autism or initial signs of behavioral regression were not more likely to occur within time periods following vaccination than during other time periods.
Between January 1990 and February 1998, only 15 cases of autism behavior disorder after immunization were reported to the Vaccine Adverse Events Reporting System (VAERS), and it was determined that because of the small number of reports, the cases reported are likely to represent unrelated chance occurrences that happened around the time of vaccination.
In 2000, the American Academy of Pediatrics convened a multidisciplinary panel of experts to review what is known about the development, epidemiology and genetics of ASD and the hypothesized associations with IBD, measles and MMR vaccine. The panel concluded that the available evidence does not support the hypothesis. And, recently, the National Childhood Encephalopathy Study was examined to see if there was any link between measles vaccine and neurological events. The researchers found no indication that measles vaccine contributes to the development of educational and behavioral deficits or other possible signs of long-term neurological damage.
The Centers for Disease Control and Prevention (CDC), Federal Drug Administration, National Institutes of Health and other federal agencies continue to routinely examine any new evidence that suggests possible problems with the safety of vaccines. Currently, the CDC is conducting a study in the metropolitan Atlanta area to further evaluate any possible association between MMR vaccination and autism.
Source: QuackWatch. Misconceptions About Immunization. Misconception #9: Vaccines Cause Autism. Accessed at www.quackwatch.org/03HealthPromotion/immu/autism.html.
Trudie Mitschang is a staff writer for BioSupply Trends Quarterly magazine. Vaccine proponents argue that a decision against immunization puts entire communities at risk.