Between a rock and a hard place
In the study by Dr. Kempe and her associates, almost all pediatricians and family practitioners reported receiving requests for a delayed immunization schedule. As immunization is one of the cornerstones of pediatric primary care, this presents a challenging conundrum. We are faced with a request to go against what we believe is an important standard of care that protects not only the child in front of you, but also the other children in your practice and community. At the same time, we are trying to build and maintain an effective therapeutic relationship. It appears that this dilemma most often results in acceptance of requests to delay vaccination, even if clinicians do not agree with the request and have concerns that this places children at risk. Although 92% of respondents in Dr. Kempe’s study felt that it was important to give vaccines in the primary series on time, 82% felt that accepting requests to delay vaccination would help build trust.
Decreasing trust in the medical system has been cited as a key contributor to rising vaccine hesitancy. Trust is needed, but should it be at the cost of safety or a clinician’s belief about what is best for the care of a child? Current events have shown us the consequences of undervaccination as outbreaks of measles and pertussis have been associated with groups of unvaccinated individuals. A recent Institute of Medicine report supports the safety of the currently recommended immunization schedule, and there is no available evidence to suggest that delayed schedules are any safer. Still, concerns about vaccines persist, and if maintaining trust provides a platform for effective communication that can reduce vaccine hesitancy and facilitate the acceptance of other recommendations, then this may be an equally important goal.
Dr. Kempe’s study, however, suggests that accepting requests to delay vaccination to build trust and decrease hesitancy may not necessarily do the trick, particularly for parents who have already made up their minds. As pediatric clinicians accept delayed schedules, more and more families request them. Very few of the communication tools used by clinicians in this study were considered to be very effective, even though provider recommendation is a well-established predictor of vaccine acceptance. Other studies also have suggested that parents with strongly held negative beliefs about vaccines are less likely to trust their provider. Increasingly, parents bring the influence of many other voices to the table.
Building trust includes establishing mutual respect and ensuring consistency and open communication. It is important to listen to and acknowledge concerns, but perhaps building trust also requires us to be consistent and strong in the communication of our own beliefs and recommendations for best practice. Building trust may then mean that requests to delay immunization are not ultimately accepted. Could such an approach actually strengthen provider-family relationships? In this study, only a small proportion of providers reported that they ask families requesting delayed schedules to leave their practice, and only 16% felt that this was somewhat or very effective. These results, however, reflect perception. It is clear that more work is needed to determine the true impact of different communication strategies and recommendation practices on maintaining trust and reducing vaccine hesitancy.
Dr. Kristen A. Feemster is a pediatrician who specializes in infectious diseases at the University of Pennsylvania, Philadelphia, and is research director at the vaccine education center of the Children’s Hospital of Philadelphia. She said she had no relevant financial disclosures.
Practice good scientific medicine
Parents are increasingly requesting to “spread out” routinely recommended pediatric vaccines doses.
Parents seem to be making these requests to be more comfortable with the number of vaccines given in infancy because they are conflicted over the safety of multiple vaccines administered concurrently, particularly in the first years of life. This may not be news to many of us, but it is surprising to find that primary care providers also are increasingly agreeing to these requests (13% in 2009, compared with 37% in the present study).
Such actions lead to children being vulnerable longer to vaccine-preventable diseases because of the delays inherent in spreading out vaccines. The problem is that, as more parents and physicians agree to spread out required immunizations, this practice is increasingly being accepted as the norm or okay.
This study highlights a need for us to better empower providers to discuss the rationale for the current schedule, including residents and medical students. This could allow them to have constructive discussions, armed with solid vaccine safety information and effective communication techniques. We need to emphasize the critical importance of protecting infants as early in life as possible and to confirm with parents that the safety and efficacy of vaccines is highest when used per the recommended schedule. Alteration of the vaccine schedule may not have a perceivable negative impact in that child in the immediate future, but it adds cumulatively to the vulnerability of children. It also reduces herd immunity needed to stem outbreaks when an inadvertent index case of vaccine-preventable disease (such as measles) appears in the community.
We know that a strong provider recommendation plays a significant positive role in a parent’s decision to vaccinate, with some studies indicating a fourfold-greater likelihood of vaccination from a strong recommendation versus one that was not strong (Pediatrics 2013;132:1037-46 and Vaccine 2011;29:890-5). Some clinicians seem to be bending to requests to delay some doses of recommended vaccines, even when they believe it is not ideal, reportedly because of the fear of losing those patients from their practice. Some of these clinicians are likely compromising with the thought that giving some vaccines is better than giving none, but some are reinforcing the science and rationale for the current schedule.
For example, one-third of participants in Dr. Kempe’s study reported spending more than 10 minutes discussing vaccine concerns with parents. It is unclear whether the other two-thirds of physicians are having any conversations, perhaps assuming there will be no benefit. Or perhaps they feel that it may take more time than they have for that office/clinic visit, or perhaps simply that they do not want to antagonize the parents. Any of these concerns could result in a less-than-strong vaccine recommendation. If providers assume the outcome of discussion with parents and agree to delay vaccines without a discussion, it becomes harder to maintain schedules for other patients – word gets around.
For the few hard-core antivaccine parents, discussions are likely not beneficial and only create stress, but for parents who are truly conflicted about the data (spacing them out, but still giving vaccines), what they may need is a sense that their trusted primary care provider believes strongly in the safety and efficacy of childhood vaccines when given on schedule as much as possible. Thus, a solution could be to remind providers that the scientific medical community has no question that vaccines protect best and are safest when given per the recommended schedule. Add to that easy access to vaccine safety information for providers and effective communication techniques, and we could hope for a reversal of this alarming trend to delay vaccines.
Practitioners in the field need quick, evidence-based interventions to redirect parents making these requests. They need to be comfortable giving a 3- to 5-minute summary of why vaccines should be given on schedule and to consider how best to practice good scientific medicine.
Dr. Barbara Pahud is assistant professor of pediatrics at the University of
Missouri, Kansas City. She said that she had no relevant financial disclosures.
