Peer Exchange: Vaccines, Physicians, and the Public

Published Online: Tuesday, November 11, 2011

To download a pdf of this article as it appeared in MD Magazine: Peers & Perspectives, click here.

A sampling of some of the conference updates inspiring reactions on our website

Discussing America’s Anti-vaccine Movement
American Academy of Pediatrics 2011 National Conference and Exhibition
Boston, October 15-18

Despite overwhelming evidence that vaccines are safe and protect against deadly infectious diseases like polio, measles, and whooping cough, some parents, influenced by misleading claims including that the MMR vaccine causes autism, have begun to refuse them for their children.
 
In an early-morning speech to a jam-packed crowd, Paul Offit, MD, offered a rousing defense of vaccines. Offit is chief of the division of infectious diseases and director of the Vaccine Education Center at the Children’s Hospital of Philadelphia and professor of vaccinology and pediatrics at the University of Pennsylvania School of Medicine. He is also co-creator of the rotavirus vaccine, which is credited with saving the lives of hundreds around the world every day.
 
Offit said that he would prefer to look on the bright side of things when it comes to the role of parents in vaccinating their children. As he pointed out, approximately 90% of parents adhere to their pediatrician’s recommendations and the official vaccination schedule—a fact that is often lost in media reports that focus on the small minority of parents who choose not to vaccinate their children due to religious beliefs or fear of harmful effects.
 
But even the media is beginning to pull back on alarmist reports about supposed ill effects of vaccines, Offit said, perhaps because they have been burned badly by people like Andrew Wakefield, the disgraced British researcher who lost his medical license when it was revealed that his study supposedly finding a link between the MMR vaccine and autism wasn’t just wrong, it was fraudulent.
 
In explaining how medical institutions are taking a hard line to ensure that health care workers get vaccinated, Offit told a story of a group of nine employees at his hospital who were fired because they refused to get the influenza vaccine. Five of the vaccine resisters fought the dismissal through their union, claiming that a vaccination requirement was not included in their collective bargaining agreement. A moderator decided against them.
 
Another story illustrated the potentially deadly consequences of refusing vaccines. Offit explained that a young child who had not been vaccinated for pertussis contracted the disease and then infected several infants, one of whom died. (The pertussis vaccine is not administered to infants under two months old, and full protection for those who have been vaccinated is not established until a child is nearly a full year old.) The mother of the infant who died became a proponent of vaccination, speaking from her tragic experience about the damage that can be done by parents who refuse to vaccinate their children.
 
In sum, Offit emphasized that when parents act based on misinformation about vaccines from celebrities or others rather than the sound, evidence-based advice of their pediatricians, they not only put their own children at risk, they put other children at risk as well. Each year there are deaths from vaccine-preventable diseases that could easily have been avoided.
 
 
I am amazed parents refuse to vaccinate their children in this age when the benefits of vaccination are well documented by the body of knowledge available from the decrease in disease burden on the community and country at large.
—Pushpendra Jain, MD
 
I am no longer amazed of anything in pediatrics. In 15 years of primary care suburban practice I have learned the following: . . . My patients’ parents do more “research” than I do—AKA a Google search. They think I should be available at their whim and see them at a time convenient to their kid’s soccer schedule as a walk-in service, and parents that think nothing of texting while driving their kids to said soccer game think that a 1-in-10,000-to-100,000 risk of a vaccination negates its well-documented scientific benefits. We are in a cycle where people no longer believe in science, but they’ll be back when we see resurgences of diseases I haven’t seen since medical school.
—Matthew Segedy, MD
 
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Vaccine Perceptions in the Physician Community
49th Annual Meeting of the Infectious Diseases Society of America
Boston, October 20-23
 
Researchers presented two studies on physicians’ perceptions of vaccines: one on doctors’ own beliefs on vaccine safety and efficacy, and one on pediatricians’ experience of parental resistance to vaccines. The first study found that physicians who have graduated from medical school recently are more likely to perceive vaccines in general as less efficacious and some vaccines as less safe than physicians who graduated from medical school decades ago.
 
Study co-author Saad Omer, PhD, assistant professor of global health, epidemiology, and pediatrics at Emory University, explained that it is well known that as vaccination programs mature and direct experience with vaccine-preventable disease fades, members of the public become more concerned with the perceived danger of vaccines. His study aimed to determine whether the same was true of physicians. (To see a video of Omer discussing his study, click here.)
 
The study was based on a 2005 cross-sectional survey of 551 primary care physicians broken up into cohorts based on when they graduated from medical school—ranging from the early 1960s to the early 2000s. It found that overall support for vaccination remains high, but that recent graduates were 15% less likely to believe that vaccines are efficacious compared with older doctors. Younger doctors were also more likely to believe that vaccines do more harm than good and had lower odds of believing that the inactivated polio, oral polio, measles, mumps, and rubella (MMR), and varicella vaccines are safe.
 
In response to a question, Omer explained that the study had not investigated whether there was a difference in attitudes of physicians within a given cohort based on whether they had direct experience with vaccine-preventable diseases and added that this would be an important area to investigate in future research. In response to other questions, Omer noted that the vaccines that prompted the most safety concerns are not among the newest vaccines, which typically inspire heightened skepticism, nor were they all live attenuated vaccines.
 
The second study surveyed pediatricians in nine Midwestern states on their experiences with parents’ refusing or delaying recommended vaccinations. Chris Harrison, MD, and Thomas Tryon, MD, both of the University of Missouri-Kansas City School of Medicine, explained that the results of the survey were very similar across the nine states surveyed—except for the rates at which pediatricians reported discharging patients from their practices over parental refusal to follow vaccine schedules. (To listen to an audio clip of Tryon discussing the study, click here.)
 
The study was based on an online survey completed by 909 pediatricians. In all nine states, pediatricians reported that the vaccines most frequently deferred or refused were for MMR, human papillomavirus (HPV), and influenza. The top three reasons for refusal or deferral in all states were fear that autism would be caused by vaccination; that too many vaccinations were being administered at once, overloading the immune system; and that vaccines can cause severe side effects. The top three responses to vaccine-hesitant parents by pediatricians in all states were engaging them in conversation about the benefits of vaccines, referring them to evidencebased websites, and providing them evidence-based literature.
 
Providers reported that between 1% and 50% of parents delayed or altered the recommended vaccine schedule and 0% to 40% of parents refused at least one vaccine. The majority reported less than 5% overall refusal and under 20% schedule alteration, though some reported much higher rates.
 
The greatest variability from state to state was in the portion of pediatricians who said they would “fire” parents who refuse to follow the vaccine schedule. This ranged from 0.9% in Minnesota to 38% in Iowa, with an overall average of 21%. In response to a question on why the discharge rate ranged so dramatically from state to state, Harrison noted that it was intriguing that in Minnesota, where the discharge rate was the lowest, the rate of vaccine refusal and deferral was the highest, while in Iowa, where the discharge rate was highest, the refusal and deferral rate was the lowest. The troubling implication of these findings is that as parental resistance to vaccines increases, pediatricians grow less likely to insist that parents follow the schedule.
 
 
The problem with vaccine refusal includes that the insurance carriers are going more toward pay for performance. The pediatricians are being penalized when their patients and their parents refuse or delay the vaccines. Pediatricians can do all the explaining and education, but if the parent says no, the insurance company refuses to acknowledge that the physician has done their job. Why don’t the insurance companies penalize the parents who do not want to vaccinate and put their child at risk for a disease by raising their premiums? That might change some people’s minds. I just think it is wrong to penalize a physician when every attempt is made to get children vaccinated at the appropriate time, and the parent says no. A lot of time is spent trying to convince parents of the safety and efficacy of vaccinations, and this time is not always recognized by the insurance carrier—just the opposite.
—Frank R. Baum, MD
 
Insurance companies really don’t respect the medical opinions of qualified health care professionals. In my professional medical opinion, the parents should make the final call in regard to their children; however, in the event that there is conflict of interest of medical opinions the parent should have the opportunity to consult other physicians for alternative treatment.
—Tobias R. Reid, PhD
 
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