On dismissing vaccine-refusing families from doctor practices.

The American Academy of Pediatrics recently published a guidance giving more leeway for pediatricians (the main providers of vaccines in the US) to refuse to treat families who decline vaccination for their children. An accompanying piece provided a lively discussion on the topic.

This dilemma, faced by doctors in private practice, is not new but the debate on dismissing vaccine-rejecting families occurs in a fraught emotional climate. We see ramped-up online discussions in the wake of outbreaks of measles and pertussis and a highly polarised debate.

This societal conversation spills over to the medical encounter: a frustrated parent who believes they act from vigilance and care in rejecting vaccination. An equally frustrated clinician who wants to see the child vaccinated but encounters a communication road block. Steadfast vaccine refusal challenges the professional identity of the clinician: as child health advocate, as disease preventer, as public health advocate and as expert. They must sit within a paradox of caring for the whole child while anticipating any consequences from the risks associated with vaccine refusal.

The debate about dismissing vaccine refusers signifies a wider challenge for medicine in a post-paternal age where parents value vigilance in all the choices surrounding their children and want to be active decision makers in their child’s health.

Hesitant parents who do decide to vaccinate overcome fear from commission, anticipate the regret they may feel from vaccinating, weigh benefits, accept the trade-offs, and are influenced by personal experience. Doctors face similar processes in deciding whether to see vaccine-refusing families: to overcome fear of the potential consequences, anticipate regret should another become infected in the waiting room, accept the trade-offs, and negotiate their own feelings and experiences.

When the consultation with non-vaccinating parents goes pear-shaped, there are negative consequences for their children. When studying the anti-vaccination lobby in Australia in the late 1990s, I found that parents who had not vaccinated sought advice from these networks when their child was sick and sometimes voiced reluctance to go into the mainstream system to seek treatment precisely because of alienating experiences. Those networks would caution them to avoid medical interference, take Vitamin C, homoeopathy or the like. Ultimately that is not safe for the child. There always needs to be a path back to the practice if the child becomes sick. How the waiting room risk is managed is secondary. Shutting out these children does not shut out risk.  As John Lantos put it, “Pediatricians’ waiting rooms are very dangerous places to be.”

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There always needs to be a path back to the practice for non-vaccinating families.

Up until last year, Australia had vaccine objector exemptions that were signed by a doctor or vaccination provider. We observed a range of responses to the form-signing request. Some doctors saw it as an opportunity to build rapport but others resented their role in implementing government requirements. Nearly all found these encounters difficult. Some had negative experiences as junior doctors and gave up, proceeding to adopt a practice of just signing the form without much discussion. Very few refused to sign the form and even fewer (2% in this study) dismissed the family from the practice.

Clear to us was that governments and professional societies need to support health professionals in this communication challenge. One of the elephants in the US clinician’s room is reimbursement. There is currently no code specifically for Immunization Counselling that occurs outside of Vaccine Administration. The National Vaccine Advisory committee’s report on Vaccine Confidence suggested that such a code be considered.

Aside from covering the cost of vaccine counselling, there’s a clear need for more resources to support these discussions. The SARAH project team are developing, among other things, a unique set of resources and tips for when parents won’t vaccinate so that clinicians don’t abandon hope, the door remains open for parents to build sustainable trust for the longer term. We are still testing these resources but the response so far, from parents and health professionals, is promising.

Looking to the future, there needs to be more evidence on what happens to the children of parents who are dismissed from the practice. In a 2013 study, Buttenheim et al modelled various scenarios and found that “heterogeneity in tolerance and dismissal policies will cluster unvaccinated children in a smaller number of practices, which may differentially increase the risk of exposure for some children.”

Until there is more data on the various impacts of dismissing families, there are plenty of areas where evidence shows doctors can make a big difference to vaccination rates:

  • Asking whether any patient is due for a vaccine;
  • Asking all patients whether they or their children are Aboriginal or Torres Strait Islander to they can receive vaccines recommended to them;
  • For doctors in the US in particular, confidently recommending HPV vaccine to parents of young adolescents;
  • Updating knowledge on true and false contraindications.

Further upstream, doctors can advocate for:

  • Supporting global efforts to assist low and middle-income countries with endemic disease. The Disneyland measles outbreak was sourced to the Philippines where a massive measles outbreak raged.
  • Reducing missed opportunities in many levels of health care – catch up vaccines for people as they go to emergency departments, outpatients departments etc.
  • Systems to remind and vaccinate adults with no or waning immunity. The Australian Immunisation Register will be launched this month and this will greatly help such efforts.
  • Addressing the pertussis and influenza vaccine efficacy issues through demand for ongoing research and development by vaccine manufacturers.
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