FROM PEDIATRICS

For years, pediatricians have sought a blessing from the American Academy of Pediatrics that acknowledged it was valid for members to dismiss families from their practice if they refused to vaccinate despite all attempts to persuade them. Now, a new clinical report has essentially delivered just that.

The report does not represent an official policy change from the AAP, but it does for the first time acknowledge that “firing” patients who persistently refuse vaccination is “an acceptable option” (Pediatrics. 2016 Aug. doi: 10.1542/peds.2016-2146 ).

“A number of pediatricians feel so strongly that if they don’t agree on vaccines, which are so basic to the delivery of care and have made such a big difference in children’s lives, how will they agree on a number of other things they’ll need to discuss?” Kathryn M. Edwards, MD , director of the Vanderbilt Vaccine Research Program, Nashville, Tenn., and a coauthor of the report, explained in an interview.

The AAP has received pressure from its members over recent years as increasing numbers of pediatricians choose to dismiss some or all of their patients whose parents were resolved not vaccinate, coauthor Jesse M. Hackell, MD , a practicing pediatrician and managing partner at Pomona Pediatrics, an affiliate of Boston Children’s Health Physicians, said in an interview.

In fact, a new study has revealed that 12% of pediatricians reported dismissing vaccine-refusing families in 2013, up from 6% in 2006. At the same time, the proportion of families refusing vaccines has nearly doubled in the same time.

“There was a groundswell of opinion that enough is enough and we can’t provide quality care if we can’t provide something we know is so important,” Dr. Hackell said. “We felt the Academy needed to stop being so adamantly opposed to the possibility of dismissal – not to recommend dismissal but simply to state it is an acceptable option.”

The AAP responds to fellows’ concerns

While the AAP continues to recommend doctors attempt to persuade families as long as possible to vaccinate, the new report discusses dismissal as a viable option as long as it adheres to relevant state laws that prohibit abandonment of patients.

“The decision to dismiss a family who continues to refuse immunization is not one that should be made lightly, nor should it be made without considering and respecting the reasons for the parents’ point of view,” the report states. “Nevertheless, the individual pediatrician may consider dismissal of families who refuse vaccination as an acceptable option.”

The report does note that some practice settings, such as hospitals or large health care organizations, may not allow dismissal of patients, and that pediatricians “should carefully evaluate the availability of other qualified providers for the family” if they live in an area with limited access to pediatric care.

But the report finally acknowledges those pediatricians who are “just philosophically wired to not accept vaccine refusals,” Stuart A. Cohen, MD , an assistant professor of pediatrics at the University of California, San Diego, and chair of AAP District 9 in California, said in an interview.

“It really interferes with your physician-patient relationship,” Dr. Cohen said, who was not a coauthor of the report.

Now, if pediatricians feel it necessary to dismiss nonvaccinating patients, “then the Academy understands because of concerns for other patients, but it must be done in a way that’s respectful and tries to ensure patients understand the safety and necessity of vaccines,” Dr. Edwards said.

The report still includes the AAP recommendation that “pediatricians continue to engage with vaccine-hesitant parents, provide other health care services to their children, and attempt to modify their opposition to vaccines.” And a number of members of the AAP’s infectious diseases and bioethics committees were uncomfortable with dismissing patients, Dr. Edwards said, but “there were certain people who needed this, who needed some blessing that this was not inappropriate after all the other things the pediatrician had done.”

Vaccines undergo thorough testing for safety and effectiveness

But the report also aims to provide pediatricians with strategies for doing everything possible first.

“We needed to address enabling the clinician to have some very specific talking points to use and not get involved in a philosophical discussion that can take an hour,” Dr. Hackell said. “They need to make a clear statement that vaccines are important, and if you don’t get them, bad things like death can happen.”

The report therefore provides a comprehensive overview of vaccine development, from the initial identification of the need for a vaccine through the various phases of clinical testing and ongoing postlicensure monitoring. This background information can arm pediatricians with foundational knowledge that’s helpful in talking with patients.

“Vaccine development is a long and arduous process, often lasting many years and involving a combination of public and private partnerships,” the report states. “The current system for developing, testing and regulating vaccines requires that the vaccines demonstrate both safety and efficacy before licensure and that long-term safety is monitored.”

The report briefly explains the multiple mechanisms for continuing to track and study adverse events and other safety concerns:

• Vaccine Adverse Events Reporting System ( VAERS ). A voluntary passive reporting system used to identify potential safety signals.

• Vaccine Safety Datalink ( VSD ). A network of linked databases from health care systems across the United States involving millions of individuals

• Post-Licensure Rapid Immunization Safety Monitoring system ( PRISM ). A system which monitors vaccine safety using health insurance claims data from 107 million individuals .

• Clinical Immunization Safety Assessment Project ( CISA ). A system that answers individual health care providers’ specific questions on vaccine safety.

Vaccine hesitancy and vaccine exemptions

Opposition to vaccination is not new, the report states, describing it as dating back to Edward Jenner’s smallpox vaccine in the early 1800s.

“Although vaccine hesitancy is not a new phenomenon, it may have a greater effect on public health today,” the report states. “With the ease of global travel, vaccine-preventable diseases are spread more quickly and may unexpectedly appear in areas where health care professionals are unfamiliar with their clinical presentation.”

The historical presence of vaccination opposition has led to circumstances in the United States today in which parents can seek nonmedical exemptions from vaccines in 47 states, and their use has increased with their availability. Yet, the increase in use of exemptions and of “alternative” immunization schedules runs the risk of eroding the herd immunity that protects the community, the report notes.

“For these reasons, we believe the better approach is to work to eliminate all nonmedical exemptions for childhood vaccines,” the authors write. The American Medical Association and the Infectious Diseases Society of America espouse this position, and the AAP is developing a similar statement.

“Families should not have to fear going to school or the grocery store or a house of worship and worry about their kids getting sick,” said Dr. Cohen. “We now strongly say that we need to work with legislators, families, and other advocates for children at the state level to spread more laws like California’s SB 277 that would abolish philosophical exemptions.”

Dr. Cohen also emphasized the importance of communicating to parents that there are no valid “alternative schedules” for vaccination. There is the Centers for Disease Control and Prevention recommended schedule and anything else is a “nonrecommended vaccine schedule because it hasn’t been studied.” That change in terminology drives home the point that the CDC schedule is the only one fully tested for safety and effectiveness.

Meanwhile, however, pediatricians need the tools to address vaccine hesitancy, starting with understanding it. The report describes the pattern of disease incidence, vaccine uptake, disease reduction, adverse event increase and resulting vaccine hesitancy, punctuated by periodic outbreaks that restore eroded confidence in vaccines.

“When diseases are present, parents are worried and want a vaccine, and when they’re gone, they don’t,” Dr. Edwards said. “We need to remember that there is a dependence on the maintenance of herd immunity by immunization by your neighbors.”

Specific strategies to counter vaccine hesitancy

Just over half of physicians spend 10-19 minutes discussing vaccines with concerned parents, and 8% spend at least 20 minutes with such parents, found a study cited in the report. Other research has found these discussions take a toll on doctors’ job satisfaction.

Yet pediatricians remain the single biggest influence on parents’ vaccination decisions, cited by nearly 80% of parents in one large study.

“The pediatrician should appreciate that vaccine-hesitant parents are a heterogeneous group and that specific parental vaccine concerns should be individually identified and addressed,” the report states. “Although many techniques for working with vaccine-hesitant parents have been suggested, scant data are available to determine the efficacy of these methods.”

It goes on to recommend that physicians should discuss the development and safety testing of vaccines “in a nonconfrontational dialogue with the parents while listening to and acknowledging their concerns.”

Pediatricians should not, however, delay vaccines or limit the number per visit – thereby deviating from the CDC recommended and AAP-endorsed schedule – unless it’s the only way a parent agrees to vaccinate.

Another strategy is the presumptive approach: Present all vaccine recommendations as required immunizations that the provider expects a parent to agree to, although pediatricians should consider their experience and relationship with a family since this approach may not work well for some parents.

The report also emphasizes the potential effectiveness of personalizing vaccine conversations by having doctors share their own experience, such as the fact that they vaccinated themselves, their children, and/or their grandchildren.

“Parents often are more likely to be persuaded by stories and anecdotes about the successes of vaccines,” the authors write. “Personal examples of children who were sick with vaccine-preventable illnesses can be much more effective than simply reading the numbers of children infected with a disease each year.”

The report also offers several suggestions for reducing the pain from administering vaccinations: administering vaccines quickly without aspirating; saving the most painful injection for last; holding the child upright; providing tactile stimulation; breastfeeding or providing sweet solutions and topical anesthetics after administration; and using distraction, such as deep breathing, pinwheels, or toys to decrease children’s pain and anxiety.

But the bottom line is that pediatricians have one key message they must communicate to parents, the report states: “The clear message parents should hear is that vaccines are safe and effective, and serious disease can occur if your child and family are not immunized.”

pdnews@frontlinemedcom.com

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