PRO:

LINDA S. NIELD, MD
It certainly is reasonable for pediatricians to discharge patients if parents consistently refuse vaccinations. More than one-third of surveyed pediatricians agree.¹ Although the American Academy of Pediatrics suggests avoiding the dismissal of vaccination refusers, it also recommends consideration of dismissal “when a substantial level of distrust develops, significant differences in the philosophy of care emerge, or poor quality of communication persists.”² The main reason for the discharge is the implication that the parent does not trust the pediatrician’s judgment about such a crucial personal and societal issue.

For the establishment of an effective parentpediatrician relationship, trust must ensue. Research by Benin and colleagues³ highlights the important role that the establishment of a positive, trusting relationship has on parents’ acceptance of vaccinations. Salmon and coworkers⁴ report that vaccinationresistant parents are more likely to trust alternative medicine professionals. The pediatrician fears that because parents distrust his or her vaccination recommendations, then they may distrust his or her recommendations about several other medical issues that will arise in the child’s life.

The act of dismissing the unvaccinated child from a pediatrician’s office emphasizes the seriousness of the parents’ decision to refuse vaccinations and limits the number of unvaccinated children in the waiting room.⁵

REFERENCES:

1. Flanagan-Klygis EA, Sharp L, Frader JE. Dismissing the family who refuses vaccines: a study of pediatrician attitudes. Arch Pediatr Adolesc Med. 2005;159:929-934.
2. Diekma DS; American Academy of Pediatrics Committee on Bioethics. Responding to parental refusals of immunization of children. Pediatrics. 2005;115:1428-1431. (A statement of reaffirmation for this policy was published May 1, 2009.)
3. Benin AL Wisler-Scher DJ, Colson E, et al. Qualitative analysis of mothers’ decision-making about vaccines for infants: the importance of trust. Pediatrics. 2006;117:1532-1541.
4. Salmon DA, Moulton LH, Omer SB, et al. Factors associated with refusal of childhood vaccines among parents of school-aged children: a case-control study. Arch Pediatr Adolesc Med. 2005;159:470-476.
5. Offit B. Voices from the field: controversies in vaccine mandates. Curr Probl Pediatr Adolesc Health Care. 2010;40:59-60.

CON:

USHA PHILLIPS, MD
Vaccinations have not only reduced morbidity and mortality, they have also nearly eliminated some vaccine-preventable diseases (VPD). The effectiveness of vaccines lies in their ability to protect the majority of the population by herd immunity. Vaccination is neither risk-free nor 100% effective, and it is an ongoing challenge to balance individual rights against mandated vaccinations in settings of low disease prevalence. Unimmunized children pose a risk to other children who lack immunity, as witnessed by recent outbreaks of mumps and measles.¹ Reservoirs of adolescents and adults with asymptomatic infections who have waning antibody titers are responsible for outbreaks of pertussis in young infants.²

Adverse effects and disorders without a known cause, such as autism, have contributed to the controversies about the safety of vaccines. Moreover, adverse publicity by antivaccination advocacy groups and via the media and the Internet have increased concerns about the safety of vaccines.³

Most vaccination refusals are nonmedical exemptions. ⁴ Pediatricians may be able to build trust by addressing parental concerns and by providing literature that supports vaccine safety. The goal is to correct parental misperceptions and promote the right choice by shared decision making. Loss to follow-up represents not only the missed opportunity of ever vaccinating the child but also the lack of continued surveillance against VPD, and exposure to communicable disease can occur anywhere.

Continued refusal after adequate discussion should be respected, and surveillance for VPD should be maintained.⁵

REFERENCES:

1. Parker AA, Staggs W, Dayan GH, et al. Implications of a 2005 measles outbreak in Indiana for sustained elimination of measles in the United States. N Engl J Med. 2006;355:447-455.
2. Wendelboe AM, Njamkepo E, Bourillon A, et al; Infant Pertussis Study Group. Transmission of Bordetella pertussis to young infants. Pediatr Infect Dis J. 2007;26:293-299.
3. Gust DA, Darling N, Kennedy A, Schwartz B. Parents with doubts about vaccines: which vaccines and reasons why. Pediatrics. 2008;122:718-725.
4. Salmon DA, Moulton LH, Omer SB, et al. Factors associated with refusal of childhood vaccines among parents of school-aged children: a case-control study. Arch Pediatr Adolesc Med. 2005;159:470-476.
5. Diekema DS; American Academy of Pediatrics Committee on Bioethics. Responding to parental refusals of immunization of children. Pediatrics. 2005;115:1428-1431.