The Disneyland measles outbreak of 2015 was a tipping point for many pediatricians in the United States after more than 100 people in 14 states (including Pennsylvania) were infected and came down with measles. Most of the victims were either unimmunized or underimmunized against measles. The epidemic refocused pediatricians and public health experts on what had been, and still remains, an ethical dilemma: Does personal preference related to the refusal of childhood vaccinations trump public health? Since 2015, more and more pediatricians have closed their practices to families that refuse to immunize their children — not to punish them but, rather, to protect children who “play by the rules” by receiving immunizations completely and on time, as well as the ones they might know and love who become vulnerable due to illness or other circumstances to vaccine-preventable diseases (like a classmate attending school while undergoing outpatient chemotherapy for leukemia, a grandparent or uncle receiving immune treatments for their chronic illness, a stranger who can’t receive immunizations due to a medical contraindication). The decision to not accept new patients or discharge existing ones because they refuse vaccines is not an easy one for pediatricians, says Lena H. Sun:

But the decision is ethically fraught. Doctors must balance their obligation to care for individual children against the potential harm to other patients. They must respect parents’ right to make their own medical decisions. And they need to consider the public health consequences of a refusal to treat, which could result in non-vaccinating families clustered in certain practices, raising the risk of disease outbreaks.

Until recently, the American Academy of Pediatrics considered it unacceptable to refuse families for not vaccinating.


But now more primary care pediatric practices are losing their tolerance for personal exemptions, like this group practice Sun found:

At the large Salem, Ore., pediatric practice where Mark Helm is a partner, clinicians eventually felt that their top priority was to protect their many medically fragile patients, including children with cancer or weak immune systems and infants not yet old enough to be fully vaccinated. Last year, Childhood Health Associates of Salem became the first practice in Oregon to require all of its families to vaccinate their children fully and on schedule for the diseases most easily spread from person-to-person contact.

“Our policy happened because it simply did not seem ‘just’ to permit the kids who could not be vaccinated to face dire risks because another child’s parent ‘disbelieved’ vaccination,” Helm explained. “We did not want anyone to get measles because they passed through our waiting room.”


The response from parents was fierce and positive:

The overwhelming majority of Childhood Health’s families have supported the move, blurting out thanks in person, on the practice’s website and Facebook page.

“These are young parents and they’re saying, ‘I’m so glad about your policy. . . . I don’t understand why people don’t vaccinate their kids,’ ” Helm recalled. “That kind of spontaneous comment did not used to happen.”

After years of meeting hesi­ta­tion or reluctance from parents, he said, “it’s just nice to hear parents say that — that they want their children to be vaccinated.”


Pediatrician Sarah Kohl (Pediatric Alliance – Chartiers/McMurray) still wonders why parents refuse vaccines. She writes on her blog at TravelReadyMD about the “secret forces” that shape vaccine refusal:

Karen was in the office last week with her daughter who just turned 16. Madison eagerly awaited her driver’s permit and selected the Meningitis B vaccine. Once again they declined the HPV vaccine. Sigh.

Now I’m not saying that you shouldn’t give Meningitis B vaccine. I’m saying that data clearly show that HPV protection is more likely to save the Madison’s life.

This is because HPV infection is common and it causes 23,000 cancers and 6000 cancer deaths every year in the USA, whereas Meningitis B is rare with 30 cases and 5 deaths per year.

But patients don’t often see vaccine decisions that way. It has to do with hidden factors which influence our choices.


Dr. Kohl says providing some social proof by offering personal testimony while also maintaining an earned level of authority helps her help parents who are hesitant to vaccinate their children:

Karen was refusing HPV vaccine because her friends on facebook discouraged vaccination. This is especially hard to overcome, since the influence of friends is often seen as equal to the influence of authorities. After some discussion, based on the facts, but framed by authority, liking, and social proof she chose to start the vaccine series for her daughter.

“I understand your concerns, and those of your friends. The experts at the CDC are clear that HPV vaccination is a safe and effective vaccine, one designed to protect Madison. The good news is that by choosing HPV vaccination you can give her a lifetime of protection against a preventable cancer. I had to think carefully when my own children were old enough for the vaccine, I chose it because I wanted my children to be protected.”


It’s these unseen forces that influence parents’ decisions about vaccines that are so powerful and have been so difficult for pediatricians to overcome over the years:

We must appreciate that our patients experience these forces everyday, and empathize with how hard it is to make decisions with little understanding and powerful, often contradictory advice.

I have changed they way I talk about vaccines in the office to bring clarity to the discussion. Of course not every patient agrees with my recommendation, but at least I understand a bit more about why we disagree.



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