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Dismissal of Patients Who Refuse Vaccinations

Solomon Behar, MD and Louay Keilani, MD
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Parents refuse vaccines for various reasons including concerns regarding vaccine safety and religious objections.  Options are discussed for encouraging vaccination and the ethical issues involved with dismissal of patients from a practice who refuse vaccinations.

Pearls:

  • Every visit with a family is an opportunity to educate families about vaccines.

  • When approaching a family who is refusing vaccines, do not challenge their belief systems; rather offer an explanation of what the vaccine is, what is protects against and why we worry about it.

  • Remember, because vaccines work so well we are not seeing many cases of vaccine preventable illnesses; this may make it hard for a family to see a tangible benefit in giving a vaccine to a child which may temporarily cause discomfort.

 

Background

Vaccines are always a topic that makes for a heated discussion among pediatricians.  Recently, the topic of “dismissal”, which is releasing a patient from one’s care secondary to vaccine refusal, has taken hold. If we, the pediatricians, refuse to care for this child, who has been placed at risk by no fault of his or her own, where does that leave us in our duty to protect those without a voice? 

  • How many children are under vaccinated or not vaccinated? In the United States, there are about 10% of children who are under or non-vaccinated.

Editor’s Note: The latest data from the CDC is from 2014 and shows that over 90% of children are vaccinated for MMR, Dtap, polio, Hep B, Varicella;  over 80% are vaccinated for Hib and pneumococcal; over 70% are vaccinated for rotavirus and over 50% are vaccinated for hepatitis A.

  • Are there trends in the families who choose not to vaccinate? These families tend to be more educated, more well-off and able to find means to do their own research. Many of these families prefer homeopathic options for dealing with illness. Many of these families do not have a background in medicine; but may have influential family members who are health care professionals and state that they have seen vaccine reactions.  This may scare a family into not wanting to vaccinate.

    • While a family being informed is ideal, the issue is where a family may be getting their vaccine information. Many vaccine websites feature individual stories and are not applicable to a whole population.  

  • Do some families pick and choose vaccines and how do you handle this? This is commonly seen in families who choose an alternative vaccine schedule. Keilani recommends trying to get the family to do the full vaccine schedule. He explains there is no evidence for choosing an alternative schedule; if after explaining this to the family and they still want to only “pick two”, for example, the “which two” choice can be made at your clinical discretion; there is no science behind this.

  • How do you keep track of a child’s “alternative” vaccine schedule? The electronic medical record helps. Some families will keep their own schedule or bring in a schedule they have read about in a book or on the internet. It is important to tell families that with alternative schedules, mistakes can be made with respect to timing of vaccines and missed vaccines.

  • What are medical contraindication to vaccinations? Ill-appearing and/or with high fever are contraindications to receiving vaccinations on that day; if a child has a low grade fever and is well appearing, vaccination on that day is not contraindicated. Previous anaphylactic reaction to a particular vaccine should exclude that patient from receiving that specific vaccine again. Immunocompromised patients, including those going through active chemotherapy, should not be given live vaccines. If a patient has received IVIG treatment for Kawasaki disease, the patient must wait 11 months prior to giving vaccines.

Editor’s Note:  It can be challenging to remember all the contraindications and relative contraindications to vaccination, even in the immunocompetent patient; the CDC has a helpful table summarizing these recommendations and it can be found here.  Specific consideration should be given to pregnancy, high dose corticosteroid use (> 2 mg/kg/day for > 14 days), re-immunization following chemotherapy and/or BMT, certain neurologic disorders such as multiple sclerosis or transverse myelitis.     

  • How do you approach a family that is refusing vaccines? The first thing to say is “tell me your fears so I can address those.” After this, it is important to remember that you should not attack a family's belief system as this will put them on the defensive.  Rather, tell them about the vaccine itself.  

    • Simply say, for example, “This vaccine protects against diphtheria, tetanus, and pertussis. This is why we worry about it. This is what a kid sounds like when they have pertussis.  This is what I've seen in my career. These are the concerns I have." Keilani explains to the family that he is “evidenced-based”.

    • If a family is still hesitant, Keilani brings them back to keep the discussion going.

    • Presumptive statements work better than participatory statements. Presumptive statements would include “Today, your child is due for two vaccines” in contrast to a participatory statement such as, “Do you want to vaccinate your child today?”

    • Some physicians with children use personal stories and may say “I would not put something in your child that I haven’t already put in my kid.” This may hit home for a families.

  • How do you approach a family that states their child had a vaccine reaction?  A mild reaction can be discussed in the sense that no long-term effects have been seen.  Severe reactions should be documented and therefore, if a family states their child has had  a severe reaction to a vaccine, hopefully, you would be able to find that in the record.  If not, remember that parental recall of traumatic events are not always chronologically correct.  

  • What are some ethical considerations of vaccine refusal and dismissal? This is a very tough question. We have to ask ourselves, is it morally correct to dismiss a family from your practice?  Who do you put first? Do you put the other parents and children at your practice in jeopardy because someone is choosing not to vaccinate? Or, if you send this family to another clinic, you are losing a family you could potentially change and leaving a child vulnerable. Keilani’s practice does not accept new patients that do not vaccinate. 

    • To explain this he states “This is probably not the right practice for your family because at the end of the day, I’m going to be making the medical decisions, and if you don’t trust my medical decisions to vaccinate your child, why would you trust me to treat an ear infection, treat pneumonia, do lab work?”

    • Keilani’s practice has a “grandfather clause” in place - they are not accepting new patients who do not vaccinate; but they are not dismissing those in their practice who have chosen not to vaccinate and/or chosen an alternative schedule.

  • Explanation of California’s new vaccination law, Senate Bill 277 (SB277).  California, following West Virginia and Mississippi as the other two states with similar laws, signed into law that parents can no longer refuse to vaccinate their children in public or private schools and/or child care centers based on their personal opposition.  The personal belief exemption, PBE, was a form physicians used to fill out for families that refuse to vaccinate. This law went into effect January 1st, 2016; families with PBEs already in place are exempt until certain “checkpoints.” These checkpoints are in kindergarten and 7th grade and are now mandatory vaccination points.

Editor’s Note:  Private or public child care centers, preschools, elementary schools and secondary schools in California cannot admit children unless they are immunized against 10 diseases: diphtheria, Haemophilus influenzae type b, measles, mumps, pertussis, polio, rubella, tetanus, hepatitis B and varicella. There are two exemptions: 1) a medical exemption and an exemption for students who are enrolled in homeschooling or 2)independent study without classroom instruction.  It is unclear how the law will apply to unvaccinated students who receive special education services.

 

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Parental Discretion Required (for the Doctor) Full episode audio for MD edition 168:49 min - 79 MB - M4AHippo Peds RAP April 2016 Summary 427 KB - PDF