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Turning Vaccine Refusals Into Teachable Moments

More and more parents who object to vaccination aren't getting their children immunized, leading to outbreaks of measles, whooping cough and other diseases.

Some states have responded by making it much harder for parents to get exemptions from required vaccinations based on their personal beliefs.

But Dr. Edgar Marcuse, a pediatrician at Seattle Children's Hospital, says that strategy is likely to backfire. He's trying to come up with new ways to balance parents' freedom of choice with public health needs. He described the problem in the latest issue of the Archives of Adolescent and Pediatric Medicine.

Shots called him to get the scoop. Here are highlights from our conversation, edited for length and clarity.

Q: State legislatures are creating what you call "nuisance barriers" for parents who want a personal beliefs exemption from vaccination. What are they?

It's simply a barrier that does not provide any education or benefit to the process, except for putting an obstacle between the parent and the exemption, like requiring that the form be notarized. It seems to me that any barriers you put in there should have some benefit.

Q: In Washington state, where you live, almost 10 percent of parents had exempted their families from immunization requirements. What have you done to try to get more kids vaccinated?

A: We had a definite problem in Washington state that I think we've gone a long way to correct. We think a substantial number of the exemptions were what I call convenience exemptions. When you go to register a child at school, if you don't have your child's immunization record, you might very well be encouraged by the school clerk to opt out so you child could be enrolled that day.

Q: In this case you think it was too easy for parents to opt out?

A: There was just one form. One side of the form said my child has been immunized, the other side said I'm going to opt out.

One thing we did is very simple; we separated the two forms. Another thing we did is say if you're going to opt out you have to be counseled first by a provider of vaccines.

Q: But a big problem is that can be really hard to understand which vaccines children need, when and why.

A: When's the last time you looked at the [CDC] immunization schedule? It's really complicated. It's not easy for parents to figure out what to believe. If you define hesitancy broadly, you have about 30 percent of the population who have real questions about the immunization schedule. It includes people of all ages and ethnicities.

Q: Pediatricians and public health advocates haven't made much headway on that 30 percent. Why have they failed to communicate that vaccines are important, both for a child's health and for the community?

A: Having physicians forcefully state their position is not sufficient. They need to approach [it] from the standpoint that parents really do want to do the best for their children.

It's a dialogue that's got to be respectful and assumes that parents are well motivated, and doesn't start from the standpoint of judgmental views of parents as scientific illiterates.

Q: You're also trying to figure out ways for parents to talk with each other about their vaccine worries.

A: Peer networks have a huge influence on immunization decision-making. In today's society, they've replaced grandma. But people are generally very respectful of other people's health decision-making. [In our research,] we tell a group of parents of preschool kids about the proportion of kids who are unimmunized in their classroom or child care center. Then, parents do become motivated to engage with their peers in conversation.

Q: Couldn't those conversations be a little scary?

A: I know that there are people who absolutely adamant about this and are not open to discussion, but that's a pretty small percentage – you're looking at 3 to 4 percent. The vast majority are people who have concerns about vaccine safety. They have concerns about specific vaccines, or about too many vaccines at one time.

Q: Public health officials don't talk much about freedom of choice when it comes to vaccines. But you say we've got to. Why?

A: We have these two conflicting values. We're very respectful of people making their own choices about their diets or health care behaviors. I think that's a value we really care about. We also care very much about protecting the public health. There are times when those two things come in conflict. If you have multidrug-resistant tuberculosis, the health department has extraordinary powers to make sure you take your medication. That's because the danger to the community is really substantial.

Where it gets tricky is that vaccine-preventable diseases do not present comparable risks to the public health. If you choose not to get the vaccine for tetanus, the only risk to the public is spending public funds to take care of you if you get sick.

With measles, it's a highly infectious disease. If anything over 5 percent of the population are not immunized, it will spread in the community.

I really wish what we were talking about on talk radio is how to balance those two priorities.

We are just now beginning to realize the full potential of modern vaccines to prevent and treat disease. It's absolutely incredible what science and technology are going to come up with in the next decade. We need to get this right so that that the public can look at what comes down the pike and evaluate it appropriately, and decide where it fits in their lives.

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